Broken Bones: Common Pediatric Lower Extremity Fractures—Part III

Home , Avulsion fracture, Avulsion injury

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Erin S. Hart ▼ Brenda Luther ▼ Brian E. Grottkau

Lower extremity injuries and fractures occur frequently in young usually have pain with hamstring stretching and hip flex- children and adolescents. Nurses are often one of the first ion/abduction). Patients also frequently demonstrate an healthcare providers to assess a child with an injury or fracture. antalgic gait and have pain during their activity or sport. Although basic fracture care and principles can be applied, An anteroposterior radiograph of the pelvis usually reveals nurses caring for these young patients must have a good under- the avulsed fragment. Comparative views of the contralat- standing of normal bone growth and development as well as eral side are often helpful in confirming the diagnosis and avoiding further unnecessary advanced imaging studies. common mechanisms of injury and fracture patterns seen in This injury is usually treated symptomatically and often children. Similar to many of the injuries in the upper extremity, involves rest, application of ice, and relaxation of the in- fractures in the lower extremity in children often can be treated volved tendon (O’Kane, 1999). Conservative treatment of nonoperatively with closed reduction and casting. However, this pelvic avulsion fractures is usually successful. Crutches are article will also review several lower extremity fractures that often needed for several weeks to reduce symptoms and frequently require surgical intervention to obtain a precise rest the extremity involved. Complications following pelvic anatomical reduction. Common mechanisms of injury, fracture avulsion fractures in children are rare, and most patients patterns, and current management techniques will be discussed. will have decreased symptoms in approximately 2–4 weeks. Teaching strategies and guidelines that will enable nurses and To avoid reinjury or chronic apophysitis, the injury should heal completely before the patient returns to normal ac- nurse practitioners to confidently educate parents, families, and tivities. This will often require 2–3 months of activity other providers caring for these young patients will be reviewed. modifications/rest from the sport. A physical therapy pro- gram with conditioning, strengthening, and gentle stretching is often needed prior to resuming competitive sports Pelvic Avulsion Fractures (Boyd, Peirce, & Batt, 1997). Nurses and nurse practition- Avulsion fractures of the pelvis are a relatively common ers can have a key role in educating both patients and par- injury in children. The most common avulsion injuries in ents about the importance of rest from activity with this the pelvis occur at the ischial tuberosity (hamstring and type of injury. With the increasing expectations among adductor tendon attachment) and the anterosuperior iliac higher level/elite athletes, orthopaedic surgeons may occa- spine (quadriceps/rectus femoris attachment) (Herring, sionally consider operative intervention for larger, dis- 2002) (see Figure 1A and B). They can also occur at the placed pelvic avulsion fractures. However, numerous stud- iliac crest and at the lesser trochanter of the femur (iliop- ies have failed to substantiate improved outcomes with soas attachment). The highest incidence of pelvic avulsion surgical fixation of the avulsion fragment (Cimerman, fractures occurs in boys between the age of 12 and 14 years Smrkolj, & Veselko, 1995; Rosenberg, Noiman, & Edleson, just prior to apophyseal closure (Sunder & Carty, 1994). 1996; Sunder & Carty, 1994). The most frequent cause of injury is a sudden forceful muscle contraction (such as making a quick turn, kicking a Femoral Neck Fractures ball, or sprinting). The powerful contraction of the attached muscle will often cause an avulsion of the muscle from the Femoral neck fractures are an uncommon injury in chil- bone. Although acute avulsion fractures of the pelvis are dren (approximately 1% of all pediatric fractures) and are more common, chronic repetitive trauma can also cause a usually associated with high-energy trauma. This is in similar injury. Overuse injuries of the hip in adults often lead to a tendonitis or a bursitis, whereas an apophysitis or ▼ Erin S. Hart, MS, RN, CPNP, Pediatric Orthopaedic Nurse Practitioner, Massachusetts General Hospital for Children, Department of Orthopaedic avulsion injury is much more common in children and Surgery, Yawkey Center for Outpatient Care, Boston, MA. adolescents (see Figure 2). ▼ Brenda Luther, MS, RN, Doctoral Fellow, University of Utah, College A physical examination usually reveals localized tender- of Nursing, Salt Lake City, UT. ness at the avulsion site. Pain is also aggravated by passive ▼ Brian E. Grottkau, MD, Chief of Pediatric Orthopaedic Surgery, motion of the hip that places tension on the attached mus- Massachusetts General Hospital for Children, Department of Orthopaedic cle (i.e., patients with ischial tuberosity avulsion fractures Surgery, Yawkey Center for Outpatient Care, Boston, MA.

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FIGURE 2. A. CT scan with 3D reconstruction of right anterior superior iliac spine avulsion fracture. Used with permission from White, J (2002). Journal of Pediatric Orthopaedics 22, (5) Sept- October 2002, 578-582. B. Location of common pelvic avulsion B fractures [Used with permission from learningradiology.com]. FIGURE 1. (A and B). Ischial tuberosity avulsion fractures (hamstring attachment). type I fracture is a transepiphyseal separation of the femoral head. This is the least common type of proximal marked contrast to hip fractures in elderly patients, in femur fracture in children (Herring & McCarthy, 1986). whom minor torsional forces acting on osteoporotic bone This fracture is very difficult to appreciate in newborns can often cause a hip fracture. Common mechanisms of and infants because the femoral head is unossified and injury in children include a fall from a height, a pedestrian cannot be seen on radiographs. Type I fractures can be as- versus motor vehicle collision, a motor vehicle crash, or a sociated with nonaccidental abuse/trauma, especially in fall from a bicycle. When assessing a young patient with a the infant and toddler population (Staheli, 2001). With this known or suspected femoral neck fracture, providers must type of femoral neck fracture, there is an associated dislo- always rule out nonmusculoskeletal injuries to the chest, cation of the femoral head in nearly 50% of the cases. With head, or abdomen. Femoral neck fractures can also be a concurrent femoral head dislocation, there is nearly seen occasionally in young patients with fibrous dysplasia, 100% incidence of osteonecrosis/avascular necrosis (AVN) osteogenesis imperfecta, or large unicameral bone cysts and premature physeal closure with this fracture (Gray, (which weakens the surrounding bone). They are also seen 2002). A type II femoral neck fracture occurs at the tran- in patients with neuromuscular disease and underlying scervical region (midportion of femoral neck). This is the osteopenia/osteoporosis. If the trauma is significant, but most common type of femoral neck fracture, accounting the history is not consistent, nonaccidental trauma (NAT) for approximately 40–50% of hip fractures, in skeletally should always be considered (Swischuk, 2003). Proximal immature patients (Gerber, Lehmann, & Ganz, 1985) (see femur fractures in children have a relatively high compli- Figure 3). This type of femoral neck fracture also has a cation rate and require urgent referral to a pediatric ortho- very high association with secondary AVN of the femoral paedic specialist for definitive operative management. head (approximately 50%). Type III fractures occur at the Femoral neck fractures are frequently classified into cervicotrochanteric region of the proximal femur (base of four types depending on their location (Delbet, 1928). A the femoral neck). The overall reported incidence of this

