Fracture Management “Oh Snap!”

Home , Greenstick fracture, Jones fracture, Torus fracture

Cassidy Foley Davelaar, DO, FAAP, CAQSM Department of Orthopedics and Sports Medicine Assistant Professor University of Central Florida College of Medicine 5th October, 2018 Disclosure

. I have no relevant financial relationships with industry to disclose . I will not discuss off label use and/or investigational use in my presentation Importance

. A large proportion of orthopedic referrals indicated either a lack of basic textbook knowledge or lack of examination skills and appropriate diagnostic tools . For pediatric residents, skills in recognizing and managing pediatric fractures were suboptimal.

Reeder et al. Referral patterns to a pediatric orthopedic clinic: implications for education and practice. Pediatrics. 2004 Mar;113(3 Pt 1):e163-7. Ryan LM et al. Recognition and management of pediatric fractures by pediatric residents. Pediatrics. 2004 Dec;114(6):1530-3. Learning Objectives

. Identify STABLE fracture vs UNSTABLE . Identify common fractures by mechanism of injury . Learn the appropriate immobilization for each fracture Kids are not just little Adults

. Pediatric skeleton is relatively elastic and rubbery . Growth plates are the area of greatest weakness . Ligaments and tendons are strong relative to bone . Fractures heal quickly; more quickly the younger you are. Pediatric Bone – Anatomy 101

. Epiphysis . Physis . Metaphysis . Diaphysis . Apophysis Pediatric Fracture Classification

. Buckle/Torus – compression, does not effect growth plate . Plastic deformation – bowing, no cortical disruption . Greenstick – unicortical tension, cortical disruption . Complete – spiral, oblique, transverse . Physeal – Salter- Harris Classification (l-V) . Apophyseal avulsion Buckle/Torus Fracture

. Compression of the periosteum . Typically at the metaphyseal/diaphyseal junction . Open growth plates

– Distal radius and ulna buckle fractures Plastic Deformity

. Bowing w/o fracture . Often deformed . Requires reduction . Associated w/ fracture

– Fibular plastic deformity Greenstick Fracture

. Only one cortex is fractured . Incomplete . Typically open growth plates – Distal radius greenstick fracture Complete Fractures

. Transverse – perpendicular to shaft . Oblique – across bone @ 45-60º – unstable . Spiral – rotational force Salter- Harris Classification Salter-Harris continued Clues

. Kids are not good historians . Mechanism – very low impact, can be any fall . May not be swollen, bruised or deformed . Non-weight bearing/limping child . Knee swelling . Not using the arm, keeping it flexed close to body . Walking on toes or heel Easily missed

. Salter-Harris 1 fractures (straight/slipped) . Buckle/Torus fractures . Avulsion fractures . Occult (toddlers fracture and humeral fractures) Fracture mimickers

. Causes of limp – legg-calve-perthes, transient synovitis, septic arthritis . Flexed arm, refusing to use – Nursemaids . Pathological fractures – Bone cyst – Tumors . Osteomyelitis – bone pain and fever Pearls for Elbow Fractures

. Multiple physes – compare to contralateral side . Look for swelling . Range of motion – Humerus = loss of flexion/extension – Radial head or Olecranon = loss of supination/pronation . Supracondylar fractures in the very young . Radial head fractures in the older child

Nursemaids Elbow

. Traction injury . No swelling or deformity . Does not improve with time . Child cries and will not use, holds arm flexed close to body . Subluxation of the radial head . Annular ligament slides off the radial head . Occurs from 6 months to 5 years (peak 27 months) . Change in the shape of radial head to “hammer” @ 5-6 yrs Reduction Maneuver

. Fully Supinate or Pronate and Flex TREATMENT Nursemaids

. Attempt reduction maneuver *ONCE* . Wait 10 minutes

If not reduced: . Elbow sling, refer to Orthopedics, *next day* appointment . Multiple attempts can cause trauma to ligament or displace a missed fracture Appearance of Ossification Centers Ossification Centers of the Elbow

