FRAKTUR EKSTREMITAS BAWAH

PADA ANAK

Oleh :
Khairuli Amri, dr
FRAKTUR DAN DISLOKASI SENDI
PADA ANAK
 Fraktur pada anak-anak berbeda dengan
orang dewasa, karena adanya perbedaan
anatomi, biomekanik serta fisiologi tulang.

Perbedaan Anatomi
Anatomi tulang pada anak-anak terdapat
lempeng epifisis yang merupakan tulang
rawan pertumbuhan. Periosteum sangat
tebal dan kuat dan menghasilkan kalus yang
cepat dan lebih besar daripada orang
dewasa.
 Perbedaan Biomekanik
Perbedaan biomekanik terdiri atas: biomekanik
tulang, biomekanik lempeng pertumbuhan,
biomekanik periosteum.

 Perbedaan Fisiologis
Pada anak-anak, pertumbuhan merupakan
dasar terjadinya remodeling yang lebih besar
dibandingkan pada orang dewasa.
ATAS DASAR KELAINAN PERBEDAAN ANATOMI,
BIOMEKANIK DAN FISIOLOGIS, MAKA FRAKTUR
PADA ANAK-ANAK MEMPUNYAI GAMBARAN
KHUSUS, YAITU:

1. Lebih sering 6.Terdapat perbedaan

ditemukan dalam komplikasi
2. Periosteum yang 7. Berbeda dalam
sangat aktif dan kuat metode pengobatan
3. Penyembuhan fraktur 8. Robekan ligament
sangat cepat dan dislokasi lebih
4. Terdapat problem jarang ditemukan
khusus dalam 9. Kurang toleransi
diagnosis terhadap kehilangan
5. Koreksi spontan pada darah
suatu deformitas
residual
BEBERAPA JENIS FRAKTUR KHUSUS PADA
ANAK
FRAKTUR EPIFISIS
Fraktur epifisis merupakan suatu fraktur
tersendiri dan dibagi dalam:
1. Fraktur avulsi akibat tarikan ligament
2. Fraktur kompresi yang bersifat komunitif
3. Fraktur osteokondral
FRAKTUR LEMPENG EPIFISIS
 Anatomi, Histologi, dan Fisiologi
Daerah yang paling lemah dari lempeng epifisis
adalah zona transformasi tulang rawan pada daerah
hipertrofi dimana biasanya terjadi garis fraktur.
 Diagnosis
Diagnosis dapat ditegakkan dengan melakukan
pemeriksaan rontgen dengan dua proyeksi dan
membandingkannya dengan anggota gerak yang
sehat.
 Klasifikasi
Klasifikasi menurut Salter-Harris yang paling mudah
dan praktis serta memenuhi syarat untuk terapi dan
prognosis.
SALTER-HARRIS
FRAKTUR LEMPENG EPIFISIS
 Penyembuhan
Setelah reduksi dari fraktur epifisis tipe I, II dan III
akan terjadi osifikasi endokondral pada derah
metafisis lempeng pertumbuhan dan dalam 23
minggu osifikasi endokondral ini telah mengalami
penyembuhan. Sedangkan tipe IV dan tipe V
mengalami penyembuhan seperti pada fraktur
daerah tulang kanselosa .
 Prognosis terhadap gangguan pertumbuhan
85% trauma lempeng epifisis tidak mengalami
gangguan dalam pertumbuhan. Sisanya 15%
akan memberikan gangguan dalam
pertumbuhan.
FRAKTUR AKIBAT TRAUMA
KELAHIRAN

