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

2. 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)

3. 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

4. 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

5. 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

6. 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

7. 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!

8. 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

9. 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!

10. 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!

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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)

17. 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

18. 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

19. 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)

20. 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)

21. 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)

22. 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

23. Galeazzi Fracture
Displaced fracture of the distal radius with disruption of the distal radioulnar joint
Requires closed reduction and immobilization for 6 weeks

24. Bones of the Wrist: Scaphoid (Navicular) Lunate Triquetrum Pisiform
Trapezium
Trapezoid
Capitate
Hamate

25. 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)

26. 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

27. 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

28. 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)

29. 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)

30. 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

31. 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

32. 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)

33. 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 7-10 days
Walking cast X 3-4 weeks (may need LLC for first 1-2 weeks)

34. 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)

35. 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

36. Metatarsal Fractures
Rx: SLC or stiff-soled shoe, weightbearing as tolerated; repeat 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

37. 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

38. 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