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39th National Conference on Pediatric Health Care
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March 19-22, 2018 CHICAGO
Fracture vs. Break:Is There a Difference?
Jennifer Weiner, MS, RN, CPNP‐AC/PCMarch 21, 2018
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Disclosures
• I have no conflicts of interest related to this presentation to disclose
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Learning Objectives
• Understand how to read an x‐ray and communicate clearly with consultants
• Describe types of fractures specific to pediatrics
• Discuss fracture management in pediatrics
• Describe potential complications associated with fracture management
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Fracture vs. Break
• Fracture is the technical term for a “break”
• Severity is not indicated when using one or the other
• Fracture defined: break, or cause to break
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Introduction
• Orthopedic surgery is second most common type of inpatient surgery
• 1 in 5 children will sustain a fracture during childhood or adolescence
• Peak age group is 10‐14 years of age
• Males are twice as likely to sustain a fracture than females
• Most common fracture is distal radius
• Upper extremity fractures account for 2/3 of all childhood fractures
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Communication
• Age
• Gender
• Mechanism of injury
• Anatomic location
• Soft tissue involvement
• Key physical findings
• Imaging
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Reading an X‐ray
• Bone is opaque on XR
• Appears smooth, any breaks in continuity indicate injury
• View from many angles
• Never diagnose based solely on XR, incorporate clinical exam
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How to Describe a Fracture
• Mnemonic OLD ACID
• Open vs Closed
• Location
• Degree
• Articular extension
• Communiution/Pattern
• Intrinsic bone quality
• Displacement, angulation, rotation
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Open vs Closed
• Open
– Compound
– Penetrates the skin
– Types 1‐3
• Wound size
• Degree of tissue damage
– IV antibiotics and sometimes operative
• Closed
– No disruption to skin
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Location
• Which bone
• Anatomic orientation
– Proximal, distal, medial, lateral, anterior, or posterior
• Anatomic landmarks
– Head, neck, body/shaft, condyle, base
• Segments or thirds
– Proximal, middle, or distal third
– Epiphysis, diaphysis, physis, metaphysis
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Anatomy
• Diaphysis– Shaft
• Metaphysis– Adjacent to physis away from the joint
• Epiphysis– Physis on one side, articular cartilage
on the other; secondary ossification center
• Physis– Growth plates
• Periosteum
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Degree
• Complete
– Complete cortical disruption
• Incomplete
– Periosteum intact
– Only one cortex involved
– Ex: Greenstick fracture, type 1 supracondylar
humerus fracture
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Articular extension
• Involves the articular surface
• Dislocation
• Fracture‐Dislocation
–Monteggia fracture
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Communition/Pattern
• Transverse
• Oblique
• Spiral
• Linear/longitudinal
• Segmental
• Comminuted
• Compression/Impacted
• Distraction/avulsion
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Intrinsic bone quality
• Normal
• Osteopetrosis
• Osteopenia
– CP
– Tumor
– Nutritional
– Cysts
– Rickets
– Osteogenesis Imperfecta
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Displacement/Angulation/Rotation
• Displacement
– Two ends of the fracture moving away from each other
– Described as a percentage
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Displacement/Angulation/Rotation
• Angulation
–Motion relative to the long axis of the bone
– Direction and degree are important to note
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Displacement/Angulation/Rotation
• Rotation
– Extent to which fragments are rotated relative to
each other
– Describe the distal fragment
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Name this Fracture
• A. Right midshaft both bone forearm fracture with 50% dorsal displacement and 30% apex volar angulation
• B. Right both bone forearm fracture
• C. Left both bone forearm fracture
• D. Right midshaft both bone forearm fracture with angulation and displacement
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What should be included when speaking to a consultant?
