Introduction to Pediatric Orthopaedics: Common Fractures

1. Introduction to Pediatric Orthopaedics: Common Fractures Stephen P. England, MD MPH Department of Orthopaedic Surgery Park Nicollet Orthopaedics

3. The Pediatric Skeleton “Children are not simply small adults” (though some adults are simply large children)

4. Pediatric Skeleton • Less dense and more porous • Lower bending strength • Lower mineral content • Periosteum is very thick • Presence of growth plates (physes) • Ends of long bones are nonossified cartilage • Tendon may be stronger than bone insertion sites (adolescents)

5. The Pediatric Skeleton • Comminuted fractures are uncommon • Large pores in the immature cortex can prevent propagation (greenstick) • Long plastic phase with loading relative to mature bone (plastic deformation) • Fail with compression - buckle fracture • Remodeling potential of fractures

6. Anatomy of the Pediatric Skeleton

7. Anatomic Differences • Epiphysis - the cartilaginous end with a secondary ossification center • Physis- the growth plate • Metaphysis - cylindrical end of long bones. This portion is more porous and has a thinner cortex than the shaft • Diaphysis – principal portion of the long bone or “the shaft”

8. Anatomic Differences Growth Plates • The most obvious difference is the presence of growth plates and thick periosteum • Growth plate injuries may lead to significant growth disturbances if managed poorly • Reduction of the growth plate injury must be precise

9. Anatomic Differences Periosteum • Periosteum has greater bone forming potential in children • It helps to maintain alignment of simple fractures • It also reduces the amount of displacement of fractures • Can aid in the reduction of fractures

10. Anatomic Differences Remodeling • Remodeling may make reduction accuracy somewhat less important than in an adult • Occurs in the plane of a joint (25 degrees / metaphyseal region / less than 8 years old) • Will not occur for rotational deformity or for angular deformity not in the plane of the joint • >10 degrees of angulation in the midportion of long bones is not acceptable

11. Remodeling and Healing • The younger the patient the greater the remodeling potential • Side-to-side apposition of long bone fracture fragments may be acceptable as long as shortening doesn’t occur • Intra-articular fractures must be anatomically reduced and will not remodel • Nonunions are virtually unheard of in simple pediatric fracture

12. Classification of Children’s Fractures • Plastic deformation • Buckle/Torus factures • Greenstick fractures • Complete fractures • Epiphyseal or Growth plate fractures

13. Plastic Deformation • Unique to children • Most commonly seen in the ulna and fibula • May rarely occur in the femur as well

14. Plastic Deformation • The angular deformity may be permanent • Without a hematoma, no significant callus will form • A fracture on the tension does not propagate

15. Buckle or “torus” fractures • Injury primarily in early childhood • Occurs at metaphyseal-diaphyseal junction • Secondary to compressive force • Very common • Heal in 2-3 weeks

16. Buckle fractures • Also known as “torus” fractures • Treated in a short cast or splint for 2-3 weeks • No long term sequelae

17. Torus fracture = Buckle fracture • Torus = Latin for a cushion of this shape

18. Torus fracture = Buckle fracture • Torus = Ring at column base

19. Torus fracture = Buckle fracture • Torus = Ring at column base

20. Greenstick Fractures • Occur when a bone is bent with failure of the tension side • Fracture doesn’t propagate entirely through the bone • Compressive side undergoes plastic deformation • “Incomplete fracture”

21. Complete Fractures • Spiral fractures • Oblique fractures • Transverse fractures • Epiphyseal fractures

22. Spiral Fractures • Created by a rotational force on the bone • An intact periosteum enables easy reduction by reversing the rotational injury • Broad fracture surface area

23. Oblique Fractures • Occur diagonally across diaphyseal bone • Usually at approximately 30 degrees to the axis of the bone • May cause significant disruption of the periosteum • Broad fracture surface area

24. Transverse Fractures • Occur from three-point bending • Butterfly fragments may occur • Small fracture contact/surface area

25. Epiphyseal Fractures • Injuries to the epiphysis of a bone usually involve the growth plate • Problems are uncommon but potentially serious • Distal radial physis is the most commonly injured physis • Growth plate heals quickly in 3-6 weeks

26. Salter-HarrisSalter-Harris Epiphyseal Fracture Classification

27. Salter-Harris Type I • The periosteum usually stays intact and prevents displacement • The fracture runs directly through the growth plate

28. Salter-Harris Type II • The injury passes through the growth plate and out through a portion of the metaphysis

29. Salter-Harris Type III • An intra-articular fracture that passes through the epiphysis until it hits the growth plate • Usually occurs when the growth plate is partially closed

