39 th National Conference on Pediatric Health Care Fracture vs. Break: Is There a Difference? Jennifer Weiner, MS, RN, CPNP AC/PC March 21, 2018 March 19-22, 2018 CHICAGO Disclosures I have no conflicts of interest related to this presentation to disclose 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 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 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 Age Gender Mechanism of injury Anatomic location Soft tissue involvement Key physical findings Communication 1
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 Reading an X ray How to Describe a Fracture Mnemonic OLD ACID Open vs Closed Location Degree Articular extension Communiution/Pattern Intrinsic bone quality Displacement, angulation, rotation 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 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 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 Anatomy Degree Complete Complete cortical disruption Incomplete Periosteum intact Only one cortex involved Ex: Greenstick fracture, type 1 supracondylar humerus fracture 2
Involves the articular surface Dislocation Fracture Dislocation Monteggia fracture Articular extension Transverse Oblique Spiral Linear/longitudinal Segmental Comminuted Compression/Impacted Distraction/avulsion Communition/Pattern Normal Osteopetrosis Osteopenia CP Tumor Nutritional Cysts Rickets Osteogenesis Imperfecta Intrinsic bone quality Displacement/Angulation/Rotation Displacement Two ends of the fracture moving away from each other Described as a percentage Displacement/Angulation/Rotation Angulation Motion relative to the long axis of the bone Direction and degree are important to note Displacement/Angulation/Rotation Rotation Extent to which fragments are rotated relative to each other Describe the distal fragment 3
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 Name this Fracture 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 A. Right midshaft tibia and fibula fracture B. Closed right transverse midshaft tibia and fibula fracture with mild apex anterior angulation and 50% displacement of the tibia C. Right transverse midshaft tibia fracture D. Left closed transverse midshaft tibia and fibula fracture with angulation and displacement Name this Fracture 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 The Physis Buckle Greenstick Plastic deformation Salter Harris classification for growth plate injuries Pediatric Fracture Variance 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 4
Physeal Fracture Description 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 Supracondylar Humerus Fractures 60% of pediatric elbow fractures Ages 5 10 years Fall on an outstretched hand Non dominant extremity Supracondylar Humerus Fractures Inspection Pulse Perfusion Neurologic function AP and true lateral of elbow Supracondylar Humerus Fractures 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 5
Both Bone Forearm Fractures 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 Inspection Neurovascular exam Both Bone Forearm Fractures AP and lateral of forearm Open Closed reduction, casting vs OR for formal I&D 24 48 hours IV antibiotics Closed Closed reduction, casting Strict instructions on monitoring 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 Inspection Palpation Neurovascular Distal Radius Fractures AP and lateral of wrist Include forearm and elbow if concerns per history Closed reduction and casting if closed Open fractures IV antibiotics Closed reduction and casting vs OR 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 Age dependent 6
Proximal Humerus Fractures Proximal Humerus Fractures AP and lateral views of the humerus Immobilization Sling and swathe Hanging arm cast Coaptation splint Enormous remodeling potential Do not need anatomic alignment Can usually avoid OR 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 Femur Fractures Standard AP and lateral films 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 Femur Fractures 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 Inspection Palpation 7
Tibia Shaft Fractures Tibia Shaft Fractures AP and lateral views Varies depending on mechanism and age Can mostly close reduce and cast Surgery is rarely indicated with shaft fractures 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 Toddler s Fracture AP and lateral of tibia May show faint fracture line that is easily missed Immobilization in short leg cast Allowed to ambulate in cast 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 Inspection Palpation Neurovascular exam AP, lateral, and mortise views CT scan Types SH 1 5 fractures Tillaux Triplane Ankle Fractures 8
Tillaux Fracture Type of SH 3 fracture Occurs in ages 12 14 Triplane Fracture Type of SH 4 fracture Average age is 13 Ankle Fractures Ankle Fractures Depends on age, type, displacement, and stability Closed reduction and casting Open reduction and casting Open vs closed reduction with internal fixation 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 Name this Fracture Remodeling Follow up Fracture Management Remodeling Remodeling Three phases of fracture healing Inflammatory Hematoma forms Incites production of proteins Reparative Initial callus formed Remodeling Can last months to years 9
Factors Amount of growth remaining Plane of deformity Wolff s Law Location of fracture Metaphysis Diaphysis Relationship to physis Remodeling Follow Up Closely monitor first 48 72 hours Follow weekly first 2 weeks Every other week until cast off Follow physical injuries for years 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 Complications Casting Pressure related injuries Loss of reduction Needs to be well padded and molded 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 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 10
Summary Communication Age, gender, mechanism, key physical findings, imaging, anatomic location, and soft tissue involvement OLD ACID Also using unique names Remodeling Complications 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). 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 11