1 How do the pediatric musculoskeletal system and its response to stress differ from those in the adult?

2 What unique categories of fractures are commonly seen in pediatrics as a result of these differences?

Bachman D, Santora S: Orthopedic trauma. In Fleisher G, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins 2006, pp 1525–1569.

3 Describe the Salter-Harris classification of fractures.

Salter RB, Harris WR: Injuries involving the epiphyseal growth plate. J Bone Joint Surg 45A:587–622, 1963.

4 Why is the Salter-Harris classification important?

The Salter-Harris classification of fractures categorizes fractures that involve the growth plate. The classification has implications for both prognosis and treatment. Fractures categorized within the higher numbers of the classification are more likely to affect joint congruity and disrupt blood supply to the growth centers of the bone, leading to greater potential for future growth disturbance.

5 What is the Thurston-Holland sign?

This is the triangular fracture segment of the metaphysis found in Salter-Harris type II fractures.

6 What are the four zones in the physis? Through which zone do fractures commonly occur?

There are four zones in the physis, which are found in the following order from the epiphysis to the metaphysis:

Fractures typically occur through the zone of hypertrophic/maturing cells. The blood supply enters the bone through the epiphysis and is most crucial to the resting and proliferating cell layers.

7 At what age are physeal injuries most likely to occur?

Eighty percent occur between 10 and 16 years of age, with a median age of 13 years. Hypertrophy of the physis during the growth spurt and increased participation in physical activity and sports at this age are responsible for the increased incidence.

Peterson CA, Peterson HA: Analysis of the incidence of injuries to the epiphyseal growth plate. J Trauma 12:275–281, 1972.

8 How does a mallet finger deformity differ in children and adults?

The adult mallet finger is the result of disruption of the extensor tendon. In young children, the underlying injury involves a fracture through the growth plate—a Salter I fracture with displacement of the epiphysis. In older children or teenagers, the injury is an avulsion or Salter III fracture through the epiphysis. Such injuries may cause difficulty in reducing the finger and may require open reduction.

9 In what order do the growth centers in the elbow ossify? Why is this clinically important?

The mnemonic CRITOE is a useful reminder of the order in which these ossified growth centers appear:

An ossified fragment that is present out of its expected order suggests a fracture rather than a normal ossification center.

Radiology cases in pediatric medicine: elbow ossification centers in a child: www.hawaii.edu/medicine/pediatrics/pemxray/v1c11.html

10 What are plastic fractures?

Plastic fractures result from the pliability of the bones in childhood. Pediatric bones respond to compressive and transverse forces through plastic deformation. With a small amount of force, the bone is capable of bending slightly and then returning to its natural state. If excessive force is applied, the bone eventually exceeds its capacity for full elastic recoil and deforms. Depending on the degree of force and how it is applied, one of the three plastic fractures of childhood may result.

11 Name the three types of plastic fractures of childhood.

12 Why is it important to reduce a forearm bowing fracture?

These fractures do not include injury to the periosteum and therefore do not undergo as vigorous stimulation to remodel. This may result in permanent angulation of the bone, which can have deleterious effects on the normal range of motion and function of the involved forearm.

Vorlat P, De Boeck H: Bowing fractures of the forearm in children. Clin Orthop Relat Res 413:233–237, 2003.

13 In what situations are comparison films most useful?

14 How do you evaluate distal nerve function in an uncooperative or preverbal child following extremity or digit injury?

Placing the fingers in a bowl of warm water for several minutes results in wrinkling of the skin on the finger pads if distal nerve function is intact.

Eberlein R: Hand and finger injuries. In King C, Henretig FM (eds): Textbook of Pediatric Emergency Procedures. Baltimore, Williams & Wilkins, 2007.

15 What is a FOOSH? What is its significance to pediatric extremity injuries?

A FOOSH is a fall on an outstretched hand. This is the most common mechanism of forearm, elbow, and wrist injuries in children.

Perron AD, Miller MD, Brady WJ: Orthopedic pitfalls in the ED: Pediatric growth plate injuries. Am J Emerg Med 20:50–54, 2002.

