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 © 2011 Children’s Mercy Hospitals and Clinics. All Rights Reserved. • June 2011 Disclosures • 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 2 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 The Game Plan • 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 3 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Fractures in Pediatrics ? • 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 4 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 The Pediatric Skeleton • 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 5 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Anatomy of Pediatric Bone • Epiphysis • Physis • Metaphysis • Diaphysis • Apophysis 6 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 7 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 The Physis aka “Growth Plate” ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Pediatric Fracture “Language” • 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 9 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Buckle (Torus) Fracture • Buckled Periosteum • Metaphyseal/ diaphyseal junction 10 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Greenstick Fracture • Cortex Broken on Only One Side – Incomplete 11 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Plastic Deformation 12 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Physeal Fractures - General • “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 13 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Physeal Fractures: Salter‐Harris 14 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Salter- Harris 3 Salter-Harris 4 Salter- Harris 1 15 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 “The History” • 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! 16 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Musculoskeletal Physical Exam 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 17 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 X‐Ray’s • Consider 2‐3 views = AP, Oblique, Lateral • Focus XR beam: try to pinpoint pain • Minimize radiation when possible 18 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Splinting: General Principals • 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. 19 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Case #1 • 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 20 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 The FOOSH • 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 21 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 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 at 14 & 21 days • No need for return for cast removal or re‐xray ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Case #2 • 16 y/o basketball player lands on outstretched hand after getting undercut while getting rebound (FOOSH) • Now c/o Right Wrist Pain 23 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Scaphoid Fracture • 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 24 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Case #3 • 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 25 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Differential to Consider • Acromioclavicular sprain – Shoulder separation •Fracture • Sternoclavicular dislocation • Glenohumeral dislocation 26 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 8 weeks CLAVICLE FRACTURE An Example of Pediatric Healing Potential ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Be Careful ! Palpate both ends of the clavicle! 28 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Treatment • Sling for pain/protection – vs. Figure of 8 brace • Pain Control • Progressive ROM/Strengthening • RTP ?? – Clavicle fx: Contact sports ~ 8 weeks 29 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Case #4 • 9 yo fell off monkey bars earlier today • C/o elbow pain and swelling • Refuses to fully extend elbow due to pain and swelling 30 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 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 31 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Ossification Centers of the Elbow (CRITOE): • 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 32 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Elbow Fat Pads • Anterior – normal if lying flat against the humerus, abnormal if elevated – “sail sign” • Posterior – always pathologic! • Indicates hemarthrosis ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Occult Fracture 34 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Case #5 16 yo male football player injured left 4th finger while tackling an opposing player… 35 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Jersey Finger • 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 36 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Case #6 15 yo female basketball player injured her index finger while catching a pass 37 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Mallet Finger • 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 38 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Mallet Finger Treatment ‐ • Constant splinting of the DIP in full extension/hyperextension x 6‐ 8 weeks • May RTP with proper splint when pain controlled 39 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Visual Inspection • Give every hand & finger injury the Kentucky Quick‐Eye Test ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Phalangeal Fractures • Assess closely for angulation and need for reduction • Beware of malrotation! • Tx if stable/ nondisplaced/ nonangulated….buddy‐tape and splint