Dennis R.

Wenger, MD, and Mercer Rang

(1933-2003), MD, Toronto—2001
(Dr. Wenger was a prior fellow at HSC—Toronto—
Mercer Rang and Dennis Wenger have been
involved in multiple publication efforts)
 Maya E. Pring, MD
Dr. Pring attended medical school at the University
of Colorado and took her orthopedic residency at
the Mayo Clinic followed by a fellowship in
children’s orthopedics at Rady Children’s Hospital,
San Diego/UCSD. She is a UCSD faculty member
and residency coordinator at Rady Children’s
Hospital. She has clinical and research interests in
children’s fractures.
 Andrew T. Pennock, MD
Dr. Pennock attended medical school at the
University of Chicago and took his orthopedic
residency at the University of California, San Diego
followed by a fellowship in sports medicine at the
Steadman Hawkins Clinic in Vail, Colorado. His
practice is devoted to sports medicine in children
and adolescents, but he also has an extensive
interest in children’s trauma including research in
both sports medicine and trauma.
 Vidyadhar V. Upasani, MD
Dr. Upasani attended medical school at University
of California, San Diego and took his orthopedic
residency at UCSD followed by a fellowship in
children’s orthopedics at Boston Children’s
Hospital. He is now active in both clinical and
research aspects of children’s orthopedics with a
special interested in hip disorders in childhood,
spine conditions, and children’s trauma. He is
widely published in multiple areas.
RANG’S
CHILDREN’S
FRACTURES
Fourth edition

Dennis R. Wenger, MD
Director, Pediatric Orthopedic Training Program
Rady Children’s Hospital, San Diego
Clinical Professor of Orthopedic Surgery
University of California, San Diego
San Diego, California

Maya E. Pring, MD
Coordinator, Pediatric Orthopedic Residency
Rady Children’s Hospital, San Diego
Clinical Professor of Orthopedic Surgery
University of California, San Diego
San Diego, California

Andrew T. Pennock, MD
Staff Orthopedic Surgeon
Rady Children’s Hospital, San Diego
Associate Clinical Professor of Orthopedic Surgery
University of California, San Diego
San Diego, California

Vidyadhar V. Upasani, MD
Staff Orthopedic Surgeon
Rady Children’s Hospital, San Diego
Assistant Clinical Professor of Orthopedic Surgery
University of California, San Diego
San Diego, California
Acquisitions Editor: Brian Brown
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Library of Congress Cataloging-in-Publication Data
Names: Wenger, Dennis R. (Dennis Ray), author. | Pring, Maya E., author. |
Pennock, Andrew T., author. | Upasani, Vidyadhar V., author. | Preceded by
(work): Rang, Mercer. Rang’s children’s fractures.
Title: Rang’s children’s fractures / Dennis R. Wenger, Maya E. Pring, Andrew T.
Pennock, Vidyadhar V. Upasani.
Other titles: Children’s fractures
Description: Fourth edition. | Philadelphia : Wolters Kluwer Health, [2018] |
Preceded by: Rang’s children’s fractures / Mercer Rang, Maya E. Pring,
Dennis R. Wenger. | Includes bibliographical references and index.
Identifiers: LCCN 2017043478 | ISBN 9781496368171
Subjects: | MESH: Fractures, Bone | Child
Classification: LCC RD101 | NLM WE 180 | DDC 617.1/5083—dc23 LC record
available at https://lccn.loc.gov/2017043478
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 Table of Contents
Chapter 1 – Children Are Not Just Small Adults
Chapter 2 – The Physis and Skeletal Injury
Chapter 3 – Orthopedic Literacy: Fracture
Description and Resource Utilization
Chapter 4 – Emergency Fracture Reduction
Chapter 5 – Casts for Children’s Fractures
Chapter 6 – Clavicle
Chapter 7 – Shoulder and Humeral Shaft
Chapter 8 – Elbow—Distal Humerus
Chapter 9 – Elbow—Proximal Radius and Ulna
Chapter 10 – Radius and Ulna
Chapter 11 – Hand
Chapter 12 – Pelvis and Hip
Chapter 13 – Femoral Shaft
Chapter 14 – Knee
Chapter 15 – Tibia and Fibula
Chapter 16 – Ankle
Chapter 17 – Foot
Chapter 18 – Spine
Chapter 19 – Fractures in Special Circumstances
Chapter 20 – Accident Prevention, Risk, and the
Evolving Epidemiology of Fractures
Coda
Index
 Contributors
James Bomar, MPH
Research Coordinator
Department of Orthopedics
Rady Children’s Hospital, San Diego
San Diego, California

Henry Chambers, MD
Director, Cerebral Palsy Center
Co-Director, 360 Sports Medicine
Rady Children’s Hospital, San Diego
Professor of Clinical Orthopedic Surgery
University of California, San Diego
San Diego, California

Eric Edmonds, MD
Director of Orthopedic Research
Co-Director, 360 Sports Medicine
Rady Children’s Hospital, San Diego
Associate Professor of Clinical Orthopedic Surgery
University of California, San Diego
San Diego, California

Scott Mubarak, MD
Surgeon-in-Chief for Rady Children’s Specialists of
San Diego
Clinical Director, Division of Orthopedics and Scoliosis
Rady Children’s Hospital, San Diego
Professor of Clinical Orthopedic Surgery
University of California, San Diego
San Diego, California

Peter Newton, MD
Orthopedic Division Chief
Director, Scoliosis Service
Rady Children’s Hospital, San Diego
Clinical Professor of Orthopedic Surgery
University of California, San Diego
San Diego, California

Sun Min Park, CPNP

Nurse Practitioner
Department of Orthopedics
Rady Children’s Hospital, San Diego
San Diego, California

Andrew T. Pennock, MD
Staff Orthopedic Surgeon
Rady Children’s Hospital, San Diego
Associate Clinical Professor of Orthopedic Surgery
University of California, San Diego
San Diego, California

Maya E. Pring, MD
Coordinator, Pediatric Orthopedic Residency
Rady Children’s Hospital, San Diego
Clinical Professor of Orthopedic Surgery
University of California, San Diego
San Diego, California

Vidyadhar V. Upasani, MD
Staff Orthopedic Surgeon
Rady Children’s Hospital, San Diego
Assistant Clinical Professor of Orthopedic Surgery
University of California, San Diego
San Diego, California

C. Douglas Wallace, MD
Director, Orthopedic Trauma
Rady Children’s Hospital, San Diego
Associate Clinical Professor of Orthopedic Surgery
University of California, San Diego
San Diego, California

Dennis R. Wenger, MD
Director, Pediatric Orthopedic Training Program
Rady Children’s Hospital, San Diego
Clinical Professor of Orthopedic Surgery
University of California, San Diego
San Diego, California

Burt Yaszay, MD
Staff Orthopedic Surgeon
Rady Children’s Hospital, San Diego
Associate Clinical Professor of Orthopedic Surgery
University of California, San Diego
San Diego, California
 Foreword

Colin F. Moseley, MD
Hospital for Sick Children—Toronto Shrine Hospital—Los
Angeles Hilton Head Island—South Carolina

When Dr. Mercer Rang published the first edition of this

book in 1974, it quickly became the go-to reference for
residents and others learning children’s fractures. From
the Hospital for Sick Children in Toronto, it was the
product of a busy clinical practice in a highly academic
environment. It took advantage of Mercer’s distinctive
talents as teacher and author, for he was a lateral thinker
and often had a different slant on things. He was skilled at
getting down to brass tacks. When he presented his views
on a subject, they were usually more interesting, engaging,
and entertaining than other views and were often
presented in a light-hearted and humorous manner. His
personality shone through in everything he wrote.
His illustrations were also distinctive. Mercer drew
many of his own so that they would say exactly what he
wanted them to say with no distracting detail. These simple
line drawings, almost ghost-like depictions of babies and
children, were a hallmark of his teaching and writing.
It was natural that for the third edition of his text, he
found a kindred spirit in Dr. Dennis Wenger as a co-author.
Also a lateral thinker, Dennis had been a fellow at the
Hospital for Sick Children where the two became fast
friends. Their collaboration was a very comfortable fit and
must have been great fun for both of them. Most important,
the resulting text continued the ideals of earlier editions
with engaging text, clear illustrations, a light-hearted
approach, and an emphasis on human values. Mercer felt
that more improvement in fracture care would derive from
better understanding of established concepts than from
new knowledge, and the authors continued the
commitment to clear explanation of principles.
Since Mercer Rang’s death in 2003, Dr. Wenger has
been joined by Dr. Maya Pring and other colleagues as
authors of this text, and the clinical foundation has shifted
to San Diego, notably another busy pediatric orthopaedic
practice in a strong academic environment. Drs. Wenger,
Upasani, Pring, and Pennock, the authors of this, the fourth
edition, are therefore ideally situated to provide a
comprehensive and tested approach to children’s fractures.
This book is not a compendium of all knowledge on the
subject, nor is it a cookbook, but follows a practical path
between the two by presenting a solid working approach
supported by basic principles. It augments earlier editions
by presenting historical references that provide meaning to
commonly used terminology.
 Mercer Rang would be pleased to see that the current
authors have embraced the principles of his earlier editions
and would be delighted to see the extent to which they
have taken advantage of modern tools to produce a book
that is beautifully presented and visually stunning. It is
meat for the mind, candy for the eyes, and deserves a place
on the bookshelves of orthopedic residents and emergency
departments everywhere.—Colin F. Moseley
 Preface

Dennis R. Wenger, MD
University of California, San Diego Rady Children’s
Hospital, San Diego

The world of children’s fracture care has changed

remarkably since the 1974 first edition of this textbook.
When Mercer Rang (a native of England) was recruited
from Kingston, Jamaica, to the Hospital for Sick Children in
Toronto in 1967, one of his assignments was to study
fracture care in children. At that time, the only significant
textbook on children’s fractures was that of Walter Blount,
which had last been published in 1955.
Mercer Rang recognized this void and understood that
contemporary orthopedic residents needed to know more
than the principles that Walter Blount had espoused if they
were to provide state-of-the-art fracture care for children.
(It should be noted that Blount’s text said nothing about
growth plate injuries.) The A-O concepts from Switzerland
made their first North American appearance in Canada
(especially Toronto and Montreal) in the late 1960s and
early 1970s, and Rang was quick to recognize that many of
their principles applied to children’s fractures. This is
particularly true of forearm fractures in children over age
10, who up until that time had been primarily treated by
closed methods, with almost any degree of angulation
accepted. Rang clarified that older children had little
potential for remodeling and required adult treatment
methods.
Rang’s first edition text briefly presented the traditions
of children’s fracture treatment and then proceeded to
illustrate and explain children’s fractures in a way that was
clearer and more entertaining than in any prior publication.
The success of the text was immediate, becoming a
standard reference throughout the orthopedic world. This
success was further aided by Rang’s brilliant speaking
style, which made all who heard him speak want to buy the
book.
A second equally successful edition was published in
1983. Two decades later the idea of a third edition evolved
in conversations between Mercer Rang and me in 2002.
Later that year, we initiated the revision. By that time, our
children’s hospital in San Diego had an extensive clinical
and research unit devoted to treatment of children’s
fractures, and we decided that the third edition should be
based in San Diego, and Dr. Maya Pring was added as an
author/editor. This 2005 third edition included Mercer
Rang as an author and illustrator; however, a serious
illness limited his involvement to the first half of the text,
and sadly he passed away in October 2003. We journeyed
on, adding many new chapters, including casts in children,
fracture epidemiology, and cultural issues related to
children’s fractures.
This fourth edition is again designed for medical
students, physician’s assistants, residents, emergency room
doctors, general orthopedists, and children’s orthopedists.
The practical, sometimes playful style, and the thinking of
Mercer Rang, has as much as possible been maintained. We
have expanded to four author/editors (myself, Maya Pring,
Vidyadhar Upasani, and Andrew Pennock), all of whom are
on our Rady Children’s Hospital/University of California,
San Diego faculty.
All contributing authors are from our hospital, thus
ensuring a somewhat “standard philosophy.” The growth of
“orthopedic sports medicine/surgery” in our center, with 3
of our 10 faculty dedicated to the field, greatly strengthens
this edition. The exponential growth of youth sports in
North America, with its accompanying common injuries,
has become an important segment of our fracture
treatment experience.
We have expanded and further illustrated the chapter
on “casts in children,” which has become a popular and
important source of information on what some consider a
“dying art” (at least in the hands of surgeons). This is most
true in advanced Western cultures where “orthopedic
technicians” (also known as “cast technicians”) have taken
over this responsibility.
As in prior editions, we have focused on a style
somewhere between that of a traditional medical text and
that of a typical college textbook. I have always been struck
by the friendliness and ease of use of contemporary
textbooks used in North American high schools and
universities, and we have tried to emulate that style here.
In closing, I wish to dedicate this fourth edition to the
spirit of my mentor, Mercer Rang, who introduced me to
logical orthopedic thinking and an educational style that
remains unsurpassed. His grace, style, and sense of humor
made orthopedic education a brilliant art form.

Dennis R. Wenger, MD
San Diego, 2017

Mercer Rang and Anne Wenger (age 2 years) in

San Diego—1985. The picture beautifully illustrates
two of Mercer’s loves; that is, being an artist of
some renown as well as a great friend of children.
 A Note From The Rang
Family
Conversations with our dad often spanned a wide range of
topics. He was equally comfortable discussing the best way
to paint a cloud (remember the bottom), why wing chairs
have antimacassars (hair oil came from Makassar,
Indonesia), why it is useful to know that Lisfranc was
Napoleon’s surgeon (when soldiers fell off horses, their feet
were held fixed in the stirrups), and his idea for #48 in his
forever upcoming book, “101 Uses for a Coat Hanger” (split
ring for a sailboat backstay). Of course, all of this dinner
table conversation often got interrupted with “I have to go
down to the buildings to drain a hip.”

And that was Mercer Rang in a nutshell—intensely

interested in the world around him—devoted to making
complex ideas simple and passionate about children’s
health.

Dad would be absolutely delighted to know a publisher

would believe that Children’s Fractures was worthy of
another edition. And he would have been even more
pleased to see what his old friend, Dr. Dennis Wenger,
along with the talented authors/editors, Drs. Pring,
Upasani, and Pennock; a book design team led by JD
Bomar, MPH; and an excellent team of contributors have
produced.

In fact, dad’s usual parting greeting was “Enjoy

Yourselves!” and we feel that you will do just that as you
read this book.
Best wishes,

Caroline McInnis, Sarah Rang, and Louise Rang

(Mercer’s daughters)

P.S. “The inside of the cast should be as smooth as a baby’s

bottom.”
 Acknowledgments

JD Bomar, MPH
Research Coordinator
Rady Children’s Hospital, San Diego
Mr. Bomar is a Research Coordinator at Rady Children’s Hospital,
San Diego, and a leader of the hip research team. He is an expert in
digital methods, orthopedic illustration, and digital layout for
publications. His energy and skills have helped to make Rady
Children’s Hospital, San Diego, a leading orthopedic center for both
clinical research and publication.

We are grateful to our faculty colleagues in San Diego for

their assistance and interest in revising this text. Working
in an academic program that includes 10 faculty, all of
whom have extensive experience in managing children’s
fractures, is a distinct privilege. Our level one trauma
center provides a volume of both straightforward and
complex injuries, which provides the experience that has
allowed us to become a widely recognized center for
fracture care in childhood. We thank our hospital for our
excellent physical facilities and support for orthopedic care.
A fracture treatment philosophy, which evolved at the
Hospital for Sick Children in Toronto, has been transferred
and expanded at Rady Children’s Hospital, San Diego. We
fortunately have been able to expand and further develop
the children’s fracture cognitive base, including extensive
research with many publications on the subject. We would
like to thank Tracey Bastrom, our Research Program
Manager, and Morgan Dennis and Amanda Davis-Juarez,
our trauma research team, for making our
research/publication mission so successful.
We have a sophisticated staff of advanced care
practitioners (nurse practitioners and physician assistants)
who allow us to manage a high-volume fracture experience
and who have also contributed to this fourth edition. Sun
Min Park’s authorship of Chapter 4 exemplifies the
academic support of this team.
We also want to thank JD Bomar, MPH, Research
Coordinator and digital content expert in the orthopedic
department, who is a co-author on several chapters and has
been responsible for the majority of the images and, more
important, the layout of this text. He has dedicated more
hours to this fourth edition than any of us.
We also wish to thank Brian Brown, Acquisitions Editor
at Wolters Kluwer, as well as Dave Murphy, the Editorial
Coordinator, who have guided us in this revision. We want
to thank them not only for traditional
management/editorial advice but also for allowing us the
freedom to produce a text with a layout that differs from
traditional medical texts.
We also thank our families for the time lost to them.
Their understanding that the creative process has great
rewards, and sometimes outweighs other activities,
confirms their wisdom.
Finally, we wish to thank the Rang family, especially
Dr. Louise Rang (Mercer’s daughter), for their kindness
and consideration as this fourth edition evolved.

Dennis R. Wenger, MD
San Diego

Maya E. Pring, MD
San Diego

Vidyadhar V. Upasani, MD
San Diego

Andrew T. Pennock, MD
San Diego
 1
Children Are Not Just
Small Adults

Dennis Wenger
Mercer Rang (1933-2003)
Anatomic Differences
Biomechanical Differences
Terminology—Children’s Fractures
Physeal (Growth Plate) Injuries
The Physis
Physeal Terminology
Periosteal Biomechanics
Physiologic Differences

“The heartening fact emerged that

improvements in fracture care are more
likely to come from greater use of the
present corpus of knowledge than from
advances.”
— Mercer Rang

INTRODUCTION
Fractures in children differ from those in adults. Because
the anatomy, biomechanics, and physiology of a child’s
skeleton is very different from that of an adult fractures,
children demonstrate differences in fracture pattern
resulting in unique problems of diagnosis and special
treatment considerations. This chapter introduces the many
differences encountered when comparing children’s
fractures to adult injuries.

ANATOMIC DIFFERENCES
Because much of a young child’s skeleton is composed of
radiolucent growth cartilage, often injury can only be
inferred from widening of the growth plate or from
displacement of adjacent bones on plain or stress films.
Understanding the reaction of adjacent soft tissues to
trauma is more important in analyzing childhood skeletal
injuries and is made even more complex because in some
cases occult infection can present as a fracture (Fig. 1-1).
The periosteum is thicker and stronger and produces callus
more quickly and in greater amount than in adults.
 Figure 1-1 This 10-year-old male thought he had sprained his right
ankle several days before. The outside plain films (left) were read as
normal. He came to our clinic a few days later and we noted warmth
and redness. An MRI study showed distal tibial osteomyelitis (right).

BIOMECHANICAL DIFFERENCES
Biomechanics of Bone
In the distant past, it was thought that fractures were less
common in children as compared to adults because “the
proportionate excess of the animal over the earthy
constituents” made bending of bone possible.
Subsequently, it has been determined that the osteoid of a
child’s bone is not significantly less calcified (as compared
to adults); however, the density of a young bone is certainly
less. Young bone is more porous (Fig. 1-2) with a pitted
cortex and can be cut easily because haversian canals
occupy such a great part of the bone. In effect, a child’s
bone is more like Gruyére cheese than cheddar and can
tolerate a greater degree of deformation than an adult’s
bone can.

The pores in the cortex of a child’s bone may limit the

extension of a fracture line in the same way that a hole
drilled through the end of a crack in a window will prevent
the crack from extending. Compact adult bone fails in
tension, whereas the more porous nature of a child’s bone
allows failure in compression as well. So-called “buckle
fractures” of the distal radius are among the most common
childhood fractures.

Figure 1-2 Microradiographs of the distal radial diaphysis of an adult

and of an 8-year-old child. The haversian canals are larger in the
child. Children’s bones are more porous than adult bones.

TERMINOLOGY—CHILDREN’S FRACTURES
The porous character of a child’s bone noted above
accounts for the various fracture types (Fig. 1-3). The
following commonly used terminology, although somewhat
overlapping (and not always agreed upon) has become part
of the essential language of children’s fractures.

Figure 1-3 Fracture types in children.

“A buckle fracture is also called a torus fracture because of its resemblance to
the raised band around the base of an architectural column.”

PHYSEAL (GROWTH PLATE) INJURIES

Fracture Severity Descriptions

Buckle or Torus Fracture. Compression failure of bone

produces a buckle fracture, which is also called a torus
fracture because of its resemblance to the raised band
around the base of an architectural column. These
fractures occur near the metaphysis, where porosity is
greatest, particularly in younger children. Disabled
teenaged children who do not bear weight and hence have
porous bones may also sustain buckle fractures. Such
fractures are commonly seen in the distal femur in a
disabled adolescent who falls from their wheelchair.
 Figure 1-4 Traumatic bowing of the ulna in a child.

Traumatic Bowing of Bone. Bending of bones, most

commonly recognized in the ulna and fibula, can occur
without any evidence of acute angular deformity (Fig. 1-4).
If you try to break a child’s forearm, either post mortem or
during osteoclasis, you will find that the bones may be bent
30 to 45 degrees or more before the telltale sound of a
fracture is heard. If you stop before the bone fractures, you
will find that it will slowly, but incompletely, straighten
itself out over several minutes. Such is the mechanism for
traumatic bowing.
 Figure 1-5 Greenstick fracture in a child.

This phenomenon has also been described as plastic

deformation of bone. In dogs, the bone deforms because
microscopic shear fractures — at about 30 degrees to the
long axis—develop on the concave aspect of the bone.
Because there is no true fracture, there is no hemorrhage,
no periosteal new bone formation, and no remodeling.

Greenstick Fracture. When a bone is angulated beyond

the limits of bending, a greenstick fracture occurs (Fig. 1-
5). This is a failure of the tension side of the bone while the
compression side only bends. A greenstick fracture occurs
when the energy is sufficient to start a fracture but
insufficient to complete it. The remaining bone undergoes
plastic deformation. At the moment of fracture, there is
considerable displacement—as in most fractures—and then
elastic recoil of the soft tissues improves the position. The
fracture can hinge open again subsequently, owing to
muscle pull. Complete closure of the fracture defect, which
is prevented by jamming of spicules, can usually only be
achieved by completing the fracture and momentarily
overcorrecting the angulation. This is often done when
there is marked angulation, whereas in an only modestly
angulated fracture, simply molding the cast will produce a
satisfying result.

Figure 1-6 Complete fracture in a child.

Complete Fractures. Complete fractures are usually not

comminuted in children (Fig. 1-6). This may be because a
child’s bone is more flexible than that of an adult. Some of
the force of impact is dissipated in bending the bone,
whereas in adults, the kinetic energy of impact is entirely
used to disrupt the intermolecular bonds in the bone.
Fracture Patterns
The treatment of fractures is helped by an understanding of
the common fracture patterns. Understanding the patterns
also helps to interpret the mechanism of injury, as reported
by the family, and may guide you in the reduction.

Spiral Fractures. The direction of force decides the

direction of the fracture line (Fig. 1-7). A spiral fracture,
produced by a twist, has an intact periosteum hinge along
the straight, axial part of the fracture. If you can find where
this is, you can determine whether the fracture can be
reduced by clockwise or counterclockwise rotation and the
intact periosteal hinge will help maintain reduction. These
fractures are not held by the three-point pressure principle
applicable to transverse fractures and are better held by a
“crank-handle” cast (several right angles), which controls
rotation (Fig. 1-8).
Figure 1-7 The shape of the fracture tells you how it was produced.
Spiral fractures are shaped like a pen nib. Oblique fractures are like a
ski jump.
 Figure 1-8 Spiral fracture. There is an axial periosteal hinge
providing longitudinal stability. A crank handle cast prevents
displacement.