Bayi besar sungsang

forsep

Fraktur femur bilateral fraktur humerus

fraktur clavikula
FRAKTUR AKIBAT PENYIKSAAN
( CHILD ABUSE )
 Ditemukan kebiruan pada badan anak yang
tampak berulang yang tanpa didahului oleh
kejadian kecelakaan.
 Dibawah usia 3 tahun (25% kejadian dari child
abuse)
Diagnosa :
 Riwayat injuri yg tidak jelas
 PE:
 Multiple bruises (in varying stages of resolution)
 The child usually has a sad countenance
 Radiographic + scintigraphic:
 Need to be extensive (include the skull, chest, and all
four limbs)
 MRI  soft tissue injuries
THE FOOT
THE FOOT
Fraktur tulang metatarsal
Fraktur pada beberapa tulang metatarsal lebih
sering terjadi dibandingkan hanya pada satu
tulang.
Disebabkan karena crushing injury (kaki tertimpa
benda berat)
Cidera biasanya disertai adanya injuri pada arteri
dan vena kaki
Penanganan awal : Realignment of metatarsals
and elevation of the foot.
Penggunaan balutan yang terlalu ketat
merupakan suatu kontraindikasi
Nonweightbearing selama 3 minggu walking
cast (retained for 3 weeks)
Avulsion Fracture of the Base of the Fifth
Metatarsal
Sering dialami pada anak usia lebih besar

Sudden inversion injury of the foot  an

avulsion of the bony insertion of the peroneus
brevis tendon into the base of the fifth metatarsal
(insertion maybe into a separate center of
ossification)
Local tenderness, comparable radiographic
projections of the opposite foot in assessing the
injury.
Penanganan dengan pemakaian Walking cast
dengan posisi kaki eversi (4 weeks)
Fracture of the Os Calcis
Crush injury or compression type fracture dapat
terjadi ketika anak jatuh dari ketinggian dan
mendarat tepat di tumit kaki.
Spine (tulang belakang) juga harus dilakukan
pemeriksaan (clinically and radiographically)
Untuk memastikan posisi dari fraktur dapat
dilakukan pemeriksaan CT scan
Few days of bed rest with the foot elevated 
allowed up on crutches without bearing weight on
the injured foot for several weeks. (active
exercise to regain a normal ROM)
In older children / adults / intra-articular fracture
may require ORIF
THE ANKLE AND LEG
Type I – injury of the distal fibular
epiphysis
Sudden inversion injury of the ankle

Significant local tenderness at the site of

epiphyseal plate is an indication to obtain
stress radiographs
Treatment: below knee walking cast (3 weeks)
Type II – injury of the distal tibial epiphysis
Even severly displaced type II epyphiseal plate
injuries around the ankle can be radily reduced bt
closed means.
Reduction maintained by plaster cast (3 weeks)
Type III – injury of the distal tibial epiphysis
In older children who are almost fully grown

Fracture of the lateral corner of the distal tibial

epiphysis (the last part of the epiphysis to
become fused to the metaphysis)
Readily detected in the lateral radiographic
projection
ORIF is indicated

The triplane fracture is a variant of type III +

type II epiphyseal plate injury
TYPE III – INJURY OF THE DISTAL TIBIAL
EPIPHYSIS
Type IV – injury of the distal tibial epiphysis
Severe inversion injury  type IV intra-articular
fracture through the medial portion of the distal
tibial epiphyseal plate
Fracture is unstable

ORIF is indicated to obtain and

maintain perfect apposition of

the fracture fragments
TYPE IV – INJURY OF THE DISTAL
TIBIAL EPIPHYSIS
Type V - injury of the distal tibial epiphysis
Severe angulation of the ankle  type V
epiphyseal plate injury
Nonweightbearing on the ankle for at least 3
weeks
Subsequent growth disturbance is almost
inevitable
Poor prognosis

As soon as complication become apparent, it

should be trated by excision of the bony bar that
crosses the epiphyseal plate
Fracture of the Tibia
Majority of tibial shaft fracture in children relatively
undisplaced (strong periosteal sleeve)
Closed reduction (must correct angulatory and
rotational deformities)
 Long-leg cast with the knee flexed to a right angle (4
weeks)
 Long-leg walking cast (4 weeks)
Correction of alignment by closed reduction is
important when the fracture is in the proximal
metaphysis of the tibia  Nonweightbearing until the
fracture is united
Displaced fracture of the proximal third of the tibia and
fibula are potentially serious (risk of injury of the
anterior and posterior tibial arteries  compartment
syndromes)
THE KNEE AND THIGH
Most significant injuries involve the epiphyseal
plate or the epiphysis of either the proximal tibia or
the distal femur