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femoral neck fracture is between 25 and 35% in children with AVN occurring in approximately 25% of these cases (Herring, 2002). A type IV femoral neck fracture occurs at the intertrochanteric region (between the greater and lesser trochanter). Overall, these fractures are much less common and have a much lower incidence of AVN (approximately 10%). Children with femoral neck fractures will usually hold the hip in a fixed position with varying amounts of external rotation, abduction, and flexion. On physical examination, this position allows for maximum relief of hip irri- tability due to capsular distention by fracture hematoma (Shah, Eissler, & Radomisli, 2002). In general, the patient will be unable to move the hip actively or bear weight on the affected side. Anteroposterior and lateral (if tolerated) radiographs should be obtained and the patient should be referred urgently to a pediatric orthopaedic surgeon for definitive management. Treatment of pediatric femoral neck fractures depends upon the age of the child, the type of fracture, and the amount of displacement of the fracture (Herring, 2002). The overall goal of treatment is to provide fracture fragment stability through an anatomic reduction while avoiding complications that are common with this injury. FIGURE 4. Same 17-year-old female patient’s status post inter- Nearly all pediatric femoral neck fractures are now treated nal fixation with three cannulated screws. in the operating room under general anesthesia and fluo- roscopic guidance. Following closed/open reduction of the fracture, the surgeon will often need to place internal fixa- Proximal femur fractures in the pediatric population tion to prevent displacement (see Figure 4). In younger are associated with a relatively high rate of complication. children, many surgeons will use smooth pins for fixa- Owing to the significant vascular vulnerability in this tion. They will then supplement it with a spica body cast area, osteonecrosis (AVN) of the femoral head continues and immobilize the patient for approximately 6–8 weeks. to be the most frequent and serious complication after hip Smooth pins are usually used in the younger pediatric fractures in children. Providers should inform patients and population as they can cross the physis with a relatively their families of the significant risk for osteonecrosis at the low incidence of subsequent growth arrest. Infants and time of injury and at each follow-up appointment. The toddlers with a femoral neck fracture can usually be overall incidence of AVN following femoral neck fractures treated with isolated spica cast immobilization (no inter- is estimated between 20 and 50% (Cheng & Tang, 1999). nal fixation). Older children and adolescents with a prox- Most researchers agree that the best predictors for devel- imal femur fracture will frequently require cannulated oping AVN are the age of the child and the amount of dis- or pediatric hip compression screw fixation through the placement of the fracture at the time of injury (Moon & physis to stabilize the fracture. Mehlman, 2006; Cheng & Tang). In general, older children with type I and II femoral neck fractures that are significantly displaced are at the highest risk for developing osteonecrosis. There is growing evidence that early and more aggressive operative management including core decompression or hip aspiration followed by internal fixation reduces this risk (Cheng & Tang; Ng & Cole, 1996). There is no clearly effective treatment for posttraumatic AVN in children, and older children/adolescents will often have persistent pain and stiffness. When AVN is detected, the internal fixation (screws) can be removed to prevent hardware penetration into the joint once the fracture has healed (see Figure 5A and B). Treatment for the posttraumatic AVN is otherwise focused on maintaining motion and containment of the femoral head. Unfortunately, the long-term results of posttraumatic AVN are poor in more than 60% of patients (Davison & Weinstein, 1992). Addi- tional complications that are associated with this fracture include nonunion, coxa vara, premature physeal closure, and infection.

FIGURE 3. Minimally displaced type II femoral neck fracture in Femoral Shaft Fractures a 17-year-old ambulatory female with encephalocele/cerebral Femoral shaft (diaphysis) fractures constitute 62% of all palsy. pediatric femur fractures, are one of the most common

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A B

FIGURE 5. A. CT scan of left hip showing AVN of femoral head with collapse and hardware close to joint space. B. AP x-ray of the pelvis status post hardware removal [Note flattening/deformity of femoral head from AVN].