Oblique Fracture. An oblique fracture, because of axial

overload, usually propagates at about 30 degrees to the
axis of the bone because the periosteum is widely torn;
these fractures are unstable and are best reduced by
distraction—a straight pull. They are held either in traction
or by a cast applying potentially risky circumferential
pressure. Longitudinal loading obviously displaces the
fracture (Fig. 1-9). In some cases, internal fixation may be
needed.
 Figure 1-9 An oblique fracture. An overloaded column fails in this
fashion.

Transverse Fractures. A transverse fracture results from

angulation with the periosteum torn on one side as a
fragment of bone buttonholes through. A severely displaced
transverse fracture is often best reduced by increasing the
deformity to 90 degrees, so that the end can be
unbuttoned; by pulling hard in this 90-degree angulation
position; and then (still pulling) by straightening the bone.
A three-point pressure cast will best maintain the reduction
(Fig. 1-10). John Charnley, the inventor of the modern total
hip replacement, beautifully illustrated this reduction
concept with two engaged cog-wheels in his early classic
text “The Closed Treatment of Common Fractures” (Fig. 1-
11).
 Figure 1-10 A transverse fracture. Reduction requires retracing the
path of the injury. It is held by three-point pressure.

Butterfly Fracture. A butterfly fracture is due to a

combination of axial overload and angulation (Fig. 1-12).
When the fracture is produced by a blow, the butterfly
fragment lies on the side of the bone that was struck. The
periosteum is most damaged on the opposite side, and the
fractures are unstable. When the butterfly fragment is
small, three-point pressure may hold the fracture, but
usually distraction is required. Internal fixation may be
needed in complex cases.
 Figure 1-11 J. Charnley—how to reduce a displaced fracture.

THE PHYSIS
The physis (growth plate), once known as conjugal
cartilage (joins or “conjugates” adjacent bone), was
confirmed to be the center for bone growth by John Hunter.
This renowned British surgical scientist, who in the early
1700s while enjoying a pork dinner with a friend, noted
slightly “colored” transverse lines at the ends of a young
pig’s bone (the pig had been fed garbage contaminated by
madder—a dye for cloth—which was selectively deposited
in the growing pig’s physis).

Suspecting this as the area where bones grow

longitudinally, he then conducted experiments, by placing
transverse pins in growing animal bones. Those placed at a
certain distances apart in the diaphysis (mid-bone)
remained similarly spaced over time. When one pin was
placed in the epiphysis and the other in the diaphysis, the
pins separated over time, clarifying that longitudinal
growth came from the physes (growth plate).

Figure 1-12 Butterfly fracture. The numbers indicate the order in

which the fractures occur.
 Solving the Mystery—How Do Bones Get Longer?

Bone Growth—The Role of the Physis

John Hunter of London was the leader of the movement to place the discipline
of surgery on a scientific basis. He helped translate “barber surgeons” into
trained surgeons with a scientific background, setting the stage for formation
of the Royal College of Surgeons. His early animal studies demonstrated that
longitudinal growth occurs at the physis.

PHYSEAL TERMINOLOGY
In describing the physis (growth plate) and adjacent bone,
we will use traditional terminology (Fig. 1-13). Minimal
reference to classic language (Greek) clarifies the terms
which center on the physis (growth plate). Growth “plate”
describes the shape of the physeal growth cartilage, in that
it is shaped like a small dish (not very thick, varying
diameters). Be cautious when using this term with parents
because the term “dish” often confused them. We
sometimes use the singular term “growth center” (unless
one has the time to explain the evolution of orthopedic
language!). The “growth plate” is becoming a better-known
term however. When the term was typed in, Google
produced 2.1 million results (2017)!
 Figure 1-13 The physis (growth plate). This term often confuses
parents who begin to think about lunch.

The adjacent bone is named by its relationship to the

physis. The articular end of the bone is positioned “upon”
the physis, thus is called the epiphysis (epi = upon). The
adjacent bone on the opposite side of the physis is called
the metaphysis (from Greek—“meta” meaning “beside” or
“next to”). The mid portion of a long bone is called the
diaphysis (from Greek—“dia” meaning “apart from”).

Physeal Language Errors

The most difficult remaining descriptive problem relates to
the clinical use of the term epiphysis when one really
means physis. One still hears the term “epiphyseal
fracture” when the speaker really means “physeal
fracture.” Fractures can involve the epiphysis, but when
they do, there is appropriate language to describe them.
Learning accurate, clear, internationally accepted language
for the description of injuries within and about the physis
remains integral to mastering children’s orthopedics.

“Learning accurate, clear, internationally

accepted language for the description of
injuries within and about the physis
remains integral to mastering children’s
orthopedics”

Greek Words and a Growing Child’s Bone

Physeal Biomechanics
Ruysch was one of the earliest experimentalists to find
(1713) that considerable force is required to separate the
epiphysis from the metaphysis because they are firmly
connected externally by the periosteum and internally by
mamillary processes. In 1820, James Wilson showed that a
longitudinal force of 550 pounds was required to detach the
epiphysis from the metaphysis but that if the periosteum
was divided first, the force required was only 119 pounds.
A few years later, in 1845, Salmon again demonstrated the
importance of periosteum. Although he could separate the
epiphysis of a newborn’s distal femur by hyperextending
the knee, he could not produce displacement until he cut
the periosteum.
 Figure 1-14 Strong ligaments attached to the epiphysis account for
epiphyseal separation being more frequent than joint dislocations.
Poland was perhaps the first to emphasize this, also noting that
children have frequent physeal fractures but few joint dislocations.

In 1898, John Poland wrote Traumatic Separation of the

Epiphysis, a book of 900 pages that summarized what was
known about the epiphysis to that time. Since then, very
little new information has been added, and those interested
in children’s fractures should read his book. Poland was
probably the first to show experimentally that it was easy
to produce epiphyseal separation but difficult to produce
dislocations in children (Fig. 1-14). He wrote, “This is easily
understood when the comparatively weak conjugal
neighborhood in the young subject is realized. The violence
producing the two forms of injury—epiphyseal separation in
children and dislocations in adults—is frequently of the
same character.” (This quotation is better understood if you
appreciate that the growth plate was once called conjugal
cartilage, because it joins two bones intimately together.)
Poland concluded that ligaments are stronger than growth
cartilage.

At least one attachment of a ligament is to an epiphysis in a

growing child. Hence, when a valgus force is applied to the
knee of a child, the distal femoral growth plate gives way,
whereas in an adult, the medial ligament will rupture or
detach. Diagnosis of a pure physeal (Salter-Harris I)
fracture of the distal femur can be difficult.

Figure 1-15 Load required to separate the proximal tibial epiphysis

of a rat using forces applied at different angles to the growth plate.
(Based on Bright RW, Elmore SM. Physical properties of epiphyseal
plate cartilage. Surg Forum. 1968; 19:463.)

Growth cartilage has the consistency of hard rubber. When

the plate is thick, the epiphysis can be rocked slightly on
the metaphysis because of the elasticity of the plate. This
property not only protects the bone from injury but appears
to protect the joint surface from the type of crushing injury
that is common in adults.

In 1950, Harris revived interest in biomechanical testing of

the growth plate and found that the hormonal environment
greatly influences the strength of the bond between the
epiphysis and the metaphysis. Bright and Elmore studied
the force required to separate the upper tibial epiphysis in
a rat (Fig. 1-15) and found that the age of the animal and
direction in which the force is applied are both important
factors. The plate is most resistant to traction and least
resistant to torsion. Furthermore, the epiphysis can be
displaced 0.5 mm before separation begins. In a
subsequent paper, they showed that small cracks
developed within the physis when 50% of the force
required to separate the plate was applied.

PERIOSTEAL BIOMECHANICS
The periosteum is much thicker, stronger, and less readily
torn in a child than in an adult, and continuity of the
periosteum determines whether or not a fracture displaces.
When displacement occurs, the intact hinge of periosteum
can help or hinder reduction.
 Figure 1-16 The basis of remodeling.

PHYSIOLOGIC DIFFERENCES

Growth Remodeling
Growth provides the basis for a greater degree of
remodeling than is possible in an adult. As a bone increases
in length and girth, the deformity produced by a fracture is
corrected by asymmetric growth of the physis and the
periosteum (Fig. 1-16). Karaharju and associates studied
fractures in puppies’ tibiae that had been plated with
angulation. The physis grew asymmetrically to straighten
up the articular surface. Most of the correction occurred
early.

Remodeling occurs most efficiently in younger children and

if the deformity is in the axis of rotation of the adjacent
joint. Thus, in a 3-year-old child, a distal radius fracture left
in an angulated position (lateral view) will straighten itself
over the next year (Fig. 1-17).
 Figure 1-17 Five-year-old child with a distal radius fracture that
healed in a mal-reduced position. At 3 months, the deformity persists.
One year later, the radius is straighter.

The bump of a malunion is corrected by periosteal

resorption; the concavity is filled out by periosteal new
bone. This is an example of Wolff law, which may be
mediated by piezo-electric potentials. The compression side
of a loaded bone develops a negative potential, which is a
stimulus to bone formation.

Figure 1-18 Remodeling has two meanings. (1) Rounding off does
not help the patient; radiologists call this remodeling to lure the
physician into inappropriate optimism. (2) Realignment or
“straightening itself out” is the real meaning of remodeling.
Remodeling (perhaps better thought of as realignment),
which restores the function of a bone to normal, must be
distinguished from rounding off, which improves the
radiograph but does little for the patient (Fig. 1-18), often
leaving the joint to function at an abnormal angle.

Overgrowth
A fracture through the shaft of a long bone stimulates
longitudinal growth, probably because of the increased
nutrition to growth cartilage produced by the hyperemia
associated with fracture healing. In practice, an
nondisplaced fracture of the shaft of the femur will, in the
course of a year or two, cause the femur to be about 1 cm
longer than its opposite member. An incomplete,
asymmetric metaphyseal fracture (especially proximal
tibia) can cause undesirable progressive angulation over
the year following fracture, causing deformity so severe
that on occasion, it requires surgical correction. This was
best described by Lewis Cozen of Los Angeles, and the
fracture bears his name (eponym—“Cozen fracture”) (Fig.
1-19).
 Figure 1-19 Cozen fracture with progressive valgus angulation.

Progressive Deformity
Permanent damage to the growth plate will produce
shortening (Fig. 1-20) or progressive angular deformity.
Such complications have been recognized for many years,
and in 1888, Lentaigne even diagnosed this condition in an
Egyptian mummy.

“Remodeling occurs most efficiently in

younger children and if the deformity is
in the axis of rotation of the adjacent
joint”
 Figure 1-20 A. Salter Harris I left distal radius fracture. B. Three
years following injury, note radial physeal closure and ulnar
overgrowth. C. MRI confirms physeal arrest.

Nonunion
Nonunion is an adversary almost unknown to the children’s
orthopedic surgeon. In fact, when it does occur, especially
in the distal tibia, one thinks of associated disease as the
cause (congenital pseudarthrosis because of
neurofibromatosis). Displaced intra-articular fractures and
the rare shaft fracture with gross interposition may not
unite, but otherwise union is easily achieved. As in adults,
femoral neck and scaphoid (carpal navicular) fractures may
go on to nonunion. The reason for ready union in children is
not known with certainty, but perhaps the periosteum is
actively (not dormantly) osteogenic and clearly children
have an excellent vascular supply to most fractures.

“Nonunion is an adversary almost

unknown to the children’s orthopedic
surgeon”

Speed of Healing
Children heal quickly; therefore, reduction should be
performed early. The orthopedic surgeon does not have as
 long to deliberate over a fracture in a child as compared to
an adult.

Refracture
Refracture occurs under several circumstances:

1. Early, when the cast is removed too soon.

2. Late, when the fracture has healed with deformity so that
the fracture is a stress concentrator (Fig. 1-21).
3. Late fracture in cases where the cast was maintained for
the advised time period and the fracture is well aligned.
4. In children, who after cast removal, pursue very aggressive
sports (against your advice) (Fig. 1-22).

Figure 1-21 Classic example of refracture. This 9-year-old child had a

typical fracture that was not anatomically reduced. Three months
after cast removal, a mild fall led to refracture. The patient was taken
to the OR for reduction and fixation.

Studies in rabbit bones show four biomechanical healing

stages, each of which can allow refracture.
Stage I: The sticky stage—refracture through the original
fracture site with low stiffness.
Stage II: Early union—refracture through the original site
with high stiffness.
Stage III: Refracture occurs partly through the original
fracture site and partly through intact bone.
Stage IV: Refracture entirely through intact bone.

SUMMARY
Children’s fractures differ from similar adult injuries in
many ways. The relatively weak physis is prone to injury,
thus a fracture is more likely than a joint sprain in a child.
Recognition of the many types of physeal injury, with
application of appropriate treatment methods, is central to
the art and practice of children’s fracture treatment. The
vigor of childhood bone growth, with a corresponding
excellent blood supply to bone, assures healing in most
children’s fractures. Refracture, thought to be uncommon
in the past, is a regular occurrence in the modern era that
emphasizes “extreme sports.” Overall, the biology of the
child’s musculoskeletal system, blessed with the positive
attributes of growth, makes treating children’s fractures a
positive experience.
 Figure 1-22 Refracture is common in children who pursue aggressive
sports. (Image by Tyler Bolken
https://www.flickr.com/photos/tylerbolken/8768566497 Image has
been cropped.)

SUGGESTED READINGS
Alman B. The immature skeleton. In: Flynn JM, Skaggs DL, Waters PM, eds.
Rockwood and Wilkins’ Fractures in Children. 8th ed. Philadelphia, PA: Wolters
Kluwer; 2015.

Borden S. Traumatic bowing of the forearm in children. J Bone Joint Surg.

1974;56A:611.

Bright RW, Burstein AH, Elmore SM. Epiphyseal plate cartilage. A

biomechanical and histological analysis of failure modes. J Bone Joint Surg.
1974;56A:688.

Currey JD, Butler G. Mechanical properties of bone tissue in children. J Bone

Joint Surg. 1975;57A:810.

Diab M. Lexicon of Orthopedic Etymology. Amsterdam: Harwood Academic

Publishers; 1999.
Harris WR. The endocrine basis for slipping of the upper femoral epiphysis. J
Bone Joint Surg. 1950;32B:5.

Hirsch C, Evans FG. Studies on some physical properties of infant compact

bone. Acta Orthop Scand. 1965;35:300.

Houshian S, Holst AK, Larsen MS, et al. Remodeling of Salter-Harris type II

epiphyseal plate injury of the distal radius. J Pediatr Orthop. 2004;24(5):472–
476.

Jackson DW, Cozen L. Genu valgum as a complication of proximal tibial

metaphyseal fractures in children. J Bone Joint Surg Am. 1971;53(8):1571–
1578.

Mabrey JD, Fitch RD. Plastic deformation in pediatric fractures: mechanism

and treatment. J Pediatr Orthop. 1989;9:310–314.

Macsai CE, Georgiou KR, Foster BK, et al. Microarray expression analysis of
genes and pathways involved in growth plate cartilage injury responses and
bony repair. Bone. 2012;50(5):1081–1091.

Poland J. Traumatic Separation of the Epiphysis. London: Smith, Elder; 1898.

Pritchett JW. Growth plate activity in the upper extremity. Clin Orthop.
1991;268:235–242.

Treharne RW. Review of Wolff’s law and its proposed means of operation.
Orthop Rev. 1981;10:35.

Tschantz P, Taillard W, Ditesheim PJ. Epiphyseal tilt produced by experimental

overload. Clin Orthop. 1977;123:271.

Wolff J. The classic: concerning the interrelationship between form and

function of the individual parts of the organism. Clin Orthop. 1988;228:2–11.

Image Credit
Torus column image by Chrisfl https://commons.wikimedia.org/wiki/File:Temple_of_Olympian_Zeus_-
_Olympieion.jpg Image has been cropped.
 2
The Physis and Skeletal
Injury

Dennis Wenger
James Bomar
Epiphyseal Fractures
Physeal (Growth Plate) Injuries
Healing Reactions of the Physis and Epiphysis
Salter-Harris Classification
Guide to the Care of Physeal Injuries

“The physician is only nature’s

assistant”
— Galen

INTRODUCTION
Many simple fractures in children would heal well, whether
they were looked after by a professor in a university
hospital or by an aborigine on an undiscovered island.
Fractures through the physis (growth plate) are a different
story.

EPIPHYSEAL FRACTURES
Fractures of the true epiphysis usually involve the growth
plate but occasionally occur in isolation. They may be
classified as follows (Fig. 2-1):
Avulsion at the site of ligamentous attachment
Comminuted compression fracture
Displaced osteochondral fragment

Figure 2-1 Epiphyseal fractures not involving the growth plate.

Avulsion at the Site of Ligamentous Attachment

The common sites of this injury are the tibial spine (Fig. 2-
2), the ulnar styloid, the base of phalanges, and the
secondary ossification centers of the pelvis (see Chapter
12). The bony fragment retains an adequate blood supply
and does not undergo avascular necrosis. If the fragment is
displaced, union is rare because synovial fluid inhibits
callus formation. The displaced fragment may block joint
movement or may leave the joint unstable because of
functional ligamentous lengthening. These problems justify
accurate reduction and may require open reduction.
 Figure 2-2 Anterior tibial spine fracture (arrow).

Osteochondral Fragments
Osteochondral fragments are most commonly sheared off
the distal femur, the patella, the capitellum (humerus), and
the radial head. A displaced fragment produces the
problems of a loose body and articular cartilage injury. If
the fragment is large and from an important part of the
joint, it should be replaced and fixed anatomically (Fig. 2-
3). If small, it should be removed. Often the fragment has
little bone attached and is difficult to see on x-ray
(especially radial head and capitellum).

PHYSEAL (GROWTH PLATE) INJURIES

Growth plate injuries can cause significant distress to
worried mothers. These mothers often immediately Google
the term “growth plate” on their phone while in clinic. Such
searches produce over two million results and these
mothers often zero in on the most alarming search results.
Be prepared to explain that injuries to the growth plate
make up approximately one-third of skeletal trauma in
children. Possible consequences of such injuries include
progressive angular deformity, progressive limb-length
discrepancy, and joint incongruity. It is important to note
that although damage to the growth plate has the potential
for causing many disastrous problems, in fact the area
repairs well, and problems after injury are uncommon
when treated well. When growth is disturbed, the reason is
one of the following:

Figure 2-3 Osteochondral fracture of the lateral femoral condyle

secondary to acute traumatic patellar dislocation. The fragment was
large enough that it could be surgically repositioned.
Avascular necrosis of the physis
Crushing or infection of the physis
Formation of a bone bridge between the bony epiphysis
and the metaphysis
Hyperemia producing local overgrowth

The problems and the means of their prevention can only

be understood by an appreciation of the anatomy and the
healing reactions in the growth plate area.

Figure 2-4 Blood supply of the growth plate. Damage to the

epiphyseal artery can destroy the plate. Damage to the metaphyseal
artery is less important.

Anatomy
The growth plate is a cartilaginous disc situated between
the epiphysis and the metaphysis, with germinal cells
attached to the epiphysis and a blood supply from
epiphyseal vessels (Fig. 2-4). Repeated multiplication of
these germinal cells provides the cell population for the
rest of the physis. The daughter cells multiply further,
secreting a cartilage matrix, and increase in size, thereby
producing growth. The matrix calcifies. Metaphyseal
vessels enter the cell columns, remove a little matrix, and
lay down bone upon the cartilage matrix to form
metaphyseal bone.

With a fracture, the plane of separation is most frequently

the junction between calcified and uncalcified cartilage. A
transverse section through the growth plate in this region
demonstrates the small amount of structural matrix
present, which probably accounts for the relative weakness
of the area. The important germinal part of the plate—
indeed the greater thickness of the plate—remains mostly
with the epiphysis. This plane of separation is relatively
bloodless, so that an epiphyseal separation often has little
associated swelling.

However, when the plane of fracture separation has been

examined carefully, the anatomic fracture line is often less
“pure.” Johnston and Jones performed biopsies of fractures
requiring open reduction and found that the fracture line
often passes between the epiphysis and the germinal layer.
 Figure 2-5 The irregularity and undulations in certain physes may
increase the risk for physeal closure with fracture (e.g., “Kump’s
bump”—distal tibial physes).

This is commonly seen in fractures through physes that

have significant natural undulations (a “hilly terrain”) such
as the distal femur and distal tibia (Fig. 2-5). These
undulations may be evolutionary design features that
prevent easy disruption of the physis but when it finally is
forced to give, the shearing action often disrupts the
germinal layer. If reduction is not anatomic, there will be
epiphyseal to metaphyseal bone contact, which with
healing, may form a bar across the physis. Obviously, if
much of the germinal layer is disturbed, there is a chance
for growth arrest.
 Figure 2-6 The blood supply of two types of epiphyses. A. Vessels to
the femoral head track in the periosteum under the synovium. A
periosteal tear or a high-pressure effusion may cause AVN. B. Vessels
to the distal femur pass through a thick wad of soft tissues and are
rarely disrupted with a fracture.

Blood Supply to the Epiphysis

The blood supply of the epiphysis is important. Dale and
Harris showed that there are two fundamental types of
epiphyses (Fig. 2-6) according to how they receive their
blood supply. The prognosis after physeal injury is greatly
determined by this factor.

Epiphyses Totally Clad with Cartilage (such as head of

femur, head of radius). Total interruption of the blood
supply to the germinal cells may follow fracture separation.
Avascular necrosis of the plate and epiphysis, and arrest of
longitudinal growth naturally follow (Fig. 2-7). Ganz et al.
after a study of femoral head blood supply clarified how
conditions such as acute SCFE (slipped capital femoral
epiphysis), a type of acute physeal separation, so readily
lead to AVN.

Epiphyses with Soft-Tissue Attachments (most physeal

injuries—distal radius, distal tibia, distal femur, etc.). When
these are separated, the soft-tissue hinge will remain
attached to the epiphysis, so that the circulation to the
epiphysis remains intact. The germinal cells are not
injured, and longitudinal growth continues unscathed.

Figure 2-7 This 13-year-old boy fractured his femoral neck. Although
promptly and anatomically reduced, he developed AVN of the femoral
head because of disruption of the vessels that ascend the femoral
neck.

HEALING REACTIONS OF THE PHYSIS AND

EPIPHYSIS
Dale and Harris have published the most credible
description of growth plate separation. The plate separates
mostly between the calcified and uncalcified layers of the
growth plate. For a week or 2, the hiatus is filled by fibrin.
Initially the physis becomes wider, because growth
cartilage continues to be produced without invasion by
metaphyseal vessels. After about 2 weeks, the vessels begin
to invade the cartilage columns again with the physis
becoming narrower once more, and healing occurs without
leaving a scar. In this way, the growth plate heals more
quickly than a fracture through bone (Fig. 2-8). The repair
of an injury at right angles to the plane of the growth plate
shows more variation (Fig. 2-9).

Cartilaginous Epiphysis. If they remain displaced, both

portions of the epiphysis continue to grow separately,
producing a double-ended bone.
 Figure 2-8 Healing after growth plate separation occurs by means of
new bone formed by the growth plate and by the periosteum. This
can be seen clearly 3 weeks after the initial injury.

Ossified Epiphysis. If the fracture surfaces are not in

contact, both fragments continue to grow for some time.
Eventually, premature arrest of growth adjacent to the
fracture line takes place.