Avulsion Fracture of the Anterior Tibial Spine

ACL inserted to anterior tibial spine
In children the ligaments are stronger than the
epiphysis
Associated with a hemarthrosis
Cylinder cast in complete extension 4 weeks (if
avulsed anterior tibial spine only slightly elevated)
ORIF or Arthroscopic reduction and internal
fixation (cannot be reduced, often because of an
entrapped meniscus)
Type II Injury of the
Proximal Tibial Epiphysis
Severe hyperextension injury
of the knee  type II fracture-
separation of the proximal tibial
epiphysis
Risk of injury to the popliteal
artery
Type II Injury of the Distal Femoral
Epiphysis
More often separated from its metaphysis than
the proximal tibial epiphysis
Hyperextension injury  type II fracture-
separation of the epiphysis
May injure the popliteal artery and the medial or
lateral popliteal nerves
Difficult to reduced unless the child is lying face-
down
Traction is applied to the leg with the knee
slightly flexed
Reduction is maintained by percutaneous
pinning + long-leg cast with the knee slightly
flexed (3 weeks)  active exercise
Type IV Injury of the Distal Femoral
Epiphysis
Uncommon at the knee

Prognosis concerning subsequent growth is very

poor, unless the reduction is perfect
Traumatic Dislocation of the Patella
Girls who have some degree of genu valgum and
generalized ligamentous laxity  lateral dislocation of
the patella
Abduction, external rotation injury to the knee
Experiences sharp pain, her knee gives way
completely, and she fall

Diagnosis:
Grossly swollen knee (gross hemarthrosis)
Patella can be felt lying on the lateral aspect of the
knee
Radiographic examination must include a tangential
superoinferior projection to detect the presence of an
associated osteochondral fracture of the either medial
edge of the patella or the lateral lip of the patellar
groove
Treatment:
Dislocated patella should be reduced by closed
manipulation with the knee in extended position 
immobilized in a cylinder cast (ankle to groin) in
extension (6 weeks)
Presence of an osteochondral fracture: indication for
open operation with removal of the fragment + repair
of the torn soft tissue
Quadriceps exercise is important during and after
period of immobilization, to prevent recurrence of the
dislocation

Complication:
Reccuring dislocation (each dislocation, the articular
cartilage of the patella is reinjured  chondromalacia
 degenerative arthritis
Internal Derangements of the Knee
The semilunar cartilage (menisci) of the knee in
children are resilient and relatively resistant to
disruption.
They may occur in older children and adolescents
as a result of injuries incurred in such sports as
skiing, football, and hockey.
Fractures of the Femoral Shaft
Common in children (middle third of
the femur)
Even with significant displacement
of the fragments, at least part of the
strong periosteal sleeve remains
intact
Highly unstable

Diagnosis
Clinical examination

Apply a temporary splint before

radiographic examination
Treatment:
From birth to 5 years
 Initial skin traction (few days)  hip spica (hip and knee
slightly flexion)
 Children <2 yrs, temporary overhead (Bryant’s) traction
 Children 2-5 yrs, the brief period of traction is with the
involved limb in a Thomas splint and the child on an
inclined frame  hip spica
From 5 to 10 years
 Few days in skin traction  closed reduction followed
either by hip spica treatment or the blind insertion of
flexible intramedullary nails.
 Alternative: external skeletal fixation
Older than 10 years
 After a brief period in traction  blind insertion of rigid,
locked intramedullary nail (control rotation)
 Alternative: ORIF
Temporary Overgrowth of the
Fractured Femur
Always occurs after displaced
fractures of the femoral shaft
(average 1 cm, redial LLD 1 year
after fracture is permanent)
Ideal position in which to allow the
fragments to unite with
nonoperative treatment is side-to-
side (bayonet) apposition with
approximately 1 cm overriding

