1. 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

2. 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

3. 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

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

5. 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

6. Anatomy of Pediatric Bone
Epiphysis
Physis
Metaphysis
Diaphysis
Apophysis

7. 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

8. Plastic Deformation
Bowing without fracture
Often requiring reduction

9. Buckle (Torus) Fracture
Buckled Periosteum
Metaphyseal/ diaphyseal junction

10. Greenstick Fracture
Cortex Broken on Only One Side
Incomplete

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

12. Salter-Harris ClassificationII
III IV V

13. 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

14. 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

15. 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

16. 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

17. Ossification Centers Appearance

18. 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

19. Elbow Fat Pads

20. 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

21. Occult Fracture

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

25. 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

26. 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

27. 2 3 1

28. Reduction Maneuver: Full supination and flexion2. 1.

29. 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

30. Volar Bruise

34. 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.

35. Navicular Fractures can happen in Skeletally Immature

36. Avulsion Fx common in the Fingers

37. 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

38. SCFE

39. 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

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

41. SHII Proximal Tibia - Periosteal Recoil

42. 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

43. Distal Fibula Salter-Harris I

44. 8 y/o male soccer player

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

47. 12 yo football player
SH III

48. SH IV Tibia

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

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

51. 5th Metatarsal Apophysis

52. Please Visit

53. Thank You