Pediatric Pediatric Orthopedic Orthopedic FracturesFractures

Dafina Good, MDDafina Good, MDPediatric Emergency Medicine Pediatric Emergency Medicine

FellowFellowEmory University School of Emory University School of

MedicineMedicineChildren’s Healthcare of AtlantaChildren’s Healthcare of Atlanta

ObjectivesObjectives Review unique structural and physiologic Review unique structural and physiologic

differences between children and adult differences between children and adult skeletal systemsskeletal systems

Review fracture patterns unique to Review fracture patterns unique to childrenchildren

Review the Salter-Harris classification of Review the Salter-Harris classification of pediatric physeal fracturespediatric physeal fractures

Review common presentations and Review common presentations and EPONYMS of common pediatric and adult EPONYMS of common pediatric and adult fracturesfractures

Review Ottawa ankle and knee criteriaReview Ottawa ankle and knee criteria

EpidemiologyEpidemiology

Orthopedic trauma accounts for 10-Orthopedic trauma accounts for 10-15% of ED visits in urban pediatric 15% of ED visits in urban pediatric hospitalshospitals

It is estimated that over 40% of boys It is estimated that over 40% of boys and over 25% of girls will sustain a and over 25% of girls will sustain a fracture during childhood fracture during childhood

Rapid growth of organized sportsRapid growth of organized sports

Skeletal Differences Skeletal Differences between Children and between Children and

AdultsAdults Presence of Growth Plates (Physis)Presence of Growth Plates (Physis)

Growth plate injuries constitute up to 25% of all skeletal Growth plate injuries constitute up to 25% of all skeletal injuries in childreninjuries in children

Presence of Secondary Ossification Centers Presence of Secondary Ossification Centers (Epiphysis)(Epiphysis)

Rapid healing Rapid healing More metabolically active periosteum in childrenMore metabolically active periosteum in children

Greater Potential to RemodelGreater Potential to Remodel More porous and more pliable bonesMore porous and more pliable bones Fracture patterns unique to childrenFracture patterns unique to children Fractures are more common than sprains in young Fractures are more common than sprains in young

childrenchildren Ligaments and tendons attaching one bone to another have Ligaments and tendons attaching one bone to another have

greater strength than immature bonesgreater strength than immature bones

Normal Bone AnatomyNormal Bone Anatomy

Normal Bone AnatomyNormal Bone Anatomy

Describing FracturesDescribing Fractures Open vs. ClosedOpen vs. Closed Location (shaft, through growth plate etc.)Location (shaft, through growth plate etc.) Displacement in mmDisplacement in mm Shortening in mmShortening in mm Impaction if presentImpaction if present Angulation, degree and direction Angulation, degree and direction

(midshaft-direction of terminal fragment)(midshaft-direction of terminal fragment) Salter Harris ClassificationSalter Harris Classification Neurovascular statusNeurovascular status

Describing FracturesDescribing Fractures

Describing FracturesDescribing Fractures

Salter Harris Salter Harris ClassificationClassification

Fractures Unique to Fractures Unique to ChildrenChildren

Buckle or Torus Fractures

Fractures Unique to Fractures Unique to ChildrenChildren

Greenstick Fractures

Fractures Unique to Fractures Unique to ChildrenChildren

Greenstick Fractures

Fractures Unique to Fractures Unique to ChildrenChildren

Bowing Fractures

Fractures unique to Fractures unique to childrenchildren

Fractures unique to Fractures unique to childrenchildren

Toddler’s Fracture

Common Fracture Common Fracture EponymsEponyms

Who Named It?Who Named It?From the neck down to the toes!From the neck down to the toes!