. C – Capitellum – 2 years . R – Radial head – 4 years . I – Internal / Medial epicondyle – 6 years . T – Trochlea – 8 years . O –Olecranon –10 years . E – External / Lateral condyle – 12 years Elbow Fat Pad

. Anterior – can be normal if lying flat against the humerus – abnormal if elevated “sail sign” . Posterior – always abnormal = occult fracture . Indicates hemarthrosis in the setting of appropriate mechanism . Fracture of the distal humerus > proximal radius > ulna Elbow Fat Pads continued Posterior Fat Anterior Fat Pad Pad Occult Fracture Supracondylar Distal Humerus

. Physical exam: – Swelling – May appreciate extension Anterior Humeral Line . Should intersect the middle 1/3 of the capitellum in children >5 yrs and touch the capitellum in children <5 yrs Baumanns Angle . Baumanns angle should be 70-50 degrees . Deviation >5-10 degrees should not be accepted . Lateral condyle fractures . Increase carrying angle TREATMENT

. Supracondylar fractures cause neural injury 10-15% cases – Recovery from neuropraxia can take up to 6 months – Most common nerve is AIN (can’t make “OK” sign) First: Warm perfused hand without neuro deficits . Type 1 (non-displaced) . Type 2 : Meeting the following criteria – anterior humeral line intersects the capitellum – acceptable Baumann’s angle *GOOD* LONG ARM SPLINT & SLING ~ 90 º elbow flexion . Ortho F/U within 1 week Radial Neck Fracture Forearm Fractures

. Most common fracture in pediatrics . FOOSH . May have swelling, bruising, deformity . Tender 1 inch proximal to the radiocarpal joint . Loss of supination/pronation

. * Always obtain 2 VIEW (AP/LAT) FOREARM Volar Bruising – Distal radius and ulna buckle fractures – Ulna styloid and distal metaphyseal fracture of the radius TREATMENT Buckle/Torus Fracture

. Brace vs Cast . Level 1 evidence splint is as good as a cast for prevention of re-fracture and loss of alignment . No difference in pain . Easier to bath . Better function . No need to return for cast removal . Re-xray Fracture Reduction

. Sooner is better . Reduce if obvious deformity . Correct angulation and/or displacement . Older children require more reductions . 3 Factors: – Age to skeletal maturity – Proximity to the physis – Angle of motion @ the jt. Remodeling

. 10 year old Salter-Harris ll distal radius TREATMENT Reduced or Unstable Forearm Fracture

. LONG ARM SPLINT (SHORT ARM IS INSUFFICIENT) . IMMOBILIZE the ELBOW . Supination of the forearm – Avoid tension across the brachioradialis (avoid pronation) . Sling . Prompt F/U with orthopedics – Younger age – More instability Scaphoid Fractures

. Still occur in the skeletally immature . Most frequently fractured carpal bone . 15% of acute wrist injuries . 65% occur at the waist – Proximal 1/3 25% – Distal 1/3 10% . Distal pole & waist most common in kids . Risk AVN is high Scaphoid cont.

Physical exam: – Anatomical snuff box tenderness – Scaphoid tubercle tenderness volarly – Pain with resisted pronation Radiographs: – AP/LAT and scaphoid view (30º wrist extension, 20º ulnar deviation) TREATMENT

. Stable nondisplaced fracture (majority) . If normal xrays, but positive exam THUMB SPICA CAST IMMOBILIZATION START IMMOBILIZAITION EARLY to avoid nonunion Typical duration > 5 weeks, but reevaluate at 12-21 days Avulsion Fractures - Fingers

. Extremely common . Kids heal EXTREMELY quickly . If displaced refer < 1 week . Will heal poorly Jersey Finger

. Jersey Finger – 4th finger hyperextended at the DIP – FDP avulsion from the volar base of the distal phalanx – cannot flex the DIP TREATMENT Jersey Finger

. Ultrasound has been shown to be the optimal imaging . Wide awake surgery offers optimal intraoperative assessment of the tendon repair . ACUTE diagnosis and prompt SURGICAL referral . 8-12 weeks of recovery