16 What name is associated with a Salter III fracture of the distal tibia? How is this fracture related to the age and growth of a child?

A Salter III fracture of the distal tibia is called a Tillaux fracture (Fig. 54-1). It classically occurs in teenagers shortly before growth plate closure. The medial segment of the distal tibial physis fuses last, and the medial aspect of the distal epiphysis remains anchored to the fibula by the anterior tibiofibular ligament. External rotation of the foot with sufficient force produces an avulsion fracture through the unfused medial segment of growth plate and down through the epiphysis.

Figure 54-1 Salter III fracture of the distal tibia, commonly called a Tillaux fracture.

Koury SI, Stone CK, Harell G, et al: Recognition and management of Tillaux fractures in adolescents. Pediatr Emerg Care 15:37–39, 1999.

17 What is a “wagon wheel injury”?

Fracture of the distal femoral epiphysis. In the 19th century, such fractures resulted when the child’s leg became entrapped between the wagon and the spokes of a wagon wheel. The femoral physis is at particular risk of injury. The medial and lateral collateral ligaments of the knee insert on the femoral epiphysis and provide no support for the growth plate.

18 What is the difference between Galeazzi and Monteggia fractures?

Both injuries involve a combination forearm fracture and dislocation. The Galeazzi fracture is a fracture of the radius with dislocation of the radioulnar joint. The Monteggia fracture is an ulnar fracture with radial head dislocation. The dislocations associated with these fractures are at risk of being overlooked once the fracture has been identified.

19 What is a toddler’s fracture?

A toddler’s fracture is described most commonly as a hairline, nondisplaced spiral or oblique fracture of the distal third of the tibia. It occurs, as its name suggests, in ambulatory children up to approximately 4 years of age. It often results from relatively minor force, such as a fall from a step or the end of a sliding board.

Tenenbein M, Reed MH, Black GB: The toddler’s fracture revisited. Am J Emerg Med 8:208–211, 1990.

20 What is the apprehension test? When is it useful?

The apprehension test is a provocative test consisting of lateral force applied to the patella with the leg in full extension. It is useful when a recent patella dislocation with spontaneous reduction is suspected. In a positive test result, the child resists the examiner for fear of recurrence of the dislocation.

21 How do you differentiate an avulsion fracture at the proximal fifth metatarsal from the normal secondary site of ossification?

Avulsion injuries of the proximal fifth metatarsal occur during inversion of the ankle. Stress is transmitted through the peroneus brevis ligament, which inserts on the proximal fifth metatarsal. The resulting fracture line is transverse to the foot, whereas the secondary site of ossification (os vesalianum) occurs in a longitudinal orientation. A comparison view of the normal foot may be helpful. Palpating for tenderness over the area is a simpler means of making the distinction.

22 What is the mechanism of injury in a “boxer’s fracture”?

Fractures of the fourth or fifth metacarpal (“boxer’s fractures”) are sustained when a person strikes an object with a closed fist. Destructive infections of the hand and metacarpophalangeal joint can occur when one person strikes another in the teeth and mouth flora are introduced into the resulting lacerations.

23 Describe the initial approach to the trauma victim with a significantly deformed extremity fracture.

The initial approach to any trauma patient should focus on potential life-threatening injuries. The primary survey consists of evaluation and stabilization of the airway, breathing, and circulation. The physician should not be distracted by the more obvious extremity injuries, which are rarely life-threatening. Extremity fractures are more appropriately addressed as part of the secondary survey.

24 What factors determine the need for fracture reduction?

Pediatric bones have a high capacity to remodel. As a general rule, remodeling should not be relied upon to correct all deformities. Fractures should be immobilized as close to anatomic position as possible. No degree of deformation is considered acceptable in all cases. The decision to actively reduce a particular fracture or to rely on remodeling depends on several factors:

25 What pediatric extremity injuries require emergent orthopedic consultation?

Bachman D, Santora S: Orthopedic trauma. In Fleisher G, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins 2006, pp 1525–1569.

