10173-06_ON2506-Hart.qxd 11/9/06 3:51 PM Page 390 Broken Bones: Common Pediatric Lower Extremity Fractures—Part III 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 stretch- ing 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. 390 Orthopaedic Nursing November/December 2006 Volume 25 Number 6 10173-06_ON2506-Hart.qxd 11/9/06 3:51 PM Page 391 A A B 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 Orthopaedic Nursing November/December 2006 Volume 25 Number 6 391 10173-06_ON2506-Hart.qxd 11/9/06 3:51 PM Page 392 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 (ap- proximately 10%). Children with femoral neck fractures will usually hold the hip in a fixed position with varying amounts of exter- nal rotation, abduction, and flexion. On physical examina- tion, 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 frag- ment stability through an anatomic reduction while avoid- ing complications that are common with this injury. FIGURE 4. Same