fractures in children (Rewers et al., 2005), and are the nonaccidental (NAT) and this concern remains significant most common cause of fractures requiring hospitalization throughout the toddler years (Scherl et al., 2000). (Wright, Wang, Owen, Stephens, et al., 2005) (see Figure 6A and B). They are the most common, major pediatric injury treated by orthopaedic surgeons. Care of these frac- Nonaccidental Trauma tures involves achieving fracture union with acceptable Rewers et al. (2005) recently reported an extensive review amount of angulation and limb length discrepancy while of 1139 cases of pediatric femur fractures (occurring at minimizing hospitalization and impact on the patient’s infancy through adolescence) and discovered that 48 of family (Wright, 2000). The treatment modalities for femur those cases were found to be nonaccidental. This study fractures depend upon the fracture location as well as the found that NAT femur fractures in children under the age age and weight of the child. In general, younger, smaller of 4 were more common in boys, the injury occurred most children are treated with closed reduction and spica cast- often at home, and 60% were classified as diaphyseal ing or Pavlik harness, and older children/adolescents are (midshaft) fractures (Rewers et al.). Gross and Stranger treated with flexible/rigid intramedullary nailing (Brock, (1983) reported a higher incidence of abuse in their popu- 2001; Anglen & Choi, 2005). The choice of treatment also lation, finding that 80% of children who sustain a femur depends upon the mechanism of injury, whether the frac- fracture below walking age (12–14 months) were victims ture is open or closed, presence of neurovascular injury, of child abuse. Yet, conversely, Schwend, Werth, and head injury, multiple trauma, pathologic fractures, and Johnston (2000) demonstrated that there did not appear the child’s social environment. Nurses caring for children to be a correlation between preambulatory status and with this type of fracture should provide the children’s NAT femur fractures. Although the Gross and Stranger families with the knowledge and support they need to care study on pediatric fractures was specific to the preambu- for a child with limitations in mobility and self-care. latory population and the Rewers et al. study was inclusive of all children, both represent significant knowledge for Etiology practitioners to guide their awareness of NAT. Assessment The mechanism of injury for femur fractures in children of the possibility of NAT, or child abuse, remains a real can vary from a simple playground accident to a high- concern for practitioners caring for any young child pre- energy injury such as a motor vehicle crash (Gray, 2002). senting with a femur fracture, especially one not walking Causes of femoral shaft fractures are often reported as or lacking significant explanation of the circumstances of age dependent; children between the age of 1 and 6 years a fall or trauma (see Figure 7A and B). most commonly sustain this fracture due to falls, children between 6 and 9 years sustain fractures due to motor Physical Examination/Assessment vehicle–pedestrian accidents, and adolescents are often Most patients with a femur fracture are unable to walk and injured by motor vehicle accidents (Hinton, Lincoln, are in extreme pain with obvious fracture. However, the di- Crocket, Sponseller, & Smith, 1999). Many studies have agnosis might be more difficult in obtunded patients with shown the leading cause of femur fracture for child- head injury or multitrauma. Multidisciplinary trauma ren under 1 year of age, or children not yet walking, is service evaluation is recommended for children sustain-

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A B

FIGURE 6. A. 3-month-old male with right midshaft femur fracture [Patient has underlying connective tissue/bone disorder]. B. 10- year-old male with left midshaft femur fracture. C. 13-year-old female with markedly displaced right supracondylar femur fracture (Salter Harris IV fracture).

ing injury in motor vehicle collisions at speeds of more knee should be obtained. Clearance of the child’s cervical than 30 mph, involved in a vehicle versus pedestrian acci- spine as well as assessment of all systems is also necessary, dent, sustaining a fall greater than 20 feet, or whenever as trauma to other systems is assumed to be present until nonaccidental injury or abuse is a possibility (Dowd, ruled out (Wilbur, 1998). Waddell’s triad of femoral frac- McAneney, Lacher, & Ruddy, 2000), as using trauma ture, intraabdominal or intrathoracic trauma, and head in- service can decrease treatment time and improve survival jury are associated with high-velocity automobile injuries rates in children (Dowd et al.; Vernon, 1999). An ante- (Kasser & Beaty, 2005). It is important to note isolated rior–posterior and lateral radiograph including the hip and closed fractures of the femur should not cause an acute

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FIGURE 8. 1-month-old female in Pavlik harness.

harness (see Figure 8). The harness is preferred to spica casting, as the risks of skin breakdown are avoided while adequate union and acceptable limits of deformity can often be achieved (Beaty & Kasser, 2005). The Pavlik harness is easily adjusted and is generally well tolerated in infants, providing adequate outcomes as compared with spica casting (Podeszwa, Mooney, Cramer, & Mendelow, 2004). Children between the age of approximately 6 months and 5–8 years (under 80 lbs) are usually treated with spica cast immobilization (see Figure 9). Closed reduction and spica casting usually provide adequate union, B acceptable amounts of limb length discrepancy, and angulation deformity (Ferguson & Nicol, 2000; Infante, Albert, FIGURE 7. A. 14-month-old male with right radius/ulna fracture Jennings, & Lehner, 2000). Spica casting has been shown in advanced stage of healing. B. Same patient also found to have to provide simple, safe, and effective care for femoral shaft left midshaft femur fracture. fractures in the younger population (Anglen & Choi, 2005); there are no requirements for specialized tools or implants drop in the patients’ hematocrit. Providers must search for other sources of blood loss when there are declining levels or if it is less than 30% (Ciarallo & Fleisher, 1996).

Treatment Treatment of femoral shaft fractures varies greatly and ranges from lengthy hospitalizations involving traction and spica casting to immediate operative fixation using internal or external devices (Beaty & Kasser, 2005). Current treatment methods in children include the application of a Pavlik harness (newborns and infants less than 6–9 months), application of spica cast (6 months to 5–8 years), traction followed by application of a spica cast, external fixation, flexible intramedullary nails (6–12 years), interlocking rigid nails (skeletally mature/closed physes), and compression plate fixation (Gray, 2002).

Spica Casting and Pavlik Harness Newborns and infants (up to 6 months of age) with a FIGURE 9. 2-year-old male with right femur fracture in spica femur fracture can often be treated successfully in a Pavlik cast.

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with spica casting, although it does cause minimum anes- thetic risk to the patient. It also requires knowledge of placement and maintenance of spica cast, as well as education of cast care for the child’s caregivers. There are condi- tions that make a spica cast for the younger population a disadvantage. Patients with multiple trauma will have re- stricted access and there will be issues with difficulties in evaluating soft tissues as well as mobilization and positioning. Children who are large for their age or obese may present challenges in achieving acceptable alignment. For these reasons, evaluation during the first 3 weeks is recommended, as the most common complication of spica casting is excessive femoral shortening of greater than 20 mm (Anglen & Choi).

