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

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