• A. Age
• B. Gender
• C. Mechanism of injury
• D. Key physical findings
• E. All of the above
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Name this Fracture
• A. Right midshaft tibia and fibula fracture
• B. Closed right transverse midshafttibia and fibula fracture with mild apex anterior angulation and 50% displacement of the tibia
• C. Right transverse midshaft tibia fracture
• D. Left closed transverse midshafttibia and fibula fracture with angulation and displacement
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The Physis
• Zone of Ranvier– Contributes to latitudinal or circumferential growth
• Perichondral ring of LaCroix– Strong support for cartilage‐bone junction
• Four zones– Resting or germinal zone
– Proliferative zone
– Zone of hypertrophy
– Zone of endochondral ossification
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Pediatric Fracture Variance
• Buckle
• Greenstick
• Plastic deformation
• Salter Harris classification for
growth plate injuries
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Salter Harris Fractures
• Grades 1‐5– Grade 2 are most common
• Most commonly used descriptor of physeal fractures
• S traight across (1)
• A bove (2)
• L ower (3)
• T hrough (4)
• E nd or Erasure (5)
• R
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Physeal Fracture Description
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Name this Fracture
• A. Left distal tibia SH 3 fracture
• B. Left distal tibia SH 4 fracture
• C. Left distal tibia SH 2 fracture with fibular bowing
• D. Left distal tibia SH 2 fracture
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Supracondylar Humerus Fractures
• 60% of pediatric elbow fractures
• Ages 5‐10 years
• Fall on an outstretched hand
• Non‐dominant extremity
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Supracondylar Humerus Fractures
• Inspection
• Assessment
– Pulse
– Perfusion
– Neurologic function
• Imaging
– AP and true lateral of elbow
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Supracondylar Humerus Fractures
• Type 1– Non‐displaced fracture with radiographic evidence of effusion– “Sail sign”– Can be casted
• Type 2– Displaced with intact posterior periosteum– Appears to be “hinging”– Usually require OR
• Type 3– Displaced with no continuity between the proximal and distal fragments– Definitely going to OR
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Supracondylar Humerus Fractures
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Both Bone Forearm Fractures
• 40‐50% of all childhood fractures
• More common distally
• Midshaft fractures are the most common site of refracture
• Commonly caused by a fall on an outstretched hand
• Assessment
– Inspection
– Neurovascular exam
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Both Bone Forearm Fractures
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Both Bone Forearm Fractures
• Imaging
– AP and lateral of forearm
• Treatment
– Open
• Closed reduction, casting vs OR for formal I&D
• 24‐48 hours IV antibiotics
– Closed
• Closed reduction, casting
• Strict instructions on monitoring
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Distal Radius Fractures
• Most common wrist injury in children
• Occur most frequently in 10‐14 year olds
• Usually from a fall on an outstretched hand
• Assessment
– Inspection
– Palpation
– Neurovascular
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Distal Radius Fractures
• Imaging
– AP and lateral of wrist
– Include forearm and elbow if concerns per history
• Treatment
– Closed reduction and casting if closed
– Open fractures
• IV antibiotics
• Closed reduction and casting vs OR
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Proximal Humerus Fractures
• More common in children than adolescents
• Second most common birth related fracture
• Causes– Fall on an outstretched hand
– Birth
– Pathologic fracture
– Child abuse
• Assessment– Age dependent
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Proximal Humerus Fractures
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Proximal Humerus Fractures
• Imaging– AP and lateral views of the humerus
• Treatment– Immobilization
• Sling and swathe
• Hanging arm cast
• Coaptation splint
– Enormous remodeling potential• Do not need anatomic alignment
• Can usually avoid OR
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Femur Fractures
• Bimodal age distribution
– Peaks in toddlers and adolescents
• Most common orthopedic injury in hospitalized patients
• Mechanism depends on age
– Infants younger than walking age: abuse
– Toddlers: falls
– Teens: motor vehicle collisions
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Femur Fractures
• Imaging– Standard AP and lateral films
• Treatment– Varies by age, weight, social situation, fracture location, stability, soft tissue injury and co‐morbidities• Pavlik harness• Casting• Traction• Submuscular plating• Flexible nailing• Rigid trochanteric entry nails• External fixator