If the fracture surfaces are approximated but without

anatomic reduction of the growth plate, a bridge of callus
will form between the epiphysis on one side and the
metaphysis on the other. This bony bridge produces a
brake on growth. When the bridge is at the center of the
epiphysis, the two outside edges will continue to grow,
resulting in tenting of the end of the bone. When the bridge
is toward one margin of the growth plate, a progressive,
angular deformity develops.
 Figure 2-9 Healing patterns of Type IV injuries.

If the fracture is accurately reduced so that there is

coaptation of the growth plate, there will be a small scar at
the site of growth plate injury, but this is not sufficient to
disturb growth. If there is no reduction and there is poor
apposition of the fragments, the result is non-union.

Effect of Internal Fixation. Small Kirschner wires passed

through the center of the plate do not interfere with
growth. If they are passed near the margin of the plate,
growth is occasionally disturbed. Threaded pins or screws
across the plate act as effectively as Blount staples in
inhibiting growth.

Salter and Harris, both internationally recognized orthopedic surgeons from

the University of Toronto, published a classification of growth plate fractures
in 1963 that remains the most commonly used worldwide.

Repair of Articular Surfaces. Cartilage defects in a joint

invite intra-articular adhesions. Salter and associates have
shown that continuous passive motion (CPM) not only
discourages adhesions but also stimulates more rapid and
complete healing of full-thickness defects in rabbits. Motion
—not immobilization—for injured joint surfaces would seem
wise; however, often early motion will increase the chance
for pseudarthrosis. Finding a happy medium is the art.
CPM is rarely required following primary treatment of
children’s joint fractures (as opposed to adults who are
much more likely to become stiff).

SALTER-HARRIS CLASSIFICATION
The Salter-Harris classification of growth plate injuries
remains the most practical and commonly used. Founded
on the pathology of injury, the classification is well suited
to an accurate verbal description of a fracture and provides
an excellent guide to rational treatment (Table 2-1). Most
growth plate injuries can be easily classified, leaving very
few fracture patterns that produce arguments at fracture
rounds. The classification should be studied in the original,
as it is one of the classic papers in orthopedics.

Table 2-1 Salter Harris Classification

There have been others. In 1898, Poland illustrated the

common variations of separation (Fig. 2-10). The Weber
classification (from the A-O) provides the extreme of
simplicity (Fig. 2-11). In very general terms, a Weber Type
A (equivalent to Salter-Harris I or II) can be treated
conservatively, and a Type B (equivalent to Salter-Harris III
or IV) requires surgery.

Figure 2-10 Poland’s classification of growth plate injuries (1898).

The antithesis of the Weber classification is that of Ogden

who proposed nine types of physeal injuries (including
intra-articular fractures, osteochondral avulsions, etc.). His
system may be useful for research studies but has proven
to be too complex for easy memorization (and thus
everyday clinical use). Most classification systems in
medicine that have more than three or four subgroups
cannot be readily memorized and therefore are not on a
day to day basis.

Only simple, practical classifications gain wide acceptance

(and get inserted into medical records and
correspondence). Thus, the classic Salter-Harris
classification system remains the most commonly used
world-wide.

Figure 2-11 This extremely simple classification was described by

Weber and Brunner in St. Gallen Switzerland. Type A can be treated
with closed reduction, and Type B requires surgery (in most cases).
 Prolonged Immobilization or Early Motion?
The controversy regarding whether fractures should be immobilized for
prolonged periods of time or allowed to engage in early movement has a rich
history. The above experts were champions of both sides of the argument.
Thomas believed that fracture immobilization should be enforced, prolonged,
and uninterrupted to ensure fracture healing. Lucas-Championniere vigorously
opposed principles of prolonged rest when treating fractures. He advocated
early motion and is considered one of the founding fathers of modern fracture
brace treatment which allows early mobilization of joints. A-O principles and
Salter’s CPM ideas follow this concept.
 Figure 2-12 Type I fracture, the epiphysis separates completely from
the metaphysis.

Fracture Types (Salter-Harris)

Type I. Type I injuries are usually the result of a shearing,
torsion, or avulsion force. In a Type I fracture (Fig. 2-12),
the epiphysis separates completely from the metaphysis.
The germinal cells (the growth cells) remain with the
epiphysis, and the calcified layer remains with the
metaphysis. If the periosteum is not completely torn, there
may be little or no displacement. The radiograph in these
circumstances may be normal, and the diagnosis is made
on clinical suspicion (Fig. 2-13).
 Figure 2-13 Typical Salter-Harris I fracture of the distal fibula. The x-
rays appear normal, but the patient has focal tenderness over the
physis (not over adjacent ligaments) confirming the diagnosis.

Most parents look on these injuries as sprains, since there

often is little swelling and little deformity. You will be
alerted to them by tenderness over the growth plate and
should not be disturbed by the absence of radiologic signs.
Stress radiographs may be taken if accurate diagnosis is
imperative but are rarely performed in the modern era
(pain issues, how much stress?, what is learned?).
Diagnosis of separation of an unossified epiphysis in a very
young child is more difficult and is made on clinical signs,
the presence of soft-tissue swelling, possible swelling noted
on an x-ray, with ultrasound, or with an MRI study.

Apophyses can also be separated with a Type I pattern

(base of 5th metatarsal, medial epicondyle) with an
avulsion force the likely mechanism. Pathologic Type I
injuries occur in scurvy, rickets, disorders associated with
hormonal imbalance, and osteomyelitis (Fig. 2-14). The
current controversy regarding over-diagnosis of vitamin D
deficiency (thus leading to a proposed subtle, sub-clinical
form of rickets which could pre-dispose to fractures) will be
discussed in Chapter 20.
 Figure 2-14 Separation of both distal femoral epiphyses. For 6
weeks, this boy, aged 3 years, had been treated with antibiotics and
steroids for fever and multiple joint pain. By the time a diagnosis of
osteomyelitis was reached, the epiphyses had separated.

When the periosteum is torn, displacement is easily

reduced without any satisfying crepitus and often with little
sensation that the fragment is snapping back into position,
because the two fracture surfaces are covered with
cartilage.

Early healing occurs within 3 weeks, and problems are

rare. Exceptions include a displaced fracture of the
proximal femoral physis with subsequent avascular
necrosis which has a grim prognosis. Nonunion of a
separated medial humerus epicondyle is not uncommon
which may cause subsequent elbow instability.
 Figure 2-15 Classic Salter-Harris II fracture of the distal femur with a
triangular Thurston-Holland sign (arrows). Even with anatomic
reduction, nearly 40% of distal femoral physeal fractures will have
subsequent physeal closure.

Distinguishing between a Type I injury of the growth plate

(which has an excellent prognosis) and the rare Type V
injury (in which the plate is crushed and which has a poor
prognosis) can be difficult. The history of injury is the best
guide with Type V injuries produced by axial compression.
These injuries will need to be followed more closely
regarding subsequent physeal closure.

Type II. The cleavage plane of a Type II injury (Fig. 2-15)

passes transversely through much of the physis before
angling through the metaphysis. The fracture is produced
by lateral displacement force, which tears the periosteum
on one side but leaves it intact in the region of the
triangular metaphyseal fragment, known as the Thurston-
Holland fragment (after the radiologist who first described
it).

The fracture is easily reduced, and over-reduction is

prevented by the intact periosteum. The cartilage-covered
surfaces usually prevent the sensation of crepitus as the
fragment is pushed into position. When the radial head is
separated, for example, it may be impossible to judge the
success of a reduction by clinical means.

Occasionally, the shaft of a bone will become trapped in the

buttonhole tear of the periosteum. This is most common at
the shoulder if there is a large, metaphyseal fragment
poking through a small periosteal tear. If the degree of
displacement is unacceptable, open reduction is sometimes
required. Also distal femoral fractures often require open
reduction plus K-wire fixation (and have a high risk for
physeal closure).
 Figure 2-16 Classic Type II fracture (arrow) of the medial malleolus in
a child.

Type III. Type III injuries are most commonly seen in

partially closed growth plates such as the distal tibia. The
plane of separation passes along with the growth plate for
a variable period before entering the joint through a
fracture of the epiphysis. The fracture is intra-articular and
requires accurate reduction to prevent malarticulation.

Open reduction is often required, but the fragment should

not be dissected free of its blood supply. The most common
site is at the distal end of the tibia, toward the end of
growth, when the medial half of the plate is closed (Tillaux
fracture). Growth disturbances, therefore, are not a
problem. Another common site is the medial malleolus;
however, often a tiny Thurston-Holland fragment remains
attached, making a Type III versus Type IV call difficult
(Fig. 2-16).

Figure 2-17 Classic Type IV fracture of the lateral condyle of the

distal humerus requiring open reduction.
Type IV. The fracture line in a Type IV injury passes from
the joint surface, across the growth plate, and into the
metaphysis (Fig. 2-17). The most common example is a
fracture of the lateral condyle of the humerus; medial distal
tibial fractures (medial malleolus) are also common (but as
just noted, this can sometimes be a Type III injury).

Figure 2-18 Not all Type IV fractures are the same. A. When the
fracture line crosses a bony epiphysis, the risk of bony callus bridging
the growth plate and causing a growth disturbance is great if accurate
reduction is not achieved. B. When the fracture line passes through a
cartilaginous epiphysis, bridging is less likely. C. A stepped fracture
line sometimes allows a stable closed reduction.

This is an injury for which a surgeon can do a great deal

(Fig. 2-18). Left alone, this injury will produce joint
stiffness and deformity owing to loss of position, nonunion,
and growth disturbance. The fracture must be accurately
reduced, usually by open reduction and internal fixation,
both to secure a smooth joint surface and to close the
fracture gap. This allows cell-to-cell apposition of the
growth plate and ensures that growth is not disturbed as
well as minimizing the risk for non-union.
 Figure 2-19 One of the earliest radiographs of a Type V injury was
published by Poland in 1898. The growth plate of the radius has
closed, and the radius has not grown. Note ulnar overgrowth.

At other sites, the growth plate cannot be seen clearly, and

when there is doubt about whether it is accurately reduced,
some have suggested that the surgeon should improve the
view by removing the metaphyseal fragment (medial distal
tibia). The gap can be filled with fat to discourage bridging.
The efficacy of removal of the metaphyseal fragment to
decrease the chance for physeal closure has not been
clearly established.

Type V. Concepts about Type V injuries are changing. In

the original concept, the plate is crushed, thereby
extinguishing further growth (Fig. 2-19). All or part of the
plate may be affected. A compression injury of the plate
may seem like nothing more than a sprain at first, and only
later will the true nature of the lesion be recognized.

At other times, a Type I or Type II injury is obvious initially

with a crush component not suspected. Pressure from the
most prominent corner of the metaphysis has produced a
crushing injury, to the chagrin of the surgeon and to the
detriment of the patient. Also, a Type V injury can occur in
an occult manner. In association with a long bone fracture
(Fig. 2-20), patients with high energy injury mechanisms
should often be followed for at least a year to be sure that
physeal closure has not occurred. In the case of an occult
closure, the clinical exam may be more important (limb
length change, angular deformity) than the x-ray (which
will be initially directed at the injury site (midshaft femur)
rather than the physis.

Figure 2-20 This 8-year-old girl fell from a balcony and was thought
to have a simple right midshaft femoral fracture and was treated with
a spica cast. Three years later, her right femur was found to be short
because of occult distal femoral physeal closure. Hresko et al. and
Bowler et al. have described the phenomenon (see Suggested
Readings).
 “All significant growth plate injuries
should be followed for at least six
months and perhaps a year because
growth disturbance is a possibility”

Since the work of Langenskiold, Bright, and Peterson on

growth arrest owing to bony bridging, the classical concept
of a Type V injury needs reexamining. When a small area of
the growth plate is damaged, there is a race to replace the
defect. Either regenerated growth cartilage or bone may
win. Growth is threatened if bone forms. The surgeon’s
focus should be on the bridge rather than the crush,
because only the bridge can be treated.

All significant growth plate injuries should be followed for

at least 6 months and perhaps a year because growth
disturbance is a possibility. The cost for follow-up
examination and x-rays as well as the added x-ray exposure
make mandatory follow-up less critical in mild injuries
(Type I, Type II in younger children with mild fracture
mechanisms) particularly in small bones (hands, feet).
Again the art of practice is required.
 Figure 2-21 Diagram of scalping injury (Type IV) of medial malleolus
as might be seen with a lawn mower injury.

In such cases, we state that “physeal closure is possible but

very unlikely, if your limb seems to be getting shorter or
appears to angulate over time, see your family doctor for
confirmation and referral to orthopedics.” PRN returns are
often unwise in dictations; instead tell the patient, “If you
detect or suspect any problem, please return to see me”
and dictate “the patient is encouraged to return if either
they, or their family doctor, note any abnormalities.”

Type VI. A scalping injury to the edge of the physis

produces a perichondral ring injury, removing both the
edge of the physis and associated perichondral ring of
Ranvier (Fig. 2-21). Injuries of the medial malleolus, from
lawn mower injuries, are the most common cause in the
mid-western part of the USA (where children help their
parents with lawn mowing chores—or at least share the
ride). Such lawn mowing injuries are much less common in
the southwestern USA where hired adults (gardeners)
operate many lawn mowers.

Often there is associated skin loss and the avulsed bone

fragment is not recoverable (ground to bits at the scene of
the accident). These injuries are difficult to treat and
almost routinely lead to physeal closure. Plastic surgery
assistance may be needed to get skin coverage, and
subsequent operations may be needed to deal with physeal
closure.

The perichondrial ring may also be lifted from the distal

femoral condyle by the lateral collateral ligament, and this
too carries the risk of bridging unless it is accurately
replaced. A progressive varus deformity follows because
bone replaces the perichondrium.
 Figure 2-22 X-rays of a 12-year-old male baseball pitcher who tried
to pitch every day. He presented with right shoulder pain. The physis
(arrows) shows widening (really thickening) because of chronic
repetitive stress.

Stress Injuries of the Growth Plate

The concept of stress fracture through the growth plate
was introduced by Godshall and others. It is a natural
development, from the observation by Bright and
associates, that shear cracks in the growth plate occur
when the load applied to the plate is 50% of that necessary
to separate the plate. Continued injury could be expected
to inhibit healing. Godshall and associates described pain
in the knee, inability to run, and circumferential tenderness
around the distal femoral growth plate. X-ray films showed
widening of the growth plate. After 12 weeks of rest, the
lesion healed. These lesions are seen in gymnasts (distal
radius) and baseball pitchers (proximal humerus, elbow)
(Fig. 2-22). Osgood-Schlatter disease offers a further
example.

GUIDE TO THE CARE OF PHYSEAL INJURIES

Define the Exact Line of the Fracture

The fracture line is usually obvious, but some injuries can
be very difficult, particularly in the young child with little
or no ossification in the epiphysis. Multiple views, with
comparative views of the opposite side, may help. (An
orthopedist should selfishly think that humans are made
symmetrical for the purpose of radiographic comparison.)
Stress films are occasionally considered, and arthrography
may be helpful.

CT scans and particularly MRI studies have greatly

improved our diagnostic capacity. The demanding parent,
who insists on an MRI study (sometimes annoyingly), may
be on track in this instance. Occasionally, even after an
arthrogram or MRI, you will remain puzzled and still
suspect a displaced intra-articular fracture but cannot
prove it. In such cases, it is usually wiser to err in favor of
exploration than to rely on your small stock of undeserved
miracles.
 Figure 2-23 Before you go to surgery with a puzzling physeal
fracture which you do not understand, you should consult a wise
senior colleague (the late Drs. David Sutherland, San Diego, and
Heinz Wagner, Nuremberg)(photo—1990—Children’s Hospital, San
Diego).

Consulting Senior Colleagues

When in doubt, discuss the case with a radiologist and
consult a senior colleague (Fig. 2-23). One should not
finalize a treatment plan until the diagnosis is clear. As
noted above, it is usually better to explore a puzzling
physeal injury (open surgery), rather than just applying a
cast, with hope that all will “turn out well.”

Other Issues
Reduction should be early and gentle. Physeal injuries unite
quickly, so that attempts to correct physeal malposition
after 7-10 days are liable to do more damage than good to
the physis. Repeated efforts at reduction may do nothing
more than grate the plate away. If long-term problems are
anticipated, whenever possible they should be
communicated to the parents preoperatively (without
unduly alarming them).

“Attempts to correct physeal malposition

after 7-10 days are liable to do more
damage than good to the physis”

Open or Closed Reduction?

It is usually possible to secure closed reduction of Type I
and Type II injuries. Exact anatomic reduction, though
desirable, may be unnecessary, because remodeling can
correct many imperfections. Occasionally, soft tissue is
interposed (e.g., at the ankle) or the part is so deeply
placed (e.g., the radial head) that open reduction will be
needed.

Open reduction is also required for significantly displaced

separations of the medial epicondyle. Stability is sometimes
achieved with a few periosteal sutures, or more commonly
a screw. Type III injuries commonly need open reduction in
order to secure a smooth joint surface. Type IV injuries are
commonly unstable, and accurate reduction is mandatory,
both to assure an anatomic joint but also to assure
subsequent normal physeal growth.

This applies particularly to the lateral condyle of the

humerus; it may be possible to reduce this injury, but it is
difficult to be sure that it is stable, and almost impossible to
be sure (by examining radiographs of a flexed elbow taken
through a cast) that the position is maintained. For these
reasons, open reduction and internal fixation are much
safer.
 Figure 2-24 A. This child had a lateral condyle fracture with
attempted K-wire reduction. B. The technique was suboptimal with
the pins crossing at the fracture site. The child was very active and
the fragment rotated on the cross pins. C. The subsequent films show
malunion of the condyle, as well as probable AVN.

Infection—Chondrolysis
A growth plate may be destroyed by infection. This is a risk
in all open fractures and to a lesser extent, in any fracture
in which open reduction is carried out. Kirschner wires
used to maintain reduction often traverse joints and can
lead to joint sepsis and chondrolysis as well as
osteomyelitis (Fig. 2-24). For this reason, all K-wires should
be either buried below the skin or removed early to
minimize risk.
 Figure 2-25 Plain films and CT study of a distal radius physeal bar
(arrows).

Length of Immobilization
Various rules are invoked. The elbow may become stiff if
immobilized for more than 3-4 weeks. For other joints, we
allow 4 weeks for early union of an epiphyseal separation,
and 6 weeks in a metaphyseal or diaphyseal fracture. Note
the term “early union.” The cast is removed well before
solid structural union has occurred, and the family must
know this.

The child’s activity level and temperament may require

variations in advice (longer immobilization for dynamic
athletes, attention deficit disorder [ADD] patients, and
when parental control is an issue). Children rarely get stiff
joints, even if the cast immobilization extends a few weeks
beyond what is usually advised. When the cast is removed,
the fracture is only partially healed and patients must be
advised of this (“healing”—not “healed”). Post-case
splinting may decrease the chance for re-fracture in the
dynamic (most children fit this category).

Patient from “Elsewhere General Hospital”

—Late Diagnosed Cases

Children presenting late with Type I and Type II injuries
more than 7-10 days old, even though not adequately
reduced should be left with the displacement uncorrected,
for fear of damaging the growth plate. Corrective
osteotomy can be performed later if remodeling fails.

Open reduction of displaced Type III and Type IV injuries

may be better undertaken late than never. Be careful not to
devascularize the fragment at the time of replacement.
Bony Bridging (Physeal Closure because of Trauma)
Growth stops when a significant bony bridge joins the
epiphysis to the metaphysis. (Note that a very small bridge
can form and then be “broken” by the distractive power of
a growing physis.) An early sign of a bony bridge may be a
converging Harris line. In the early stage, the patient is
free of deformity and complaints. In most patients, it takes
many months to be sure that the bridge is real. Declaring
physeal closure either too early or too late is inappropriate.
A CT or MRI should be taken to confirm the diagnosis and
to define the size of the bridge (Fig. 2-25).
 Figure 2-26 A. Salter-Harris I distal radius fracture. B. Three years
following injury, note radial physeal closure and ulnar overgrowth. C.
MRI confirms physeal arrest.

Since Langenskiold, Bright, and Peterson described

operative intervention that can allow resumption of growth
after resection of the bridge, there has been much more
reason to follow growth plate injuries carefully.
Langenskiold replaced the bridge with autogenous fat,
Bright with silicone rubber, and Peterson with methyl
methacrylate. Silicon is no longer available, thus fat or
methyl methacrylate remain as the surgeon’s choices.
Careful delineation of the bridge size is made using a CT or
MRI methods.

A central bridge can be approached by making a window in

the metaphysis. Loops and a headlamp improve vision. The
bridge is pale bone, in contrast to the red bone of the
normal metaphysis. The bridge is removed with a curette or
burr until the normal plate is seen. The bridge is usually
more extensive than expected (Fig. 2-26). Image views
during surgery may help to localize the bridge so that not
too much and not too little is removed. The defect is then
replaced with fat or methyl methacrylate. Peripheral
bridges can be directly excised but results following
excision are less likely to be positive (as compared to a
central bridge).

Langenskiold reviewed 33 cases in 1978 with excellent

results. A second operation for recurrence was indicated in
three patients. Deformity has improved in most, but some
have required osteotomy. Peterson has also reported
promising results. Our experience suggests that his
operation has only a 30%-50% chance for success. The
surgery is technically demanding and surgeon experience
benefits the patient. Even referral centers, with multiple
orthopedic staff, should have one surgeon do all of these
cases (so that the benefit of experience can be
accumulated).

Because of the difficulty in successfully excising a physeal

bridge, we usually perform the procedure in younger
children with physeal closure (boys—under age 12 years;
girls—under age 10 years). In older children, the problem
caused by the physeal bar (angular deformity, short limb)
can be more predictably dealt with by angle correcting
osteotomy and/or contralateral epiphysiodesis.

SUMMARY
Fortunately, the majority of growth plate injuries involve
little risk of growth disturbance. In a few, simple surgical
intervention can make a great deal of difference to the
outcome of the injury. Happily, the number of children who
have irretrievable damage is very small.

SUGGESTED READINGS
Bowler J, Mubarak S, Wenger D. The tibial physeal closure and genu
recurvatum after femoral fracture. J Pediatr Orthop. 1990;10:653.

Bright RW. Operative correction of partial epiphyseal plate closure by osseous-

bridge resection and silicone-rubber implant. J Bone Joint Surg Am.
1974;56A:655.

Brunner CH. Fracture in and around the knee joint. In: Weber BG, Brunner C,
Freuler F, eds. Treatment of Fractures in Children and Adolescents. New York:
Springer-Verlag; 1979.

Carlson WO, Wenger DR. A mapping method to prepare for surgical excision of
a partial physeal arrest. J Pediatr Orthop. 1984;4:232–238.

Flynn JD, Skaggs DL, Waters PM. Rockwood and Wilkins’ Fractures in
Children. 8th ed. Philadelphia, PA: Wolters Kluwer Health; 2015.

Gautier E, Ganz K, Krügel N, et al. Anatomy of the medial femoral circumflex

artery and its surgical implications. J Bone Joint Surg Br. 2000;82-B:679–683.
Hresko M, Kasser J. Physeal arrest about the knee associated with non-physeal
fractures in the lower extremity. J Bone Joint Surg Am. 1989;71:698.

Langenskiold A. Surgical treatment of partial closure of the growth plate. J

Pediatr Orthop. 1981;1:3.

Manson J, Brannon P, Rosen C, et al. Vitamin D deficiency—is there really a

pandemic? N Engl J Med. 2016;375(19):1817–1820.

Peterson HA. Operative correction of post-fracture arrest of the epiphyseal

plate: case report with ten-year follow-up. J Bone Joint Surg Am. 1980;62:1018–
1020.