Bachoura et al. A review of mallet finger and jersey finger injuries in the athlete. Curr Rev Musculoskelet Med. 2017 Mar;10(1):1-9. Mallet Finger

. Mallet Finger – Impact to the distal phalanx of the finger or dorsal laceration – Disrupts terminal extensor tendon attachment (bone or tendon) TREATMENT of Mallet Finger

. EXTENSION SPLINTING OF DIP JOINT 6-8 WEEKS . Can move at the PIP . Volar splinting preferred over dorsal . Avoid hyper extension Seymour Fracture

. Distal phalangeal physeal fracture with nailbed injury . Middle finger is the most common . Direct trauma or laceration (similar to mallet finger) Exam: – Nail plate lying superficial to the eponychial fold – Open fracture Radiographs: – AP/PA may appear wnl – True lateral necessary TREATMENT Seymour Fracture

. Removal of the nail . Irrigation and debridement of the fracture . Percutaneous wire stabilization Phalangeal Neck Fractures

. Limited potential to remodel & propensity to re-displace Radiographs: – True lateral will show displacement best

Goodell et al Problematic pediatric hand and wrist fractures. JBJS 2016;4(5):e1. TREATMENT Phalangeal Fractures

TREATMENT if: – Extraarticular – <10º angulation – <2mm shortening – no rotation 3 weeks of immobilization followed by aggressive motion If not the above criteria: – Percutaneous pinning – Open reduction should be avoided secondary to risk of osteonecrosis of the phalangeal condyles

Goodell et al Problematic pediatric hand and wrist fractures. JBJS 2016;4(5):e1. FEMUR

. Proximal – SCFE – Apophyseal avulsion – Femoral neck . Shaft – Depending on age concern for abuse . Distal – Supracondylar – Salter-Harris Femoral Neck Fractures . Severe injuries associated with femoral head necrosis . Luckily < 1% of pediatric and adolescent fractures . Poor blood supply makes epiphysis vulnerable to osteonecrosis following femoral neck fracture (~29%)

. Factors that suggest increased risk of necrosis are: – Greater risk with more proximal fractures – Greater risk with more displacement – Other causes include tamponade of vessels – High suspicion for osteonecrosis from 6 – 18 months post injury

Spence et al. Osteonecrosis after femoral neck fracturs in children and adolescents:analysis of risk factors. J Pediatr Orthop; 36(2): 2016. Spiral Fractures of Femur

. Concern for abuse if no mechanism . TREATMENT: – Hip spica if proximal – LLC for distal – Lateral body splint . Change weekly Distal Metaphyseal/Supracondylar Femur Fractures

. Slipped while running, landed on knee . Tender above the physis . Minimal swelling . Refusal to bear weight . No effusion . A form of toddlers fracture . Pain with manipulation of the knee . Salter-Harris classification Toddlers Fracture

. Any toddler who refuses to bear weight, low impact injury . Regardless of exam or xray . Occult fracture common TREATMENT Toddler Fracture

If displacement is acceptable: . > 50% apposition . < 1cm shortening . < 5-10 angulation in sagittal and coronal plane

LONG LEG POSTERIOR SLAB SPLINT . Refer to orthopedics in 1-2 weeks Calcaneal fractures

. Jump from a height into shallow water onto hard surface . Xrays often negative, occult fracture . Occasionally bilateral TREATMENT Calcaneal Fractures

. Harris and lateral calcaneal views . Immobilization of ankle . Short Leg Splint . Cast non-weightbearing x 6 wks Metatarsal Fractures

. Buckle proximal first metatarsal most common in toddlers 5th Metatarsal Fractures

. 5th metatarsal – Avulsion of the apophysis – Jones fracture – Shaft fracture Jones Fracture

. Zone 1 (pseudo jones fracture) – Proximal tubercle . Zone 2 – Jones fracture – avascular watershed – increased risk of nonunion (15-30) . Zone 3 – Proximal diaphyseal fracture – Also increased risk of nonunion – Common site for stress fractures TREATMENT 5th Metatarsal Fractures Zone 1 . Protected weightbearing in stiff soled shoe, boot or cast Zone 2 . Non-weight bearing short leg cast for 6-8 weeks . Advance only after signs of radiographic healing Intramedullary screw fixation in competitive athletes and nonunion Pressure Ulcers

