A Baby with Broken Bone – A Parents guide for fractures in children.


Fractures in children following injury are common and cause sudden panic among parents. Children are not small adults but a different sub set of patients and thier injury pattern is completely different. Hence ,It is important for the Parents/ Gaurdians to understand these basic trends of injury in children.
It is estimated that significant Percentage of children sustain fracture between 0-16 years ( 42 % boys & 27% girls). The children have soft bones and stong ligaments therefore any small injury fractures a bone rather than causing soft tissue ( ligament) injury. A normal Xray does not exclude the fracture completely and if clinical symptoms predominate ( tenderness, pain , swelling) its better to immobilise with plaster etc. In such cases a xray after few days will reveal a hairline or previously unseen fractue. Majority of the fractures are treated with immobilisation ( Slings or plaster). It is important that displaced fractures are properly aligned. This is better achieved if child is under anaesthesia or sedation. Angular malalignment up to 15 degree is well tolerated however any rotational malalignment is not tolerated. The normal process of bone remodeling in a child may correct malalignment, making near-anatomic reductions less important in children than in adults. Remodeling can be expected if the patient has two or more years of bone growth remaining. Because the amount of remodeling is not predictable, displaced fractures should still be reduced to maximize the chances of achieving acceptable alignment.
The fractures in children heal fast and non unions are very rare. While this faster healing has the advantage of little immobilisation period , it leaves with little time for manipulation if the fracture is malaligned. This is significant if proper medical help is not taken within 3-5 days because after this the fracture becomes sticky and getting alignment is difficult even under anaesthesia. Majority of children do not show all the classical signs and symptoms of fractures and many will still walk with limp. Hence any subtle signs need to be properly investigated and evaluated by Specialist.
The fractures in children are also peculiar due to presence of Growth plates which are found at ends of bones. These are responsible for the growth and ulimate height attained over the years. The transition area of bone and growth plate is the weakest part of the bone and is most likely to be fractured. If medical treatment is not taken promptly it could result in “ Growth Arrest” (the bone stops growing) or bowing of bone . However sometimes fractures in children may stimulate longitudinal growth of the bone, which may make the bone longer than it would have been had it not been injured. Some degree of fracture fragment overlap and shortening is, therefore, acceptable and even desirable in certain fractures to counterbalance the anticipated overgrowth. This is particularly true for fractures of the femoral or tibial shaft.
Children tolerate prolonged immobilization ( Plaster or Slings) much better than adults. Disabling stiffness or loss of range of motion is distinctly unusual after pediatric fractures. After cast immobilization, physical therapy is rarely needed because children tend to resume their normal activity gradually without much supervision. Playing in a swimming pool may speed up return to full function, if desired. Even though fractures of growing bones generally heal with a large callus, this new bone is still fibrous and not yet restored to its original strength. Because of this, the child should avoid collisions or contact activities for two to four weeks, depending on activity level and age, after discontinuing immobilization.
The distal radius is perhaps the most common fracture site in children and adolescents. The incidence of fractures of the distal forearm has increased 40% over the last 30 years, with most of the increase occurring in fractures associated with recreational activities. The peak incidence of distal radial fractures ( around wrist) coincides with the peak growth velocity for children, because of the relative porosity of the bone during this time. The usual mechanism of injury is a simple fall on the extended wrist. Other areas commonly fractured are supracondylar ( above elbow), clavicle , leg bone and thigh bone. Toddler's fractures occur most commonly in children younger than 2 years old who are learning to walk. Frequently, there is no definite history of a traumatic event, and the child is brought to the clinic because of reluctance to bear weight on the leg.
A majority of fractures in children younger than 1 year are caused by physical abuse, and a significant percentage of the fractures in children younger than 3 years are the result of abuse. Although all children are potentially at risk of maltreatment and abuse, first-born children, premature infants, stepchildren, diabled children and children with both working Parents are at greater risk. It is not unusual for young children to fall, but it is unusual for them to sustain a significant injury from the fall alone. It is rare for an infant to sustain a fracture from a fall from a sofa or changing table. It is important to see whether the reported history of the trauma is consistent with the pattern, severity, and extent of the injury. Femoral fractures in children younger than 1 year are highly suspicious for child abuse . Because scapular fractures result only after significant force, a scapular fracture in a child without a clear history of violent trauma should raise suspicion of abuse.
Fractures during childhood are common. Being knowledgeable about injury patterns, typical mechanisms of injury, and physical findings helps ensure adequate evaluation and treatment.
Dr. Harinder Batth
M.S(PGI)
Orthopedic Surgeon

Key Points
1. Significant Percentage of children sustain fracture between 0-16 years ( 42 % boys & 27% girls).
2. A normal Xray in children does not exclude the fracture completely.
3. Remodeling is expected if the patient has two or more years of bone growth remaining.
4. Children tolerate prolonged immobilization ( Plaster or Slings) much better than adults.