Effects of Casting All children are affected by the prolonged casting and possible hospitalization while being treated in a spica cast (Newman, 2005), with older children and adolescents being more affected by the prolonged immobility and loss of independence (Hughes et al., 1994). Family members are affected by the significantly increased caregiver burden for these children. For these children and their families, issues such as decreased autonomy and independence, social isolation of the child and the parent, missed school, lost work, and altered self-image are all reasonable to anticipate further children and families (Newman). Education and anticipatory guidance with FIGURE 10. 6-year-old male with extensive bilateral lower ex- frequent assessment of the ability of the family to provide tremity trauma [Note external fixation of femur and tibia]. adequate care for their children as well as themselves are hallmarks of quality pediatric orthopaedic care. Teams organized by nurses that include social workers and ther- and found a 72.6% incidence of at least one documented apists can assess the family for adequate knowledge, serv- pin tract infection. The patients or their parents must be ices, and equipment necessary to adapt their home and taught pin care and how to identify early symptoms of in- school environments and allow a rapid return to the fection (drainage, redness, increased pain). External fixa- child’s normal routine. tion has been used much less frequently in the treatment of pediatric femur fractures because of the recent ad- External Fixation vances of flexible intramedullary nailing. External fixation is often thought of as a form of “portable traction” for a pediatric femoral shaft fracture. External Intramedullary Nailing fixation offers a valuable solution for several difficult prob- Intramedullary nails are placed to provide internal support lems: open fractures or fractures associated with severe through the intramedullary canal during fracture healing. soft-tissue injury, children with multiple trauma or head Two types of nails are available for use: rigid and flexible. injury, or fracture patterns that are not amenable to flexi- Flexible nails are less likely to cause AVN but due to their ble intramedullary nailing (see Figure 10) (Flynn et al., lack of fixation on the bone they have less stability than 2002). Most pediatric orthopaedic surgeons use a stable rigid locking nails (Beaty & Kasser, 2005). Flexible nails unilateral external fixator along the lateral aspect of the are placed either antegrade (from the hip) or retrograde femur in children. External fixation can be applied quickly (from the knee). Children between 6 and 12 years of age with minimal anesthesia time allowing access to wounds (more than 60–80 pounds) with a femur fracture are usu- and soft tissue as well as early mobilization of the patient ally candidates for flexible intramedullary nailing proce- (Krettek, Hass, Walker, & Tscherne, 1991) although there dures (see Figure 11). Flexible nailing procedures usually are significant disadvantages such as pin tract infections, eliminate the need for casting and immobilization and knee stiffness, and higher refracture rate (Blasier, Aronson, also decreases the length of hospitalization (Anglen & & Tursky, 1997; Skaggs et al., 1999) as well as an increased Choi, 2005). Most patients are placed in a simple knee im- caregiver burden for the family. mobilizer postoperatively to reduce knee pain and quadri- Pin site care with half-strength hydrogen peroxide is ceps spasm. Touch-down weight bearing is usually allowed usually started on the second postoperative day. as soon as the patient is comfortable. The rods are usually Showering is allowed once the wound is stable and there removed approximately 9–12 months after injury when the is no communication between the pin and the fracture fracture line is no longer visible on radiograph. hematoma. Numerous studies have shown the high rates Rigid intramedullary fixation is an option for fixation of infection following application of pins associated with of femur fractures in children older than 12 years of age external fixation. Miner and Carroll (2000) reported on and often eliminates problems with angular malalignment outcomes of external fixation in pediatric femur fractures and shortening. These rigid nails are stronger and provide

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FIGURE 11. 10-year-old male with left diaphyseal femur fracture status post flexible intramedullary nailing.

rigid fixation, thereby providing more internal support for a child or adolescent (Beaty & Kasser, 2005) (see Figure 12A and B). Reamed nailing with rigid nails is not recommended for children under the age of 12 years because of the smaller size of the femur as well as the increased risk for proximal femoral growth arrest and AVN of the femoral head (Mileski, Garvin, & Huurman, 1995). Studies continue to evaluate unacceptable limb length discrepancy, angulation deformities, and rates of complications, as well as the impact on family care and healthcare costs with these difficult treatments.

Developmental Issues Related to Immobilization and Treatment Children are significantly affected by immobilization, pain, fear, and lack of independence brought on during the care and healing of a femur fracture. This type of fracture can require long periods of immobility until suf- ficient callus formation has occurred to allow for ambu- lation with or without assistive devices. Assessing the ef- B fects that these restrictions have upon the development of FIGURE 12. A. 14-year-old male with left subtrochanteric independence and self-care of a child or young adult is a femur fracture (Note previous SCFE with screw). B. Same pa- specialized skill for pediatric orthopaedic nurses and tient status post fixation with rigid interlocking nail. nurse practitioners. The child’s home environment needs to be thoroughly assessed to optimize recovery and ensure safety. Can the child safely move about his or her home or very soon after going home to assist the family home and use safety restraints in the car, use the toilet, in the problem-solving process. The child’s school or pre- and bath? Does the family have the knowledge to provide school environment should also be assessed. Keeping a safe and accessible care for their child? Are there com- child in school is vital for his or her school success and munity or home-based services available if needed? These also promotes emotional healing, as normal schedules questions are ideally addressed prior to sending a child and routines are reestablished. School accommodation

