PEDIATRIC FRACTURES

Simon J. Hambidge, MD, PhD

April 5, 2004

Denver Health Pediatric Resident Noon Conference

Pediatric Bone Architecture• Diaphysis = middle shaft of long bone

• Metaphysis = wider part of bone, between diaphysis and physis; area of spongiosa

• Physis = cartilagenous growth plate; primary center of ossification

• Epiphysis = the end of a long bone; secondary center of ossification

• Apophysis = independent center of ossification (tubercle or tuberosity)

Pediatric Bone - Unique Aspects

• More porous and pliable (larger Haversian canals); therefore more incomplete fractures

• Open growth plates

• Periosteum = thicker and more osteogenic potential

• Ligaments stronger than bone, and more flexible than in adults

• Rapid healing and remodeling potential

Fracture Definitions I

• Longitudinal = fracture along axis of bone

• Transverse = fracture line at right angle to bone

• Oblique = fracture at an angle to axis of bone

• Spiral = oblique Fx that encircles bone shaft

• Impacted = crushing, due to compression

• Comminuted = complex, multiple Fx fragments

Fractures Unique to Pediatrics• Plastic deformity: bending/bowing

• Greenstick: plastic deformity with partial Fx on the side of the bone opposite the impact

• Torus/Buckle/Cortical: occur at junction of metaphysis and diaphysis due to compressive forces (15% of all pediatric fractures)

• Avulsion Fractures (apophyseal fractures)

• Physeal Fractures

Fracture Definitions II

• Closed vs. Open (if communicates with air)

• Stress = Fx at microscopic level

• Displaced (expressed in percentage)

• Angulated (expressed in degrees)

• Compression = impacted or depressed

• Segmental = > 2 fractures in a single bone

Physeal Fractures - General

• “Weak link” of pediatric bone (cartilage)

• Adults - sprains & dislocations; children - physeal injuries

• Rapid healing (1/2 time of shaft fractures)

• Anatomic alignment critical for minimal deformity

• Tenderness over physis: suspect a fracture, even with normal radiographs!

Salter Harris Classification• I = “Same”: through the physis

• II = “Above”: from metaphysis into physis (75% of physeal injuries)

• III = “Lower”: from physis into epiphysis (more unstable; ensure good alignment)

• IV = “Through”: from metaphysis to epiphysis (surgical pinning usually indicated)

• V = “Everything Rong” (including the spelling): disruption of physis

Musculoskeletal Physical Exam• Observation: swelling, bruising, angulation,

deformity, shortening, or rotation

• Gentle Palpation: with focus on bony vs. soft tissue structures ($1,000,000 exam tool: finger to localize tenderness)

• Evaluation of ROM, distal motor function, vascular function, and sensory perception

• Beware of bony tenderness in the absence of any trauma history!

Splinting: General Principals

• Inspect for any open wound, swelling, or deformity

• Check distal pulse and neuro status

• In general, immobilize the joint above and below the fracture

• Pad all rigid splints (minimum 2 layers, with 3 around bony prominences)

• When in doubt, splint!

Clavicle Fractures• Dx: usually obvious based on PE and X-ray

• DDx: AC separation (sprain)

• Rx: simple arm sling for 3-4 weeks (4-6 weeks if > 12 yo); figure-of-8 sling outdated

• Education: – presence of callus (“lump”) after Fx is healed– ROM exercises (gentle) after 1-2 weeks

• Red Flag: nonunion after 4 months Rx– displaced Fx at AC joint may need surgery

Proximal Humerus Fractures

• DDx: AC separation, rotator cuff tear, rupture of long head of biceps, dislocation

• Rx: simple Fx = sling only for 3-6 weeks, ROM exercises after 1 week

• midshaft humeral fractures: similar, but check radial nerve, and may need coaptation splint for comfort

Elbow Fractures

• Dx: AP and lateral X-ray

• Small anterior fat pad is normal

• Posterior “fat pad” is always abnormal: suggests effusion and fracture

• Long axis of radius should bisect capitellum in any view

• Anterior line of humerus should transect capitellum (humeral epiphysis) in posterior 2/3