Peterson HA. Partial growth plate arrest and its treatment. J Pediatr Orthop.
1984;4:246–258.

Rigal WM. Diaphyseal aclasis. In: Rang M, ed. The Growth Plate and its
Disorders. Baltimore, MD: Williams and Wilkins; 1969.

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

Salter RB, Simmonds DF, Malcolm BW, et al. The biological effect of continuous
passive movement on the healing of full-thickness defects on articular cartilage.
J Bone Joint Surg Am. 1980;62A:1232.
 3
Orthopedic Literacy:
Fracture Description and
Resource Utilization

Dennis Wenger
James Bomar
Fracture Language
Orthopedic Language and Discussion with Families
Fracture Description and Resource Utilization
What Requires Emergency Reduction?
Educating Families Regarding Urgency

“In a work of art the intellect asks the

questions; it does not answer them”
— Herbel

INTRODUCTION—TERMINOLOGY
Fracture language, which has evolved in a relatively
standard manner throughout the world, makes medical
communication more efficient. Learning fracture language,
like learning a foreign language, requires time and
exposure. In this chapter, we will present common
orthopedic terminology which facilitate orthopedic
communication and care. We will also discuss how
contemporary technology can aid in this process, but also
note how data privacy regulations have stunted fluid
application of the digital revolution to our emergency care
mission.

Descriptive Planes
Describing fractures depends on first understanding the
accepted terms used to describe the human body in three
dimensions. The coronal plane (frontal plane) divides a
structure into anterior and posterior portions, whereas the
sagittal plane provides a pure lateral view. The axial
(transverse) plane is a cross section, as one might see on a
CT or MRI study of the spine.

Common Greek and Latin Terms Used in

Orthopedics
Cubitus = Elbow
Coxa = Hip
Genu = Knee
Hallux = Great toe
Pes = Foot
Carpus = Wrist
Tarsus = Ankle
Pronation = Forearm turned inward
Supination = Forearm turned outward

The Forearm—Pronation and Supination

Pronation (from Latin pronus): Turned or inclined forward. The Roman
scholar and husbandman M.T. Varro (116-27 B.C.E.) defined the prone position
as lying on the belly with the hands above the head, such that the back
projects away from the palms and the palms project toward the ground.

Supination (from Latin supinus): Turned or thrown backward, opposite of

Latin pronus.
From Diab M. Lexicon of Orthopedic Etymology, 1999
Also, orthopedic terminology is generally described as if
one were visualizing a standing human with the upper
extremities in extension and the forearm externally rotated
(the so-called “anatomic position”). This standard can lead
to confusion when describing forearm and hand anatomy.
With the forearm pronated, one would think of the thumb
as being a medial structure yet by the anatomic standard
(forearm supinated) it is lateral. Thus, the terms “radial”
and “ulnar side” are best used for localizing forearm and
hand conditions.

FRACTURE LANGUAGE
Beginning orthopedic residents rapidly learn the “tools of
their trade” which include development of an “orthopedic
language” as one of the most critical learned skills, both for
the spoken and written word (medical record, operative
dictations, clinic notes). Direction of displacement is
commonly used to describe joint dislocation with wide
acceptance that when one describes a posterior dislocation
of the knee that one means the more distal member (tibia)
is posteriorly positioned in its relationship to the femur.
 Valgus Position
Rather than stating that “the fracture has healed in slight angulation with the
heel in a more lateral position than would normally be expected,” we simply
state, “the ankle is in valgus.”

Left ankle in valgus position.

X-ray viewed from behind.

The efficiency of “varus” and “valgus” rather than a full

descriptive sentence quickly becomes apparent. Rather
than stating that “the ankle fracture has healed in slight
angulation with the heel in a more lateral position than
would be normally expected,” we simply state “the ankle is
in valgus.” What a triumph of efficiency! Once this “lingua
franca” has been mastered, life becomes easy for the
doctor but frustrating for patients, especially if their doctor
does not understand the necessity of reverting to common
language when speaking to children and their families.
 Learning Varus and Valgus “The ‘R’ and ‘L’ School
of Thought”
This simple method works well for many.

vaRus—focus on the R; R = round like a circle.

vaLgus—focus on the L; A valgus deformity (in a severe form) looks like the
letter L.
 Figure 3-1 Cubitus varus, right elbow following a right supracondylar
humerus fracture.

Frontal Plane Descriptions (Coronal Plane)

The terms varus and valgus, easily learned on externally
evident joints (knee and ankle), require a bit of experience
to be used for the elbow and hip. None of the many memory
assisting methods speed the process very much. Salter
emphasized that varus deformities conform to an imaginary
circle with a patient placed inside the circle (circular legs =
bowed legs, cubitus varus = a bowed elbow).
 Figure 3-2 125 to 135 degrees is generally considered to be normal
for neck shaft angle. Below this range is coxa vara and above it is
coxa valga.

This may help some learners, particularly for the externally

apparent joints (elbow, knee, ankle). Logically, the opposite
deformity (valgus) does not conform to a circle.

For most orthopedic learners, hearing and using the terms

again and again while viewing the appropriate x-rays seems
the best way to master orthopedic language. Seeing and
learning about the complications in children’s fractures are
best described by varus and valgus helps. For example, a
poorly treated supracondylar fracture almost always heals
in cubitus varus (Fig. 3-1). Similarly, inattention to a
femoral neck fracture will lead to coxa vara (Fig. 3-2). Coxa
vara is also seen secondary to skeletal dysplasia and in an
idiopathic form.
 Varus, Valgus, and the Midline

One of the many methods used to learn the application of varus and valgus in orthopedics.
(After Salter RB. Textbook of disorders and injuries of the musculoskeletal system. 3rd ed. Baltimore,
MD: Williams & Wilkins, 1999.)
 Table 3-1 How to Describe This Fracture?
INCORRECT
“The fracture is dorsally angulated”

CORRECT
“The fracture is dorsally displaced with apex volar angulation”—Some might
say “dorsally tilted.”
 Anterior Dislocation
Anterior dislocation of the knee means that the tibia is lying anterior to the
tibia.

Sagittal Plane Descriptions

Sagittal plane abnormalities related to fracture position
and fracture reduction can be efficiently described, but the
use of interchangeable terms has caused confusion. The
confusion is due to a lack of standardization as to whether
one should describe fracture deformity by the direction of
the apex of the deformity or by the displacement of the
distal fragment.

Distal both-bone fracture deformities are common, and the

confusion that exists in describing them is understandable.
The most common pattern is for a fall on an outstretched
hand (so-called FOOSH injury) with the fracture occurring
3-4 cm above the physis with the distal fragments
displacing dorsally with volar angulation at the fracture site
(Table 3-1).

Most orthopedists like to describe this fracture by

describing both the angulation and displacement and might
say “displaced distal forearm fracture with volar angulation
of 45 degrees” Perhaps even clearer, one could say
“dorsally displaced distal forearm fracture with 45 degrees
of apex volar angulation.” Although some variance is
accepted, the language clearly defines the fracture.

The opposite deformity also occurs at the same level (so-

called Smith variant) with apex dorsal angulation and the
distal fragment displaced volarly.

Also by convention, when describing a joint dislocation

(e.g., when stating that “the knee is dislocated
posteriorly”), “posterior” applies to the distal member as
compared to the proximal. “Posterior dislocation of the
knee” means that the tibia is lying posterior to the femur.
 Figure 3-3 Most would describe this fracture as having an anterior
angulation.

Other Descriptions
The concept of dorsal and ventral terminology is related to
embryologic development and innervation. The segment of
the leg innervated by the dorsal division of motor roots
(back of leg; hamstrings, gastroceles) is considered dorsal
(or posterior), whereas the ventral division of motor roots
innervate the ventral (or anterior muscle groups—
quadriceps, anterior tibial). Unfortunately, the embryologic
rotation of the limb makes clear understanding and
application of this concept difficult. Simpler terminology is
therefore used.

Lower Extremity Descriptions

Lower limb issues include defining fracture deformity in
both frontal and sagittal planes (Fig. 3-3). In the femur, one
commonly describes a fracture as being in varus or valgus,
with anterior angulation or posterior angulation (with
dorsal and ventral less well understood).

As one moves distally, the term recurvatum (angulated

posteriorly) and procurvatum (angulated anteriorly) are
sometimes used. This term is often used for distal femoral
fractures, tibial fractures, and deformity about the knee
because of physeal closure (e.g., recurvatum because of
tibial tubercle fracture with physeal closure) (Fig. 3-4).

Thus, “curvatum” terminology is more widely used in the

lower extremity, likely because the terms dorsal and
ventral are less well visualized in the biped (upright
species), as compared to dorsal and volar in the forearm. In
some parts of the world, an “apex ventral deformity” of the
lower extremity might be easily understood as occurring on
the anterior surface of the femur or the tibia; however, this
terminology is not used in North America.

Figure 3-4 This could be described as a “posterior bow at the knee”

but is more commonly described as genu recurvatum (in this case
due to traumatic closure of the tibial tubercle growth plate). This can
be evaluated clinically by having the child lay prone on the exam
table with the lower legs hanging off the table.
An example of how this language is used would be a distal
tibial fracture, perhaps 4-5 cm above the ankle. If this
fracture had an anterior angulation, it would be described
as being in procurvatum (with apex anterior angulation).
More commonly, this fracture has a posterior angulation
(Fig. 3-5). If such fractures are casted with a neutral foot
position, muscle and tendon forces tend to worsen the
recurvatum or posterior angulation. Initial casting in
equinus is advised (also see Chapter 15).

Figure 3-5 This tibial fracture has apex posterior angulation

(recurvatum). Reduction plus casting in equinus will be required.

Foot Language
Language describing foot deformity leads to another level
of confusion because the foot is generally perceived to be
at right angles to the trunk and legs, thus the terms dorsal
and ventral are hard to visualize. Do you visualize the
bottom of your foot as being ventral or dorsal?

Angulation in the sagittal plane in the foot is sometimes

described as apex dorsal or plantar angulation. Yet from a
classic anatomic view point the bottom of the foot is its
dorsal surface. Dorsal and plantar have been adopted as
the most logical descriptions, although not anatomically
correct. If humans only swam, dorsal and ventral would
suffice (Fig. 3-6).

The term adduction and abduction are often used to

describe forefoot position. Adduction implies that the distal
segment is more toward the midline as compared to the
proximal segment. Deviation away from the midline is
called abduction.

Figure 3-6 Dorsal and plantar describe the foot in stance phase.

A congenital deformity of the foot with medial deviation of

the forefoot is referred to as either metatarsus varus or
metatarsus adductus (Fig. 3-7). The varus term is applied
because of the bowed deformity of the foot with the
convexity appearing laterally (thus conforming to a circle).
Adductus can also be used because the distal portion of the
foot is more medial than the proximal segment. A first
metatarsal fracture can produce an adduction deforming
(or be described as in an adducted position—Fig. 3-8).

Deformity of the great toe with angulation of the metatarsal

phalangeal joint (bunion deformity) is referred to as hallux
valgus—the more distal segment (toe) deviates laterally
making the metatarsal head translate medially (Fig. 3-9).

Figure 3-7 Common terms to describe the foot. Are these coronal or
axial deviations? If the patient is standing, the axial plane prevails.

ORTHOPEDIC LANGUAGE AND DISCUSSION

WITH FAMILIES
A growing area of orthopedic language application relates
to discussions with patient, parents, and relatives. Sizing
up the child and family you are treating includes assessing
their knowledge base, allowing you to adopt terminology
that is clear, descriptive, and appropriate for their level of
understanding.
 Figure 3-8 Adduction deformity in a first metatarsal fracture.

Internet savvy families often make special demands,

mandating that you communicate at their newly attained
level of communication. A gracious approach is required,
acknowledging what they have learned and then adding
your wisdom, gained through experience. Much can be
learned by both listening to internet savvy parents and
briefly reviewing the hard copies of the material that they
have gathered.

Upon entering the consult room, one quickly determines

whether the child and the parents should be communicated
to in a more traditional method, relying on lay terminology,
versus a more high tech “parental internet knowledge”
manner. As a general principle, it is usually best to use
simple terms until the conversation leads elsewhere. For
example, when describing a physeal injury it may be better
to use the term “growth center.” Terms such as varus,
valgus, procurvatum, recurvatum, etc. are confusing and
instead should be defined in terms that most parents use in
day-to-day conversation (“bowed,” “angled,” etc.).

When discussing diagnostic studies such as MRI’s or CT’s,

most patients light up because they have a relative who had
such a study or they have seen a TV show that has
presented the concept. Of course, everybody wants one
(Fig. 3-10). To limit the voracious consumer demand for
these studies, a brief explanation concerning the risk
versus benefit issues of such a test (especially potential
risks to the child such as radiation for CT scans) is more
effective than stating that the test is too expensive, which
only leads to frustration. When holding off on ordering a CT
or MRI study you should assure the family that if the
straight forward tests (exam, x-ray, CBC, sed rate, CRP) do
not solve the problem that you will then order the special
studies. Evolving insurance concepts that require
significant patient “co-pays” may make it easier to advise a
family that an MRI study is not really needed.
 Figure 3-9 Hallux valgus—the toe deviates laterally in relation to the
more proximal segment of the foot.

Language at Follow-up
At follow-up for femoral fractures and other lower
extremity physeal injuries, one commonly assesses limb
length difference. We prefer the term “difference” rather
than shortening. If one is describing limb length difference
to an assistant, I find it better to state that one limb is
longer than the other. “Short” has a negative connotation
that can lengthen your explanatory day. Also with femoral
fractures, the injured limb may in fact be the long one
(because of growth stimulation).

Radiographic concepts such as angulation, bayonet

apposition, and other issues confuse orthopedic surgeon-
parent discussions. One must be cautious as to when one
uses films to explain a child’s orthopedic problem. In
general, x-ray images (printed on sheets of paper in the
digital image era) should be taken into the examination
room (or displayed on the in-room computer) because they
greatly simplify your explanation. If fracture films show
complete bayonet apposition, and you choose to
demonstrate them (in all their glory) you often must be
prepared for a lengthy explanation.
 Figure 3-10 This child’s parents insisted on a spine MRI (occasional
back-ache). Amazingly, a syrinx was found. The wide availability of
sophisticated diagnostic methods sometimes produces more
questions than answers.

Ideally one has a set of teaching images in the clinic that

can quickly be shown as an example of a patient who had a
similar type of injury (and in which the fracture remodeled
—Fig. 3-11). On a busy day, you may decide that the art of
children’s orthopedics (on that day) includes not showing
the parents their child’s bayonet apposition film on a
fracture check visit.

Patient’s who present to the clinic for surgical follow-up

often have implants that are visible on x-ray. In such
instances, the term “implant” is generally preferred to the
more pedestrian term “hardware.”

21st Century Imaging and Communication

Internet message and image transmission has
revolutionized fracture language communication. The
current era allows a home, automobile, or satellite office
positioned orthopedic surgeon to be given the history and
review diagnostic images from a distance. This has
radically improved analysis of cases and allocation of
resources, allowing accurate decisions about “splint and
send to clinic later this week” versus “splint and bring to
clinic tomorrow” versus “needs to be admitted and go to
the operating room today.”
 Figure 3-11 When parents get worried about what we consider
acceptable angulation or apposition, we show them films from our
teaching file that demonstrate the child’s ability to remodel. This case
demonstrates how a femoral fracture in an infant will remodel.

This simultaneous discussion of images with the primary

care and ER physician who is analyzing the patient
improves physician musculoskeletal education, allowing
“orthopedic terminology” (dorsal and volar angulation,
dorsal displacement, varus, valgus, antecurvatum,
retrocurvatum, etc.) to be better understood by primary
care colleagues. Unfortunately this idealized concept, as
was stated in our third edition, has been stunted by
intervening regulation as noted below.

21st Century Communication and HIPAA Regulations

As the name of this USA law suggests, the Health
Insurance Portability and Accountability Act (HIPAA) of
1996 was signed into law in the USA to improve the
portability and accountability of health insurance coverage.
The program also promised to reduce waste and fraud in
the healthcare and health insurance industries.
Unfortunately, HIPAA failed to accomplish these goals and
over a decade later (2009) the Affordable Care Act (ACA, or
Obamacare) was made into law with the goal of improving
health insurance availability as well as the prior HIPAA
goals (portability, accountability).

Today, the remaining impacts of HIPAA include the

extreme penalties that it issues to prevent breaches of
privacy. These include four tiers of violations in civil
complaints, and three tiers of criminal complaint violations.
The most important tier for the average healthcare
institution is the first tier, which is that the “covered entity
or individual did not know (and by exercising reasonable
diligence would not have known) the act was a HIPAA
violation.” This tier of violation can produce a fine of up to
$50,000 per violation, up to a maximum of $1.5 million for
identical provisions during a calendar year, and up to 1
year in prison.

Hospital administrators are terrified by this law and

provide frightening examples of this law being enforced
(on-campus pharmacies print receipts with patient name on
them—patient walks out of pharmacy and tosses the receipt
in trash—regulatory agency personnel sift through the
trash—find dozens of receipts—each a HIPAA violation—
hospital then fined $50,000 dollar for each receipt).

“The unintended consequence of

extreme data security requirements
have greatly diminished the expected
benefits from the digital revolution on
emergency orthopedic care.”

Understandably, hospital administrators then insist that

medical staff, residents, etc. be absolutely certain that
there will be no HIPAA violations. Even carrying a printed
list of one’s weekly surgical cases is looked upon with
suspicion. Unfortunately these burdensome regulations
impede many of the positive benefits of the digital
revolution that we described in the third edition of this
book (2005).

For example in 2018, using commonly available technology,

the following can occur:

“A young orthopedic resident encounters a puzzling case in

the ER and sends a text message to a senior staff member
who is out for dinner. The text includes a clinical photo of
the patient’s injury and a note stating that a somewhat
longer email has been sent to the staff physician’s email
account, which describes the history and physical exam.
The staff physician then opens the email on their mobile
phone, reads about the case, and launches a PACS (picture
archiving and communication system) app on their phone
to evaluate the patient’s x-rays. The staff physician also
looks at the child’s medical record (on their phone) and
notes pertinent information from the endocrinology division
that will affect treatment, and then calls the resident to
advise on the next treatment steps.”

Unfortunately, this type of fluid, efficient, exchange of

information (that our patient population hopes for and
expects), cannot currently happen because almost every
step of that scenario represents a HIPAA violation that can
result in thousands of dollars in fines.

In response to HIPAA concerns, our hospital, along with

other American hospitals, have enacted rigorous policies
related to patient data and computers (including mobile
phones). These policies dictate how, where, and to whom
patient information can be sent. These policies include
special apps, virtual private networks, and keystroke
recording software that raise many concerns from staff
physicians, residents, and other hospital personnel. The
cumulative result of these policies is that many important
messages are either missed, or aren’t sent in the first
place. The unintended consequence of extreme data
security requirements have greatly diminished the
expected benefits from the digital revolution on emergency
orthopedic care.
 Figure 3-12 This was called in as an acute supracondylar fracture
requiring emergent surgery. In fact, this is a lateral condyle fracture,
and surgery could be done any time in the next 4-5 days.

FRACTURE DESCRIPTION AND RESOURCE

UTILIZATION
“This is a severe supracondylar fracture. You must see the
child urgently in your ED” (Fig. 3-12). As a consequence of
such a message, the receiving surgeon’s OR staff may be
kept past their regular hours (sometimes on overtime pay)
awaiting the urgent case only to find upon the patient’s
arrival that the fracture was not severe or was a lateral
condyle fracture, either of which could have been seen in
the clinic the following day—saving thousands of dollars.

The growth of emergency medicine as a specialty as well as

more prevalent urgent care centers, combined with the
usual pediatric trauma initially seen in the office of family
practitioners and pediatricians emphasizes the need for
improved musculoskeletal communication skills among
non-orthopedic surgeons.

Part of the problem relates to the limited musculoskeletal

education provided to North American medical students.
The crowded medical school curriculum, focused on basic
science and molecular medicine, provides little time for
musculoskeletal education, despite the fact that 30% or
more of urgent medical care deals with musculoskeletal
issues.

Orthopedic surgeons can help to improve this situation by

encouraging increased attention to musculoskeletal disease
education, both for the medical school curriculum and also
by providing primary care, family practice, and pediatric
residencies with the opportunity for clinic exposure and
rotations on an orthopedic service.

As noted above, accurate description of the fracture type

and its severity has important economic consequence. Is
the fracture open, thus requiring emergency débridement?
As already noted, descriptions of deformity versus
angulation are often confusing. Perhaps the best that one
can expect is an accurate description of the degree of
angulation of the fracture. Whether the displacement or
angulation is dorsal or volar (upper extremity) or anterior
or posterior (lower extremity) is less important for the
initial discussion.
WHAT REQUIRES EMERGENCY REDUCTION?
The topic of orthopedic language and children’s fracture
treatment logically leads into efficient resource utilization.
In this section we will present a few notes on treatment
urgency which will also be mentioned in Chapter 4.

Figure 3-13 John Royal Moore developed a fracture management

system in which non-emergent fractures were scheduled for
treatment on Thursdays.

Fracture Reduction Urgency

The urgency for fracture treatment in children has varied
greatly. Often decisions about urgency are made according
to the type of institution providing treatment and/or the
social structure of the family. A commonly quoted system is
that of John Royal Moore in Philadelphia (mid 20th century)
who held a children’s fracture reduction clinic every
Thursday (Fig. 3-13, see also Chapter 4). Children injured
throughout the week were consolidated and treated on a
single day. Obviously true emergencies were accepted.

Traditionally, many orthopedic practices probably have

provided same day reduction and treatment for many
fractures, except for cases where swelling could not allow
it. A child injured in school would hope to see an orthopedic
surgeon that day with a cast applied and/or a reduction
performed as needed. Splinting alone would be used only if
swelling were extreme. This efficiency is less common in
the current era. The need for an efficient clinic with little
tolerance for cases that “slow down” patient visit schedules
usually makes immediate reduction impossible. Concern for
clinic efficiency combined with regulations regarding what
form of anesthesia can be provided in an office (sedation,
local block, etc.) has led to fewer “office reductions.”

The development of large children’s hospital treatment

centers, particularly with resident manpower available,
sometimes leads to an exaggerated sense of urgency
regarding the need for acute reduction. Other factors have
also contributed to this. These would include the
development of emergency medicine as a specialty and also
the use of the emergency department as an urgent care
center by a large segment of the population, particularly
the under-insured.
 Primary Children’s Hospital—Salt Lake City. Their efficient fracture
care model includes a “Wednesday Fracture Clinic” with no limit on
referrals.

Patients arriving early in the evening are assessed by the

emergency department attending and determined to need a
reduction. With a resident available, it seemed only logical
to get a consult and, if feasible, reduce the fracture on an
urgent basis, using conscious sedation anesthesia. The
problem lies with late arrivals, need for a certain length of
NPO status (4-6 hours), even for conscious sedation, and
the 80-hour resident work week. Suddenly one is faced with
a child arriving at 9:00 p.m. who cannot be reduced until
1:00 a.m.

The pattern noted above can lead to over-utilization of an

institution’s resources for fracture care and reductions.
Clearly emergency nighttime care is more expensive than
elective, daytime care and passing the load to on-call
residents may not always be the appropriate solution.
Different solutions have evolved in different centers and
practices. Our approach to this dilemma is presented in
Chapter 4.
 Rady Children’s Hospital, San Diego, also has an efficient, high-
volume fracture care system.