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should be focused on providing the least restrictive, the tures are nondisplaced, type II fractures are partially dis- most safe, and also the most reasonable accommodation placed (avulsed fragment remains hinged on posterior available. School staff such as the school nurse, teacher, border), and type III fractures are completely displaced disability counselor, occupational or physical therapists with complete separation of the avulsed fragment from should be available for consultation to assist in keeping a the epiphysis (see Figure 13A). Anteroposterior and lateral child in school as much as possible. radiographs should be obtained if this injury is suspected. The lateral radiograph is most important as it shows the fracture fragment in the best manner (Herring, 2002). A Tibial Eminence Fractures computerized tomography (CT) scan can also be used to Tibial eminence fractures are the anterior cruciate liga- image the fracture and determine the degree of displacement (ACL) tear equivalent injury in skeletally immature ment. Physical examination usually reveals a large children. They are relatively rare injuries in children and hemarthrosis, pain and difficulty or inability bearing usually occur following a fall from a bicycle or during ath- weight on the affected leg. The knee will usually be held letic activities. Isolated ligamentous injuries of the knee flexed and passive extension will be quite painful, often are a somewhat rare occurrence in children under the age limited by muscle spasm. Although it is usually quite diffi- of 14 years with open physes. The incompletely ossified cult to assess ligamentous stability following an acute in- tibial eminence in a child usually fails before the ACL. jury, there frequently will be laxity of the ACL on examina- There is, however, some overlap between ACL ruptures tion with a positive anterior drawer and Lachman test. and tibial eminence fractures, and injuries to the ACL are Nondisplaced (type I) tibial eminence fractures are usu- now recognized more frequently in children and preado- ally treated conservatively with closed reduction and long- lescents (Flynn et al., 2002). Tibial eminence fractures leg casting. There is some controversy between placing the occur most commonly in boys who are 10–14 years old. knee in slight extension versus flexion. If tolerated, most The most common mechanism of injury is planter flexion pediatric orthopaedic surgeons prefer to treat nondis- (axial loading) with hyperextension of the knee. A blow to placed tibial eminence fractures in slight extension. If the front of a slightly flexed knee may drive the femur pos- there is a tense hemarthrosis, aspiration of the knee can teriorly onto the fixed tibia, causing an avulsion fracture at assist in achieving extension (Herring, 2002). Local anes- the tibial eminence (Wiley & Baxter, 1990). This is very thesia can be instilled at the time of needle aspiration to similar to ACL injuries in older adolescents and adults. provide additional pain relief. Most type II and III tibial The classification system described by Meyers and eminence fractures require open or arthroscopic reduction McKeever (1970) is a very simple way to group these frac- and internal fixation of the fracture fragment (see Figure tures based on the amount of displacement. Type I frac- 13B). Although mild, asymptomatic laxity of the ACL is

A B FIGURE 13. A. CT scan of 14-year-old female with left type III (displaced) tibial eminence fracture. B. Same patient status post open reduction and internal fixation of left tibial eminence fracture.

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quite common following this injury. Postoperative stiffness with the fixation of the fracture (Buckley, 2002). It is also of the knee is common with this injury, and early range of important to note that the tibia is the second most com- motion and physical therapy are often instituted. monly fractured bone in children who are abused and providers must always assess for this possibility. Approx- imately 26% of abused children with a fracture are found Tibia Fractures to have an injured tibia (King, Defendorf, Apthort, et al., Tibia fractures are a common injury in children. They are 1988). the third most common type of fracture (representing 15% Closed fractures of the tibia that do not involve the of the total fractures) in children and can be seen following physis (growth plate) are often classified by their anatomic significant or relatively minor trauma (Heinrich, 2001; location (proximal metaphyseal, diaphyseal, and distal Herring, 2002). Displaced, open, or comminuted fractures metaphyseal fractures). The diaphyseal fractures are of the tibia can be seen in children, following a motor vehi- then subdivided into proximal, middle, and distal third. cle crash or a significant trauma, whereas a toddler’s Approximately, 50% of the pediatric tibia fractures occur fracture of the tibia is often seen with a simple trip over a in the distal third (at the ankle) and 39% occur in the mid- toy. A general principle to remember is that a more sig- shaft region (Heinrich, 2001). Seventy percent of pediatric nificant trauma is necessary to fracture the tibia and/or tibia fractures occur as an isolated injury, and 30% are fibula in older children and adolescents. The treatment seen with fibula fractures. Tibia fractures can be caused will vary greatly depending on the age of the child, the type by a direct (impact) or an indirect trauma (rotational and location of the fracture, and the amount of angulation stress), and the fracture pattern often varies with the age that is present. In general, closed fractures of both the tibia of the child. The most common causes of tibia fractures in and the fibula in children have much fewer complications, children are falls, pedestrians being struck by a car, motor heal faster, and have less morbidity than those in adults vehicle crashes, and sporting injuries (especially skiing (Buckley, 2002). Most pediatric tibia fractures can be man- and football injuries). aged nonoperatively with reduction and immobilization Most children with tibia fractures present with a his- techniques (see Figure 14). However, there are several tory of a traumatic event. The child will usually have an types of tibia fractures that are notorious for causing com- acute pain and will demonstrate an unwillingness to plications and long-term sequela. bear weight on the affected limb. On physical examina- Open fractures of the tibia are often the result of a tion, frequently there is an extensive swelling, ecchymo- motor vehicle crash or pedestrians being struck by a vehi- sis, and deformity with this injury (Setter & Palomino, cle, and account for approximately 7–8% of all tibia frac- 2006). Toddlers and very young children with nondis- tures (Kreder & Armstrong, 1995). As with any case of placed tibia fractures (Toddler’s fracture) may present open fracture, providers should urgently refer these pa- with guarding and a limp or an inability to bear weight tients for operative treatment. Complications can often but will often lack the extensive swelling and noticeable be minimized with prompt initiation of treatment, in- deformity seen with displaced fractures. It is important cluding the administration of parenteral antibiotics to determine whether the mechanism of injury was a di- (intravenous) as well as irrigation and debridement along rect or an indirect force. Fractures that result from a direct trauma (such as being run over or hit by a motor vehicle) require very careful examination of the soft tissues. Any evidence of skin penetration at the fracture site is an indication that the fracture is open and contami- nated. Damage to the soft tissues surrounding the tibia is often much greater than that initially apparent on examination. Although acute compartment syndrome following tibia fractures in children is relatively rare, providers must assess for pain with passive dorsiflexion of the toes, complete a thorough neurovascular assessment including motor and sensory examination, and measure compartment pressure if necessary (Herring, 2002). Any child suspected of having a tibia fracture should have anteroposterior and lateral radiographs of the tibia and fibula. Radiographs should include both the knee and the ankle.