. Please pad the heel before application of splint . Warn family not to apply pressure to heel, support at calf . Alert them this can cause significant pain, not the fracture Splinting Pearls

. Immobilization – promotes healing, decreases pain . Splint initially for most fractures (risk of swelling) – Not necessary for toddler fracture or buckle/torus fracture – Include joint ABOVE AND BELOW in splint

. Cast when swelling has subsided > 4 days . Reduction recommended within 1 week . Encourage the use of fingers toes when immobilized . Cannot get wet or needs to be seen promptly Abuse Related Fractures

. In infants and toddlers, physical abuse is the cause of 12- 20% of fractures . 80% of fractures by abuse occur under 18 months

. Child’s age and developmental stage . Mechanism of fracture . Age of the fracture(s) . Multiple fractures – & presence of other injuries Location of Fractures by Abuse

. Single long bone diaphyseal fracture most common – Femur and humerus in nonambulatory patients . Classic metaphyseal lesions (CML) – Planar (along the plane of bone) fracture through the metaphysis – Pulling or twisting and infants extremity – Corner or bucket-handle fracture . Rib fractures – Posterior medially

Flaherty et al. Evaluating children with fractures for child physical abuse. PEDIATRICS. 2014;133:2. Open Fractures

. When bone pokes through the skin from inside outward . If there is a hole in the skin or nailbed laceration . Generous cleansing of the wound . Oral antibiotics . Splinting and referral to orthopedics in 24 hours

Laine et al. High-risk pediatric pitfalls. Emerg Med Clin N Am; 28 (2010) 85-102. High Risk Pediatric Orthopedic Pitfalls

. Intra articular fractures can lead to osteoarthritis . Physeal involvement can lead to growth disturbances . Compartment Syndrome can be harder to diagnose in children, level of suspicion should be high

Laine et al. High-risk pediatric pitfalls. Emerg Med Clin N Am; 28 (2010) 85-102. Recap of Treatments TREATMENT Nursemaids

. Attempt reduction maneuver *ONCE* . Wait 10 minutes

If not reduced: . Elbow sling, refer to Orthopedics, *next day* appointment . Multiple attempts can cause trauma to ligament or displace a missed fracture TREATMENT

Bachoura et al. A review of mallet finger and jersey finger injuries in the athlete. Curr Rev Musculoskelet Med. 2017 Mar;10(1):1-9. TREATMENT of Mallet Finger

. EXTENSION SPLINTING OF DIP JOINT 6-8 WEEKS . Can move at the PIP . Volar splinting preferred over dorsal . Avoid hyper extension TREATMENT Seymour Fracture

. Removal of the nail . Irrigation and debridement of the fracture . Percutaneous wire stabilization TREATMENT Phalangeal Fractures

Goodell et al Problematic pediatric hand and wrist fractures. JBJS 2016;4(5):e1. Spiral Fractures of Femur

. Concern for abuse if no mechanism . TREATMENT: – Hip spica if proximal – LLC for distal – Lateral body splint . Change weekly TREATMENT Toddler Fracture

If displacement is acceptable: . > 50% apposition . < 1cm shortening . < 5-10 angulation in sagittal and coronal plane

LONG LEG POSTERIOR SLAB SPLINT . Refer to orthopedics in 1-2 weeks TREATMENT Calcaneal Fractures

. Harris and lateral calcaneal views . Immobilization of ankle . Short Leg Splint . Cast non-weightbearing x 6 wks TREATMENT 5th Metatarsal Fractures Zone 1 . Protected weightbearing in stiff soled shoe, boot or cast Zone 2 . Non-weight bearing short leg cast for 6-8 weeks . Advance only after signs of radiographic healing Intramedullary screw fixation in competitive athletes and nonunion Thank You

. Dr. Andrew Gregory, Vanderbilt University . Nemours Children’s Health System