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Femur Fractures
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Tibia Shaft Fractures
• Third most common type of fracture in children
• Most common in boys under age 10
• Mechanism depends on age
– Less than 4 years
– Older than 4
• Assessment
– Inspection
– Palpation
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Tibia Shaft Fractures
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Tibia Shaft Fractures
• Imaging
– AP and lateral views
• Treatment
– Varies depending on mechanism and age
• Can mostly close reduce and cast
• Surgery is rarely indicated with shaft fractures
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Toddler’s Fracture
• Specialized case of spiral fractures of the tibia
• Ages 9 months to 3 years
• Often from relatively minor trauma
• Present with inability to bear weight
• Difficult to assess if already crying
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Toddler’s Fracture
• Imaging
– AP and lateral of tibia
–May show faint fracture line that is easily missed
• Treatment
– Immobilization in short leg cast
– Allowed to ambulate in cast
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Ankle Fractures
• Common in the skeletally immature athlete– Age 10‐15 years
–More common in boys
• Second most common physical injury
• Can range in severity
• Assessment– Inspection
– Palpation
– Neurovascular exam
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Ankle Fractures
• Imaging
– AP, lateral, and mortise views
– CT scan
• Types
– SH 1‐5 fractures
– Tillaux
– Triplane
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Ankle Fractures
• Tillaux Fracture
– Type of SH 3 fracture
– Occurs in ages 12‐14
• Triplane Fracture
– Type of SH 4 fracture
– Average age is 13
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Ankle Fractures
• Treatment
– Depends on age, type, displacement, and stability
• Closed reduction and casting
• Open reduction and casting
• Open vs closed reduction with internal fixation
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Name this Fracture
• A. L SH 2 distal tibia and fibula fracture
• B. L closed distal comminuted tibia and fibula fracture rotated medially with 50% lateral displacement with mild soft tissue swelling
• C. L open proximal tibia and fibula fracture
• D. Right closed distal comminuted tibia and fibula fracture with apex anterior angulation and 50% displacement laterally
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Fracture Management
• Remodeling
• Follow up
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Remodeling
• Three phases of fracture healing
– Inflammatory
• Hematoma forms
• Incites production of proteins
– Reparative
• Initial callus formed
– Remodeling
• Can last months to years
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Remodeling
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Remodeling
• Factors
– Amount of growth remaining
– Plane of deformity
• Wolff’s Law
– Location of fracture
• Metaphysis
• Diaphysis
• Relationship to physis
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Follow Up
• Closely monitor first 48‐72 hours
• Follow weekly first 2 weeks
• Every other week until cast off
• Follow physical injuries for years
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What are potential complications of fracture management?
• A. Loss of reduction
• B. Compartment syndrome
• C. Physeal growth arrest
• D. Cast related injuries
• E. All of the above
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Complications
• Casting
– Pressure related injuries
– Loss of reduction
– Needs to be well padded and molded
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Complications
• Physeal growth arrest
– 1‐10% chance
– Counsel and warn patients to watch out for it
– Number of factors affect likelihood
–May not be evident until 1 year after injury
– Treatable
• Observation
• Completion
• Resection
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Complications
• Compartment Syndrome
– Life and limb threatening
– From increased tissue pressure within an enclosed compartment
– Associated with trauma, tight casts or dressing
– 6 P’s or 3 A’s
– Treatment
• Observation
• Bivalve cast or remove dressings
• Operative
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Summary
• Communication
– Age, gender, mechanism, key physical findings, imaging, anatomic location, and soft tissue involvement
• OLD ACID
– Also using unique names
• Remodeling
• Complications
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Resources
• Berg, E. (2005). Pediatric distal double bone forearm fracture remodeling. Orthopaedic Nursing, 24 (1). • Beutler, A. (2017). General principles of fracture management: Bone healing and fracture description. In T. Post (Ed.). UpToDate.