High Volume Fracture Care Models

Salt Lake City. Several contemporary children’s fracture
treatment centers have developed efficient methods to deal
with a high volume of children’s fracture patients. In 2001,
John Smith and his children’s orthopedic colleagues at the
Primary Children’s Hospital in Salt Lake City (associated
with the University of Utah Medical Center) developed a
21st century variation of John Royal Moore’s Philadelphia
clinic (mentioned above). In Salt Lake City, Wednesday was
established as “Fracture Clinic Day” and any child with a
fracture could be seen without an appointment. By using
mini-image intensifiers and other efficiencies, many
patients could be rapidly cared for (often up to 130 patients
in a single day). Fractures that require reduction are not
managed in this clinic but instead are sent on to the
Emergency Department where conscious sedation is
available for reduction.

This Primary Children’s Hospital “Fracture Clinic Day”

continues to operate (2017) and has proven to be a
valuable community resource, which allows good teaching,
especially for orthopedic, primary care, and emergency
medicine residents. Hospital administration supports the
program because it avoids referral delays and improves the
hospital’s “community image.” Also, high volume data
gathering provides information for research. The system
concentrates the burden of fracture care on a single day,
allowing the staff pediatric orthopedists more time to focus
on complex, elective conditions. Personnel requirements for
a busy fracture care day include: Receptionists (5), Medical
Assistants (6), Nurses (1), Coordinators (1), X-ray Techs
(3), Residents (1-2), and Staff Physicians (1-2) (Source—
John Smith, MD—Salt Lake City). Clearly extensive
resources are needed to provide for quality care for over
100 patients in a single day. Disadvantages include that
“open access” can lead to “patient dumping” with outside
orthopedic systems sometimes keeping the better paying
patients and referring these with little or no funding (this
pattern is not unique to Salt Lake City).

“To make such a system function, we

have a dedicated orthopedic trauma
room available in the AM for each
weekday.”

San Diego. We deal with our high volume fracture care at

Rady Children’s Hospital, San Diego in a different, yet also
efficient manner. We routinely receive up to 250 fracture
patient referrals for care in a week’s time. Our system
includes 10 children’s orthopedic surgeons on staff (plus
four fellows) as well as 10 Nurse Practitioners
(NP)/Physician Assistants (PA) to provide high volume
care. These practitioners lead multiple independent
fracture clinics per week (approximately 10-12) where each
practitioner sees about 18-20 patients per half day. These
are held in parallel clinics with staff orthopedic surgeons
available to help with decisions on more complex cases.
Obviously receptionists, medical assistants, and a skilled
group of Orthopedic Technicians (cast techs) are required
to assure high volume patient flow.

As in the Salt Lake City model, fractures requiring

reduction are not treated in these clinics but instead are
sent to the Emergency Department where conscious
sedation is available. An added advantage of our San Diego
model is that we also train our NP/PA team members in
fracture reduction. They run clinics into the evening and
are then also available to perform fracture reduction in the
Emergency Department (both assisting the on-call
orthopedic resident and also performing independent
fracture reductions when the residents are in the operating
room). The NP/PA “evening shift” ends at 11 p.m. As in the
Salt Lake City model, extensive resources are required to
support our systems.

To make such a system function, we have a dedicated

orthopedic trauma room available in the a.m. for each
weekday. This minimizes late night OR use for straight-
forward (non-emergent) children’s fracture cases. The
value of such a system has been documented by Brusalis et
al.

Open Fractures
A cardinal rule of fracture care at any age has been that an
open fracture must be taken to the operating room and
débrided within 6-8 hours of the injury (Fig. 3-14). Classic
literature has suggested that if this time limit was not met,
infection and even osteomyelitis were more likely. Skaggs
et al. as well as Yang suggested a change in this protocol,
particularly in Type I injuries. These publications suggest
that if patients have a clean wound, the wound is cleansed
and sterilely dressed and the patient is given intravenous
antibiotics, the operative débridement of an open fracture
can perhaps be done the next morning. This is highly
controversial and should be applied only after careful study
of the literature, one’s experience, and the institutional
standards.

Figure 3-14 Open fractures require urgent surgery for débridement

as well as reduction and stabilization. This child fell off a horse and
sustained this severely contaminated open fracture.
Supracondylar Fractures
A typical urgency issue concerns treatment of
supracondylar fractures which can be quite severe, with
complex cases more likely to have neurovascular
complications. Accordingly, this fracture has been given a
great deal of urgency with traditional advice for urgent
reduction plus pinning upon arrival (Fig. 3-15).

Figure 3-15 Severe Type III supracondylar fracture of the humerus.

When must this be reduced as a super-emergency?

With large volumes of patients with supracondylar

fractures having been concentrated in children’s centers, it
has been demonstrated that these patients can, in most
cases, be splinted with reduction the following day.

The study by Gupta et al. from Los Angeles clarifies that

most supracondylar fractures (even Type III injuries),
providing they do not have a significant neurologic deficit
or skin tenting upon arrival, can be safely splinted and
treated surgically within the next 24 hours at a time that is
better for the surgeon (and economical for the hospital)
while still producing good results.

Clearly a careful examination of the patient is required.

Splinting in extension (about 30 degrees of flexion) to avoid
increasing the pressure within the elbow hematoma is
essential. In most cases, the child should be admitted to
hospital so that they can be monitored and taken to surgery
the next morning. Obviously cases with vascular/neurologic
issues do not fit into this “wait until morning” reduction
concept.

Other Angulated Fractures

Since even supracondylar fractures can be splinted and
reduced the next day, clearly moderately angulated
forearm fractures do not require emergent reduction at
night. Our hospital has a very large number of such
patients, and if the patient comes in early at night on an
empty stomach, it is easy to give conscious sedation and
reduce the fracture.

Because modern conscious sedation protocols (Chapter 4)

are progressively geared toward making the child NPO for
4 to 6 hours prior to sedation, the child who arrives at 9:00
at night might not be able to have a reduction until 1:00
a.m. Neither a practicing orthopedic surgeon nor an
orthopedic resident will want to reduce a fracture at these
hours if safe alternatives are available. A moderately
angulated forearm fracture can simply be splinted and
reduced and casted sometime within the next several days
or even week (Fig. 3-16). Many private orthopedic
practices and institutions have already had these more
practical policies in place for some time.
 Figure 3-16 Does this fracture mandate urgent formal reduction at 3
a.m.? If you ask your resident to do this reduction at 3 a.m. in the ER,
he or she will not be available for surgery the next afternoon (and
may miss doing an important case).

EDUCATING FAMILIES REGARDING URGENCY

Systems that have traditionally provided immediate
fracture reduction (even though it is not scientifically
required or justified) will take some time to re-educate
their families when making the transition to a less urgent
philosophy. The first task is to educate emergency doctors
(both in your hospital and elsewhere). Giving an
instructional course on how to splint makes a good start.
Families can be educated concerning the safety and value
of delayed reduction and casting, and much of this
instruction can be given through your ER staff (Table 3-2).
Also you must be certain that your office or clinic has
readily available openings for appointments (and
reductions) within the next few days.

Table 3-2 Advantages of Splinting

Fractures (with formal reduction later)
Safer—allows swelling to decrease
Definitive treatment in daytime hours—by experienced team
Correct billing for reduction plus casting

The first advantage that can be pointed out to the family is

that casting will be safer after swelling has receded.
Careful splinting with casting in 48-72 hours allows the
swelling to diminish, allowing a cast to be applied that
often will not need to be split or bi-valved. This can save an
added visit to the orthopedic office to tighten the cast.

A second advantage is that they will have definitive

treatment during daytime hours by the most experienced
team. This often includes the most experienced cast
technicians and orthopedic surgeons. This decision making
is described in some detail in Chapter 4.

Finally, as the true cost of night and weekend care

becomes apparent, and insurance schemes further involve
families in sharing cost, it will become even clearer that
definitive treatment by a specialist in the middle of the
night is not sustainable. Those who demand emergent
reduction (when it is not medically required) will need to
bear the added cost (insurance companies or families).

SUMMARY
Proper use of orthopedic language and technology makes
children’s fracture care more efficient. The transmission of
digital images allows decision makers to determine how
severe the fracture is and whether or not urgent reduction
is required (even if the treating surgeon is far from the
hospital). Government inspired privacy regulations have
hampered full application of the “digital revolution” to
children’s fracture care issues. Splinting protocols can be
improved. Fracture reduction can then be performed
during daytime hours. Late night and early morning hour
care can be allocated to truly emergent injuries (severe
open fractures, fractures with vascular compromise).

SUGGESTED READINGS
Brand RA. Biographical sketch: John Royal Moore, MD 1899–1988. Clin Orthop
Relat Res. 2011;469(10):2679–2680.

Brusalis CM, Shah AS, Luan X, et al. A dedicated orthopaedic trauma operating
room improves efficiency at a pediatric center. J Bone Joint Surg Am.
2017;99(1):42–47.

Diab M. Lexicon of Orthopaedic Etymology. Amsterdam: Harwood Academic

Publishers; 1999.

Gupta N, Kay RM, Leitch K, et al. Effect of surgical delay on perioperative

complications and need for open reduction in supracondylar humerus fractures
in children. J Pediatr Orthop. 2004;24(3):245–248.

Gustilo RB, Anderson JT. Prevention of infection in the treatment of one

thousand and twenty-five open fractures of long bones: retrospective and
prospective analyses. J Bone Joint Surg Am. 1976;58(4):453–458.

Harley BJ, Beaupre LA, Jones CA, et al. The effect of time to definitive
treatment on the rate of nonunion and infection in open fractures. J Orthop
Trauma. 2002;16(7):484–490.

Ibrahim T, Riaz M, Hegazy H, et al. Delayed surgical debridement in pediatric

open fractures: a systematic review and meta-analysis. J Child Orthop.
2014;8:135–141.

Salter RB. Textbook of Disorders and Injuries of the Musculoskeletal System.

3rd ed. Baltimore, MD: Williams & Wilkins; 1999.

Skaggs DL, Kautz SM, Kay RM, et al. Effect of delay of surgical treatment on
rate of infection in open fractures in children. J Pediatr Orthop. 2000;20(1):19–
22.

Yang EC, Eisler J. Treatment of isolated type I open fractures: is emergent

operative debridement necessary? Clin Orthop. 2003;(410):289–294.
 4
Emergency Fracture
Reduction

Vidyadhar Upasani
Sun Min Park
Dennis Wenger
Developing a Children’s Fracture Treatment System
Analgesia for Reduction
Manipulative Reduction

“Those that do not feel pain, seldom

think that it is felt”
— Dr. Johnson

INTRODUCTION
Traditionally simple minimally displaced or non displaced
fractures in children were treated in the emergency
department (ED) with minimal or no anesthesia.
Moderately displaced fractures were sometimes treated in
the ED with local anesthesia (hematoma block, propofol, IV
lidocaine methods); however, most moderate and all severe
fractures were treated in the operating room (OR) with
general anesthesia.

With the development of new methods for analgesia and

the availability of compact digital imaging units, currently
many significantly displaced and angulated children’s
fractures can be treated in EDs, clinics, and office-based
treatment centers. This has reduced the number of
reductions performed in the OR, freeing those rooms for
more severe cases.

This chapter will clarify how our hospital has developed

and applied these new methods in a region of 5 million
people with a clinic/emergency setting in which thousands
of new children’s fractures are evaluated and treated
annually. Key elements in this evolution include the
following:
 Figure 4-1 Ketamine alone has proven to be a very safe agent for
conscious sedation in children.

A progressive orthopedic surgery group interested in safe,

cost effective fracture care that minimizes OR use and
hospitalization
In busy hospital-based systems: residents and advanced
care practitioners (ACPs), (nurse practitioners [NPs], and
physician assistants [PAs]), trained in fracture care.
Advanced Life Support (ALS) and Pediatric Advanced Life
Support (PALS) certified doctors, nurses and medical
personnel—Full-time ED medical staff
Development of safe, effective conscious sedation
anesthesia techniques (Fig. 4-1)
Compact portable, low-radiation, digital image intensifying
machines to guide fracture reduction
Use of telemedicine (taking images that can be loaded on
to patient’s chart, also allows efficient triage and
institutional transfer)
Certified orthopedic technicians—for cast application and
care
“Next morning” dedicated orthopedic trauma room in OR
(avoids most “middle of the night” surgery—minimizes
“surgeon burnout”)

ER or ED?
Emergency rooms have grown in size and complexity and have often become
departments. As such, they often ask that they be known as the “ED”
(emergency department). Yet the overall culture seems to prefer “ER”—
perhaps a vestige of the popular television program.
 Advanced Care Practitioners—Who Are They?
Also referred to as “Allied Health Professionals,” “Mid-level Providers,” and
“Physician Extenders.” These advanced care professionals are physician
assistants and nurse practitioners who have become experts in children’s
orthopedic care. Our service trains them much as residents are trained. They
run their own fracture clinics and take calls and form an important part of our
care team.

The combination of these factors has revolutionized

fracture care efficiency for children in our center.

Advanced Care Practitioners (ACPs)

The development of ACPs in specialty care makes
children’s fracture care more efficient in centers with the
volume to support such a system. In our center, the
orthopedic staff train not only orthopedic residents and
fellows but also ACPs in fracture management, including
closed reductions in the ED. This has helped us deal with
resident work requirements and with increased patient
volume. Proper training and supervision allows ACPs to
manage children’s fractures safely and efficiently.

Current Trends
Today most children’s fractures can be safely reduced in
the ED ranging from forearm fractures to femur fractures
(in very young children). Initially the treating orthopedic
surgeon had the sole responsibility for analgesia, reduction,
and casting. With newer methods, most EDs can provide an
environment that allows a systematic “team approach” for
fracture reduction. The ED staff physician can oversee the
administration of conscious sedation, a nurse can monitor
the patient, and a portable image intensifier allows one to
monitor fracture reduction (Fig. 4-2).
 Figure 4-2 Compact image intensifiers allow accurate monitoring of
reductions with minimal radiation exposure.

Trends in mechanism of injury for childhood fractures are

both consistent and evolving. Although monkey bars and
trampolines continue to be a common cause of many
pediatric fractures, we have also seen a rise in fractures
sustained from hoverboards and “small wheeled” scooters.
Seasonal trends are also noted; football-related injuries and
fractures occur mostly in the fall season and snow-related
(ski, snowboard, sledding) fractures occur mostly in the
winter.

Fractures occurring during a patient’s vacation are

common because our institution is located in a city
considered to be a tourist destination. We provide our
services, as appropriate, and direct the patient and family
to obtain their imaging studies and records via our Medical
Records office for return to their often distant home city.
We also assist the family in finding a pediatric orthopedist
who can continue their care in a timely manner based on
their home city (we use the POSNA site
http://orthokids.org to find a pediatric orthopedist).

Fracture Care Involving Orthopedic Residents in

Training
In centers with resident training programs, the
improvements noted above have allowed residents to
provide efficient fracture care, decreasing the need for
staff orthopedic surgeons to be present for every reduction.
Traditionally, most North American centers required a staff
orthopedic surgeon to be present for all reductions
performed in the OR. The presence of supervising,
attending emergency room physicians (who provide overall
supervision for the case) now allows resident fracture
reduction in the ED with the on-call staff orthopedic
surgeon in attendance only for problem cases. The staff
physician reviews the case by telephone/digital x-ray
images prior to treatment in all but the simplest of cases.
The same applies to ACPs who reduce fractures.

The continuing development of the electronic medical

record (EMR) and picture archiving and communication
systems (PACS) help with efficient off-site staff supervision
of residents. Also, the resident and ACPs now have the
ability to take a photo of a wound with their cell phone that
is immediately deposited in the child’s EMR, which is
accessible by an off-site staff physician to help guide
treatment when needed.

“To treat a high volume of fractures, an

efficient system that coordinates care
between the ED staff and the orthopedic
team is required ”

There are many advantages in using this technology;

however, there are also pitfalls that can negatively affect
patient care. Obtaining a clear and thorough history of
present illness and the patient’s physical exam is of utmost
importance prior to obtaining and sending digital images.
This is especially important in situations when outside
facilities are transferring this information to a resident or
ACP.

Each fracture reduced during nighttime hours is reviewed

with the on-call staff in the morning. Also, all reductions
are reviewed in a weekly conference that all orthopedic
residents, an ACP representative, and staff in attend. The
goals of the conference include ensuring that patients have
received appropriate care and timely follow-up, as well as
providing constructive feedback to residents regarding
closed reduction and cast application quality.

DEVELOPING A CHILDREN’S FRACTURE

TREATMENT SYSTEM
To treat a high volume of fractures, an efficient system that
coordinates care between the ED staff and the orthopedic
team is required, and in this section, we will describe the
methods that we have developed (Rady Children’s Hospital,
San Diego). These methods can also be applied in a
specialized fracture reduction clinic model, if appropriately
trained personnel are available to manage conscious
sedation.

Prior to beginning their rotation at our center, the

orthopedic residents attend an “Ortho Boot Camp.” This 2-
day course includes applying casts and splints, suturing,
setting up traction and managing traction pins. The course
is organized and supervised by our staff orthopedic
surgeons, along with our most experienced orthopedic
technicians. This is also an opportunity for physician
extenders to receive initial or supplemental training.

Efficient fracture care in a busy children’s hospital requires

a tiered team that can focus on musculoskeletal problems.
In our system, this team is headed by an attending surgeon
and includes an orthopedic resident, an advanced care
practitioner (NP or PA), and an orthopedic technician.

Table 4-1 Guidelines for Referring

Doctors, Clinics, and ERs Send
Urgently or Splint and Refer Later?

Arrival
Patients arrive to our ED either through self-referral or
referral from an outside facility or from their primary
doctor. When a child is sent from an outside facility, a call
has usually already been made notifying either the
orthopedic team or the ED staff. In some cases, the team
may decide (after talking with the referring
person/institution) that an expensive emergency visit is not
required and the patient can be managed in our early
evening “Fracture Clinics” that run daily from 4 to 6 p.m.
(Table 4-1).

“Not all fractures require reduction and

not all patients need treatment in the
middle of the night”

Simple fractures (or suspected fractures) should be

managed with a splint and sent to our outpatient clinic
within a few days. Of course, this is often hard to ascertain
by telephone, and we note errors weekly. A small puncture
wound may not be recognized as an open fracture, and a 1
a.m. transfer for a “severe supracondylar fracture” is
sometimes just a buckle fracture.

Who Requires Urgent Treatment

Not all fractures require reduction, and not all patients
need treatment in the middle of the night. Even in our very
busy system, the full team (NP/PA, resident, and
orthopedic technician) is available only until 11 p.m. (the
resident continues to be available throughout the night).
Fractures that are only modestly displaced or angulated do
not require reduction at a very late hour. Such cases can be
splinted by your ED staff and brought back for formal
reduction in a few days.

Delaying manipulative closed reduction is sometimes

difficult to implement because parents are anxious and
concerned about their child’s injured extremity. Although
most parents want an immediate reduction, in almost every
type of fracture, there is no clear evidence that immediate
reduction provides a better result.

However, several recent studies have emphasized the need

for proper education for residents and ED personnel on
splint application. Poorly applied splints can be painful as
they do not properly immobilize the fracture or can even
cause skin pressure or necrosis. Our system strives to
improve patient care and safety; however, with the ever-
changing “guard” of ED and orthopedic resident providers,
splint-related complications can likely never be reduced to
zero.

John Royal Moore

Moore, a prominent orthopedic surgeon from Philadelphia, created and
implemented an effective fracture reduction clinic that met only once a week
(every Tuesday). His method proved to be safe and effective, and its
principles are still used today. Splinting small fractures with reduction (if
needed) in 3-5 days allows swelling to subside, making casting safer.

Streamlining Care—Nurse Triage

Once a patient has been accepted for treatment, both the
orthopedic team and the ED staff should be notified so that
triage can be started immediately upon arrival. This
assures prompt treatment and limits unnecessary waiting
time in an already busy ED.

Splinting Fractures
A key element to a sensible musculoskeletal urgent care program is the
widespread availability of safe and practical fracture splinting by outlying
facilities. Fiberglass-felt-foam composite splints (available on bulk rolls)
combined with an elastic wrap roll allow easy application for the trained
orthopedist; ERs seem to do it well also. Training primary care doctors to
splint safely is a great investment toward rational fracture care. Training
sessions for referring practitioners provide a great community service that will
save time, money, and frustration for you and the patient.

Upon arrival the ED triage nurse can assess the child and
usually order the appropriate x-rays (sometimes after brief
consultation with the ED staff or an orthopedic team
member). Patients who have a CD/DVD disk with the
outside facility images can submit the disk to have the
images loaded into the digital imaging program almost
immediately upon being placed into a patient room in the
ED. This capability minimizes the risk of losing the initial
images and repeating x-rays in our ED. However, caution
must be taken in only using outside facility x-rays; if
quality, true, orthogonal views have not been taken they
may need to be repeated.
ED Physician Assessment
Because the child has entered the ED, most systems
mandate that each child be briefly evaluated by the ED
physician. The ED physician ensures that there is no
underlying systemic injury and evaluates injury
circumstances, social dynamics, and the child’s overall
health.

Orthopedic Assessment
With the patient now under orthopedic care, a history and
physical are performed with special focus on issues such as
neurovascular compromise and whether the fracture is
open. A neurovascular assessment can be difficult in a
young child who is in pain. You should document only that
which is documentable. For example, in a 2-year-old child
with no ulnar nerve function post reduction, it is important
not to have stated that it was functioning pre operatively. If
you are uncertain, it is better to write that accurate
documentation is not possible.

Treatment Strategy
In busy centers, the attending surgeon and the resident are
often busy in the OR, which makes the role of the ACP
important. In our hospital the ACP is trained to
reduce/treat children’s fractures in the ED, as well as
manage straightforward orthopedic concerns. On a busy
day, the ACP can call the OR and have a patient’s x-rays
brought up on the digital x-ray program for a quick read
and advice on treatment (splint and send home? Reduce in
ER? Requires OR?—See technique tips pathway).

The treatment plan is implemented. All care is under the

direction of the on-call staff surgeon who may be in the ED,
in the OR, or off-site and available by phone and/or
computer.

Fracture Reduction
In planning reduction, fracture location helps to decide
whether conscious sedation in the ER is required. Most
forearm fractures are good candidates whereas femur
fractures in older children (above age 5 years or so) and
significantly angulated tibial fractures are often best
treated in the OR with general anesthesia (Table 4-2).

“Parental anxiety may determine where

the fracture should be reduced ”

Table 4-2 Reduction in ED vs. OR

Good Candidates—ED OR Reduction Preferable
Reduction
Wrist fractures Complex tibia fractures (older child)

Forearm fractures Femur fractures (older child)

Hand/foot fractures Open fractures

Infant femur fractures Fractures with neurovascular

compromise

One must recognize that not all 8-year-olds have the same
temperament; different children react differently to the
same type of fracture; therefore, the decision about
anesthesia methods should be adjusted according to the
child’s temperament and family dynamics.

Also, parental anxiety may determine where the fracture

should be reduced (Table 4-3). We ask the parents to go to
the waiting room while the actual reduction takes place (to
avoid their exposure to the sounds and apparent aggression
required to reduce a stubborn fracture). A few insist on
staying; in such cases, OR reduction may be better and the
treating surgeon should offer this option. We believe that
the person who performs the actual manipulation deserves
the degree of privacy that allows optimum performance.
The reduction quality may depend on this.

