Alabama AAP Fall Meeting Sept.19-20, 2009 Pediatric Fracture Care for the Pediatrician

Andrew Gregory, MD, FAAP, FACSM Assistant Professor Orthopedics & Pediatrics Program Director, Sports Medicine Fellowship Vanderbilt University

Vanderbilt Sports Medicine

Disclosure No conflict of interest - unfortunately for me, I have no financial relationships with companies making products regarding this topic to disclose

Objectives Review briefly the differences of pediatric bone Review Pediatric Fracture Classification Discuss subtle fractures in kids Discuss a few other pediatric only conditions

1 Pediatric Skeleton Bone is relatively elastic and rubbery Periosteum is quite thick & active Ligaments are strong relative to the bone Presence of the physis - “weak link” Ligament injuries & dislocations are rare – “kids don’t sprain stuff” Fractures heal quickly and have the capacity to remodel

Anatomy of Pediatric Bone Epiphysis Physis Metaphysis Diaphysis Apophysis

Pediatric Fracture Classification Plastic Deformation – Bowing usually of fibula or ulna Buckle/ Torus – compression, stable Greenstick – unicortical tension Complete – Spiral, Oblique, Transverse Physeal – Salter-Harris Apophyseal avulsion

2 Plastic deformation

Bowing without fracture Often deformed requiring reduction

Buckle (Torus) Fracture Buckled Periosteum – Metaphyseal/ diaphyseal junction

Greenstick Fracture Cortex Broken on Only One Side – Incomplete

3 Complete Fractures

Transverse – Perpendicular to the bone Oblique – Across the bone at 45-60 o – Unstable Spiral – Rotational force

Salter Harris Classification I II

III

IV V

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

4 Subtle Fractures Salter Harris I Buckle Avulsions Occult Mimickers – nursemaids, other causes of limp - legg-calve-perthes, transient synovitis, septic arthritis, osteomyelitis (bone pain/ fever)

Elbow Fractures 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

Ossification Centers of the Elbow (CRITOE): C = Capitellum 2 Years R = Radial Head 4 Years I = Internal 6 Years (Medial) T = Trochlea 8 Years O = Olecranon 10 Years E = External 12 Years (Lateral )

5 Ossification Centers Appearance

Elbow Fat Pads Anterior – normal if laying flat against the humerus, abnormal if elevated – “sail sign” Posterior – always abnormal Indicates hemarthrosis and in the setting of appropriate mechanism, a fracture of the distal humerus, proximal radius or ulna

Elbow Fat Pads

6 Posterior Fat Anterior Fat Pad Pad

Occult Fracture

Posterior Fat Pad Non-Displaced Supracondylar Fracture

7 Nursemaid’s Elbow Traction injury usually when it is “time to go” FOOSH Child cries and will not use the arm No swelling or deformity Does not improve with time

8 Nursemaid’s Elbow Subluxation of the radial head Small tear in the annular ligament which slides off the radial head and into the joint Average 2-4 years but up to age 8 Radial head goes from being shaped like a pencil eraser to that of a hammer head by about age 5-6 yo

Reduction Maneuver – full supination and flexion

9 Forearm Fractures Most common fracture in pediatrics Becoming more common FOOSH May have no swelling, bruising or deformity Tender 1” proximal to the RC joint FROM or loss of supination

Volar Bruise

10 11 Splint vs. Cast for buckle fractures of the Distal Radius 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 No need for return for cast removal or re- xray

Navicular fractures still happen in skeletally immature

Avulsion common in the fingers

12 Slipped Capital Femoral Epiphysis (SCFE) SH Fracture through proximal femoral physis Consider in any child with limp or hip/ knee pain AP/ Frogleg pelvis Catch before the slip Can be bilateral ORIF

SCFE

Distal Metaphyseal/ Supracondylar Slipped while running Tender above the physis Minimal swelling Refusal to bear weight No effusion A form of Toddler’s fracture

13 12 yo football player

SH III

Tibial Eminence Fractures – Rare ~ 3/100,000 – Anterior > posterior – Hinge

osteo CHONDRAL Fracture

sliver of bone often attached to a significant piece of cartilage

14 Tibial Tubercle Fractures – < 3% epiphyseal fractures – minimal increased risk with Osgood- Schlatter’s – Mechanism
Forceful quad acceleration / deceleration – Problems
extensor lag if displaced interposed periosteum

SHII Proximal Tibia - periosteal recoil

Toddler’s fracture Any toddler with a mechanism who refuses to bear weight Regardless of exam or xray SLWC x 2-3 weeks

15 Ankle Fractures Physis located 1” above distal maleolar tip SH I of the fibula common with inversion injury ER stress test useful in distinguishing fracture from sprain Tibia closes medial to lateral before the fibula

Distal Fibula Salter Harris I

8 y/o male soccer player

16 Salter-Harris II Distal Tibia

SH IV Tibia

17 Calcaneal Fractures Jump from height Jump into shallow water Xrays sometimes negative, subtle Occasionally bilateral

Metatarsals Physis proximal on the 1 st and distal on the others 1st MT epiphysis often bipartite

5th Metatarsal Apophysis

18 Bad Actors (Deformity, Malunion) Displaced Supracondylar Fractures Any Lateral Condyle Fracture Any Displaced distal femur or Proximal Tibia Fracture Midshaft Forearm Fractures Salter-Harris III/IV Osteochondral Fractures

References

Kelly Butler,MD; Vanderbilt Pediatric EM Conference ’03 Greg Mencio, MD; Vanderbilt CME - Sports Medicine for the School Age Athlete Conference ’04 John Batson, MD; ACSM Workshop ’06; Pediatric UE Fractures Green, NE; Swiontkowski, MF; Skeletal Trauma in Children, Vol. 3; 3 rd Edition, Saunders ’03 Khosla et al; Incidence of Childhood Distal Forearm Fractures over 30 years, A population-Based Study; JAMA 2003; Vol 290, No. 11, pp1479-1485 Plint et al; A RCT of Removable Splinting vs. Casting for Wrist Buckle Fractures in Children; Pediatrics 2006; 117;691-697

Diversity Bluegrass Music Connoisseur – The Station Inn, Nashville, TN Dabble on the 6 & 12 string guitar My sister Megan is the lead singer/ fiddle player in a Band called Meridian - www.meridianband.com , The Down Home, Johnson City, TN

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