Elbow Ossification Centers

• Capitellum: appears by 1 year (unites at puberty)

• Radial head: by 4-5 years

• Medial Epicondyle: by 5 years (unites at age 20)

• Trochlea: by 9 years

• Olecranon: by 9 years

• Lateral Epicondyle: by 12 years

Elbow: Supracondylar Fractures• > 50% of all pediatric elbow fractures

• Mechanism = FOOSA with hyper-extension

• PE: careful NV exam (brachial artery)

• Can be occult: suspect if + fat pad, or displacement of AH line

• Cannot tolerate > 5 degrees angulation (can result in a varus “gunstock” deformity)

• Rx if not displaced or angulated: posterior 90o splint or LAC for 3-6 weeks

Elbow: Condyle Fractures

• Lateral: young children; Medial: teenagers

• May need oblique X-rays for Dx

• Rx: conservative only if < 2 mm displacement

• f/u X-ray within 3-5 days

• All lateral condyle fracture are SH IV and need ortho consult (can get a valgus deformity)

Elbow: Olecranon Fractures

• Mechamism = direct blow

• Relatively rare

• Don’t mistake ossification center for a fracture (can get comparison views with other elbow if unsure)

• Rx if nondisplaced: posterior 90o splint with rubber ball hand exercises

Elbow: Radial Head/Neck Fractures

• Dx = palpation of radial head with elbow at 90o; gentle pronation/supination of forearm

• Mechanism = FOOSH with supinated arm in a school aged child

• Rx if < 30o angulation: padded splint and sling for 3-4 weeks; early ROM

Nursemaid’s Elbow• Subluxation of the radial head (which slips through

the annular ligament)

• Mechanism = “POOSH”

• PE = toddler holding arm in pronation

• X-ray if any swelling or point tenderness (can have parent perform exam while you watch the child’s face)

• Rx = closed reduction (1 technique = flexion/supination)

Midshaft Forearm Fractures

• Often involve both radius and ulna

• Mechanism = FOOSH

• If angulated > 10-15o and/or displaced: consult ortho for closed reduction or internal fixation (then LAC for 6-10 weeks)

• Rx if not angulated or displaced: LAC until clinically and radiographically healed (6 weeks)

Monteggia Fracture

• Ulna fracture with dislocated radial head

• Check radial pulse

• Must recognize for adequate Rx (reduction of the dislocation as well as management of the fracture)

Fractures of the Distal Radius• Account for up to 1/4 of all pediatric Fx

• Mechanism = FOOSH

• Torus Fx: SAC or volar splint for 3-4 weeks

• SH II Fx common: need closed reduction if > 15o angulation

• Fx of distal radius and ulna or greenstick Fx of radius: closed reduction if > 15o angulation (have excellent remodeling potential)– Rx = LAC for 2-3 weeks, then SAC

Galeazzi Fracture

• Displaced fracture of the distal radius with disruption of the distal radioulnar joint

• Requires closed reduction and immobilization for 6 weeks

Bones of the Wrist:

• Scaphoid (Navicular)• Lunate• Triquetrum• Pisiform• Trapezium• Trapezoid• Capitate• Hamate

Wrist: Scaphoid Fracture• Always rule out if have snuffbox tenderness

• Blood supply from distal 1/3 of bone, and covered by articular cartilage

• Any displacement has high nonunion rate; proximal Fx lead to osteonecrosis

• X-ray: scaphoid views = PA with wrist in ulnar deviation, and oblique view

• If X-rays normal, but pain persists: thumb spica cast and repeat X-rays (may need bone scan)

Scaphoid Fracture: DDx

• Distal radius Fx

• deQuervain’s tenosynovitis (Finkelstein test)

• Scapholunate dissociation (>3 mm separation on a clenched fist PA radiograph)

• Arthritis of the wrist

Boxer’s Fracture

• Fx of the 4th or 5th metacarpal neck

• If > 15o angulation with extensor lag, or if >40o angulation: refer for reduction (2nd & 3rd MC Fx need reduction if > 10o)

