Ouch, That's Gotta Hurt! Pediatric Fractures & Injuries

Ouch, That’s Gotta Hurt! Pediatric Fractures & Injuries Greg Canty, MD Medical Director, Sports Medicine Center Attending Physician, Emergency Medicine Children’s Mercy Kansas City

• I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity • I do not intend to discuss any unapproved/investigative use of a commercial product/device in my presentation

• Review the unique features of pediatric bone • Understand how to best assess suspected fractures in the urgent care • Implement the latest evidence for acute management of fractures and injuries

• 1/3 of patients will have a fracture before age 17 • 42% boys & 27% girls • 10‐15% of all childhood injuries involve a fracture • Most common – Distal forearm – Clavicle – Fingers – Ankle

• Bone  porous and flexible…unique fractures • Periosteum is very thick & active • Ligaments are strong relative to the bone • Presence of the physis ‐ “weak link” • Ligament injuries & dislocations are less common – “kids don’t sprain” • Fractures heal quickly and have the capacity to remodel

• Epiphysis • Physis • Metaphysis • Diaphysis • Apophysis

• Buckle/ Torus – compression, stable • Plastic Deformation – Bowing esp. fibula or ulna • Greenstick – plastic deformity w/ partial fx on one side of the bone • Complete ‐ Spiral, Oblique, Transverse • Physeal – involves growth plate “Salter‐Harris fx” • Avulsion – involves an apophysis

• Buckled Periosteum • Metaphyseal/ diaphyseal junction

• Cortex Broken on Only One Side – Incomplete

• “Weak link” of pediatric bone (cartilage) • Adults=sprains....kids=fractures! • Rapid healing (1/2 time of shaft fractures) • Anatomic alignment critical • Risk of premature growth arrest leading to limb length discrepancy or angular deformity

Salter- Harris 1

• Kids are not good historians • Mechanism - Any Fall – Sports/Trampolines/ Monkey Bars/ Skating • May not be much swelling, bruising or deformity • Non-weight bearing •Limp • Not using the arm • Be suspicious!

1) Inspection: swelling, bruising, deformity, skin intact? 2) Gentle Palpation: focus on bony structures, crepitus, step‐ offs, & growth plates 3) ROM: flexion, extension, abduction, adduction, 4) Neurovascular: motor function, sensation, and strength 5) Special maneuvers: ligaments, tendons, laxity

• Consider 2‐3 views = AP, Oblique, Lateral • Focus XR beam: try to pinpoint pain • Minimize radiation when possible

• 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! A sugar‐tong is safe choice.

• 8 yo skateboarder fell yesterday onto his wrist • Mild swelling but persistent pain • Parents waited a few days because it didn’t look too bad

• Fall On the Out Stretched Hand • Common mechanism – Forearm fx’s #1 • Distal radius fractures = ¼ of all pediatric fx’s • Excellent remodeling capability • Growth disturbance is unusual

• Level I ‐ Splint as good as a cast for prevention of re‐ fracture or loss of alignment • No difference in pain • Easier to bathe • Better function at 14 & 21 days • No need for return for cast removal or re‐xray

• 16 y/o basketball player lands on outstretched hand after getting undercut while getting rebound (FOOSH) • Now c/o Right Wrist Pain

• Pain on radial side of wrist • Palpate snuffbox region • Immobilize if any concern! • Tricky blood supply • Scaphoid view xrays • Consider MRI if persistent symptoms and negative xrays • Thumb spica x 6 weeks or longer

• 15 y/o QB is tackled hard and crashes into the ground landing on his right shoulder • He has severe shoulder pain and refuses to raise his Right arm

• Acromioclavicular sprain – Shoulder separation •Fracture • Sternoclavicular dislocation • Glenohumeral dislocation

CLAVICLE FRACTURE An Example of Pediatric Healing Potential

Palpate both ends of the clavicle!