26 List the key factors that should be communicated when an orthopedic consultation is requested.

27 Describe the appropriate acute management for the vast majority of extremity injuries.

The mnemonic PRICE summarizes the key elements:

The various components of this therapy help to reduce hemorrhage, posttraumatic edema, and pain. Immobilization prevents extension of soft tissue and neurovascular injury. The lack of consistent attention to pain management is a major problem in the care of injured children.

Cimpello LB, Khine H, Avner JR: Practice patterns of pediatric versus general emergency physicians for pain management of fractures in pediatric patients. Pediatr Emerg Care 20:228–232, 2004.

28 How do you reduce a dislocated patella?

A dislocated patella almost always reduces spontaneously when the leg is placed in extension; it remains dislocated only when the patient maintains the leg in flexion. Flexion of the hips to relax the quadriceps muscles may aid in the reduction. Occasionally a small amount of pressure applied on the medial side of the patella is necessary. After reduction the joint should be immobilized and radiographs obtained to rule out associated fractures. Whether prereduction radiographs are useful or simply prolong the patient’s discomfort remains controversial.

29 What clinical findings suggest a compartment syndrome?

In addition to a tense, swollen area at the injury site, clinical findings may include the 5 Ps:

Pain out of proportion or distal to the injury is the earliest and most sensitive sign of compartment syndrome and frequently the only one present. One study found pain and an increasing requirement for pain medications in 90% of children with compartment syndrome. Of the other Ps, only paresthesia was present in greater than 50% of patients. Pain is increased with passive extension of involved muscles. Notably, the absence of a distal pulse is not necessary for the diagnosis.

Bae DS, Kadiyala RK, Waters PM: Acute compartment syndrome in children: Contemporary diagnosis, treatment and outcome. J Pediatr Orthop 21:680–688, 2001.

30 What extremity injuries are at the highest risk for compartment syndrome?

Compartment syndrome can occur in the hand, foot, forearm, thigh, or leg, but most frequently involves the anterior tibial and peroneal compartments of the leg and the deep flexor compartment of the arm. Most compartment syndromes in children involve fractures (75–85%). Open fractures are at twice the risk of compartment syndrome as closed fractures. Specific injuries associated with compartment syndrome include:

Grottkau BE, Epps HR, Discala CD: Compartment syndrome in children and adolescents. J Pediatr Surg 40:678–682, 2005.

31 What is Volkmann’s contracture?

Volkmann’s contracture is the deformation that results from ischemia of the muscles and other soft tissues. It occurs most commonly in the forearm as the result of a compartment syndrome. The predisposing injury in children is frequently a supracondylar fracture.

32 What is a gunstock deformity?

A gunstock deformity or cubitus varus deformity occurs when a supracondylar fracture heals with poor alignment. This results in medial displacement of the distal humerus. It is the most common complication of supracondylar fractures. Cubitus varus is most often a cosmetic rather than a functional deformity.

Labelle H, Bunnell WP, Duhaime M, et al: Cubitus varus deformity following supracondylar fractures of the humerus in children. J Pediatr Orthop 1:539–546, 1982.

33 Describe the diagnosis and management of metaphyseal chip fractures.

The radiograph in Fig. 54-2 depicts metaphyseal chip or “corner” fractures. The finding is highly suggestive of child abuse. The likely mechanism is vigorous pulling or shaking of the limbs. Corner fractures are most common in the distal femur and proximal tibia. Treatment should consist of splinting and pain management as well as a search for other evidence of abuse, including a skeletal survey. Social work services and child welfare should be involved.

Figure 54-2 Radiograph of a metaphyseal chip or “corner” fractures. This finding is highly suggestive of child abuse. The likely mechanism is vigorous pulling or shaking of the limbs. Corner fractures are most common in the distal femur and proximal tibia.

