Fracture Management “Oh Snap!” 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