Jefferson FractureJefferson Fracture

Hangman’s FractureHangman’s Fracture

Teardrop FractureTeardrop Fracture

Chance FractureChance Fracture

Boxer’s FractureBoxer’s Fracture

Hand AnatomyHand Anatomy

Bennett’s FractureBennett’s Fracture

Colle’s FractureColle’s Fracture

Smith’s FractureSmith’s Fracture

Nightstick FractureNightstick Fracture

Monteggia FractureMonteggia Fracture

Monteggia FractureMonteggia Fracture

Galeazzi FractureGaleazzi Fracture

Supracondylar FractureSupracondylar Fracture

Ossification Centers – C-R-I-T-Ossification Centers – C-R-I-T-O-EO-EApproximate age of appearanceApproximate age of appearance

CCapitellum - 1 yearapitellum - 1 yearRRadial head - 3 yearsadial head - 3 yearsIInternal epicondylenternal epicondyle (Medial epicondyle)-5 years (Medial epicondyle)-5 yearsTTrochlea - 7 yearsrochlea - 7 yearsOOlecranon - 9 yearslecranon - 9 yearsEExternal epicondyle xternal epicondyle (Lateral  epicondyle)-11 years (Lateral  epicondyle)-11 years

Proximal Humeral Proximal Humeral FractureFracture

Slipped Capital Femoral Slipped Capital Femoral EpiphysisEpiphysis

SCFE’s Klein’s LineSCFE’s Klein’s Line

Klein’s LineKlein’s Line

Pelvic Avulsion FracturesPelvic Avulsion Fractures

Common Locations of Common Locations of Pelvic Avulsion FracturesPelvic Avulsion Fractures

Spiral Femur FractureSpiral Femur Fracture

Osgood Slater Disease vs Sinding Osgood Slater Disease vs Sinding Larsen-JohanssonLarsen-Johansson

Patellar FracturePatellar Fracture

Knee AnatomyKnee Anatomy

Knee AnatomyKnee Anatomy

Ottawa Knee RulesOttawa Knee Rules

Characteristics of Patients Who Should Characteristics of Patients Who Should Undergo Radiography After Knee Trauma Undergo Radiography After Knee Trauma

Ottawa knee rulesOttawa knee rulesAge 55 years or olderAge 55 years or olderTenderness at head of fibulaTenderness at head of fibulaIsolated tenderness of patellaIsolated tenderness of patellaInability to flex knee to 90 degreesInability to flex knee to 90 degreesInability to walk four weight-bearing steps immediately Inability to walk four weight-bearing steps immediately after the injury and in the emergency departmentafter the injury and in the emergency department

Pittsburgh decision rulesPittsburgh decision rulesBlunt trauma or a fall as mechanism of injury plus either of Blunt trauma or a fall as mechanism of injury plus either of the following:the following:Age younger than 12 years or older than 50 yearsAge younger than 12 years or older than 50 yearsInability to walk four weight-bearing steps in the Inability to walk four weight-bearing steps in the emergency department emergency department

Corner FractureCorner Fracture

Bucket Handle FracturesBucket Handle Fractures

Maisonneuve FractureMaisonneuve Fracture

Tillaux FractureTillaux Fracture

Tillaux FractureTillaux Fracture

CT Scan of Tillaux CT Scan of Tillaux FractureFracture

Triplane FractureTriplane Fracture

Triplane FractureTriplane Fracture

What’s the Difference?What’s the Difference?

Anatomy of the Fifth Anatomy of the Fifth MetatarsalMetatarsal

Ottawa Ankle RulesOttawa Ankle Rules

Reasons to Refer to Reasons to Refer to OrthopedicsOrthopedics

Open FracturesOpen Fractures Unacceptably displaced fracturesUnacceptably displaced fractures Fractures with associated neurovascular Fractures with associated neurovascular

compromisecompromise Significant growth plate or joint injuriesSignificant growth plate or joint injuries Pelvic/Femur fractures (other than minor Pelvic/Femur fractures (other than minor

avulstions)avulstions) Spinal FracturesSpinal Fractures Dislocations of major joints other than Dislocations of major joints other than

shoulder/kneeshoulder/knee Clavicle (distal third)Clavicle (distal third) Fractures prone to Nonunion/MalunionFractures prone to Nonunion/Malunion

Why do we do it?Why do we do it?

Prevent Growth arrestPrevent Growth arrest Prevent malunion or nonunionPrevent malunion or nonunion Restore function as close to Restore function as close to

physiologicphysiologic