TECHNIQUE TIPS:
Pathway—Children’s Fractures in the ED
 Table 4-3 Should Parents Be Present for
Orthopedic Reductions? (In our center we
ask the family to leave—Some of our reasons are
listed below)
“Grotesque” maneuver required to lock fracture ends
Audible noises (crunching of bone ends)
Seemingly aggressive face of hyperfocused treating doctor
Risk of fainting (parents)
A tough reduction is like an operation (parents should not attend either)
Focus on reduction is better with no “outside audience”

ANALGESIA FOR REDUCTION

No Anesthesia
For fractures that require minimal manipulation, some
children can tolerate casting and molding without
anesthesia. The child and parent need to understand and
be willing to accept that there will be some discomfort with
this technique. Often the child will agree and select this
option once understood that formal analgesia requires
needle sticks/intravenous line placement.

An often effective technique is to apply the cast completely

and then add the three-point mold that will improve the
alignment. The “gentle pressure” applied is uncomfortable
but tolerated well by the “correctly selected” child/family.
After successful completion of this artful maneuver, the
child is praised for his or her cooperation in achieving good
fracture position without needles or lengthy wait for
conscious sedation.

“Every treating orthopedist should

develop local anesthesia injection skills
and use them whenever practical”

Oral/Nasal Medication
A second option for fractures that require minimal
manipulation can include the combination of Tylenol with
Codeine (0.51 mg/kg) and oral/nasalVersed (0.3 mg/kg).
This choice is sometimes selected for an anxious patient
that in other circumstances would be casted and molded
without analgesia. The cast is usually placed with no
preliminary manipulation with the “gentle reduction force”
applied as the cast sets (as noted in the prior paragraph).

Local Anesthesia/Hematoma Block

Despite the methods that we describe in this chapter for
conscious sedation, every treating orthopedist should
develop local anesthesia injection skills and use them
whenever practical. This is even more important because
some centers apply very strict regulations regarding N.P.O.
status (child must have empty stomach) before conscious
sedation can be given. In many cases, deft local anesthesia
skills will save you and your patient many hours and much
frustration.

The most common local anesthetic method for fracture

reduction is a hematoma block with 1% lidocaine (no
epinephrine) solution directly injected into the hematoma
at the fracture site (Table 4-4). The maximum
recommended dose for lidocaine without epinephrine is 4.5
mg/kg with maximum of 300 mg. Withdrawing blood into
the syringe, the so-called blood flash, indicates correct
needle tip position with the lidocaine then injected. Ideally,
one should wait several minutes prior to fracture reduction
to allow more effective analgesia.
 Table 4-4 Reduction with Hematoma
Block
Preparation

Prep with alcohol and povidine-iodine

Superficial Block

Using 25-gauge needle, numb the skin around the fracture

Blood Flash
Using 18-gauge needle, inject at fracture site (4-6 cc of 1% lidocaine)
Reduction

Wait a few minutes and perform reduction

Casting
Apply well-molded cast

Hematoma blocks can be used for many fractures and can

be performed without the assistance of the ED staff
(freeing them for more critical patients). These blocks work
well for forearm fractures (especially in the distal 1/3 area)
but are generally not used for larger bones such as the
femur or humerus. Also, issues of maximum dosage come
into play (risk for seizures) if one attempts to use a
hematoma block for a large bone fracture.

Lidocaine can also be used for digital nerve blocks,

allowing one to reduce various fractures of the hand
(metacarpal, phalanges, nail bed injuries, lacerations,
MCP/IP dislocations) and foot (phalanges) (Table 4-5). One
can block each nerve bundle separately or use a single
midline injection (in line with the tendon sheath) that
disperses and blocks both digital nerves.

Regional Anesthesia
Intravenous lidocaine block (Bier block) can be effective for
reducing upper extremity fractures but requires special
tourniquets, and attention to detail. The Bier block, a
technique of IV regional anesthesia, originally described by
August Bier in 1908, can be performed in an ED setting,
office, or clinic, thereby avoiding the OR. The arm is
elevated to exsanguinate it, the tourniquet is inflated, and
dilute lidocaine is injected into a superficial hand vein. We
rarely use this method in our hospital (because of custom)
but others have found it to be highly effective in children.
Also, purists suggest a double tourniquet be used (to avoid
the pain of tourniquet constriction), making this method
even more complicated.
 Table 4-5 Digital Block (Flexor Tendon Sheath)
Preparation

Prep with alcohol and povidone-iodine

Localize Flexor Tendon

Palpate flexor tendon

Injection
Using 25-gauge needle, inject 2-3 cc of lidocaine in the tendon sheath (Note:
never use epinephrine in a finger)

“Conscious sedation has revolutionized

fracture care in emergency departments
and specialized fracture reduction
centers”

Conscious Sedation
Conscious sedation has revolutionized fracture care in ED
and specialized fracture reduction centers (Table 4-6).
Ketamine (Ketalar), the most widely used agent, induces a
state of catalepsy that provides sedation, analgesia, and
amnesia. Interestingly, this drug is used illegally on the
street and is known as “Special K” because of its relation
with phencyclidine (PCP).

Ketamine is well suited for pediatric orthopedic procedures

and has been shown to provide better sedation with fewer
respiratory complications (as compared to other commonly
used agents such as propofol/fentanyl) because it preserves
protective airway reflexes (Green et al.). Ketamine can be
safely given between 1 and 2 mg/kg intravenously with the
2 mg/kg dose favored by most centers.
Nitrous oxide has been increasingly used to reduced mild
to moderately displaced fractures and has been shown to
be safe and efficacious. Especially in combination with
intranasal fentanyl, several centers have found that
patients have successful fracture management, with a
shorter recovery time, obviating the need for IV access.

Table 4-6 Medication Commonly Used for

Sedation
Medication Recommended Side Effects Contraindications
Initial Precautions
Dose/Max
Dose
Ketamine 1-2 mg/kg Hypertension, Increased
Ketalar) hypotension, intracranial pressure
respiratory (ICP), seizures,
depression, hypotension,
laryngospasm, congestive heart
hallucinations failure (CHF)
Fentanyl 10-15 Respiratory Chronic pulmonary
(oral) mcg/kg/dose depression, disease (CPD), head
(Sublimaze) max 400 hypotension injury/increased ICP,
mcg/dose cardiac disease
Fentanyl (IV) 1-2 Respiratory CPD, head
(Sublimaze) mcg/kg/dose depression, injury/increased ICP,
q 30-60 minutes hypotension cardiac disease
prn
Morphine 0.1-0.2 Central nervous Upper airway
sulfate mg/kg/dose system (CNS) and obstruction, acute
q 2-4 hours prn respiratory bronchial asthma,
depression, CPD, increased ICP
hypotension,
increased ICP,
nausea/vomiting
Midazolam 0.05-0.1 mg/kg Respiratory Existing CNS
(Versed) over 2 minutes depression, depression,
max total dose hypotension, glaucoma, shock
0.2 mg/kg bradycardia
Administration and Monitoring Sequence
Once the orthopedic team has determined that the child
should have conscious sedation, the process is then
coordinated with the ED physicians and nurses. Ideally this
is done in a single area of the ED designated for fracture
care. The orthopedic team briefly discusses the treatment
plan, and the ED staff explains conscious sedation to the
family. In some centers, the analgesia is delayed for a few
hours if the child had something to eat or drink to minimize
the risk for aspiration.

A physician should be available during and following the

sedation. The nurse monitors the patient. Ideally, the
child’s mental status, heart rate, blood pressure,
respiratory rate, and oxygen saturation are monitored
before, during, and after procedural sedation. Clearly, this
ideal model of comprehensive monitoring may not be
available in all parts of the world.
TECHNIQUE TIPS:
Six Patient Safety and Pediatric Conscious
Sedation Requirements

1. Emergency cart (pictured)—Must be present in case of cardiac

abnormalities induced by medication
2. Oxygen and section setup present at bedside in case of respiratory
emergency
3. Monitor vital signs during sedation
4. Leads to monitor ECG, heart rate, respiratory rate
5. Blood pressure monitoring
6. Oxygen saturation used to monitor patient oxygen levels

We briefly attempted to perform closed reductions in a

private room located in the post anesthesia care unit
(PACU) with the intention of having scheduled closed
reductions. By having a scheduled time for patient’s closed
reduction of a fracture under conscious sedation, all parties
required to perform closed reduction of the fracture under
conscious sedation (anesthesiologist, radiology technician,
orthopedic resident, orthopedic technician, nurse) could be
present at the same time, instead of having to page each
individual separately as we do in the ED. Despite a
concerted effort to make this a viable option for fracture
reduction, complex scheduling and staffing issues caused
us to discontinue the model.

MANIPULATIVE REDUCTION
Once ready for reduction, the image intensifier is
positioned and set up appropriately. The injury x-rays
should be placed on a view box or computer screen in the
line of sight of the reducer to allow better visualization and
pre planning for the three-point reduction maneuver (we
have seen fractures molded in “reverse” when this step is
skipped!). The casting materials should be within reach.
The reduction maneuver is then performed. Alignment is
assessed by imaging in both the AP and lateral plane, and if
adequate reduction has been achieved, a carefully molded
cast is applied.

In regions of the world where imaging resources may be

limited, ultrasound could be used to visualize fractures and
then used to perform closed reductions. This could also
limit the number of x-rays taken. We have no experience
with ultrasound-guided reductions.
 Table 4-7 Reduction under Conscious
Sedation
IV/Meds Given

IV started by ER nurse and ketamine given (2 mg/kg)

Reduction

Manipulation performed
Image View
Assess alignment after reduction (prior to casting)
Well-Molded Cast

Mold cast with x-ray in clear view

Univalve
Univalve cast to allow for swelling (with spacers to hold cast apart)

Cast Application
A cast molded according to the fracture pattern maintains
alignment and prevents loss of reduction.

Prior to the cast setting, alignment should again be

assessed with the fluoroscan to ensure adequate reduction
and molding. The finishing touches can then be applied to
the cast, and the cast can be “split” (univalved) to provide
room for swelling (Fig. 4-3) (see Chapter 5 — Casts In
Children). Finally, after reduction, traditional x-rays are
obtained to confirm alignment and to use as a comparison
at the first clinic follow-up visit. This step is important
because the compact image intensifier provides only a very
focal view of the fracture.
 Figure 4-3 Multi-width, commercially available spacers used to hold
the cast open once it has been univalved. This is especially important
for synthetic material casts, which tend to spring closed after
univalving and opening the cast.

Postreduction Events
Following reduction, another neurovascular assessment
should be performed (when the child is alert) with any
changes in status addressed and documented. Not every
child should be sent home after closed reduction. For
example, a child with a significant tibia fracture may need
to be admitted overnight for observation to assure that a
compartment syndrome does not develop. Note that
because most supracondylar fractures are now pinned, with
avoidance of severe flexion in a cast, fractures of the
tibia/fibula are the most common cause of compartment
syndrome in childhood fractures (see Chapter 19).

The parents are advised that the cast has been univalved
(split) to allow for swelling. They should expect swelling
within the next 24-48 hours. and are advised to keep the
limb elevated. We provide a typed instruction sheet
outlining the diagnosis and treatment to the family. This
sheet describes worrisome signs and symptoms and a
contact number if there are problems. We also provide a
separate instruction sheet outlining the details of cast care.
A prescription for oral pain medication is provided: usually
a 3-day course of Tylenol with codeine—elixir for smaller
children and tablets for older children.

Follow-Up Protocol
Most patients are seen for a follow-up appointment within a
week, and typically fractures requiring manipulative
reduction are evaluated every week for 2-3 weeks. This
allows early detection of reduction loss, which can
sometimes be corrected by cast wedging.

SUMMARY
Modern ED manipulative reduction of children’s fractures
using conscious sedation has been a major orthopedic
advance. Performed in an organized fashion, the method is
safe, efficient, and economical and saves hospital beds for
more severe cases. Furthermore, most children prefer to
sleep at home in their own bed!

SUGGESTED READINGS
Beebe AC, Arnott L, Klamar JE, et al. Utilization of orthopaedic trauma surgical
time: an evaluation of three different models at a level I pediatric trauma
center. Orthop Surg. 2015;7(4):333–337.
Brusalis CM, Shah AS, Luan X, et al. A dedicated orthopaedic trauma operating
room improves efficiency at a pediatric center. J Bone Joint Surg Am.
2017;99(1):42–47.

Davids JR, Frick SL, Skewes E, et al. Skin surface pressure beneath and above-
the-knee cast: plaster casts compared to fiberglass casts. J Bone Joint Surg Am.
1997;79(4):565–569.

Furia JP, Alioto RJ, Marquardt JD. The efficacy and safety of the hematoma
block for fracture reduction in closed, isolated fractures. Orthopedics.
1997;20(5):423–426.

Green S, Nakamura R, Johnson N. Ketamine sedation for pediatric procedures:

part I, a prospective series. Ann Emerg Med. 1990;19:1025–1032.

Hoeffe J, Doyon Trottier E, Bailey B, et al. Intranasal fentanyl and inhaled

nitrous oxide for fracture reduction: the FAN observational study. Am J Emerg
Med. 2017;35(5):710–715.

Kurien T, Price KR, Pearson RG, et al. Manipulation and reduction of paediatric
fractures of the distal radius and forearm using intranasal diamorphine and
50% oxygen and nitrous oxide in the emergency department: a 2.5-year study.
Bone Joint J. 2016;98-B(1):131–136.

Lee MC, Stone NE III, Ritting AW, et al. Mini-C-arm fluoroscopy for emergency-
department reduction of pediatric forearm fractures. J Bone Joint Surg Am.
2011;93(15):1442–1447.

Seeley MA, Kazarian E, King B, et al. Core concepts: orthopedic intern

curriculum boot camp. Orthopedics. 2016;39(1):e62–e67.
 5
Casts for Children’s
Fractures

Dennis Wenger
James Bomar
History
General Principles of Cast Application
Cast Splitting and Removal
Upper Extremity Casts
Lower Extremity Casts
Hip Spica Casts for Femur Fractures
Cast Complications

“Show me your cast and I’ll tell you

what kind of orthopedist you are”
— Calot

Predictable application and maintenance of complication-

free casts in children is a slowly learned art and craft. In
contrast to adult patients, in whom immobilization may
produce osteopenia and joint stiffness, children rarely
suffer long-term effects from typical periods of cast
immobilization. Instead, children have a special set of
complications, including poor application, poor fit, and
loose casts that slide off. Physicians often fail to understand
the effect that the carefree personality of a child has on the
life, durability, and function of a cast. Also, children often
do not complain if a cast is tight or irregular (producing
ulcerations) with the damage noted only when the cast is
removed.

This chapter is intended to present general principles for

safe, predictable cast application for fractures in children,
and to demonstrate the many techniques we have
developed at Rady Children’s Hospital, San Diego, to make
the use of synthetic cast materials safe and predictable.
Most of the principles also apply to plaster of Paris casts.

Casting in Children’s Orthopedics

This lovely photograph, taken in front of the Hospital for Sick Children
(Toronto) in about 1915, demonstrates a child in corrective casts for clubfoot,
attended to by her nurse. (Reproduced courtesy of Mercer Rang.)

HISTORY
Immobilization for fracture treatment can be traced to
antiquity. Traditional methods included use of (a) muslin
reinforced with egg whites or starches and (b) soft wood
splints. Plaster of Paris was first used in the late 18th
century by the Turks to immobilize limb fractures. The limb
was placed in a box that was then filled with plaster—an
awkward, bulky process.

Military surgeons were the first to push for less

cumbersome methods of fracture immobilization, and
Mathijsen was credited with the first use of plaster of Paris
dressings in 1852. In his process, the plaster of Paris was
applied to muslin or linen cloth so that the resulting
“plaster dressing” could be rolled onto the limb. This
tedious process of rubbing the plaster into the muslin or
linen was done manually, just prior to application, by the
surgeon or his assistant, and continued until about 80 years
ago.

Ready-to-use manufactured rolls of plaster of Paris were

not commonly available until the mid-20th century. In the
late 20th century (1980-2000), the use of synthetic casting
materials (fiberglass) gradually replaced plaster of Paris in
developed countries. Because synthetic materials are more
expensive, plaster of Paris casts remain common in much of
the world.
 Anthonius Mathijsen
Anthonius Mathijsen (1805-1878), a Flemish army surgeon, was the first to
use plaster of Paris impregnated in rolls of linen cloth that could be rolled onto
the limb. In his first publication in 1852, he noted that his special bandages
hardened rapidly, provided an exact fit to maintain reduction, and could be
easily windowed or bivalved.

Material Choices
Plaster of Paris has clearly been the standard material for
cast construction over the last 150 years. Exponential
improvement in the texture, “rollability,” and “moldability”
of synthetic materials has made them the cast material of
choice for most modern orthopedic surgeons. Patients like
them because they are light-weight and durable. We now
use synthetics for all pediatric orthopedic casts, except for
serial corrective foot casts used to treat clubfoot (Ponseti
casts). However, some orthopedists still prefer the
moldability of traditional plaster of Paris for reducing and
maintaining acute fractures.
 Casting Materials Timeline
From the beginning of time, sticks and mud and cloth have been used to stop
fractures from moving about. We have knowledge only of recent events.
400 BCE Hippocrates describes splints.

970 CE In Persia, Muwaffak advises coating fractures with plaster.

1740 As a child, Cheselden (Britain) has a fracture treated by a bonesetter

with bandages dipped in egg white and starch. When Cheselden
becomes a surgeon, he introduces the method for his patients. The
bandages take a day to harden.

1799 A visiting diplomat reports that he saw a Turkish patient treated by

holding the injured limb in a box that was then filled with plaster. He
tried to interest European doctors in the method. The cast was big
and heavy and prevented ambulation.

1814 Pieter Hendricks uses plaster bandages—but the idea does not catch
on.

1824 Dominique Larrey, Napoleon’s surgeon, uses egg white and lead
powder.

1835 Louis Seutin: Starch bandages.

1852 Antonius Mathijsen introduces plaster bandages in a medical book

and has a friend who popularizes it. Soon, large numbers of people
are putting plaster into bandages. Until the 1950s, it was a job for
medical students on emergency call. Then machines led to
commercial manufacture.

1903 Hoffa’s belief that “the plaster bandage will remain the essence of
orthopedics for all time” seems to be going the way of all predictions.
1970 to Development and widespread use of synthetic materials for casts.
present

Plaster did not enjoy universal popularity. Complete casts on fresh fractures
can produce dreadful complications, and this led some influential leaders to
ban casts. Thomas and Jones in Britain and Knight, founder of the first
residency program in the United States, would have nothing to do with
plaster, and Knight fired one member of his staff for promoting its use.

Courtesy of Mercer Rang

 Plaster of Paris
(Gypsum—CaSO4)

Plaster was first used in approximately 7000 BCE by ancient Egyptian, Greek,
and Roman civilizations. It took on the name “Plaster of Paris” in the late
1600s following “The Great Fire of London” in 1666. In an attempt to mitigate
against the devastation that London suffered, the King of France ordered that
all Parisian walls made of wood be covered with plaster. This led to large-scale
gypsum mining in and around Paris (where the material was abundant). When
the walls in Paris were sufficiently covered, Parisians began exporting the
substance, which became known around the world as “Plaster of Paris.”
Source http://timesofindia.indiatimes.com/home/sunday-times/Why-is-the-plaster-of-Paris-called-
so/articleshow/2624945.cms
Photo by Zinneke (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via
Wikimedia Commons

Although synthetic cast materials are more expensive than

plaster of Paris, in assessing overall expense one must
consider the costs in time, labor, materials, and repetitive
visits to cast rooms by children who have inadvertently
soaked or damaged a plaster cast.

Duration of Treatment
The issue of when and for how long cast immobilization
should be used for fracture treatment has been historically
controversial. Hugh Owen Thomas (prolonged
immobilization) and Lucas-Championniére (early motion)
developed diametrically opposing views in the late 19th
century (see Chapter 2). The controversy remains, but less
for children’s fractures, where post-casting joint stiffness is
rare and re-fracture after early cast removal is common.
We tend to cast longer.

GENERAL PRINCIPLES OF CAST APPLICATION

A great variety of cast types are used in children (body
jackets, hip spicas, extremity fracture casts), and we will
not attempt to describe them all. Instead our focus will be
on general principles of cast immobilization of extremity
fractures, including hip spica casts (Figs. 5-1, 5-2).

Basic principles should be considered. For small children,

you must decide who can best hold the child’s arm or leg
while the cast is applied. Although parents can assist, most
casts are better applied with a trained medical assistant
holding the limb. Special foot-holding stands designed to
keep the ankle at a neutral position can be useful for
adolescents and adults but are of little help in a young
child.
 Figure 5-1 A. A poorly molded long leg cast in a young child. Note
that the foot is left in equinus, which makes sliding off more likely.
Also the heel is poorly molded. B. The cast was easily “slid” off in the
clinic. C. The cast was entirely removed without splitting. These
photographs illustrate the very common practice of applying poorly
fitting casts in children. Because of their activity level, children
require snug, well-molded casts.

Several steps increase your chances for a well-fitting cast.

Whether or not stockinette should be used on the skin prior
to cast padding application (Fig. 5-3) depends on where
and for what reason the cast is being applied. For elective
casts applied in an office or an outpatient clinic, use of
stockinette decreases “bunching” of cast padding, allows a
neat-appearing cast, stops the rough edge of the cast from
abrading the skin, and makes cast removal easier and
perhaps safer (less chance for cast-saw cuts or burns).
 Figure 5-2 Toe holding for leg casts. A. If the foot holder holds the
first and second toe, the foot will drift into undesired varus. B.
Holding the third and fourth toe with the foot held in dorsiflexion
ensures that the foot will end up in a desirable position of slight
dorsiflexion, valgus, and eversion.

In postoperative casts applied in the operating room, the

presence of surgical dressings, suction drains,
percutaneous pins, etc., makes stockinette use more
difficult. Also, with difficult manipulative reductions
performed in the office or clinic, application of stockinette
is often an added step that impedes efficient, rapid
application and molding of the cast. A compromise is to use
a short segment of stockinette (perhaps 6 in. long) at the
proximal and distal end of the cast (which will leave the
carefully placed surgical dressing sponges undisturbed).

Other cast application accessories include using a 2-3 in.

wide band of felt padding proximally in the thigh, arm
(humerus), or proximal calf, which provides comfort and
decreases skin irritation (Fig. 5-4). In spica casts for thin
children, we often use both (a) a complete layer of felt and
(b) adhesive-backed foam padding for bony prominences
(iliac crest, greater trochanter, and sacrum).

Figure 5-3 Excessive padding, often applied to prevent ulcerations,

may actually increase the chance for skin irritation. Any advantage
gained by excessive padding is usually lost because it leads to a
loose, poorly fitting cast. The result is a cast that allows excessive
movement of the limb (with potential for skin ulceration), or, in severe
cases, one that slides off the limb.

We advise that almost all casts applied in the operating

room be immediately split (uni-valved) while the child is
still anesthetized to decrease the discomfort, aggravation,
and fright involved in late-night cast splitting in the
patient’s room (or in the ER during an emergent return
owing to swelling). This is particularly important in a
children’s hospital, where the parents are often in the room
with the child (and will suffer, along with their child, from
the noise of a cast saw).

Figure 5-4 Felt at the junction (when the cast is applied in 2 parts)
makes the transition safer. Felt at the end of the cast (proximal)
makes it more comfortable.

Rolling the Cast

Efficient rolling of the plaster or synthetic material requires
experience. Appropriate rolling technique, including the
placement of tucks to allow smooth wrapping over a conical
structure, is a slowly learned art. This is most important for
plaster casts in which the material will not stretch.
Orthopedic residents need instruction in this art, followed
by supervised practice. Often their opportunities for
learning are blunted by the current trend toward having
orthopedic technicians apply most casts in many training
hospitals. The sad tradition of lumpy, formless, inefficient
casts applied at “Elsewhere General” continues, applied by
both inadequately trained surgeons and technicians.