• Sling for pain/protection – vs. Figure of 8 brace • Pain Control • Progressive ROM/Strengthening • RTP ?? – Clavicle fx: Contact sports ~ 8 weeks

• 9 yo fell off monkey bars earlier today • C/o elbow pain and swelling • Refuses to fully extend elbow due to pain and swelling

• Multiple physes • Look for swelling • Effusion – Loss of flexion/ extension – No loss of supination/ pronation • Typically supracondylar in the very young and radial head in the older child

• C = Capitellum • 2 Years • R = Radial Head • 4 Years • I = Internal (Medial) • 6 Years • T = Trochlea • 8 Years • O = Olecranon • 10 Years • E = External (Lateral) • 12 Years

• Anterior – normal if lying flat against the humerus, abnormal if elevated – “sail sign” • Posterior – always pathologic! • Indicates hemarthrosis

16 yo male football player injured left 4th finger while tackling an opposing player…

• Mechanism‐ forced extension of a flexed distal phalange • Flexor digitorum profundus tendon avulsed (+/‐ bony fragment) • Inability to flex the DIP when the PIP joint is stabilized • Splint in comfortable position • MUST RECOGNIZE EARLY!! Requires repair within 7‐10 days

15 yo female basketball player injured her index finger while catching a pass

• Mechanism is direct blow onto an extended distal phalanx; “Jammed finger” • Occurs when catching ball • Extensor digitorum ruptures & DIP assumes flexed position (? pain) • Xray for avulsion fracture

Treatment ‐ • Constant splinting of the DIP in full extension/hyperextension x 6‐ 8 weeks • May RTP with proper splint when pain controlled

• Give every hand & finger injury the Kentucky Quick‐Eye Test

• Assess closely for angulation and need for reduction • Beware of malrotation! • Tx if stable/ nondisplaced/ nonangulated….buddy‐tape and splint for sports x 3‐4 weeks

• 15 yo football player presents on Sat morning • He recalls an inversion ankle injury when he stepped on another player’s foot • He was able to limp afterwards but unable to run

• Ankle x-rays if ankle pain with: 1) bony tenderness along the posterior edge/tip of lateral or medial malleolus or 2) inability to bear weight for 4 steps • Foot x-rays if foot pain with: 1) bony tenderness at the base of the 5th metatarsal or 2) bony tenderness of the navicular bone or 3) inability to bear weight for 4 steps

Distal Fibula Fractures • Common in youth and pre-adolescent athletes • Always palpate the physis! • Salter Harris I fractures are a clinical diagnosis • Excellent Prognosis

• Isolated distal fibula fractures are very common • Most are very low-risk • Casting vs. splinting • Quicker return to baseline activities • 57% casted group would have preferred brace!

5th Metatarsal Avulsions • Caused by pulling of the peroneus brevis • Always feel the bump! • CAM walker boot

• Any toddler with a mechanism and refuses to bear weight • Regardless of exam or xray • Wee Walker

• A 13 y/o gymnast presents with right hip pain and the inability to bear weight. She felt a “pop” in her hip while doing the splits.

a) Femur fracture b) Hamstring strain c) Pelvic avulsion fracture d) Slipped capital femoral epiphysis(SCFE)

• On exam she had limited ROM with hip flexion, hip IROM, knee extension. • She was tender to palpation over the ischium.

• Occur with aggressive, athletic motions • AIIS ‐ soccer/rugby • ASIS ‐ sprinters/soccer • Ischium ‐ gymnasts/hurdlers • Crutches, NWB, pain control

• 16 yo runner (XC and track) presents with L‐ hip pain x month • Worse w/ running • Does not recall injury

• The pediatric bone is unique and the forces may change during bony development • Proper fracture recognition and initial management is important in urgent care • Removable splinting wonderful for many fractures

• Sports-related fractures • Stress fractures • Acute sports-related • Sports-related concerns injuries & dislocations – Exercise induced • Sports-related bronchospasm concussion – Spondylolysis • Overuse syndromes – Mono in the athlete, etc