Pediatric Fractures In this section, we will talk a little bit more about pediatric fractures and how they differ somewhat from adult fractures.

Fractures Peculiar to Children Torus or buckling Greenstick Bowing Epiphyseal Often only incomplete fracture line is seen There are a variety of fractures that are more peculiar to children, and included in this list are the torus or the buckling fracture. The cortex becomes buckled or has a bump as a result of a compressive twisting injury. A greenstick fracture, much like when you try to break off a piece of a lilac bud on campus and it comes halfway off, breaks through one cortex and the other remains intact. A similar type of injury can occur in children. The bowing fracture, smooth curvature to the bone without disruption of the cortex. Epiphyseal fractures, a variety of fractures that actually involve the epiphyseal plate in various extents. Often only an incomplete fracture line will be identified.

Fractures Peculiar to Children B C D Here, on a single view are those fractures I just spoke about. The torus or buckle fracture, the greenstick fracture, the bowing fracture, and the epiphyseal fracture.

Torus Fracture Radius Can you identify the torus fracture on this pair of wrist films before I put the arrows in place? Look carefully; look for any disruption of the contours of the cortex. Normally the contour should be very smooth with no sharp angulations. Here we see a small bump on the cortex representing the site of the torus fracture; it’s also noted on the lateral view as well.

Torus Fracture Radius Here is another example of a torus fracture involving the radius with buckling of the cortex as indicated by the yellow arrows.

Bowing Fracture Bowing fracture of right fibula Buckle fracture of right tibia Normal left for comparison Note the bowing fracture of the right fibula. The fibula has a slight curvature convexity directed medially as a result of injury. There is also on the same individual a buckling of the distal tibia, a buckle fracture. Remember in paired bones, frequently both bones will either be fractured or there will be a fracture dislocation. The left lower leg, which is normal, is included for comparison purposes.

Greenstick Fracture Radius Dorsal cortex remains intact Ventral cortex is disrupted Angulation is ventral Here is an example of an individual with a greenstick fracture. The dorsal cortex remains intact while the ventral cortex is disrupted. There is angulation directed towards the ventral or palmar aspect or anterior aspect of the forearm with the patient in anatomic position.

Salter-Harris Fractures Epiphyseal separation Fragment from metaphysis with displacement of epiphysis Fragment runs vertically through the epiphysis and the growth plate Vertical fracture through the epiphysis, growth plate and metaphysis Crushing injury to epiphysis and plate Normal I’d like to talk now about the Salter-Harris description for fractures. Salter-Harris descriptors are helpful because the level of Salter-Harris fracture plays some role in the ultimate healing and potential for future complication of the fracture. Salter I fracture represents an epiphyseal separation. There is a disruption that goes through the physis. A Salter II fracture has a fragment from the metaphysis remaining with the epiphysis as the fracture line continues through the physis. Salter III fracture, the fragment runs vertically through the epiphysis and the growth plate with a portion of the epiphysis remaining attached to the metaphysis and growth plate. A Salter IV fracture is a vertical fracture through the epiphysis, the growth plate, and metaphysic. There may be disruption of the epiphysis as well on this type of fracture. And finally, a Salter V fracture represents a crush injury to the epiphysis and the growth plate itself. 3 2 1 4 5

Salter 2 Fracture Proximal Phalanx Early callus Slight displacement This fracture represents a Salter II fracture of the proximal phalanx of the finger. The finger involved being the thumb. Note the fact that there is some early callus formation present as this fracture is several days old. Also note that there is slight displacement of the fracture fragment as well as epiphysis towards the right side of the screen.

Salter 3 Fracture Lateral Tibia Acute injury No apparent displacement In another individual we demonstrate a Salter 3 type fracture, a fracture that passes through a portion of the growth plate and extends down through the epiphysis with that portion being separated. The remaining portions of the epiphysis remain attached to the more proximal metaphysis and growth plate. There is no displacement in this case.

Toddler refuses to walk This child refuses to walk. Can you see the abnormalities when you evaluate the lower legs?

Toddler’s fracture with early healing The original films are to your left and the follow-up films are to your right. On the films that are the follow-up, we note a sclerotic line extending across the distal portions of the tibia. If you look back to the original image there are actually some lucent lines extending through the tibia. Now we see the presence of callus formation and early healing taking place along the site of injury.

Elbow pain Supracondylar Fracture What do you think about this individual presenting with elbow pain? Did you see the disruption of the cortex in the supracondylar portion of the distal humerus? The supracondylar fracture? Supracondylar Fracture

Classic Supracondylar Fracture Perhaps easier to see in this individual where we can actually see a true disruption of the cortex of the distal portions of the humerus and we can see some straightening of the distal portion of the humerus as well as the presence of both posterior and anterior fat pads. Anterior/ Posterior Fat Pad Supracondylar fracture

Lesser trochanter avulsion iliopsoas insertion This individual has had an avulsion of the lesser trochanter of the right proximal femur, not a common injury; however, this type of injury can be seen as result of an avulsion of the iliopsoas insertion. Did you notice the separation of this lesser trochanter?

Chronic Hip Pain What do you think on this child presented with chronic hip pain? Look carefully and compare the right and left side.

SCFE Slipped capital femoral epiphysis Here is another view of that same hip. Note some sclerosis of the femoral neck just distal to the epiphysis. Also note on the lateral projection the displacement medially of the femoral capital epiphysis with respect to the femoral neck. This patient presenting with the classic appearance of a slipped capital femoral epiphysis or SCFE.

Bilateral SCFE In another individual, we identify a similar finding involving both legs, so bilateral slipped capital femoral epiphyses. More commonly seen in overweight children, prepubescent in age.