ouch, that’s gottahurt! pediatric fractures & injuries · pediatric fractures & injuries...

© 2011 Children’s Mercy Hospitals and Clinics. All Rights Reserved. • June 2011© 2011 Children’s Mercy Hospitals and Clinics. All Rights Reserved. • June 2011

Ouch, That’s Gotta Hurt! Pediatric Fractures & Injuries

Greg Canty, MDMedical Director, Sports Medicine CenterAttending Physician, Emergency Medicine

Children’s Mercy Kansas City

©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/132

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


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


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


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


Anatomy of Pediatric Bone

• Epiphysis

• Physis

• Metaphysis

• Diaphysis

• Apophysis


The Physis aka “Growth Plate”


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


Buckle (Torus) Fracture

• Buckled Periosteum

• Metaphyseal/ diaphyseal junction


Greenstick Fracture

• Cortex Broken on Only One Side

– Incomplete


Plastic Deformation


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


Physeal Fractures: Salter‐Harris


Salter-Harris 4Salter-Harris 3

Salter-Harris 1


“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!


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


X‐Ray’s

• Consider 2‐3 views = AP, Oblique, Lateral

• Focus XR beam: try to pinpoint pain

• Minimize radiation when possible


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.


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


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


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


Case #2• 16 y/o basketball player lands on outstretched hand after getting undercut while getting rebound (FOOSH)

• Now c/o Right Wrist Pain


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


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


Differential to Consider

• Acromioclavicular sprain– Shoulder separation

• Fracture

• Sternoclavicular dislocation

• Glenohumeral dislocation


CLAVICLE FRACTURE

An Example of Pediatric Healing Potential

8 weeks


Be Careful !

Palpate both ends of the clavicle!


Treatment

• Sling for pain/protection

– vs. Figure of 8 brace

• Pain Control

• Progressive ROM/Strengthening

• RTP ?? – Clavicle fx: Contact sports ~ 8 weeks


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


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

• 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


Elbow Fat Pads

• Anterior – normal if lying flat against the humerus, abnormal if elevated – “sail sign”

• Posterior – always pathologic!

• Indicates hemarthrosis


Occult Fracture


Case #5

16 yo male football player injured left 4th

finger while tackling an opposing player…


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


Case #6

15 yo female basketball player injured her index finger while catching a pass


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


Mallet Finger

Treatment ‐• Constant splinting of the DIP in full extension/hyperextension x 6‐8 weeks

• May RTP with proper splint when pain controlled


Visual Inspection

• Give every hand & finger injury the Kentucky Quick‐Eye Test


Phalangeal Fractures

• Assess closely for angulation and need for reduction

• Beware of malrotation!• Tx if stable/ nondisplaced/

nonangulated….buddy‐tape and splint for sports x 3‐4 weeks


Case #8

• 15 yo football player presents on Sat morning

• He recalls an inversion ankle injury when he stepped on another player’s foot

• He was able to limp afterwards but unable to run


Ottawa Ankle Rules• Ankle x-rays if ankle pain with: 1) bony tenderness

along the posterior edge/tip of lateral or medial malleolus or 2) inability to bear weight for 4 steps

• Foot x-rays if foot pain with: 1) bony tenderness at the base of the 5th metatarsal or 2) bony tenderness of the navicular bone or 3) inability to bear weight for 4 steps


The Pediatric “Ankle Sprain”Distal Fibula Fractures

• Common in youth and pre-adolescent athletes

• Always palpate the physis!

• Salter Harris I fractures are a clinical diagnosis

• Excellent Prognosis


Removable Ankle Braces• Isolated distal fibula

fractures are very common

• Most are very low-risk

• Casting vs. splinting

• Quicker return to baseline activities

• 57% casted group would have preferred brace!


“Ankle Injuries” with Foot Pain5th Metatarsal Avulsions• Caused by pulling of the

peroneus brevis• Always feel the bump!• CAM walker boot


Toddler’s fracture

• Any toddler with a mechanism and refuses to bear weight

• Regardless of exam or xray

• Wee Walker


Case #8

• A 13 y/o gymnast presents with right hip pain and the inability to bear weight. She felt a “pop” in her hip while doing the splits.


Her most likely diagnosis is…

a) Femur fracture

b) Hamstring strain

c) Pelvic avulsion fracture

d) Slipped capital femoral epiphysis(SCFE)


Ischium Avulsion

• On exam she had limited ROM with hip flexion, hip IROM, knee extension.

• She was tender to palpation over the ischium.


Pelvic Avulsion Fractures

• Occur with aggressive, athletic motions

• AIIS ‐ soccer/rugby

• ASIS ‐ sprinters/soccer

• Ischium ‐gymnasts/hurdlers

• Crutches, NWB, pain control


Case #9

• 16 yo runner (XC and track) presents with L‐hip pain x month

• Worse w/ running

• Does not recall injury


Femoral Neck Stress Fracture


Preventing fractures


Summary• The pediatric bone is unique and the

forces may change during bony development

• Proper fracture recognition and initial management is important in urgent care

• Removable splinting wonderful for many fractures


Sports Medicine Center (816) 701-HURT (4878)

• Stress fractures

• Sports-related concerns– Exercise induced

bronchospasm

– Spondylolysis

– Mono in the athlete, etc

• Sports-related fractures

• Acute sports-related injuries & dislocations

• Sports-related concussion

• Overuse syndromes


Questions ?

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