common fractures in young athletes february 10, 2012

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Vanderbilt Sports Medicine Common Fractures in Young Athletes February 10, 2012 Alex B. Diamond, D.O., M.P.H. Assistant Professor of Orthopaedics and Rehabilitation Assistant Professor of Pediatrics Vanderbilt University Medical Center Co-Chair, Youth Sports Safety Taskforce Team Physician Vanderbilt & Belmont Universities Nashville Sounds & Nashville Predators 40th Annual Meeting heast Chapter of the American College of Sports Medicine (SEA

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40th Annual Meeting Southeast Chapter of the American College of Sports Medicine (SEACSM). Common Fractures in Young Athletes February 10, 2012. Alex B. Diamond, D.O., M.P.H. Assistant Professor of Orthopaedics and Rehabilitation Assistant Professor of Pediatrics - PowerPoint PPT Presentation

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Page 1: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Common Fractures in Young AthletesFebruary 10, 2012

Alex B. Diamond, D.O., M.P.H.Assistant Professor of Orthopaedics and Rehabilitation

Assistant Professor of PediatricsVanderbilt University Medical Center

Co-Chair, Youth Sports Safety TaskforceTeam Physician

Vanderbilt & Belmont UniversitiesNashville Sounds & Nashville Predators

40th Annual MeetingSoutheast Chapter of the American College of Sports Medicine (SEACSM)

Page 2: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Andrew Gregory, MD, FAAP, FACSMAssistant Professor of Orthopedics & PediatricsProgram Director, Sports Medicine Fellowship

Vanderbilt University Medical CenterTeam Physician

Vanderbilt & Belmont UniversitiesNashville Sounds

USA Volleyball

Common Fractures in Young Athletes

Page 3: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Disclosures• Diamond

– NO commercial relationships– Research & Educational funding

• NIH U54 Institutional Clinical & Translational Science Award

• Gregory– No conflict of interest

Page 4: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Objectives• Review briefly the differences of pediatric

bone• Review pediatric fracture classification• Discuss subtle fractures in kids• Discuss a few other pediatric only conditions

Page 5: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

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

Page 6: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Anatomy of Pediatric Bone

• Epiphysis• Physis• Metaphysis• Diaphysis• Apophysis

Page 7: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Pediatric Fracture Classification• Plastic Deformation – bowing

– Fibula or ulna common• Buckle/Torus – compression, stable• Greenstick – unicortical tension• Complete

– Spiral, Oblique, Transverse• Physeal = Salter-Harris• Apophyseal avulsion

Page 8: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Plastic Deformation• Bowing without

fracture• Often requiring

reduction

Page 9: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Buckle (Torus) Fracture• Buckled Periosteum

– Metaphyseal/ diaphyseal junction

Page 10: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Greenstick Fracture• Cortex Broken on Only One Side

– Incomplete

Page 11: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Complete Fractures• Transverse

– Perpendicular to the bone

• Oblique– Across the bone at 45-60o

– Unstable

• Spiral – Rotational force

Page 12: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Salter-Harris Classification

I II

III

IV V

Page 13: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Clues• Kids usually poor historians• Mechanism Any Fall

– Trampolines, Monkey Bars, Skating

• May not be swelling, bruising or deformity

• Limp• Non-weight bearing• Not using the arm

Page 14: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Keep In MindSubtle Fractures

• Salter-Harris I• Buckle• Avulsions• Occult

Mimickers• Nursemaids• Other causes of limp

– Legg-Calve-Perthes– Transient synovitis– Septic arthritis

• Osteomyelitis– Bone pain + Fever

Page 15: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Elbow Fractures• Multiple physes• Look for swelling

– Effusion• Loss of flexion/ extension• No loss of supination/ pronation

• Typical pattern– Supracondylar in the very young– Radial head in the older child

Page 16: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Ossification Centers of the Elbow (CRITOE)

• C = Capitellum• R = Radial Head• I = Internal (Medial)• T = Trochlea• O = Olecranon• E = External (Lateral )

• 2 Years• 4 Years• 6 Years• 8 Years• 10 Years• 12 Years

Page 17: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Ossification Centers Appearance

Page 18: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Elbow Fat Pads• Indicates hemarthrosis

– In the setting of appropriate mechanism = a fracture of the distal humerus, proximal radius or ulna

• Anterior– Normal if laying flat against the humerus– Abnormal if elevated = “sail sign”

• Posterior– Always abnormal

Page 19: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Elbow Fat Pads

Page 20: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Posterior Fat Pad

Anterior Fat Pad

Page 21: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Occult Fracture

Page 22: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Non-Displaced Supracondylar Fracture

Posterior Fat Pad

Page 23: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Page 24: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Page 25: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

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

Page 26: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

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 age 2-4 yr but up to 8 yr• Radial head goes from being shaped like a

pencil eraser to that of a hammer head by about age 5-6 yr

Page 27: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine1

2

3

Page 28: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Reduction Maneuver: Full supination and flexion

Page 29: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Forearm Fractures• Most common fracture in pediatrics

– Becoming more common

• FOOSH• May not have swelling, bruising or deformity• Tender 1” proximal to the RC joint• FROM or loss of supination

Page 30: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Volar Bruise

Page 31: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Page 32: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Page 33: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Page 34: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Splint vs. Cast for Buckle Fractures of the Distal Radius

• LOE 1– 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

Plint AC et al. Pediatrics, 2006.

Page 35: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Navicular Fractures can happen in Skeletally Immature

Page 36: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Avulsion Fx common in the Fingers

Page 37: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Slipped Capital Femoral Epiphysis (SCFE)

• SH Fracture through proximal femoral physis• High index suspicion

– Consider in any child with limp or hip/knee pain• Xray: AP/Frogleg pelvis• Catch before the slip• Can be bilateral• ORIF

Page 38: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

SCFE

Page 39: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Toddler’s Fracture• Suspect

– Any toddler with a mechanism who refuses to bear weight

– Regardless of exam or xray

• SLWC x 2-3 weeks

Page 40: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Distal Metaphyseal/Supracondylar

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

Page 41: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

SHII Proximal Tibia - Periosteal Recoil

Page 42: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

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

Page 43: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Distal Fibula Salter-Harris I

Page 44: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

8 y/o male soccer player

Page 45: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Page 46: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Salter-Harris II

Distal Tibia

Page 47: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

12 yo football player

SH III

Page 48: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

SH IV Tibia

Page 49: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Calcaneal Fractures• Jump from height• Jump into shallow

water• Xrays sometimes

negative, subtle• Occasionally bilateral

Page 50: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Metatarsals• Physis proximal on the

1st and distal on the others

• 1st MT epiphysis often bipartite

Page 51: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

5th Metatarsal Apophysis

Page 52: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

www.vanderbiltsportsmedicine.com

Please Visit

Page 53: Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Thank You