Lower Extremity Fractures in Children

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1 Lower Extremity Fractures in Children Stephanie M. Holmes, MD Department of Orthopaedic Surgery Pediatric Orthopaedic Division University of Utah School of Medicine

2 Overview Hip injuries avulsion fractures, other fractures Femur fractures shaft and distal femur Tibia fractures proximal, shaft, patella Ankle fractures Metatarsal fractures

3 Avulsion Fractures Almost always nonoperative tx Exception: Ischial tuberosity fx >1.5-2 cm displaced or pain with sitting

4 Avulsion Fractures ASIS Sartorius AIIS Rectus femoris Ischial tuberosity Hamstrings Greater trochanter Gluteus medius/minimus Lesser trochanter Iliopsoas Symphysis Adductors

5 1 Iliac crest; abdominal obliques 2 ASIS; sartorius 3 AIIS; rectus femoris 4 Lesser trochanter; iliopsoas 5 Ischial tuberosity; hamstrings

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9 Findings Recognition History Age: Usually yo Sudden pain with specific event Pop Common sports: soccer, gymnastics, sprinting Exam Local tenderness Weakness with contraction Pain with passive stretch

10 Lesser Trochanteric Avulsion 14 y/o F kicking soccer ball and was slide tackled with hyper extension of right leg while kicking

11 Ischial Tuberosity Avulsion (Non-op) 14 y/o M landed a ski jump and leg hyperflexed when ski popped off

12 Ischial tuberosity avulsion Operative (>1.5-2 cm displaced) 13 y/o F s/p doing the splits in dance

13 6 months post-op

14 Case 20 year old thin female Recently increased training for a marathon Two weeks away from competition Hip pain for one month, difficulty training

15 Stress Fractures Fatigue fractures Normal bone, abnormal stresses Insufficiency fractures Abnormal bone, normal stress Sites of stress fractures Femoral neck Sacrum Pubic rami Acetabulum Femoral head

16 Femoral Neck Stress Fractures Exercise induced pain Hip, groin, thigh, referred knee pain Classic description Female triad Eating disorder Amenorrhea Osteoporosis Military recruits Risk factors Sudden increase in activity Smoking Steroid use

17 Femoral Neck Stress Fractures Studies Radiographs Not helpful if symptoms early MRI Bone scan

18 Stress Fractures Tension sided Superior neck Compression sided Inferior neck Treatment Weight bearing restrictions Surgical pinning >50% neck width Tension sided injuries

19 Proximal Femur Fractures 90% from high-energy trauma Complications: AVN is most common complication Location predicts risk (Delbet classification) Coxa Vara (10-30%) Physeal closure (5-65%)

20 Delbet Classification Risk of AVN: Type I: % Type II: 50-60% Type III: 25-40% Type IV: not expected Treat types I-III emergently with ORIF (pins or screws); Capsulotomy decompresses hematoma Type IV can be reduced closed and fixed if reduction acceptable

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23 Femoral Shaft Fractures Most important to know: Treatment options in each age group Remodeling and overgrowth potentials When to be concerned about NAT

24 Treatment by age-guideline < 6 months Pavlik harness 6 months-5 years Spica cast Can plate or ex fix if too short (>3 cm) or not controllable in spica Traction is now historical

25 Treatment by age--guideline 5-11 years Length stable, diaphyseal, <49 kg: flexible IM nails Length unstable, proximal/distal: plating, ex fix (less common) >11 years Rigid TAN Plating if fx pattern not amenable to nail (subtroch, distal metadiaphyseal)

26 Overgrowth Most common in younger age group (2-5y) but can occur outside range Usually about cm; can be 2+ cm Happens primarily in first 2 years after injury Set fx treated with spica about 1-2 cm short if possible

27 1 week old, birth trauma

28 2 y/o tripped over dog 1 cm short Expect 1 to 1.5 cm of overgrowth on fractured side in kids younger than 6 This is why we like them overlapped to start with when they are younger

29 2 y/o NAT

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31 2 y/o NAT

32 1.5 cm short in spica ideal position

33 NAT 2009 AAOS CPG found that all children younger than 36 months with diaphyseal femur fracture should be evaluated for NAT Fracture pattern alone is not indicative of NAT Fx from NAT more common in distal femur Most common cause of femur fractures in nonambulatory patients is NAT

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36 5 y/o male, 45 lbs, fell out of tree 2.8 cm short

37 3 mo 3 cm 9 mo 2.2 cm

38 5 years later, 3.5 cm 18 mo after epiphyseodesis

39 8 y/o crashed ATV

40 2 years post op

41 8 y/o M skiing

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43 13 y/o M ski jumping Proximal shaft Physis closing 145 lbs

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45 17 y/o shooting a layup

46 Reconstruction nail, bone graft

47 Distal Femur Fractures Metaphyseal Can treat with CRPP/cast or ORIF Physeal (Salter I-IV) 50-80% risk of growth disturbance Risk is higher with displacement and younger age Can treat with CRPP/cast or ORIF

