1. Pediatric Orthopedic Fractures
Dafina Good, MD
Pediatric Emergency Medicine Fellow
Emory University School of Medicine
Children’s Healthcare of Atlanta

2. Objectives
Review unique structural and physiologic differences between children and adult skeletal systems
Review fracture patterns unique to children
Review the Salter-Harris classification of pediatric physeal fractures
Review common presentations and EPONYMS of common pediatric and adult fractures
Review Ottawa ankle and knee criteria

3. Epidemiology
Orthopedic trauma accounts for 10-15% of ED visits in urban pediatric hospitals
It is estimated that over 40% of boys and over 25% of girls will sustain a fracture during childhood
Rapid growth of organized sports

4. Skeletal Differences between Children and Adults
Presence of Growth Plates (Physis)
Growth plate injuries constitute up to 25% of all skeletal injuries in children
Presence of Secondary Ossification Centers (Epiphysis)
Rapid healing
More metabolically active periosteum in children
Greater Potential to Remodel
More porous and more pliable bones
Fracture patterns unique to children
Fractures are more common than sprains in young children
Ligaments and tendons attaching one bone to another have greater strength than immature bones

5. Normal Bone Anatomy

6. Normal Bone Anatomy

7. Describing Fractures Open vs. Closed
Location (shaft, through growth plate etc.)
Displacement in mm
Shortening in mm
Impaction if present
Angulation, degree and direction (midshaft-direction of terminal fragment)
Salter Harris Classification
Neurovascular status

8. Describing Fractures

9. Describing Fractures

10. Salter Harris Classification
Robert Bruce Salter- a prominent Canadian surgeon was Chief of Orthopedic Surgery at Hospital for Sick Children in Toronto

11. Fractures Unique to Children
Metaphyseal Fractures from a compressive load
Buckle or Torus Fractures

12. Fractures Unique to Children
Greenstick Fractures

13. Fractures Unique to Children
Most Common Fracture pattern in children 50% of fractures are Greeenstick. Often requires completing of the fracture to correct
Greenstick Fractures

14. Fractures Unique to Children
Unique to Children. Usually occurring in the forearm. Usually require reduction in the OR b/c of the amt of force required to reduce these fx’s.
Bowing Fractures

15. Fractures unique to children
Toddler's fracture, a spiral fracture of the distal one third of the tibia, is often stable and incomplete and may be the result of a trivial rotational injury, which is often not witnessed.

16. Fractures unique to children
Other Fractures
Avulsion Fractures-Strong muscular attachments adhere to secondary ossification centers (apophyses), Most common in the pelvis
Lead Pipe Fractures- Combo of Greenstick with buckle fracture
Toddler’s Fracture

17. Common Fracture Eponyms Who Named It?
From the neck down to the toes!

18. Jefferson Fracture C1 Burst Fracture from axial loading
Sir Jefferson was an English Neurosurgeon

19. Hangman’s Fracture
Severe extension injury ie. Hanging, Unstable bilateral pedicle fx

20. Teardrop Fracture
Highly unstable, Hyperflexion and axial loading injury, Disruption of all three spinal columns

21. Chance Fracture
Hyperflexion Injury, Lap Belt Injury, 50% Associated with intraabdominal injuries
Chance was a British Radiologist

22. Boxer’s Fracture
Fracture at Base of 5th Metacarpal, Ulnar Gutter Splint, Requires reduction if >40 degrees angulation

23. Hand Anatomy

24. Bennett’s Fracture
Most common thumb fx/dislocation at base of 1st metacarpal w/ continued articulation w/ trapezium
Requires Reductions and often surgical fixation, few are managed conservatively with thumb spica, risk of affecting thumb opposition and thumb mobility
Edward Bennett-a Surgeon in Ireland

25. Colle’s Fracture
Fall on an outstretched extended arm, fracture fragment displaces dorsally. Requires reduction
Abraham Colles the greatest Dublin Surgeon who did work on Congenital Syphillis

26. Smith’s Fracture
Reverse Colles Fracture, Fall on flexed hand, Fracture fragment is displaced to the palmar side. Requires Reduction usually
Smith was a Dublin Surgeon that succeeded Colles, upon whom he performed the autopsy

27. Nightstick Fracture
If I told you this was an isolated Ulnar Fracture, What would you call this fx? But if you see this in a child its probably in combination with another injury?