Proximal Tibia Fractures Although proximal tibia fractures are much less common than midshaft and distal tibia fractures, they are often the most problematic fractures (see Figure 15). This type of fracture is most common in children aged between 3 and 6 years. The medial cortex of the proximal tibia fails in tension, often resulting in an incomplete or greenstick fracture. The fibula is generally not affected although plastic deformation may occur and can also contribute to FIGURE 14. 6-year-old girl with left tibia fracture in long leg cast. the posttraumatic valgus deformity seen with this frac-

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Diaphyseal Tibia Fractures Tibial shaft fractures are a common injury in children and are often seen in conjunction with fractures of the fibula. Most diaphyseal tibia fractures in children under 5–6 years of age are nondisplaced or minimally displaced spiral or oblique fractures. The so-called “toddler fractures” fit into this category (see Figure 16). Dunbar, Owen, and Hogrady (1964) originally described the toddler’s fracture as a spiral, oblique fracture of the distal tibial shaft in children less than 3 years of age. The mechanism of injury in children of this age group is often due to a simple fall or twist. Often, there is no known cause for the injury, and the toddler will simply start limping or refuse to weight bear on the affected limb. Providers must always assess the possibility of infection (fever, redness, etc.) rheumatological disorders, as well as neoplasm in the differential diagnosis of any limping child. Anteroposterior and lateral radiographs of the tibia/fibula should be obtained to assess a fracture. Toddler fractures typically occur in children under the age of 3–4 years, and the physical examination and radiographic findings can be quite subtle. The patient with a toddler fracture will often present with normal radiographs. Oudjhane, Newman, Oh, Young, & Girday (1988) ana- lyzed the radiographs of 500 acutely limping toddlers and identified 100 toddlers in whom a toddler fracture was the cause of the gait abnormality. The most common site of fracture was the distal metaphysis of the tibia. An infant or young child with a known or suspected toddler fracture should be treated with a short- or long-leg walking cast for 3–4 weeks. Once in the cast, the toddler or the young child can bear weight on the cast as tolerated. Sometimes a wee- walker pediatric air cast boot can be used for a toddler fracture (see Figure 17). Similar to buckle/torus fractures,

FIGURE 15. 7-year-old male with right Salter Harris II proximal tibia fracture.

ture. This fracture is usually treated with closed reduction and long-leg casting with the knee flexed approximately 5–10° and a varus mold placed at the fracture site (Setter & Palomino, 2006). The cast is usually left for 4–6 weeks depending on the age of the child (older children need a slightly longer immobilization). Although these fractures may appear to be innocuous, they can result in a late progressive valgus deformity. Parents should be ad- vised that this specific type of tibia fracture can result in a late angulation, and the child will need a follow-up for approximately 1–2 years following injury (Skak, Jensen, & Poulson, 1987). The valgus deformity is believed to result from an asymmetric growth of the physis of the proximal tibia. Spontaneous correction of this angular deformity occurs in most young children, and recent literature suggests that tibia valgus following proximal tibia fractures should not be surgically corrected until late adolescence. Because of the high percentage of both the spontaneous resolution and the recurrence, surgical correction should be post- poned until the end of the growth. Parents should be in- structed regarding the importance of follow-up visits and should also be informed about the likelihood of spontaneous correction if a valgus deformity occurs. FIGURE 16. 2-year-old male with toddler’s fracture of right tibia.

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FIGURE 18. 14-year-old male with left tibia/fibula fracture status post rigid intramedullary nailing of tibia. FIGURE 17. 16-month-old male with left tibia toddler’s fracture in pediatric wee-walker boot. tential damage to open physes is usually avoided in younger children secondary to potential damage to open toddler fractures of the tibia are stable, and casting is done physes (Setter & Palomino, 2006). Recently, there has mainly for patient comfort. To avoid delay in the treatment been an increase in the use of flexible nailing of tibia frac- of toddler’s fracture, many institutions presumptively rec- tures (see Figure 19). Kubiak, Egol, Scher, Wassermann, ommend casting toddlers and young children with a his- Feldman, Koval(2005) compared the use of external fixa- tory of acute injury, limping gait or inability to walk, no tion with flexible nailing in tibia fractures and found that constitutional signs, and negative radiographs (Halsey the flexible nails provided faster healing, decreased scar- et al., 2001). Complications following a toddler fracture ring, decreased infection rate, and decreased refracture of the tibia are exceedingly rare. rate. Many fractures of the tibia initially require a long-leg Most pediatric diaphyseal tibia fractures are caused by cast following closed or open treatment. Postoperative a torsional force (twisting) when the body rotates with the evaluations must include careful neurovascular assess- foot in a fixed position (Heinrich, 2001). Pediatric tibial ments to rule out acute compartment syndrome. Nurses and fibular shaft fractures are usually uncomplicated and must check the circulation, sensation, and movement of can be treated with simple closed reduction/manipulation the toes in all children with a tibia and/or fibular fracture. and cast application. Indications for operative treatment The treatment of a child exhibiting severe pain after a include open fracture, fractures that have failed casting, tibia fracture initially involves splitting any cast or the multiple injured child, and irreducible fractures padding. Compartment releases or fasciotomy should be (Setter & Palomino, 2006). Displaced fractures are considered if the intracompartmental pressure is above 30 often reduced in the operating room under conscious mmHg in any of the four leg compartments (Grottkau, sedation/general anesthesia. Although age-dependent, Epps, & DiScala, 2005). When recognized early and the generalized limits of acceptable positioning follow- treated appropriately, outcomes in children with compart- ing a reduction are less than 10 mm shortening, less ment syndrome are usually favorable (Bae, Kadiyala, & than 10 degrees of varus, valgus, or recurvatum, and no Waters, 2001). malrotation (Heinrich, 2001). Similar to other fractures, the length of the treatment Unstable fractures of the tibia and fibula may require depends on the age of the child and the type of fracture operative reduction and surgical stabilization. Common and ranges from 3 to 4 weeks in a toddler fracture to ap- methods of fixation include percutaneous pins, flexible proximately 3 months in an adolescent with a tibia and nails, external fixation, and plates/screws. Standard oper- fibula fracture. Older children and adolescents with tibia ative treatment for skeletally mature adolescents and fractures can usually be changed from a long-leg cast to adults with a tibia fracture is an intramedullary locking a short-leg cast after 4 weeks and then into an aircast nail (see Figure 18). This type of fixation secondary to po- walking boot after another 4–6 weeks. Physical therapy