48 Salter-Harris classification

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51 13 y/o M, ATV, reduced in WY

52 Reduce and pin urgently

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54 Distal femoral buckle fx Parent/sibling drops/falls while holding infant Usually pre-ambulatory Heals in 3 weeks Can splint, with splint from ankle to lumbar area Hard to cast, but some parents want it

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57 Patellar Sleeve Fracture Avulsion of inferior (usually) patella with small bony fragment but large articular cartilage piece Usually during eccentric contraction Lack of active knee extension Palpable gap between patella and tibial tubercule Patella alta, small distal fragment

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59 Usually fixed with suture (woven through distal tendon, brought up through 2 bone tunnels and tied over superior patella Can be fixed with traditional tension band if distal piece big enough

60 Proximal Tibial Physeal and Metaphyseal Fractures Popliteal artery is close to the physis, so displacement in the sagittal plane can cause vascular injury (like a knee dislocation!)

61 Proximal Tibia Fractures Nondisplaced Cylinder cast, WBAT Displaced Hard to hold without fixation Usually pins/cast for 4-6 weeks Watch for compartment syndrome, vascular insult!

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65 Cozen s phenomenon (posttraumatic genu valgum) Usually after nondisplaced proximal tibia fractures 5% of all nondisplaced proximal tibia fractures Presents between 6-18 months after injury 2/3 correct spontaneously, 1/3 need hemiepiphyseodesis

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69 Tibia Shaft Fractures Almost all can be treated by closed methods Indications for operative stabilization: Open (sometimes) Multiply injured Floating knee Unstable/can t hold alignment in cast Plate Flex nails Ex fix

70 Tibial Shaft Fractures

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75 Tibial Shaft Fractures Toddler s fracture: Nondisplaced tibial shaft fracture in walking age children (18 mo-4 years) First xrays often normal Diagnose by palpation along tibial diaphysis Treat with BKC and WBAT for 4 weeks

76 Toddler s fracture Can treat in a boot in older children (3-5) Most pts with this injury are too small for the smallest boot and need a cast below the knee VERY important to have the ankle at 90 deg to prevent heel sore

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78 Ankle Fractures Distal tibia Many are operative, due to physis or joint involvement Distal fibula When isolated, most are nonoperative

79 The fracture that acts like a sprain

80 Salter-Harris classification

81 SH I or SH II distal fibula fractures The fracture that acts like a sprain Ankle XR are often normal Tender right over distal fibular physis and NOWHERE ELSE (no medial tenderness) Swelling is only lateral Treat in walking boot for 4-6 weeks

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83 Ankle Fx Refer anything that involves the distal tibial physis or the ankle joint

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88 Ankle Fractures Distal tibial physeal fractures arrest 10-25% Younger = more likely to create a deformity Transitional fractures Older, physis closing so less likely to cause deformity if arrest Triplane (age 10-13) Tillaux (age 12-15)

89 Triplane Fracture Salter IV fx Distal tibial physis closes medially first 2-, 3-, and 4-part When is CT helpful? Determine displacement? Surgical planning screw trajectory

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93 Tillaux Fractures Slightly older (12-15 y) Medial physis closed, posterolateral physis closing Open physis remains at anterolateral corner Fix when displaced >2 mm

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95 Metatarsal fractures Minimally displaced fractures can be treated in a boot or a cast (4-6 weeks) and WBAT Involvement of physis is NOT worrisome Beware the displaced ones and the 5 th MT fx

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98 Refer this

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100 Beware Jones fracture = 5 th MT at metadiaphyseal junction *refer this*

101 What can you treat yourself? What you can treat if you have the resources: Time Staff Staff who knows how to cast without damage Willingness to assume risk These are injuries that will still heal easily but patients often require casting or specialized splinting Toddler s fractures SH I and II distal fibula fractures Minimally displaced metatarsal fractures, some fifth metatarsal fractures (not Jones)

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103 Splinting Malfeasance NEVER put splint material behind the heel in a child younger than 12 years old Heel sores are a common and completely avoidable complication that are often much worse than the injury itself!

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105 Splinting Need to avoid skin complications (heel sores, wrinkling in splint) Do not overpad Get position before applying any material, and do not let it change

106 U splint-leg For ankle sprains and fractures Sometimes for tibia fractures (stable) Better than a posterior splint because avoids heel sores NEVER put on a posterior splint behind the heel unless ankle is neutral and absolutely necessary and >12 years of age

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108 Sugar tong splint-arm For wrist and forearm fractures Needs to be supplemented with a sling Does NOT adequately immobilize the elbow when the elbow is injured (see next splint)

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110 Posterior splint (arm) For elbow injuries Supracondylar fx need to be at 90 degrees of elbow flexion (if type I) Operative, displaced supracondylar fx need to be at 60 degrees (not extension) to protect skin

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