Lower Extremity Fracturesin ChildrenStephanie M. Holmes, MD

Department of Orthopaedic SurgeryPediatric Orthopaedic Division

University of Utah School of Medicine

Overview

• Hip injuries• avulsion fractures, other fractures

• Femur fractures• shaft and distal femur

• Tibia fractures• proximal, shaft, patella

• Ankle fractures• Metatarsal fractures

Avulsion Fractures

• Almost always nonoperative tx

• Exception:• Ischial tuberosity fx >1.5-2 cm displaced or pain with sitting

Avulsion Fractures• ASIS

• Sartorius• AIIS

• Rectus femoris• Ischial tuberosity

• Hamstrings• Greater trochanter

• Gluteus medius/minimus• Lesser trochanter

• Iliopsoas• Symphysis

• Adductors

1—Iliac crest; abdominal obliques

2—ASIS; sartorius

3—AIIS; rectus femoris

4—Lesser trochanter; iliopsoas

5—Ischial tuberosity; hamstrings

Findings

• Recognition• History

• Age: Usually 14-25 yo• Sudden pain with specific event• Pop• Common sports: soccer, gymnastics, sprinting

• Exam• Local tenderness• Weakness with contraction• Pain with passive stretch

Lesser Trochanteric Avulsion14 y/o F kicking soccer ball and was slide tackled with hyper extension of right leg while kicking

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

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

6 months post-op

Case

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

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

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

Femoral Neck Stress Fractures• Studies• Radiographs

• Not helpful if symptoms early

• MRI• Bone scan

Stress Fractures• Tension sided• Superior neck

• Compression sided• Inferior neck

• Treatment• Weight bearing

restrictions• Surgical pinning

• >50% neck width• Tension sided injuries

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%)

Delbet ClassificationRisk of AVN:

Type I: 80-100%Type II: 50-60%Type III: 25-40%Type IV: not expected

Treat types I-III emergentlywith ORIF (pins or screws);

Capsulotomy decompresseshematoma

Type IV can be reduced closed and fixed if reduction acceptable

Femoral Shaft Fractures

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

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

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)

Overgrowth

• Most common in younger age group (2-5y) but can occur outside range• Usually about 1-1.5 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

1 week old, birth trauma

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

2 y/o NAT

2 y/o NAT

1.5 cm short in spica—ideal position

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

5 y/o male, 45 lbs, fell out of tree2.8 cm short

• 3 mo• 3 cm

• 9 mo• 2.2 cm

• 5 years later, 3.5 cm • 18 mo after epiphyseodesis

8 y/o crashed ATV

2 years post op

8 y/o M skiing

13 y/o M ski jumping

Proximal shaft• Physis closing• 145 lbs

17 y/o shooting a layup

Reconstruction nail, bone graft

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

Salter-Harris classification

13 y/o M, ATV, “reduced” in WY

Reduce and pin urgently

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

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

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

Proximal Tibial Physeal and MetaphysealFractures• Popliteal artery is close to the physis, so displacement in the sagittal

plane can cause vascular injury (like a knee dislocation!)

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!

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

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

Tibial Shaft Fractures

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

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

Ankle Fractures

• Distal tibia• Many are operative, due to physis or joint involvement

• Distal fibula• When isolated, most are nonoperative

The fracture that acts like a sprain

Salter-Harris classification

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

Ankle Fx

• Refer anything that involves the distal tibial physis or the ankle joint

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)

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

Tillaux Fractures

• Slightly older (12-15 y)• Medial physis closed, posterolateral physis closing• Open physis remains at anterolateral corner

• Fix when displaced >2 mm

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 5th MT fx

Refer this

Beware

• Jones fracture

• = 5th MT at metadiaphysealjunction

• *refer this*

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)

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!

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

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

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)

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