Great care must be taken to avoid making casts too tight.

This is a particular problem with synthetic-material casts:
They are often wrapped in the same manner that one
applies an elastic (Ace) bandage, with stretching to
accommodate limb shape change rather than placing tucks
(which makes the cast less tight). This is possible because
the underlying “cloth” is stretchable (in contrast to the
“stiff” muslin in plaster of Paris). The result is a cast that is
often too tight, particularly when applied in the operating
room following surgery. In circumstances where any
swelling whatsoever is anticipated, synthetic cast materials
should be applied with tucks, just as would be done with
ordinary plaster. This makes a less restrictive cast.

Casts in the operating room should be applied after the

tourniquet has been deflated to normalize limb volume (by
allowing the blood to return to the limb). The cast is then
applied loosely, using the tuck technique. Then in most
cases the cast should be immediately split to allow further
swelling, with the cast re-tightened 3-7 days later.
 The Disappearing Toe Syndrome
The call is classic in children’s orthopedics—“My child’s toes are
disappearing.” Disappearing toes mean the poorly fitted cast is allowing the
foot to pull up the cast. A skin ulcer will soon follow. In this case, there was an
ulcer on the heel and on the dorsum of the foot.

Cast Molding
Proper cast molding assures good cast fit, thereby
decreasing the chance for cast sores (Fig. 5-5). A cast
should fit the limb contours and be thought of in the
sculpting sense; that is, if the cast were removed and filled
with plaster or wax, the result would be a “casting”
identical to the patient’s limb. Careful molding around bony
prominences is required to achieve excellent fit. The
calcaneus is at great risk in the lower extremities; the
molding must be focused on the soft tissues above the tip of
the calcaneus, leaving a recess for the heel prominence. If
you fail to provide this recess, a skin ulceration over the
posterior calcaneus is a near certainty in a vigorous child.

The concept of a well-molded cast contrasts with the

terminology of applying a “plaster dressing” after surgery.
Many surgeons prefer a bulky “Robert Jones” dressing after
surgery, followed by application of a well-molded cast once
the swelling has subsided. We rarely do this in children
because we can achieve the same effect applying the cast
in the operating room and splitting and spreading the cast
immediately postoperatively, with later tightening. This
avoids post-operative cast changes, which children detest.

Figure 5-5 An example of a thin, well molded cast. Note that the
length along the ulnar border is longer than the opposite side.

Cast Ergonomics
Cast edge trimming is time-consuming, but it can be
avoided by careful planning when the cast material is
rolled. For instance, at the distal end of a leg cast, the
plaster should be rolled at a 30 degrees angle, keeping the
lateral side short so that subsequent trimming in the area
of the fifth toe and metatarsal head are not required. We
perhaps exaggerate by stating that no cast should ever
have a final “transverse end.” Whether in the foot, the
popliteal fossa, the groin, or the proximal humeral area,
casts predictably immobilize better, require less trimming,
and fit better if they end obliquely. Learning to wrap casts
with oblique ends greatly decreases the labor required to
trim and finalize the cast. By avoiding trimming, few sharp
edges remain (a particular problem with synthetic cast
material).

CAST SPLITTING AND REMOVAL

Cast Splitting (Bivalve, Univalve)
Traditional training suggested that any cast requiring
splitting be split completely to the skin, including the cast
padding. We have no argument with the “always split to the
skin” philosophy for hospitals with little supervision of
patients casted following fracture reduction or operations.
An edict issued by the “commanding officer” to split all
casts to the skin is likely the best insurance against cast
complications, compartment syndromes, etc., in these
circumstances. Although some orthopedists prefer a bivalve
(double) split in all casts, with the use of spacers to
maintain the separation, we have been able to use single
splits in most cases—including synthetic casts (Fig. 5-6).
 Brandon Carrell
Brandon Carrell (1910-1982). Chief of Staff at the Texas Scottish Rite Hospital,
Dallas from 1945-1977. He emphasized the need for care in removing casts in
children and was a strong advocate of splitting (univalve or bivalve) casts
applied in the operating room.

Although some insist on “always split to the skin” or

“always bivalve,” we advise a more refined approach for an
orthopedic office, or in a high-quality teaching hospital that
provides close patient monitoring. This can be safe,
economical, and, most importantly, less distressing to
children.
Synthetic-material casts require special methods because
even though the cast is split longitudinally (univalved), the
resilience of the material will not allow the cast to stay
separated. Special commercially available spacers are
needed.

Graded splitting of casts following fracture reduction or

orthopedic operations requires good orthopedic judgment.
Limited splitting can provide great economic advantage to
the hospital and surgeon without placing the patient at
increased risk. Our policy of graded splitting according to
risk is as follows:

Level 1. Only modest swelling anticipated (e.g., following

simple limb surgery or reduction of simple distal radius
fracture). Level 1 splitting includes a single longitudinal
split in the cast, combined with spreading and placing a
spacer but without cutting the underlying cast padding. In
our children’s hospital environment, 95% of cast splits are
level 1. This percentage must be interpreted within the
context that we split nearly all postoperative casts and
most fracture reduction casts.

Note that synthetic cast splits will not remain open unless
spacers are placed. Several manufacturers produce small
plastic spacers of varying sizes that are inserted to keep
the cast separated. These are removed in 4-7 days after
swelling has subsided, with the cast then tightened with
tape (upper limb), or another roll of cast material (lower
limb).
Figure 5-6 Spacers. A. Small commercially available spacers used
for upper extremity casts and for minimal spreading in lower
extremity casts. B. A variety of larger, commercially available spacers
useful for leg casts and hip spicas as well as for corrective wedging.
TECHNIQUE TIPS:
Graded Cast Splitting According to Risk
Severity
Level 1

Level 1: Cast split dorsally; soft-roll and underlying dressing not disrupted.
For routine postoperative cases and simple fractures. A spacer must be
placed to hold the cast open.

Level 2

Level 2: Both cast material and underlying soft-roll split to skin. For more
serious cases of swelling.

Level 3
Level 3: Cast split medially and laterally, with soft-roll cut down to skin.
Allows removal of entire anterior half of cast for inspection of skin and for
palpation of compartments.

Level 2. For children with significant swelling anticipated

(e.g., fracture with potential for vascular problems;
postoperative triple arthrodesis; other similar cases). The
single longitudinal split includes both the cast material and
the underlying cast padding down to the skin, allowing
wide spreading of the cast. Once the cast padding has been
split, window edema can develop; therefore, thin strips of
cast padding should be packed longitudinally into the split
and should be overwrapped with an elastic bandage. A cast
with a level 2 split can still be repaired (pulled together)
once swelling has subsided, although care must be taken to
avoid “bunching” of the cast padding (we rarely perform a
level 2 split—most are level 1, a few level 3).

Level 3. Used for cases with marked swelling anticipated

(e.g., tibial fracture in which compartment syndrome is
suspected). This includes a medial and lateral complete
split of both the cast material and the underlying cast
padding down to the skin. The anterior panel of the cast
can then be removed for complete inspection of the limb
and palpation of the compartments.

Cast Removal
Cast removal remains an often traumatic event for a child.
Potential complications can be minimized with continued
education. Shore et al. identified three primary risk factors
for cast saw injuries when removing a cast: provider
inexperience, patient sedation, and poor cast blade
condition. Although somewhat obvious, quality, dedicated
training in regard to the application and removal of casts as
well as rigorous maintenance of cast removal equipment is
the first line of defense in preventing cast saw cuts and
burns.
 Figure 5-7 Stille cast shears. Developing skills with this instrument
allows you to avoid noisy cast saws when removing certain casts.
However, they work better for plaster than for synthetic materials.

A variety of methods/techniques can make cast removal

easier and safer. Traditional cast shears can be used for
small plaster casts (Fig. 5-7). Current cast-removal saws
are loud, aggressive, somewhat terrifying to children. No
amount of conversation or playful application of the
vibrating cast blade to one’s own hand to demonstrate that
it “won’t cut” will placate a properly suspicious child.

Orthopedic technicians and orthopedists who deal with

children can apply many special techniques to minimize
cast-removal trauma. Empathy is the first step. All
orthopedic residents and fellows should have a synthetic-
material cast applied on their own limb and then removed
by a fellow resident (see how they jump!). This greatly
increases sensitivity for the child’s plight. We do a cast
application-removal session with each new group of
residents and fellows when they rotate through our
hospital.
 Figure 5-8 Proper technique is required to use a cast saw. Usually
the thumb is held against the cast and the blade itself is pushed in an
“up and down” fashion against the cast material without dragging the
saw longitudinally.

The correct mechanics of cast-saw use must be mastered.

Techniques include placing the thumb and/or fingers on
the cast as a stabilizing guide, with careful reciprocal “up
and down” movement (Fig. 5-8) rather than long dragging
movements of the blade along the cast increases the risk
for skin injury (cut or burn). Also avoid using the cast saw
over bony prominences (medial malleolus, etc.). Also pull
the cast away from the skin as you begin the cut.

Many accessory tools aid with separating the cast, cutting

the cast padding, and getting the cast off (Fig. 5-9).
Sophisticated plaster shears allow plaster cast removal in
children without use of a saw. Those made by Stille
(Sweden) are particularly effective for removing clubfoot
and other small casts. Orthopedists trained in the modern
era are sometimes unaware of these special plaster shears
that allow quiet, safe cast removal.
 Figure 5-9 Accessories required for facile cast removal. Good
scissors and a spreader are key. A plaster shears may allow removal
of small casts without using the cast saw.

UPPER EXTREMITY CASTS

Most of the principles that will be presented in the lower
extremity section apply here. Application techniques are
similar to those used for adults. We routinely use synthetic
casts, even following acute fracture reduction. The cast is
split immediately, with a spacer placed to hold the cast
open until swelling subsides.

Application Principles
Precise three-point forearm molding technique is required
both to maintain fracture reduction and to keep the cast
from sliding off (Fig. 5-10). If only rolls of casting material
are applied, the cast becomes excessively thick anteriorly
at the elbow (antecubital area) and too thin over the
olecranon. Charnley, in his classic fracture text, noted that
if plaster is wrapped uniformly around a right angle, the
cast will be four times as thick in the concavity as on the
convexity.
 Figure 5-10 Poor-quality, poorly molded long arm cast. Note that the
arm has slid up the cast and the reduction has been lost. Also note
the thickness anteriorly in the antecubital fossa area.

Excess cast padding and cast material in the concavity

makes a cast ugly and increases the chance that it will slide
off. We avoid this by using splints posteriorly over the
olecranon area or by asymmetrically rolling the cast
material with a back-and-forth motion over the convexity
(olecranon) to minimize thickness anteriorly. Careful
molding is then performed in the antecubital area to
produce a beveled right angle. A properly applied long arm
cast has a geometrically crisp look with (a) a sharp 90
degrees right angle anteriorly in the antecubital fossa and
(b) a sharp right angle posteriorly produced by a straight
border molded along the ulna and humerus (Fig. 5-11).
Such a cast is extremely unlikely to slide down or fall off,
avoiding the “shopping bag cast syndrome” (mother brings
the cast back in a shopping bag). In a teaching hospital,
such “fell off at home” casts are placed in the mail box of
the resident or orthopedic technician who applied it as a
“gentle reminder” of the need for correct cast molding.
 “Charnley, in his classic fracture text,
noted that if plaster is wrapped
uniformly around a right angle, the cast
will be four times as thick in the
concavity as on the convexity.”
 Figure 5-11 A properly applied long arm cast has a geometrically
crisp look with A. The x-ray shows a sharp right angle anteriorly in the
antecubital fossa. B. The ulnar border is straight, as is the posterior
humeral border.

Forearm Molding
For reduction of forearm and wrist fractures, you will need
to decide if you can apply a long arm (above-elbow) cast in
a single phase or whether you will better hold the reduction
and mold the cast if it is applied in two stages (first short
arm, then extend to above elbow). In most circumstances,
the latter is preferred. The junction must be carefully
padded to avoid skin injury.

Applying a cast to the forearm first and then extending it

(elbow bent to 90 degrees) carries a risk of producing a
skin ulcer if the sharp proximal edge of the cast gouges
into the antecubital fossa. A similar complication can occur
if the entire cast is applied in a single stage but in too little
elbow flexion. As the cast sets, the elbow is “adjusted” to
90 degrees with an ulcerogenic antecubital ridge produced
(Fig. 5-12).

Figure 5-12 This cast was applied in one phase. The elbow was
flexed to 90° after the fiberglass was applied creating a crease that
can lead to skin and/or neurologic problems.

Hyndman et al. emphasized the need for careful forearm

molding to maintain fracture reduction. The ratio of cast
height to width as well as three-point molding are critical
(Fig. 5-13). If you get very good at this, you may be able to
keep a distal radius fracture reduced with a short arm cast
only, whereas others may need a long arm cast.

The final effect should be a cast that is thin, aesthetic, and

biomechanically sound. Calot, the famous 19th-century
French surgeon, stated: “Show me your plaster and I’ll
show you what kind of orthopaedist you are.” We concur. I
make a hobby of observing casts (in shopping malls, in
restaurants, or on relatives of children in clinic) that have
been applied by others, guessing who applied the cast
(orthopedist, orthopedic technician, family practitioner,
other). A well-trained orthopedist should apply functional,
aesthetic casts that demonstrates pride in caring for
musculoskeletal problems.

Figure 5-13 Dr. Joe Hyndman (left) of Halifax, Nova Scotia

introduced Hyndman’s cast ratio in his now classic paper. Hyndman
noted that one needs not only a three-point mold but also a cast that
is thin from top to bottom (as compared to width). The x-rays and cast
shown here demonstrate this point.
TECHNIQUE TIPS:
Application of a Long Arm Cast to Reduce and
Maintain an Unstable Distal Radius Fracture—
Two-Stage Technique

Step 1: After reduction, padding is applied with the wrist ulnarly deviated and
flexed—the circumferential felt allows safe extension of the cast.
Step 2: Synthetic cast applied—three-point molding.
Step 3: Cast is extended above the elbow.
Step 4: The final product—a cast of beauty and reliability.

Errors—Cast Too Short

Many people make their casts too short proximally. The
long arm cast seen in Figure 5-14 was far too short (to just
above the elbow) reduction was lost despite pinning.

Conversion to Short Arm?

We rarely convert a long arm cast to a short arm cast
simply to give the child early elbow motion. The cost of cast
removal and placement of a new cast, particularly if
synthetic materials and expensive labor are required (i.e.,
you or the cast technician), is prohibitive. Reimbursement
is unpredictable. Also, children do not like their cast
removed with a cast saw, as noted above. For these
reasons, in almost all long arm casts, we have the child
wear the original cast until the fracture is healed (often 6
weeks). Many centers and/or practices may choose a
different course.

Figure 5-14 Cast too short. This child had a supracondylar fracture
that was pinned anatomically but presented to us with loss of
reduction, despite the pins. Her mini-cast is partially responsible,
extending only a few centimeters above the fracture line.
TECHNIQUE TIPS:
Application of a Risser-Type Body Cast for
Treatment of Early-Onset Scoliosis (EOS)

Step 1: A strap is suspended from a hook in the ceiling and is fashioned into
a loop. The child is placed in the lateral decubitus position with the strap
across the apex of the curve. The pelvis and head are supported by a padded
spica table. The table is lowered until appropriate curve correction is
achieved.

Step 2: The abdomen is temporarily padded with skin tape packs similar to
the method used for a hip spica cast.
Step 3: Waterproof cast padding is applied. Note the blue tape being added.
This is required when using waterproof padding because this material
provides less protection from the cast saw than does traditional padding.

Step 4: Synthetic cast material is rolled while the surgeon molds the cast.
Step 5: Once dry, the cast is marked and trimmed with the cast saw.

Step 6: The final product.

Pre-brace film
 In-brace film

Maintaining sophisticated cast skills adds to excellence in

all “subspecialties.” This wonderful reduction of an
infantile scoliosis (in our center) emphasizes the value of a
skilled casting team.

LOWER EXTREMITY CASTS

Principles—the cast should be molded with the foot in
neutral position to avoid the development of equinus in the
cast. Also, three-point molding and foot position help to
maintain fracture reduction (Fig. 5-15). To make a well-
molded ankle joint, with the plaster thicker on the heel
than anteriorly, a splint can be applied over the heel.
Otherwise, as Charnley noted, the anterior area will be
many times thicker than the heel (you will want to split the
cast anteriorly; it should be thin here).

Figure 5-15 Clearly the biomechanics of fractures and their overlying

muscles must be understood when applying casts. For example, in
the so-called Gillespie fracture, if the foot is brought up to neutral
position for casting, the distal tibial fracture will angulate
(recurvatum) (left). In this rare instance, the foot should be purposely
casted in equinus (right).

An ideal cast should be molded to demonstrate the

calcaneal prominence and the malleoli. It is impossible to
overemphasize the need for proper molding around the
calcaneus, the most common area for skin irritation and
ulceration in children’s casts (Fig. 5-16). The depth of the
sculpted inset above the calcaneus may need to be up to 2
cm, depending on the size of the child, to avoid pressure on
the calcaneus (Fig. 5-17). Examining a basketball shoe
demonstrates that manufacturers recognize the need for a
deep recess for the heel, with a supportive “counter”
above. With final heel molding, you should feel that the
calcaneus is nested in a deeply molded “cup” that you have
shaped. A cast with a straight posterior calf segment is
much more likely to produce heel ulceration.

Figure 5-16 Molding around the calcaneus. A. With final molding, the
tip of the calcaneus is palpated in the palm of your hand. There
should be a deep cup in the cast at this area so that any pressure is
taken on the soft tissues above the calcaneus rather than at the tip of
the bone. B. The final product. C. A so-called stove pipe cast with a
straight posterior border. This child is very likely to get a heel ulcer.
The posterior border of a leg cast should never be straight. D. A
properly molded long leg cast—note molded areas above ankle and
behind knee.

Similarly, the arch of the foot should be molded with a

recess in the cast for the metatarsal heads. There is no
place for a board or other rigid flat structure in molding the
bottom of a cast. The modern cast should have a bottom
shaped like the insole of a well-designed jogging shoe. With
excellent molding, less cast padding is needed and the cast
is less likely to slide off

Figure 5-17 The ideal mold (lateral view) for a short leg cast. Note
the beautiful relatively deep but smooth mold, well above the
calcaneus. This prevents heel ulcers. The area anterior to the ankle is
very thin.

Long Leg Casts (also Described as “Above Knee

Cast”)
A long leg cast requires careful molding about the knee
with the knee kept at 10-15 degrees flexion to avoid
posterior capsule strain. The decision regarding a long leg
cast in one or two segments depends on the circumstances.
 Figure 5-18 It requires experience and careful observation to avoid
creating deformity with cast application. This fracture was made
worse by the cast.

Sequence—Long Leg Cast for Tibial Fracture

For most tibial fractures that require reduction and casting,
the cast is best applied in two segments, particularly in a
larger child. Allow gravity to be your friend by applying and
molding the below-knee segment with the knee bent over
the edge of the table (tibia vertical). The cast can then be
extended for the above knee segment with the patient
supine. Be very careful as the cast hardens to carefully
attend to knee angle to avoid “late-stage hardening”
buckles.

Creating Deformity with Casts

Each year we see fractures that come in with near
anatomic alignment and after casting appear malreduced
(Fig. 5-18). It requires experience and careful observation
to avoid creating deformity with cast application,
particularly in the tibia. Also the leg (calf) section is best
applied first, with the leg in a vertical position to allow
gravity to help as you mold the tibia section. Then, after
placing a circumferential felt band at the junction, the cast
is converted to a long leg type.
Figure 5-19 A. The assistant cannot be daydreaming when the cast
is setting. If he does not pay rapt attention, the child is likely to
develop a buckle in the plaster at the knee level. This is particularly a
feature of synthetic casts. B. Buckle in cast in knee area. Such
buckles are ulcerogenic.
Casts Applied in the Operating Room
Postoperative casts are particularly difficult to apply safely
and correctly (Fig. 5-19). The surgical dressing should be
thin to allow good cast fit. We commonly use suction
drainage when bleeding is anticipated, rather than using a
thick compressive dressing that leads to poor cast fitting.

Many surgeons prefer a bulky type of cast, a posterior and

anterior splint, or even a Robert Jones bulky dressing
following surgery, with the cast applied later. Again,
sensitivity for the child and economics should be
considered. If every child that you operate on requires a
return for conversion to a circumferential cast or a
complete cast change within a week after surgery, the
expense becomes significant. Also (as already noted)
children hate cast changes.
TECHNIQUE TIPS:
Two-Stage Application of a Long Leg (Above
Knee) Cast
(For reduction of tibia fracture in a larger patient—ensures that tibial segment, foot,
and ankle are molded perfectly—then extended to proximal thigh)

Step 1: Leg vertical—padding applied plus circular felt at junction.

Step 2: Synthetic material applied.

Step 3: Splint over heel to make back thicker than front.

Step 4: Very careful molding to contour of calcaneus—maintain fracture
reduction.

Step 5: Circular felt to protect proximal thigh.

Step 6: Padding extended plus apply felt in groin (for comfort).

Step 7: Patient now supine. Extend cast-splint over knee to strengthen.

Step 8: Mold long leg cast.

Step 9: The final product. A few degrees less knee flexion might be better for
subsequent walking.

Posterior Splints in Children

Posterior splints, made of plaster or synthetics, are often
used safely in adults as a temporary form of immobilization.
Their use in children (especially in those under 5 years of
age) is risky because they almost routinely pull their heel
out of its intended spot, with a high risk for developing a
heel ulcer (Fig. 5-20). Many experts advise that children
under 6 years of age not be immobilized with a posterior
splint. A cast is safer because it holds the ankle in its
correct position.
 Figure 5-20 A. Posterior splints are risky for use in young children
because they routinely pull out of them, resulting in a risk for heel
ulcer. B. Lateral x-ray of a child placed in a splint to temporarily
immobilize for a distal tibial fracture. The child has pulled out of the
splint and is at risk for developing a heel ulcer. If they are used, it
should only be for a day or 2. Better to use an anterior plus posterior
splint or a temporary cast.

Cast Wedging
Careful planning and implementation of cast “wedges” to
correct angular deformity can simplify the management of
lower extremity fractures in children. Unfortunately, safely
performing a cast wedging with fiberglass cast materials
requires special skills and can lead to complications. In the
lower extremity, wedging can be used for femoral fractures
(hip spica wedged — Fig. 5-21) as well as for tibial
fractures. The correction is almost always an opening
wedge formed by making a circular cut in the cast at the
level of deformity, leaving about 1 cm of the cast uncut as a
fulcrum. The cast is then levered open on the opposite side
to correct the deformity. Care must be taken to make a
smooth bend to avoid skin necrosis. Inspect the x-ray for a
possible ridge, keep the patient around for 30 minutes to
be sure the “post-wedge ache” subsides, and warn them to
return if there is late pain.
Appropriate spacers are placed in the wedge, with image
intensifier or x-ray views taken with the spacer temporarily
taped in position. When the correction is adequate, the
wedge and spacer are incorporated into the cast to
maintain the new position. Artful cast room wedging has
allowed us to avoid taking many children with loss of
angular correction in femoral and tibial fractures back to
the operating room.