Waltham, Mass: Up To Date. Retrieved from www.uptodate.com• Boutis, K. (2017). Ankle fractures in children. In T. Post (Ed.). UpToDate. Waltham, Mass: Up To Date. Retrieved from
www.uptodate.com• Chapmen, J. & Cohen, J. (2017). Tibial and fibular shaft fractures in children. In T. Post (Ed.). UpToDate. Waltham, Mass: Up To Date.
Retrieved from www.uptodate.com• Erol, B. & Dormans, J.P (2005). Metabolic disorders of bone. In Dormans, J.P. (Ed.). Pediatric orthopaedics: Core knowledge in
orthopaedics, 386‐401. Philadelphia: Elsevier Mosby• Farrow, C., Bodenham, A., & Troxler, M. (2011). Acute limb compartment syndromes. Continuing Education in Anaesthesia, Critical Care
& Pain, 11 (1). • Herring, J.A. & Ho, C. (2014). Upper extremity injuries. In Herring, J.A. (Ed.), Tachdjan’s Pediatric Orthopaedics. 5th ed. Vol. 12. p 1245‐
1352. Philadelphia: Elsevier• Horn, P. (2015). Orthopaedic basics [PowerPoint slides].• Mathison, D.J. & Agrawal, D. (2017). General principles of fracture management: Fracture patterns and description in children. In T.
Post (Ed.). UpToDate. Waltham, Mass: Up To Date. Retrieved from www.uptodate.com• Nakaniida, A., Sakuraba, K., & Hurwitz, E.L. (2014). Pediatric orthopaedic injuries requiring hospitalization: Epidemiology and
economics. Journal of Orthopaedic Trauma, 28(3). • Naranje, A. M., Erali, R.A., Warner, W.C., Sawyer, J.R., & Kelly, D.M. (2016). Epidemiology of pediatric fractures presenting to emergency
departments in the United States. Journal of Pediatric Orthopaedics, 36 (4).
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References
• Olson, S.A., & Glasgow, R.R. (2005). Acute compartment syndrome in lower extremity musculoskeletal trauma. Journal of the American Academy of Orthopaedic Surgeons, 13 (7).
• Ryan, L.M. (2017a). Proximal humerus fractures in children. In T. Post (Ed.). UpToDate. Waltham, Mass: Up To Date. Retrieved from www.uptodate.com
• Ryan, L.M. (2017b). Evaluation and management of supracondylar humerus fractures. In T. Post (Ed.). UpToDate. Waltham, Mass: Up To Date. Retrieved from www.uptodate.com
• Riccio, A. I., Wilson, P.L., & Wimberly, R.L. (2014). Lower extremity injuries. In Herring, J.A. (Ed.), Tachdjan’s Pediatric Orthopaedics. 5th ed. Vol. 12. p 1353‐1516. Philadelphia: Elsevier
• Schweich, P. (2017a). Midshaft forearm fractures in children. In T. Post (Ed.). UpToDate. Waltham, Mass: Up To Date. Retrieved from www.uptodate.com
• Schweich, P. (2017b). Distal forearm fractures in children: Diagnosis and assessment. In T. Post (Ed.). UpToDate. Waltham, Mass: Up To Date. Retrieved from www.uptodate.com
• Segal, L. S. (2005). Spine and pelvis trauma. In Dormans, J. P. (Ed.), Pediatric orthopaedics: Core knowledge in orthopaedics, 116‐137. Philadelphia: Elsevier Mosby.
• Stone, K. P. & White, K. (2017). Femoral shaft fractures in children. In T. Post (Ed.). UpToDate. Waltham, Mass: Up To Date. Retrieved from www.uptodate.com
• Upton, D.S. & Chorley, J. (2017). Overview of acute wrist injuries in children and adolescents. In T. Post (Ed.). UpToDate. Waltham, Mass: Up To Date. Retrieved from www.uptodate.com
• Wimberly, R.L. (2014). General principles of managing orthopaedic injuries. In Herring, J.A. (Ed.), Tachdjan’s Pediatric Orthopaedics. 5th ed. Vol. 12. p 1199‐1233. Philadelphia: Elsevier