• Rx = ulnar gutter cast or splint for 3-4 weeks, with wrist slightly extended, MP joints in flexion, and PIP & DIP joints in extension

Phalangeal Fractures• Epiphyseal Fx common, usually no sequelae

• Rx if nondisplaced = Buddy Tape and finger splint for 3 weeks (early ROM)

• DDx: dislocation, Boutonniere deformity (tear of PIP extensor tendon), mallet or baseball finger (cannot extend DIP - splint 6 weeks in extension), rupture of profundus flexor tendon at DIP (surgical repair)

Skier’s (Gamekeeper’s) Thumb• Ulnar collateral ligament sprain +/- avulsion Fx• Mechanism: thumb forced radially by fall

while holding a ski pole• Complete tear (Dx = stress X-ray of MP joint):

surgical repair• Partial tear: thumb spica splint/cast with MP

joint at 20o flexion for 5-6 weeks (ROM after 3 weeks)

SCFE• Slipped Capital Femoral Epiphysis (a special

SH I Fracture)

• Hx: obese pre-adolescent/adolescent with leg pain (can be referred to knee!) & a limp

• Can be chronic or acute

• PE:loss of (and pain with) internal rotation with hip flexed

• X-ray: AP and frog-leg of both hips

• Rx: immediate surgical referral for pinning

Pelvic Avulsion Fractures

• Apophyseal avulsions: typically in muscular athletes aged 14 to 25

• ASIS: sartorius

• AIIS: rectus femoris (kicking)

• Ischial tuberosity: hamstring (hurdlers)

• Iliac crest: abdominal muscles

• Lesser trochanter: iliopsoas

• Rx: conservative - rest, ice, NSAIDS, PT

Fracture of the Patella

• PE: TTP over patella

• X-ray: AP, lateral, and sunrise

• Ensure there are not other injuries to the knee

• DDx: bipartite patella, patellar bursitis

• Rx: knee immobilizer X 6 weeks (ROM at 3-4 weeks)

Toddler’s Fracture• Spiral or oblique Fx of tibia

• Not suggestive of NAT in absence of other concerns

• Hx: toddler who limps or won’t walk (Hx of trauma is variable)

• Rx: posterior splint or cast; repeat X-rays @ 7-10 days

• Walking cast X 3-4 weeks (may need LLC for first 1-2 weeks)

Ankle Fractures • Most common in peds: SH1 avulsion fracture

of distal fibula (Rx = 3-6 weeks in SL walking cast)

• X-ray: AP, lateral, and oblique• Red flags for referral:

– widening or loss of medial clear space on mortise view

– isolated Fx of LM with tenderness of MM (bimalleolar injury with disruption of deltoid)

– Maisonneuve Fx (above + Fx of prox. fibula)

Fractures of the Hindfoot

• Talus and calcaneus

• Hx: major trauma (MVA or fall from a height)

• Many require surgical reduction and fixation: orthopedic referral on diagnosis

Metatarsal Fractures

• Rx: SLC or stiff-soled shoe, weightbearing as tolerated; repeat X-rays @ 3 weeks

• Referral red flags: multiple Fx, > 4 mm displacement, > 10o angulation, Lisfranc and Jones Fx, Fx of 1st metatarsal

• DDx: Lisfranc dislocation/sprain, Freiberg’s infarction (osteonecrosis of the 2nd metatarsal head), stress Fx

Proximal 5th Metatarsal Fx• Jones Fx: proximal metaphysis of 5th MT

– propensity for nonunion– Rx: referral, non-weightbearing cast for 6

weeks

• Tuberosity avulsion Fx– avulsion of very proximal tip of 5th MT

(insertion of peroneus brevis)– mechanism: inversion of ankle– Rx = gel/air splint & thick-soled shoes

Fracture of the Midfoot

• Lisfranc fracture-dislocation

• PE: most tender over tarso-MT joint

• Look for displacement of 2nd MT base from middle cuneiform = dislocation

• Rx: referral (may need surgery), 6-8 weeks of non-weightbearing cast

• high percentage of chronic midfoot pain