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