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direct blows. Pain, swelling, deformity, and difficulty/ inability bearing weight are common symptoms seen on physical examination. Anteroposterior, lateral, and mortise radiographs of the ankle should be obtained to assess a possible fracture. Radiographs of the tibia/fibula and foot may also be needed to assess the associated fractures. Distal fibula physeal injuries are the second most common growth plate fracture and are the most common injuries in the pediatric ankle. Similar to many other pediatric injuries, a distal fibula physeal fracture is more common than a ligamentous injury or sprain in a child. Because a Salter Harris (SH) I fracture often cannot be seen radiographically, it must be presumed in a growing child with tenderness over the region of the physis (growth plate). Fractures of the distal tibia and fibula are most common in children between 10 and 15 years of age and are more common in boys than in girls (Herring, 2002). Salter Harris I and II fractures account for 15 and 40% of ankle fractures, respectively (distal tibia/fibula) (Kay & Tang, 2001). These fractures can almost always be treated with closed reduction with or without manipulation and casting except in the rare instance in which soft-tissue in- terposition prevents reduction (Flynn et al., 2002). Most fractures of the distal tibia/fibula require immobilization for 6–8 weeks. Unlike SH types I and II, types III and IV are much more likely to require open reduction and surgical stabilization. Salter Harris types III and IV fractures of the ankle involve both the physis and the articular surface of the joint and often require more aggressive treatment. Although less common, these types of physeal ankle injuries include the juvenile Tilleaux fracture (SH type III) and triplane fracture (SH type IV) that will be discussed in a separate section. The overall prognosis following fractures of the distal tibia/fibula in children is dependent on the skeletal maturity of the patient, the fracture type, the severity of the injury, the degree of com- minution and displacement of the fracture, and the ade- quacy of reduction (Mashru, Herman, & Pizzutillo, 1996). With proper treatment, however, most children with distal tibia and fibula fractures do well. Avulsion fractures from either the lateral malleolus or the fifth metatarsal are also commonly seen in children with inversion sprain type injuries to the ankle (see Fig- ure 20). The fractures often persist radiographically de-

FIGURE 19. 10-year-old male with left tibia/fibula fracture status post flexible intramedullary nailing of tibia.

to assist in gait training, quadricep strengthening, hamstring stretching, and knee/ankle range of motion is often required following tibia fractures in older children and adolescents.

Ankle Fractures Foot and ankle fractures are also quite common in young children and adolescents. Similar to adults, most fractures of the tibia and fibula occur in the distal third (medial/ lateral malleolus) in children (Herring, 2002). Injuries to FIGURE 20. 15-year-old female with avulsion fracture of right the ankle in children usually result from twisting, falls, and distal fibula (lateral malleolus).

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spite immobilization in a cast. It can be difficult to determine if the fragment or ossicle represents a fracture or a normal ossification center. If asymptomatic, no treatment is required for the ossicle or avulsed fragment. However, if there is persistent pain or instability in the ankle after immobilization, simple excision may be recommended (Kay & Matthys, 2001)

Triplane/Juvenile Tillaux Fractures Triplane and juvenile Tillaux fractures of the distal tibia are known as “transitional fractures” because they occur only during the transition period that occurs from a skeletally immature ankle (open physes) to a skeletally mature ankle (closed physes). The physis (growth plate) in the distal tibia begins to close centrally, and then over a period of 18 months to 2 years the closure progresses medially, posteriorly, and laterally (Rab & Grottkau, 2001). The last portion to close is the anterolateral corner. When the cen- tral part of the physis closes (usually around the age of 12–14 years), a triplane fracture becomes common. This complex fracture may consist of two, three, or occasionally A more fragments, and there may also be an associated fracture of the fibula. The fracture is seen in three different planes (sagittal, coronal, and transverse) on radiographs. There is usually extensive swelling on physical examination of the ankle, and the patient is often unable to bear weight on the affected leg. After obtaining radiographs, a CT is usually needed to fully determine the fracture pattern and the degree of displacement (see Figure 21A and B). Because it is a SH type IV pattern, the fracture occurs at the distal tibia through the metaphysis, into the physis, and out through the epiphysis. It involves the articular surface of the ankle joint, and any step-off greater than 2–3 mm warrants open reduction and internal fixation. If there is no displacement, the fracture can usually be treated with immobilization in a long- leg cast. However, weekly follow-up visits for 2–3 weeks are needed to ensure that there is no displacement. A long-leg cast is often needed initially for 4 weeks and then a short- leg cast for an additional 2–3 weeks. Closed reduction is always attempted initially, but this type of fracture often requires open reduction and screw fixation. To avoid issues with skin breakdown and an increased risk for compartment syndrome, surgery is usually done after the acute swelling in the ankle has decreased. Failure to obtain an anatomic reduction can result in articular incongruity and posttraumatic arthritis several years later. Because the ph- B ysis is in the process of closing, late angular deformities and/or leg length discrepancies are uncommon following FIGURE 21. A. CT scan with 3D reconstructed views of left tri- fixation of this fracture. Therefore, screw fixation should plane ankle fracture. B. CT scan with 3D reconstructed views of be done to maximize stability and joint congruity. Follow- left triplane ankle fracture. ing operative reduction of this fracture, a short-leg cast is normally needed for 4–6 weeks. lateral joint line, which can help to differentiate this injury The juvenile Tillaux fracture is a SH type III fracture of from an ankle sprain where the tenderness is often below the distal tibia. It is also known as an adolescent “transi- the level of the ankle joint. However, there may only be a tional” fracture and occurs when the distal tibia physis slight swelling with this injury, and providers must evalu- starts to close/fuse. The anteroinferior tibiofibular liga- ate all adolescents during the “transitional period” of phy- ment avulses a fragment of the bone corresponding to the seal closure for this fracture. Anteroposterior/lateral/and portion of the distal tibial physis that is still open. The frac- mortise views of the ankle should be obtained, and a CT ture occurs through the epiphysis and exits out through scan is also often needed to evaluate the displacement (see the physis (growth plate) that is still open. On physical ex- Figure 22). Similar to the triplane fractures of the tibia, amination, there is often local tenderness at the anterior tillaux fractures must be reduced if more than 2 mm of

