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Vanderbilt Sports Medicine
Common Fractures in Young AthletesFebruary 10, 2012
Alex B. Diamond, D.O., M.P.H.Assistant Professor of Orthopaedics and Rehabilitation
Assistant Professor of PediatricsVanderbilt University Medical Center
Co-Chair, Youth Sports Safety TaskforceTeam Physician
Vanderbilt & Belmont UniversitiesNashville Sounds & Nashville Predators
40th Annual MeetingSoutheast Chapter of the American College of Sports Medicine (SEACSM)
Vanderbilt Sports Medicine
Andrew Gregory, MD, FAAP, FACSMAssistant Professor of Orthopedics & PediatricsProgram Director, Sports Medicine Fellowship
Vanderbilt University Medical CenterTeam Physician
Vanderbilt & Belmont UniversitiesNashville Sounds
USA Volleyball
Common Fractures in Young Athletes
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Disclosures• Diamond
– NO commercial relationships– Research & Educational funding
• NIH U54 Institutional Clinical & Translational Science Award
• Gregory– No conflict of interest
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Objectives• Review briefly the differences of pediatric
bone• Review pediatric fracture classification• Discuss subtle fractures in kids• Discuss a few other pediatric only conditions
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Pediatric Skeleton• Bone is relatively elastic and rubbery• Periosteum is quite thick & active• Ligaments are strong relative to the bone• Presence of the physis - “weak link”• Ligament injuries & dislocations are rare –
“kids don’t sprain stuff”• Fractures heal quickly and have the capacity to
remodel
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Anatomy of Pediatric Bone
• Epiphysis• Physis• Metaphysis• Diaphysis• Apophysis
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Pediatric Fracture Classification• Plastic Deformation – bowing
– Fibula or ulna common• Buckle/Torus – compression, stable• Greenstick – unicortical tension• Complete
– Spiral, Oblique, Transverse• Physeal = Salter-Harris• Apophyseal avulsion
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Plastic Deformation• Bowing without
fracture• Often requiring
reduction
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Buckle (Torus) Fracture• Buckled Periosteum
– Metaphyseal/ diaphyseal junction
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Greenstick Fracture• Cortex Broken on Only One Side
– Incomplete
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Complete Fractures• Transverse
– Perpendicular to the bone
• Oblique– Across the bone at 45-60o
– Unstable
• Spiral – Rotational force
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Salter-Harris Classification
I II
III
IV V
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Clues• Kids usually poor historians• Mechanism Any Fall
– Trampolines, Monkey Bars, Skating
• May not be swelling, bruising or deformity
• Limp• Non-weight bearing• Not using the arm
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Keep In MindSubtle Fractures
• Salter-Harris I• Buckle• Avulsions• Occult
Mimickers• Nursemaids• Other causes of limp
– Legg-Calve-Perthes– Transient synovitis– Septic arthritis
• Osteomyelitis– Bone pain + Fever
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Elbow Fractures• Multiple physes• Look for swelling
– Effusion• Loss of flexion/ extension• No loss of supination/ pronation
• Typical pattern– Supracondylar in the very young– Radial head in the older child
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Ossification Centers of the Elbow (CRITOE)
• C = Capitellum• R = Radial Head• I = Internal (Medial)• T = Trochlea• O = Olecranon• E = External (Lateral )
• 2 Years• 4 Years• 6 Years• 8 Years• 10 Years• 12 Years
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Ossification Centers Appearance
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Elbow Fat Pads• Indicates hemarthrosis
– In the setting of appropriate mechanism = a fracture of the distal humerus, proximal radius or ulna
• Anterior– Normal if laying flat against the humerus– Abnormal if elevated = “sail sign”
• Posterior– Always abnormal
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Elbow Fat Pads
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Posterior Fat Pad
Anterior Fat Pad
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Occult Fracture
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Non-Displaced Supracondylar Fracture
Posterior Fat Pad
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Nursemaid’s Elbow• Traction injury usually
when it is “time to go”• FOOSH• Child cries and will not
use the arm• No swelling or
deformity• Does not improve with
time
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Nursemaid’s Elbow• Subluxation of the radial head• Small tear in the annular ligament which slides
off the radial head and into the joint• Average age 2-4 yr but up to 8 yr• Radial head goes from being shaped like a
pencil eraser to that of a hammer head by about age 5-6 yr
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2
3
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Reduction Maneuver: Full supination and flexion
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Forearm Fractures• Most common fracture in pediatrics
– Becoming more common
• FOOSH• May not have swelling, bruising or deformity• Tender 1” proximal to the RC joint• FROM or loss of supination
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Volar Bruise
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Splint vs. Cast for Buckle Fractures of the Distal Radius
• LOE 1– Splint as good as a cast for
prevention of re-fracture or loss of alignment
– No difference in pain– Easier to bathe, better
function– No need for return for cast
removal or re-xray
Plint AC et al. Pediatrics, 2006.
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Navicular Fractures can happen in Skeletally Immature
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Avulsion Fx common in the Fingers
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Slipped Capital Femoral Epiphysis (SCFE)
• SH Fracture through proximal femoral physis• High index suspicion
– Consider in any child with limp or hip/knee pain• Xray: AP/Frogleg pelvis• Catch before the slip• Can be bilateral• ORIF
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SCFE
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Toddler’s Fracture• Suspect
– Any toddler with a mechanism who refuses to bear weight
– Regardless of exam or xray
• SLWC x 2-3 weeks
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Distal Metaphyseal/Supracondylar
• Slipped while running• Tender above the physis• Minimal swelling• Refusal to bear weight• No effusion• A form of Toddler’s fracture
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SHII Proximal Tibia - Periosteal Recoil
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Ankle Fractures• Physis located 1” above distal maleolar tip• SH I of the fibula common with inversion
injury• ER stress test useful in distinguishing fracture
from sprain• Tibia closes medial to lateral before the fibula
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Distal Fibula Salter-Harris I
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8 y/o male soccer player
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Salter-Harris II
Distal Tibia
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12 yo football player
SH III
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SH IV Tibia
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Calcaneal Fractures• Jump from height• Jump into shallow
water• Xrays sometimes
negative, subtle• Occasionally bilateral
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Metatarsals• Physis proximal on the
1st and distal on the others
• 1st MT epiphysis often bipartite
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5th Metatarsal Apophysis
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