28. Monteggia Fracture
Radial Head Dislocation w/ Ulnar Fracture, Bado Classification used Types I-IV (radial head displaced anteriorly, posteriorly, ant disloc+ulnar fx, IV-Rad/Ulna Fx w/ rad head displacement)
Giovanni Monteggia- an Italian surgeon, died from syphilis after contracting it from autopsy dissection

29. Monteggia Fracture
Radial head not aligned with the capitellum

30. Galeazzi Fracture Radial Fracture w/ Radioulnar dislocation
Galeazzi was instrumental in Italian Orthopedic Rehab services

31. Supracondylar Fracture
Posterior fat pad present, Anterior humeral line off (capitellum is posteriorly displaced), Radialcapitellar line off

33. Ossification Centers – C-R-I-T-O-E Approximate age of appearance Capitellum - 1 year Radial head - 3 years Internal epicondyle (Medial epicondyle)-5 years Trochlea - 7 years Olecranon - 9 years External epicondyle (Lateral  epicondyle)-11 years

36. Proximal Humeral Fracture
Up to 100% displacement is acceptable in young children as 80% of humeral growth occurs at the metaphyseal portion of the humerus,
Sling and swath,

37. Slipped Capital Femoral Epiphysis
Usually in obese adolescent males with acute limp or chronic limp, hip or thigh pain. More common in males

38. SCFE’s Klein’s Line

39. Klein’s Line
Klein’s Line is Line projected superiorly from the femoral neck to the femoral epiphysis should intersect with the femoral head

40. Pelvic Avulsion Fractures
Common in Adolescent Athletes ie. Soccer and gymnastics

41. Common Locations of Pelvic Avulsion Fractures

42. Spiral Femur Fracture

43. Osgood Slater Disease vs Sinding Larsen-Johansson
Osgood Slater Dz-Apophysitis of the tibial tubercle (Figure 1), is the most common pediatric overuse injury, occurring in 20% of young athletes, affecting girls between ages 8 and 13 years, and boys between ages 10 and 15 years.
Sinding-Larsen- Apophysitis of the inferior pole of the patella, affects athletes between ages 10 and 12 years, and is most common in running and jumping sports, such as basketball and volleyball
Robert Osgood- a Boston Orthoopedic surgeon and Schlatter was a Switzerland Surgeon

44. Patellar Fracture
Usually from a direct blow, uncommon fx, requires knee immobilizer

45. Knee Anatomy

46. Knee Anatomy

47. Ottawa Knee Rules
Characteristics of Patients Who Should Undergo Radiography After Knee Trauma
Ottawa knee rules Age 55 years or older Tenderness at head of fibula Isolated tenderness of patella Inability to flex knee to 90 degrees Inability to walk four weight-bearing steps immediately after the injury and in the emergency department
Pittsburgh decision rules Blunt trauma or a fall as mechanism of injury plus either of the following: Age younger than 12 years or older than 50 years Inability to walk four weight-bearing steps in the emergency department

48. Corner Fracture
Avulsion fx’s of the growth plates, First described by Caffey who noted these fx’s in children w/ subdural hematomas, often subtle,
Most common in tibia, distal femur or proximal humerus

49. Bucket Handle Fractures
Same as a corner fracture w/ splaying/avulsion of proximal tibial metaphysis

50. Spiral Fx of proximal fibula w/ fx of the medial malleoli

51. Maisonneuve Fracture
Spiral Fx of proximal fibula w/an associated fx of the medial malleoli. The foot is planted on the ground and the lower leg rotates around it. The force of the injury is translated through the interosseus membrane, travels up the leg, and exits through the top of the bone, resulting in a proximal fibular fracture.
Requires stabilization of ankle joint w/ fixation
Jacques Maisonneuve

52. Tillaux Fracture
Salter Harris Type III Fx– caused by an Avulsion Fx caused by the pull of the antero inferior tibiofibular ligament secondary to external rotation of the foot and ankle. Usually in adolescents around the time of fusion of the distal tibial physis. Depending on the amt of displacement may treat w/ long leg cast (If <2mm displacment)
Tillaux was a French surgeon

53. Tillaux Fracture

54. CT Scan of Tillaux Fracture

55. Triplane Fracture
Salter Harris IV Fracture

56. Triplane Fracture

57. What’s the Difference?
Inversion Fractures of the 5th metatarsal. Prone to Nonunion. May manage conservativley w/ non-wt bearing or may require sx if Type II or III(I to III)
Two Xrays on the Left are of PseudoJones Fx (avulsion fx of metatarsal tuberosity) seen in tennis players or dancers and the Right is a Jones Fx

58. Anatomy of the Fifth Metatarsal

59. Ottawa Ankle Rules

60. Reasons to Refer to Orthopedics
Open Fractures
Unacceptably displaced fractures
Fractures with associated neurovascular compromise
Significant growth plate or joint injuries
Pelvic/Femur fractures (other than minor avulstions)
Spinal Fractures
Dislocations of major joints other than shoulder/knee
Clavicle (distal third)
Fractures prone to Nonunion/Malunion

61. Why do we do it? Prevent Growth arrest Prevent malunion or nonunion
Restore function as close to physiologic