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Metatarsal/Phalanx Fracture Fractures of the metatarsals are a relatively common injury in children. Foot fractures account for approximately 6% of all the fractures in children, and 50% of foot fractures occur at the metatarsals (Staheli, 2001) (see Figure 24). The mechanism of injury in young children is often a direct trauma from an object falling onto the foot. This fracture also occurs commonly following a fall from a low height (i.e., jumping off a bed or a chair). Physical examination findings often include swelling, bruising, antalgic gait/limp, and/or inability to weight bear. Overall, the fifth metatarsal fractures (which include the avulsion fractures from ankle inversion injury) are the most common in children, followed by first metatarsal fractures (Owen, Hickey, & Finlay, 1995). Anteroposterior/lateral and oblique radiographs of the foot should be obtained to assess for this fracture. Metatarsal fractures are usually treated with a short-leg walking cast with an extended toe plate for approximately 3–4 weeks. Most metatarsal fractures can be treated conservatively with simple immobilization. However, markedly displaced, multiple, comminuted, intraarticular, or open fractures will usually require operative treatment. FIGURE 22. CT scan of right ankle with displaced juvenile Fractures occurring at the base (metaphyseal–dia- Tillaux fracture of distal tibia. physeal junction) of the fifth metatarsal are commonly referred to as Jones fractures (see Figure 25). This fracture is notorious for its relatively high incidence of nonunion displacement is found(Cummings, 2002). Closed reduc- especially in the adult population. This injury is typically tion is attempted; however, open reduction with cannu- seen in older children and adolescents between 15 and lated screw fixation of the fracture fragment is often nec- 21 years of age. Initially the treatment for a nondis- essary (see Figure 23). Immobilization is usually needed placed Jones fracture in children is usually conservative. for 6–8 weeks, the time when weight bearing is permitted Immobilization is done with a short-leg nonweight- and a physical therapy course is initiated. bearing cast. The healing of this fracture however, is unpredictable and nonunion can occasionally occur even in children. Immobilization is often needed for 3–4 months with this fracture. There are few literature that supports early operative fixation for Jones fractures given the slow

FIGURE 23. Same patient 1 year s/p open reduction internal FIGURE 24. 3-year-old male with a healing left 2nd metatarsal fixation of right distal tibia Tillaux fracture. fracture.

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FIGURE 26. Salter Harris II fracture of left great toe distal FIGURE 25. 15-year-old male with a left proximal 5th phalanx. metatarsal/Jones fracture. which was given to the parent/caregiver at the time of in- and often unpredictable rate of healing. Torg, Balduini, jury and at 3 and 12 months postinjury. The health-related and Zelco (1984) believed that conservative treatment and quality of life is a multidimensional construct (question- prolonged immobilization were ineffective in treating naire) that aims to assess physical, emotional, and social this injury and surgical fixation was a better option. well-being. Postinjury scores were significantly poorer at 3 More recently, Portland, Kodros, and Kelikian (2000) and 12 months in children with a lower extremity fracture demonstrated that the time to union was shorter after op- compared to those with an upper extremity fracture. Even erative treatment, with earlier return to weight bearing at 12 months postinjury, children with a tibia, fibula, and full activities. and/or femur fracture continued to report significantly Forefoot and toe injuries in children are usually poorer overall physical functioning. A limitation of this caused by crushing or stubbing injuries. These are com- study is the small sample size (100 children) and the fact mon injuries and can often be treated with a short course that only children who required hospitalization at a level I (3–4 weeks) of immobilization. The immobilization often Trauma Center were included in the group. Another limita- varies with the age of the child, the type of injury, and tion of this study is that it did not separately evaluate the provider preference. Short-leg casts, air cast boots, hard impact of the various treatments on the health-related sole shoes, and simple buddy taping are examples of the quality of life (i.e., flexible nailing vs. external fixation). treatment methods. Because most children tolerate casting It is clear that these fractures have a large impact on the well, it is often easiest to place young children in a short- child and the family. In children, fractures involving the leg-walking cast. Similar to finger fractures, physeal in- lower extremity often require longer periods of immobi- juries to the toes or phalanges are quite common. SH II lization compared to fractures of the upper extremity. fractures are also the most common type of phalanx Lower extremity fractures also frequently require non- growth plate fractures in the toe (see Figure 26). Surgery is weight-bearing status (crutches, wheelchair, etc.), which usually only needed for markedly displaced, intraarticular has an obvious impact on children and their family. (involves the joint), comminuted, or open fractures of the Parents of children with casts and/or assistive devices are phalanx. also affected by the children’s immobilization and dependence. Parents report less sleep, less social interaction, more stress, increased physical pain, and disrupted sexuality Effects of Fractures on the Child when their child is immobilized and is dependent on them A recent study by Ding, McCarthy, Houseknecht, et al. for activities of daily living and self-care needs (Newman, (2006) examined the health-related quality of life in chil- 2005). Anticipating these problems, minimizing the effects dren with an extremity fracture. Children hospitalized for of immobilization, and assessing the need for support and an extremity fracture at four pediatric trauma centers teaching is a valuable role for orthopaedic nurses and were studied using the Pediatric Quality of Life Inventory, nurse practitioners.

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Dowd, M., McAneney, C., Lacher, M., & Ruddy, R. (2000). Conclusion Maximizing the sensitivity and specificity of pediatric Lower extremity fractures are quite common in the pedi- trauma activation criteria. Academy of Emergency Medicine, atric population, and orthopaedic nurses and nurse prac- 7, 1119–1125. titioners can have a key role in facilitating a positive out- Dunbar, J. S., Owen, H. F., & Hogrady, M. B. (1964). Obscure come. Although most pediatric lower extremity fractures tibial fracture of infants: The toddler’s fracture. Journal of Canadian Association of Radiology, 25, 136–144. can be treated conservatively, this article also describes Ferguson, J., & Nicol, R. (2000). Early spica treatment of several injuries and fractures that require prompt referral pediatric femoral shaft fractures. Journal of Pediatric and surgical management. Although rare, complications Orthopaedics, 20, 189–192. can arise during the treatment and must be recognized to Flynn, J. 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