PEDIATRIC FRACTURES

1. PEDIATRIC FRACTURES Simon J. Hambidge, MD, PhD April 5, 2004 Denver Health Pediatric Resident Noon Conference

2. 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)

3. 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

4. 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

5. 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

6. 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

7. 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!

8. 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

9. 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!

10. 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!

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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)

17. 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

18. 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

19. 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)

20. 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)

21. 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)

22. 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

23. Galeazzi Fracture • Displaced fracture of the distal radius with disruption of the distal radioulnar joint • Requires closed reduction and immobilization for 6 weeks

24. Bones of the Wrist: • Scaphoid (Navicular) • Lunate • Triquetrum • Pisiform • Trapezium • Trapezoid • Capitate • Hamate

25. 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)

26. 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

27. 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

28. 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)

29. 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)

30. 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

31. 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

32. 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)

33. 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)

34. 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)

35. 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

36. 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

37. 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

38. 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