34 What extremity fractures are associated with abuse?

Up to 10% of all extremity injuries in children are inflicted. Almost any extremity injury may be the result of abuse. Classic extremity fractures that are more specific for abuse include:

35 Explain the term nursemaid’s elbow.

The term refers to the most common mechanism for obtaining a radial head subluxation injury. A nursemaid may abruptly lift a young child by the wrist while crossing a street or attempting to prevent a stumbling child from falling. Traction is applied to the forearm with the elbow extended and the forearm in pronation. A nursemaid’s elbow can occur without a history of this classic mechanism.

36 What is the typical clinical presentation for a nursemaid’s elbow?

Children typically do not appear to be in pain, but refuse to use the affected arm. The arm is held in pronation and slight flexion at the side of the body. The examiner detects no swelling, point tenderness, bruising, or warmth over the joint. The child may hold the wrist on the affected side to support the extremity, often leading the parents to believe that the wrist is involved. Mild dependent edema of the hand may appear as swelling and further confuse the picture. There is no point tenderness over the elbow, but resistance to supination, flexion, and pronation is noticeable.

37 Name the classic radiographic findings for a radial head subluxation (nursemaid’s elbow).

There are no diagnostic radiographic findings for a radial head subluxation. Radiographs appear normal. They should be obtained only when the diagnosis is in question after the history and physical examination. In this setting, radiography is performed to rule out alternative causes of elbow pain.

Swischuk LE: Emergency Imaging of the Acutely Ill or Injured Child, 4th ed. Philadelphia, Lippincott Williams & Wilkins, 2000.

38 Describe two accepted maneuvers for reducing a radial head subluxation.

In both procedures, the child is seated in the parent’s lap, facing the examiner. The examiner grasps the elbow and provides stabilization with the nondominant hand. With the dominant hand, the examiner holds the wrist or hand of the child’s affected side and either (1) hyperpronates or (2) supinates the forearm and then flexes the elbow in one smooth motion so that the child’s hand comes up to the ipsilateral shoulder. A palpable “pop” may be appreciated at the elbow as the reduction occurs. Over 90% of patients begin using the elbow normally within 15 minutes of successful reduction.

Supination or pronation with the elbow in extension also has been described as a successful means of reducing radial head subluxations.

Macias CG, Bothner J, Wiebe R: A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Pediatrics 102:e10, 1998.

39 What radiologic findings on a lateral elbow film suggest the presence of an occult fracture?

A visible posterior fat pad or outward displacement of the anterior fat pad away from the humerus is evidence of an elbow effusion. A fracture should be assumed to be present when an elbow effusion is seen in the setting of elbow trauma.

A malaligned anterior humeral line (one that does not pass through the middle or posterior third of the capitellum) suggests the presence of a supracondylar fracture with dorsal displacement of the capitellum and distal humerus.

Malalignment of the radiocapitellar line, as determined by a line through the center of the radius that does not pass through center of the capitellum on either the anteroposterior or lateral radiograph, is evidence of a dislocated radius.

Swischuk LE: Emergency Imaging of the Acutely Ill or Injured Child, 4th ed. Philadelphia, Lippincott Williams & Wilkins, 2000.

40 What is the most frequently fractured bone in a pediatric elbow injury?

In one study of children with elbow fractures, 81% of elbow fractures involved the distal humerus. Radial head fractures accounted for 9% of elbow fractures, and proximal ulnar fractures for 10%. Supracondylar fractures were found in 60% of the total, with medial epicondylar fractures in 7% and lateral condyle fractures in 19%.

John SD, Wherry K, Swischuk LE, et al: Improving detection of elbow fractures by understanding their mechanics. Radiography 16:1443–1460, 1996.

41 What are the three classifications of supracondylar fractures?

The three Gartland classifications of supracondylar fractures are:

All type III fractures and most type II supracondylar fractures (Fig. 54-3) require percutaneous pinning to obtain appropriate reduction and to reduce complications.

Figure 54-3 Supracondylar fracture.

Pediatric supracondylar fractures of the humerus. Wheeless’ Online Textbook of Orthopedic Surgery: www.wheelessonline.com/ortho/pediatric_supracondylar_fractures_of_the_humerus

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