Knee Replacement in Cardiac Patients / Walk your way to healthy heart
As our population ages more and more patients are undergoing Cardiac interventions like angioplasty (Cardiac stenting) or CABG(Heart Surgery). The favourable outcome of these procedures is largely determined by ability of such patients to exercise after surgery. However large numbers of patients have limited ability to walk because of knee arthritis. Tackling knee arthritis and easing the pain is of foremost importance in such patients.

Many people are misinformed about such cardiac patients undergoing knee replacement and fear about possible risks and complications. If some precautions are adhered the risks are not more than any other case.
The blood thinning drugs (Aspirin, Clopidegrol) are stopped 5-7 days prior to surgery. These drugs are restarted postoperatively at appropriate time. However other drugs for blood pressure are to be continued.
Simultaneous both knee replacement is not advisable in cardiac patients and is associated with more risks. A staged procedure after 4-6 weeks interval is quite safe. This is however more costlier.
We evaluated cardiovascular fitness after hip and knee replacement, found that the post-operative resumption of physical activity was associated with increased fitness, and that patients following joint replacement were fitter than the patients with arthritic joints who were treated non-operatively.
The major purpose of total knee arthroplasty is improvement in the patients quality of life. Successful total knee replacement enables increased levels of exercise and this can be beneficial to patients with anxiety, depression, High cholesterol, obesity, high blood pressure, coronary artery disease, diabetes mellitus and osteoporosis .
Liaison between the surgeon, anaesthetist and cardiologist is recommended.
Dr. Harinder Batth

Viscosupplementation for Knee Arthritis

Hyaluronan injections are a treatment option for osteoarthritis of the knee. In osteoarthritis, as cartilage wears away, synovial fluid changes and loses its ability to lubricate the joint. Pain, stiffness, and limited range of motion for the affected joint are the result of the deterioration. The treatment which injects hyaluronan into the knee, known as viscosupplementation, is an effort to improve the lubrication of the knee, reduce pain, and improve range of motion. Here are some things you should know about hyaluronan injections.
Hyaluronan is usually not a first line treatment for knee osteoarthritis.
Typically, hyaluronan injections (also sometimes called viscosupplements) are recommended for patients who have not found adequate pain relief from more conservative treatment options:
• Medications
• Exercise / Physical Therapy
• Weight loss if patient is overweight
• Heat and cold
• Assistive mobility devices (e.g., cane)
Although, hyaluronan injections are not usually recommended before trying other treatment options, the best result usually occurs if the patient is in the early stages of osteoarthritis. Patients in the later stages of osteoarthritis, who may be waiting for knee replacement surgery, are considered good candidates for hyaluronan injections so they hopefully can get some relief while waiting.
How well hyaluronan injections work has been debated.
Clinical studies have concluded that hyaluronan injections can decrease pain and improve function in patients with mild to moderate osteoarthritis of the knee. There is no evidence that suggests hyaluronan injections affect the underlying disease course. It is clear that the injections are not a cure.
Among patients who were helped by hyaluronan injections, when pain relief occurred was variable.
The most significant pain relief occurred 8 to 12 weeks after the first injection for most patients. Studies have shown that Synvisc and Hyalgan provide pain relief from knee osteoarthritis for up to six months, with some patients getting relief for an even longer duration. Patients may be able to repeat the course of treatment with hyaluronan injections. For example, a patient who has experienced up to six months of pain relief from Synvisc but has had pain return may be a candidate for another course of Synvisc injections.
To minimize potential side effects, after an injection patients should avoid strenuous activities for 48 hours.
The most common side effects around the injected joint, which are usually mild, include:
• temporary injection site pain
• swelling
• redness and warmth
• itching
• bruising
The patient does not have to stop other medications they are taking when getting hyaluronan injections.
There should be no adverse interaction with other pain medications or anti-inflammatory medications that a patient is taking.
Dr. Harinder Batth
Orthopedic & Joint Replacement Surgeon