30. Salter-Harris Type IV • An intra-articular fracture which involves the epiphysis as well as the metaphysis • The fracture line crosses the growth plate • The physis must be anatomically reduced to prevent osseus bridge formation

31. Salter-Harris Type V • Originally described as a crush injury to the growth plate. • Difficult to diagnosis • May appear to be a Type I • Fortunately, an uncommon injury

32. Common Fractures • Buckle fracture of the distal radius/ulna • Supracondylar humerus fracture • Femoral shaft fractures • Proximal tibial metaphyseal fracture • Toddler’s tibial shaft fracture • Distal fibular Salter-Harris Type I/II fracture • Special Circumstances • Pelvic Avulsion Fractures

33. Buckle fractures of the radius • Secondary to routine falls onto an extended limb • Present with varied pain • Treatment = short arm cast or splint for approximately 3 weeks • Follow-up with x-rays to assess healing • No long term sequelae

34. Treatment =Short Arm Cast (SAC) • May be applied with a waterproof liner • Should allow for full motion of the thumb and fingers • A well molded splint works just as well as a cast

35. Supracondylar Humerus Fractures • Common elbow fracture after a fall onto an extended limb • Graded Types 1,2, or 3 based up displacement of fragments • Require referral for orthopaedic management

36. Supracondylar fracture – Type 1 • Non-displaced fracture • Require approximately 3-4 weeks in a long arm cast • Do not need to be manipulated or pinned • Heal with no consequence if well aligned

37. Supracondylar fracture – Type 2 • Angulation of fractures noted on the lateral x-ray • Most common type is extended • Will require reduction of angulation while sedated • May require pins to assure stability while casted for 3-4 weeks

38. Supracondylar Fracture – Type 3 • Fracture is angulated and displaced • Requires a reduction and pinning to maintain alignment • Will require 3-4 weeks of casting • Common referral from adult orthopaedist

39. Femoral Shaft Fractures • Treatment depends upon age of patient and location/configuration of the fracture • Operative management is replacing traction and spica casting • High energy injury • Child abuse should be considered in non-walkers

40. Femoral Shaft Fractures • Spica casting is still commonly used for children <4 y.o. • Results are good as long as fracture is well-aligned • Healing time is approximately 8 weeks

41. Femoral Shaft Fractures • Options for children between 5-12 include; • immediate spica • traction and spica • compression plate • external fixation • flexible intramedullary rod • Submuscular plate

42. Femoral Shaft Fractures • Adolescents require most stable fixation • Spica casting is not well tolerated • Options include: • Compression plate • External fixation • Flexible intramedullary rods • Rigid intramedullary nails

43. Proximal Tibia Metaphyseal Fractures or“Cozen Fractures” • A non-displaced fracture with potential growth consequences • Patients present after a fall with minimal trauma • X-rays show minor fracture in the proximal tibial metaphysis • Patient requires a long leg cast for about 4 weeks

44. Proximal Tibial Metaphyseal Fractures • Patient may develop ipsilateralgenuvalgum deformity • Secondary to “overgrowth” of the tibia relative to the fibula • Treatment = assurance, follow-up and observation until complete resolution

45. Toddler’s Fracture • Common fracture in 2-3 year olds after a routine twisting fall • Present with limp or refusal to bear weight • x-rays in AP, lateral and oblique may be necessary to see the fracture line

46. Toddler’s Fracture • Patient is managed in a short leg cast and allowed to weight bear as tolerated • Follow-up x-rays in 3 weeks will show periosteal new bone • Non-displaced hairline fractures are managed in a “pediwalker”/boot

47. Distal Fibular Physeal Fracture • Present after an inversion injury or “twisted ankle” • Equivalent of an adult ankle sprain • Patient is point tender over the distal fibula rather than the lateral ligaments • Adjacent ligaments may be sprained as well

48. Distal Fibular Physeal Fracture • X-rays are usually negative for displacement • A small metaphyseal fragment (SH II) may be seen adjacent to the physis • Management is in a short leg cast for approximately 4 weeks

49. Pelvic Avulsion Fractures • Avulsion fractures result when the fracture fragment is pulled from the bone by forceful contraction of a tendon or ligament • Avulsion fractures are most common in adolescents engaging in athletic endeavors         • In the pelvis, the apophyses, are the most likely portions of the bone to avulse   

50. Pelvic Avulsion Fractures Seen almost exclusively in adolescent athletes with a 2:1 male to female preponderance        They occur most often in track events like hurdling and sprinting, or games like soccer or tennis         Most common to avulse is the ischialtuberosity followed by anterior inferior iliac spine (AIIS) and the anterior superior iliac spine (ASIS)