Complication
Volkmann’s ischemia
(compartment syndrome) of nerves
and muscles
Fractures of the Subtrochanteric
Region of the Femur
The muscles inserted into the proximal
fragment (iliopsoas, glutei) pull it into
a position of acute flexion, external
rotarion, and abduction.
Temporary continuous traction
(continuous skeletal traction trough
the distal metaphysis) + thigh flexed
+ external rotated + abducted
Children > 10 years: locked
intramedullary rod or ORIF
SUBTROCHANTER FRAKTUR
THE HIP AND PELVIS
Fractures of the Femoral Neck
In child unlike in the elderly adult, the femoral
neck is extremely strong
Severe injury is required to fracture it

Precarious blood supply to the femoral head

 high incidence of posttraumatic avascular
necrosis.
Highly unstable
Treatment:
Closed reduction + internal skeletal fixation
using percutaneous pinning (threaded pins) + Hip
spica (3 months)

Complication
Nonunion

Progressive coxa vara deformity

Posttraumatic avascular necrosis  femoral

head become deformed
Type I Injury of the Proximal
Femoral Epiphysis
risk of avascular necrosis of the
femoral head  premature closure
of the underlying epiphyseal plate
Should be treated by internal
skeletal fixation (with two or more
threaded wires)
Traumatic Dislocation of the Hip
Vulnerable to dislocation when it is in a position of flexion
and adduction
Less force is required to dislocate the hip in a child than in
an adult

Diagnosis
The clinical deformity of a posterior dislocation:
Flexion
Adduction
Internal rotation

The clinical deformity of an Anterior dislocation (rare in

childhood):
Extension
Abduction
External rotation
Treatment:
The dislocation should be reduced as soon as
possible to prevent the serious complication of
avascular necrosis of the femoral head (8 hours)
Close reduction:
 Applying upward traction on the flexed thigh
 Forward pressure on the dislocated femoral head
from behind
After reduction:
 Hip spica with the hip in most stable position
(extension, abduction, and external rotation)
 Immobilization is maintained for 6 weeks
Complication:
Posttraumatic avascular necrosis of the femoral
head (>8 hours)
Residual subluxation (soft tissue interposition of
capsule or labrum in the joint prevent perfect
reduction)
PELVIS
In child is more flexible and more yielding
(cartilaginous component at SI join, triradiates
cartilages, symphysis pubis)  serious fracture
of the pelvis is not common in childhood
The most important  associated
complitcation (internal hemorrhage from torn
vessel, extravasation of urine from rupture of
the bladder or urethra
Diagnosis
PE:
 Localswelling and tenderness
 Deformity of the hips + instability of the pelvic ring

Special rafiographic projection is required to

obtain
1. AP projection
2. Tangential projection (upward 50 degree)
3. Inlet projection (downward 60 degree)
4. CT
Treatment: centers on two major complications
Major hemorrhage (may lose 60% of circulating
blood volume)  severe hemorrhagic shock
Catheter should be inserted into bladder
(invertigate possibility of associated injury of the
bladder or urethra
Suprapubic cystotomy (if the catheter cannot be
passed)  cystogram (ruptured bladder)
Pelvic bone (cancellous bone)  unite rapidly 
treatment aimed at correcting significant fracture
deformities to prevent malunion and resultant
disturbance of function
Stable Fracture of the pelvis
do not interfere with stability of the pelvis in relation to
weightbearing  do not require reduction
Isolated fractures of the ilium  require only protection
from weightbearing until pain subsides (few weeks)
Straddle inury  likely to produce a tear of the urethra

Unstable Fracture of the Pelvis

Complete separation of the symphysis pubis  reduced
by internally rotaring both hips  hip spica cast
Bucket handle fracture  externally rotating the lower
limb  hip spica cast
Unstable fractures (half of the pelvis is driven
proximally)  continuous skeletal traction trough the
femur
Alternative methods: external skeletal fixation, ORIF
TERIMAKASIH