Common Fractures in Young Athletes February 10, 2012 40th Annual Meeting Southeast Chapter of the American College of Sports Medicine (SEACSM) Common Fractures in Young Athletes February 10, 2012 Alex B. Diamond, D.O., M.P.H. Assistant Professor of Orthopaedics and Rehabilitation Assistant Professor of Pediatrics Vanderbilt University Medical Center Co-Chair, Youth Sports Safety Taskforce Team Physician Vanderbilt & Belmont Universities Nashville Sounds & Nashville Predators

Common Fractures in Young Athletes Andrew Gregory, MD, FAAP, FACSM Assistant Professor of Orthopedics & Pediatrics Program Director, Sports Medicine Fellowship Vanderbilt University Medical Center Team Physician Vanderbilt & Belmont Universities Nashville Sounds USA Volleyball

Disclosures Diamond Gregory NO commercial relationships Research & Educational funding NIH U54 Institutional Clinical & Translational Science Award Gregory No conflict of interest 0:30 + 0:10

Objectives Review briefly the differences of pediatric bone Review pediatric fracture classification Discuss subtle fractures in kids Discuss a few other pediatric only conditions

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

Anatomy of Pediatric Bone Epiphysis Physis Metaphysis Diaphysis Apophysis

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

Plastic Deformation Bowing without fracture Often requiring reduction

Buckle (Torus) Fracture Buckled Periosteum Metaphyseal/ diaphyseal junction

Greenstick Fracture Cortex Broken on Only One Side Incomplete

Complete Fractures Transverse Oblique Spiral Perpendicular to the bone Across the bone at 45-60o Unstable Spiral Rotational force

Salter-Harris Classification II III IV V

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

Keep In Mind Subtle Fractures Mimickers Salter-Harris I Buckle Avulsions Occult Nursemaids Other causes of limp Legg-Calve-Perthes Transient synovitis Septic arthritis Osteomyelitis Bone pain + Fever

Elbow Fractures Multiple physes Look for swelling Typical pattern Effusion Loss of flexion/ extension No loss of supination/ pronation Typical pattern Supracondylar in the very young Radial head in the older child

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

Ossification Centers Appearance

Elbow Fat Pads Indicates hemarthrosis Anterior Posterior 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

Elbow Fat Pads

Posterior Fat Pad Anterior Fat Pad A small anterior fat pad is normal = coronoid fossa A posterior fat pad is always abnormal = Olecranon fossa What type of fracture do you have to worry about? Supracondylar/ Radial Head Mechanism of injury? Direct blow to the elbow or a fall on an outstreched hand with elbow extended What type of Splint ? Double Sugar Tong or Posterior Splint with A-Frame Follow-up for rex-ray

Occult Fracture

Non-Displaced Supracondylar Fracture Posterior Fat Pad Non-Displaced Supracondylar Fracture Posterior Splint and Follow-up

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

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

2 3 1

Reduction Maneuver: Full supination and flexion 2. 1.

Forearm Fractures Most common fracture in pediatrics FOOSH Becoming more common FOOSH May not have swelling, bruising or deformity Tender 1” proximal to the RC joint FROM or loss of supination

Volar Bruise

Splint vs. Cast for Buckle Fractures of the Distal Radius Plint AC et al. Pediatrics, 2006. 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 Several other LOE 1 studies & systematic review support same findings.

Navicular Fractures can happen in Skeletally Immature

Avulsion Fx common in the Fingers

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

SCFE

Toddler’s Fracture Suspect SLWC x 2-3 weeks Any toddler with a mechanism who refuses to bear weight Regardless of exam or xray SLWC x 2-3 weeks

Distal Metaphyseal/Supracondylar Slipped while running Tender above the physis Minimal swelling Refusal to bear weight No effusion A form of Toddler’s fracture

SHII Proximal Tibia - Periosteal Recoil

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

Distal Fibula Salter-Harris I

8 y/o male soccer player

Salter-Harris II Distal Tibia Fibula fractures through the growth plate = posterior splint

12 yo football player SH III

SH IV Tibia

Calcaneal Fractures Jump from height Jump into shallow water Xrays sometimes negative, subtle Occasionally bilateral

Metatarsals Physis proximal on the 1st and distal on the others 1st MT epiphysis often bipartite

5th Metatarsal Apophysis

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