Even in upper extremity fractures, opening wedges can be

used to correct an angular deformity or “sag” in the mid-
forearm following a bone fracture, sometimes avoiding re-
manipulation and cast change under anesthesia. Wedging
techniques should be mastered by orthopedists who care
for children, because angular alignment is often all that is
required for acceptable position and fracture healing. But if
there is any concern regarding whether the treating
physician has the experience (or confidence) to wedge a
cast, it should likely not be performed. If a junior resident
is on call, the staff should not advise a case wedging (the
staff physician needs to be present).

Figure 5-21 Young child with femur fracture that is drifting into varus
angulation at the fracture site can be improved by wedging of the
cast. Skill and experience are required to wedge casts safely.
 Cast Wedging
NOTE: Cast wedging requires skill and experience to avoid skin
problems

Look at the cast and x-ray together: Determine the level of fracture
angulation (where you wish to correct).

Mark the cast. Mark the hinge on the opposite side of where the cast will be
opened.
Apply the wedge and confirm improvement in alignment with radiographs.
Before wedge

After wedge
HIP SPICA CASTS FOR FEMUR FRACTURES
A spica cast is the mainstay for treatment of femoral
fractures in children. The use of femoral fracture hip spica
casts can range from use in a 7-month-old victim of child
abuse to a 6-year-old with a spiral midshaft fracture. Many
variations of spica can be used, ranging from a simple one-
and-one-half spica with the femur relatively extended to a
complex, near 90-90 degrees hip-knee position to control
shortening. We will present a few principles, focusing on a
method that only moderately flexes the hip and knee. The
more radical hip-knee flexion casts (so-called 90-90) can be
used; however, increasingly common reports of nerve
injury, skin slough, or calf compartment syndrome have
been associated with their use. The report by Mubarak et
al. has diminished our enthusiasm for the 90-90 degree
position (Fig. 5-22).
TECHNIQUE TIPS:
Application of a Hip Spica for Child with
Femur Fracture
(Cast in relative extension minimizes risk to skin and compartments)

Step 1: Elevate the child onto the spica table.

Step 2: Traction can be applied using the leg—do not place a short leg cast to
pull traction as you can an cause ulcer (and risk nerve injury and
compartment syndrome!) (see Weiss and Mubarak in suggested readings).
Step 3: Cast padding is applied from the waist to below the knee (we
recommend waterproof cast padding if available for easier care).

Step 4: Mold the cast to maintain reduction—midshaft fractures need to be

molded into valgus and recurvatum, proximal fractures molded into flexion
and external rotation, distal fractures into procurvatum.
Step 5: X-rays can be obtained while the child is still on the spica table
(wedge the cast if needed).

Step 6: Add the leg portion of the cast—if you are concerned about rotation,
you can add the foot into the cast, but we rarely put the foot in the cast.
Step 7: Trim the cast to give adequate space at the knee and abdomen.
NOTE: We prefer this more relaxed position (30-30 degrees), as compared to
the 90-90 degrees position, which has a risk for skin and compartment
problems in the calf.
Figure 5-22 The risks in using a 90-90 degrees cast include
junctional problems (if traction applied to the leg cast that is applied
 first). Reported problems include skin necrosis (behind knee),
compartment syndrome (calf), and anterior skin loss (distal calf).

We use synthetic-material casts in all age groups because

they are easier to apply, easier to wedge, and easier to
maintain. For a child under the age of 2 years, with a
simple oblique fracture of the femur, we will apply an early
spica, usually without general anesthesia. If the fracture is
a nondisplaced spiral fracture (the most common type at
this age), a single hip spica can be used, making diapering
and bathing easier.

In children aged 2-6 years, we sometimes place the

children in skin traction for 24 or 48 hours, particularly if
there are associated injuries. We then apply the hip spica
with the child anesthetized. This variation of the early spica
allows time for proper assessment of the child and to find a
civilized operating-room time. Thus, in our hospital the
term “immediate spica” has been replaced with “early
spica” and implies cast application within a few days of
injury at a time that is safe and convenient for all parties.
These children have a light general anesthesia with a one-
and-one-half hip spica cast applied. Use of an image
intensifier to confirm fracture position in the operating
room (just prior to spica application) decreases the need
for subsequent cast wedging. An immediate post-spica-
application image intensifier view confirms the position,
and, if wedge correction is required, it is done immediately
while the child is still anesthetized.

There are a variety of views regarding childhood activities

in a hip spica cast applied to treat a femoral fracture. Flynn
et al. advises a simple hip spica for simple femoral
fractures in children up to 6 years of age and also allows
the children to be weight-bearing as soon as they are
comfortable to do so.
CAST COMPLICATIONS
All orthopedic surgeons are aware of the many
complications related to cast immobilization. Some families
do not understand cast care instructions, but more often
the child is uncooperative or not properly supervised. The
resulting wet casts, damaged casts, destroyed casts, etc.,
are common to all age groups and will not be specifically
addressed here. We emphasize the importance of the
orthopedic technician and/or surgeon giving the family a
handout detailing cast care as well as providing clear,
simple instructions.
 The Stilt Cast
In circumstances in which non-weight-bearing compliance is critical, 4-8 in.
“stilts” can be added to a short leg cast.
 Figure 5-23 This child got the cast wet, resulting in skin maceration.

The Veterinary Approach—Understanding Your Client

Veterinary surgeons often use casts to immobilize limbs in
their patients. They rarely spend very much time lecturing
their “patients.” Instead they use casts that are “patient
proof.” A perhaps slightly jaded, yet practical, approach to
childhood behavior is to adopt the “veterinary approach”
when using a cast for an unstable lower limb (tibial, ankle)
fracture. With certain families, rather than relying on
instructions and handouts alone, we assume that they will
not get the message (puppies do not read their
“handouts”). Instead we create a cast that keeps them from
creating a problem. For example, in an unstable distal tibial
(or medial malleolar) fracture, the cast would be a long-leg
type with the knee flexed to 90 degrees (right angle) for
the first 4 weeks. This position prevents weight-bearing,
even in the uncooperative or those who lack understanding.
The so-called stilt cast seems to work in teenagers.

Figure 5-24 This child used a pen to itch his arm. The end of the pen
came off inside the cast.

Showering and Bathing

The issue of showering and bathing with a cast on remains
controversial, even with synthetic-material casts. Children
and adolescents seem to do poorly with the commonly
prescribed method of taping a plastic bag over an upper or
lower extremity cast for showering (Fig. 5-23). The method
commonly fails, leading to a wet cast that must be replaced
—a process whose true cost may be several hundred
dollars. Instead of showers, we suggest that the limb not be
covered with any special plastic and that the child be
bathed in a tub with the arm or leg cast left on the edge of
the tub. A parent must be present to help the younger child
with bathing.

Figure 5-25 This child returned to clinic after 4 weeks in a short leg
walking cast. A toy cog was found stuck to his skin.

On the other hand, newer types of special “shower in your

cast” protective devices are available and can be
considered. Issues, such as how well the patient applies the
device (they often leak), and who pays for the new cast
when they fail, remain.

Use of AquaCast cast liner to produce a so-called swimming

cast has gained popularity but has problems also (hard to
mold for acute fracture reduction—expensive—takes more
time to apply and remove). The AquaCast liner option is a
good one if your patient has the extra money to fund the
additional materials and technician time. We ask that our
patients who desire such a cast pay for it (cash, charge
card) before it is applied because insurance companies
rarely compensate for the added time and effort required to
apply and remove such a cast.

Figure 5-26 This family requested a “swimming cast.” The family

spent a day at the beach and got sand in the cast.

Foreign Bodies under Casts

Cast instructions should emphasize that nothing be placed
inside the cast. The need to scratch under a cast is
common, with devices such as coat hangers or other sharp
objects inserted for relief. Serious skin excoriation can
result. Despite your instructions, children will deposit all
sorts of items under their cast either purposely or
inadvertently (Figs. 5-24 to 5-26). If a child complains of
pain under a cast, you must be prepared to window or even
remove the cast to evaluate for possible skin ulceration,
which can be produced by foreign bodies under the cast.
 Figure 5-27 Typical heel ulcer over the calcaneus from a poorly
applied cast.

Cast Ulcers Due to Poor Cast Design

Many cast problems are the result of inattention to detail
by the applying surgeon or technician. Ulceration over the
tip of calcaneus is the most common skin problem
associated with leg casts (Fig. 5-27). Heel ulcers can be
almost entirely avoided by understanding the normal
contour and shape of the calcaneus and by careful cast
molding about the calcaneus. Leg casts with an entirely
straight posterior border are a set-up for heel ulceration.
When detected, they should be corrected before skin
ulceration develops.

Improperly applied leg casts can cause other types of skin

ulceration. If the foot is left in equinus when the cast
padding and/or cast material is applied, with the foot
subsequently dorsiflexed, the resulting dorsiflexion ridge in
the cast anterior to the ankle will cause predictable skin
ulceration. The entire dorsum of the foot can slough (Fig. 5-
28).

Similarly, excessive pressure on the bottom of the foot can

produce ulcerations over the metatarsal heads. Careful
molding of a metatarsal recess to accommodate the
metatarsal heads is required to avoid this complication.

The juncture between the leg and thigh segments of a long

leg cast that has been constructed sequentially (leg first,
then thigh) is a common source of skin ulceration. If the
posterior segment of the leg cast is left too long, with the
knee then flexed to apply the thigh segment, the resulting
ridge can produce a full-thickness ulceration in the
hamstring area.
Figure 5-28 Dorsal ulceration. An ulceration in the area where
anterior soft-roll and casting material was bunched. Likely the cast
was further dorsiflexed after the casting materials had been applied,
producing an ulcer.
 The Dorsiflexion “Crinkle”

This illustration for Albee’s classic 1919 text Orthopedic and Reconstruction
Surgery demonstrates the problems associated with dorsiflexing the foot after
any material has been applied, either soft-roll or plaster. The dorsal bunching
of the soft-roll and/or plaster often causes pain and sometimes causes
ulceration. This is avoided by holding the foot dorsiflexed before any
materials are applied.
Unfortunately for early detection of a problem, children
commonly do not experience any prolonged sense of pain
when an improperly applied cast is producing skin
ulcerations. It hurts only until the skin becomes numb (Fig.
5-29). In many cases, you may not detect ulcerations or
skin injury until the time of planned cast removal. It is thus
imperative that orthopedists who treat children learn to
apply postoperative casts that are extremely unlikely to
produce skin pressure.

Figure 5-29 This child had an insensate limb prior to going in the
cast. The cast was poorly molded, and when it was removed, this
wound was discovered.

SUGGESTED READINGS
Blount WP. Fractures in Children. Baltimore, MD: Williams & Wilkins; 1955.

Charnley J. The Closed Treatment of Common Fractures. Edinburgh, Scotland:

E & S Livingstone; 1950.

Chess DG, Hyndman JC, Leahey JL, et al. Short arm plaster cast for distal
pediatric forearm fractures. J Pediatr Orthop. 1994;14:211–213.

Czertak DJ, Hennrikus WL. The treatment of pediatric femur fractures with
early 90-90 spica casting. J Pediatr Orthop. 1999;19(2):229–232.
Davids JR, Frick SL, Skewes E, et al. Skin surface pressure beneath an above-
the-knee cast: plaster casts compared with fiberglass casts. J Bone Joint Surg
Am. 1997;79(4):56–59.

Difazio RL, Harris M, Feldman L, et al. Reducing the incidence of cast-related

skin complications in children treated with cast immobilization. J Pediatr
Orthop. 2015. [ePub ahead of print].

Flynn JM, Garner MR, Jones KJ, et al. The treatment of low-energy femoral
shaft fractures: a prospective study comparing the “Walking Spica” with the
traditional spica cast. J Bone Joint Surg Am. 2011;93:2196–2202.

Jaafar S, Sobh A, Legakis JE, et al. Four weeks in a single-leg weight-bearing

hip spica cast is sufficient treatment for isolated femoral shaft fractures in
children aged 1 to 3 years. J Pediatr Orthop. 2016;36(7):680–684.

Large TM, Frick SL. Compartment syndrome of the leg after treatment of a
femoral fracture with an early sitting spica cast. A report of two cases. J Bone
Joint Surg Am. 2003;85-A(11):2207–2210.

Mubarak SJ, Frick S, Sink E, et al. Volkmann contracture and compartment

syndromes after femur fractures in children treated with 90/90 spica casts. J
Pediatr Orthop. 2006;26(5):567–572.

Shore BJ, Hutchinson S, Harris M, et al. Epidemiology and prevention of cast

saw injuries: results of a quality improvement program at a single institution. J
Bone Joint Surg Am. 2014;96(4):e31.

Stork NC, Lenhart RL, Nemeth BA, et al. To cast, to saw, and not to injure: can
safety strips decrease cast saw injuries? Clin Orthop Relat Res.
2016;474(7):1543–1552.

Wehbe A. Plaster uses and misuses. Clin Orthop. 1982;167:242–249.

Weiss A, Schenck RC Jr, Sponseller PD, et al. Peroneal nerve palsy after early
cast application for femoral fractures in children. J Pediatr Orthop.
1992;12(1):25–28.

Wenger D, Rang M. Casts in Children in the Art and Practice of Children’s

Orthopedics. New York: Raven Press (now Lippincott Williams & Wilkins),
1993.
 6
Clavicle

Andrew Pennock
Maya Pring
Anatomy
Assessing the Patient
Radiographic Issues
Classification
Treatment—Midshaft Fractures
Treatment—Lateral Fractures
Treatment—Medial Fractures

“To acquire knowledge, one must study,

but to acquire wisdom, one must
observe”
— Marilyn vos Savant

INTRODUCTION
Clavicle fractures account for 8%-15% of all skeletal
injuries in children. Despite these injuries being extremely
common, little historical attention in the literature had
been focused on this topic. In fact, in the first edition of this
book published in 1974, less than 3 pages were devoted to
clavicle fractures. The principal reason for this was the
belief of Rang and others that “if the two ends of a clavicle
fracture are in the same room they will heal and remodel
adequately.”
Over the last 10 years, however, a renewed interest in the
clavicle has occurred largely driven by the work of Michael
McKee and the Canadian Orthopaedic Trauma Society. As
several clinical trials have come to light showing the
benefits of surgical stabilization of displaced clavicle
fractures in adults, many have begun to apply these
principles to adolescent and even pediatric patients. Two
recent studies have shown not only a more than doubling of
pediatric clavicle fractures being fixed surgically over the
last 10 years but also significant regional variation as to
how these injuries are treated. This trend is likely
occurring as a result of several factors including the lack of
literature in this younger patient population, fear that a
mismanaged clavicle fracture may lead to a poorer
functional outcome, parental and patient pressure to return
young athletes to the sports field quicker, and differing
reimbursement for non-operative versus operative
management.

The purpose of this chapter will be to summarize the

current literature and to discuss our institution’s
philosophy and treatment approach to pediatric and
adolescent clavicle fractures.

Figure 6-1 Muscle attachments to the clavicle.

ANATOMY
The unique design of the clavicle allows sophisticated
agility in use of the upper limb and serves as the only true
skeletal attachment of the humerus and scapula to the axial
skeleton. The clavicle protects the underlying
neurovascular structures including the subclavian vessels
and the brachial plexus. Three features put the clavicle at
particular risk for injury including its relative small size, its
subcutaneous location, and its propensity to experience
force when a patient falls directly on their shoulder.

When viewed from the front, it appears flat and straight.

Looking from above, the clavicle has an S shape from the
sternum medially to the acromion laterally (Fig. 6-1). In
cross section, it changes from a round or prismatic shape
medially to a flattened shape along the lateral third.

The deltoid, pectoralis major, and subclavius all have a

significant portion of their origin on the clavicle, whereas
the sternocleidomastoid and trapezius both insert onto this
small bone. Depending on where the fracture is located, the
muscles attached to the clavicle will displace the fracture
fragments; in a midshaft fracture, the sternocleidomastoid
will elevate the medial fracture fragment, whereas the
deltoid and the weight of the arm will depress the lateral
fragment.

Medially, the clavicle articulates with the manubrium of the

sternum creating the sternoclavicular (SC) joint. This joint
is stabilized by its capsule, an articular disc, and a series of
ligaments including the sternoclavicular ligaments
(anterior and posterior), the interclavicular ligament, and
the costoclavicular ligament. The sternoclavicular and
interclavicular ligaments are considered by some to be
thickenings of the joint capsule. Laterally, the clavicle is
stabilized by the acromioclavicular (AC) joint (including its
articular disc and ligament) as well as the coracoclavicular
ligaments (conoid and trapezoid) (Fig. 6-2).
 Figure 6-2 Ligaments connected to the clavicle.

The clavicle is unique in that it is the first bone to ossify

around 5 weeks of gestation and its medial and lateral
ossification center are some of the last to fuse around the
age of 25 years. Despite remaining open until young
adulthood, clavicular length does not change significantly
for girls after age 9 years or boys after age 12 years. These
factors need to be considered when managing pediatric and
adolescent patients with presumed AC and SC joint injuries
because many of these will represent physeal fractures
instead of ligamentous injuries. Additionally, older patients
do not have the remodeling potential that younger patients
do.

ASSESSING THE PATIENT

Infancy
Clavicle fractures are one of the most common injuries
sustained during childbirth; children of large birth weight
(greater than 4,000 g) and those with shoulder dystocia are
at the highest risk. Infants who sustain a clavicle fracture
may also sustain a brachial plexus injury because of nerve
stretch (Erb palsy). The neonate with a clavicle fracture
may present with an asymmetric Moro reflex or the
appearance of a flail upper extremity.

Differentiating a neurologic injury from a clavicle fracture

during the first few weeks of life can be extremely difficult,
and the child may have both. X-ray or ultrasound can
diagnose the fracture, but clear neurologic assessment of
the upper extremity may not be possible until the fracture
has healed.
 Ernst Moro (1874-1951)
Dr. Moro was an Austrian pediatrician who described a defensive infantile
reflex normally present in all infants/newborns up to 3 or 4 months of age.
When the infant feels as if they are falling, they immediately abduct the arms,
and then draw their arms across their chest in an embracing manner. An
asymmetric Moro reflex may be secondary to neurologic injury or fracture.
Some children are born with a congenital pseudoarthrosis
of the clavicle (Fig. 6-3). This can easily be confused with a
clavicle fracture and has instigated unnecessary child
abuse work-ups. The painless swelling over the midshaft of
the clavicle is often noted in infancy but may go undetected
for years. The x-ray will show a smooth intact cortex at the
site of pseudoarthrosis and not the jagged edges of acute
fracture. A fracture will have abundant callus within a few
weeks, and no callus will develop if it is a pseudoarthrosis.
 Figure 6-3 Congenital pseudoarthrosis of the clavicle can easily be
confused with a fracture.

The majority of children with clavicle congenital

pseudoarthrosis do well with no treatment. However, if the
patient does become symptomatic or the parents are
unhappy with the appearance, resecting the
pseudoarthrosis, bone grafting, and plating provide
predictable union.

Children and Adolescents

Most clavicle fractures occur as a result of a fall directly on
the shoulder with the arm at the side, but less commonly a
fracture may occur as a result of a direct blow or a fall on
an outstretched hand. Participation in contact sports such
as football, rugby, wrestling, and hockey are responsible
for the largest percentage of clavicle fractures in
adolescence, but with our nation’s increased interest in
extreme sports such as BMX, motocross, and mixed martial
arts (MMA), we are seeing higher-energy fractures more
frequently.
The examination of a child with a clavicle fracture is
relatively straightforward given the superficial nature of
the bone. Typically, the patient will present with the arm
being held in an adducted position close to the body with
the opposite hand supporting the injured extremity. The
skin should be inspected for an open fracture or significant
tenting (which has rarely been reported to erode through
the skin). Typically, the clinical deformity, ecchymosis,
swelling (Fig. 6-4), and point tenderness lead the physician
to the diagnosis.

Figure 6-4 The clavicle is subcutaneous, making deformity

noticeable. This patient has a healing right clavicle fracture. Patients
need to be told about the size of callus that will appear (and later
resorb).
Limb threatening concerns associated with clavicle
fractures and dislocations that need to be identified
immediately include vascular injury (subclavian vessels),
neurologic injury (brachial plexus), and injury to the
mediastinal structures (esophagus, trachea, pleura, and
lung) by angulated or displaced fragments.

RADIOGRAPHIC ISSUES
The clavicle forms from three separate centers of
ossification. There are two primary centers for the body
(medial and a lateral), which appear during the 5th or 6th
week of fetal life, and a secondary center for the sternal
(medial) end, which appears during the late teenage years.
Salter Harris fractures through the physis are often
mistaken for medial clavicle dislocations in adolescents
(although the treatment would be same for either).
 Table 6-1 Radiographic Assessment of
Clavicle Injuries
AP View
Allows good visualization of the superior/inferior displacement of shaft
fractures.

Standard AP

Apical Lordotic View

Allows better visualization of anterior/posterior translation of the fracture
fragments and visualization of the medial clavicle without overlap of the
sternum.

Tube angled 40-45 degrees Patient arching/leaning back

Almost all clavicle fractures can be adequately identified

with a single AP view. Problem fractures may require
special views. The orientation of the clavicle makes it
difficult to get two x-ray views at 90 degrees to each other.
Even with additional views, the medial portion of the
clavicle is difficult to see because of the sternum and
mediastinum. In addition to a straight AP view of the
clavicle, an apical lordotic x-ray can help visualize the
medial clavicle without overlap of the sternum (see Table 6-
1).

Apical Lordotic versus Serendipity View

The adjacent text clarifies that these describe the same x-ray technique. We
prefer the more traditional “apical lordotic” term.

The apical lordotic view (also known as the serendipity

view) has been used since early in the “x-ray era”
(beginning of the 20th century) to look for tuberculosis
involvement in the apices of the lung. The same view
provides a good oblique view of the clavicle. The origin of
the term “serendipity view” that some orthopedists use
instead of “apical lordotic view” comes from Dr. Charles
Rockwood of San Antonio. He developed an x-ray called the
“Rockwood view” to evaluate the shoulder and discovered
serendipitously that he could better evaluate the SC joints
when they were dislocated because there was less overlap
of the structures of interest.
 Figure 6-5 Greenstick clavicle fracture as frequently seen in young
children.

Any question about the nature of a complex clavicular

injury can be further investigated with a CT scan which
allows the best visualization of the clavicle. Concern for
vascular injury mandates an arteriogram.

CLASSIFICATION
Fractures can be complete, incomplete but angulated, or
plastically deformed (Fig. 6-5). The very thick layer of
periosteum surrounding the pediatric clavicle tends to
maintain the alignment of the fracture, which typically
leads to early union in infants and children. As children
become teenagers, the periosteum no longer acts as a
strong supporting structure leading to greater fracture
displacement and a higher risk of non-union.
 Classification of Pediatric Clavicle Fractures
Basic types of clavicle fractures

Midshaft: Typically have shortening and superior angulation.

Lateral: Further subdivided by Dameron and Rockwood.

Note: The epiphysis and periosteum typically remain in place and the shaft
displaces.
I: No significant displacement

II: Mild displacement (<25%)

III: Superior displacement (25%-100%)

IV: Posterior displacement

V: Superior displacement (>100%)

VI: Inferior displacement

Medial: Subdivision of medial clavicle fractures. The description of the
fracture can be based on displacement of the shaft—anterior, posterior, of
inferior.

A: Physeal fracture

B: Sternoclavicular dislocation (rare)

C: Medial shaft fracture

The basic types of fracture include medial, lateral, and

midshaft fractures. Medial and lateral fractures have been
further subdivided based on location of the fracture and
displacement of the shaft (see “Classification of Pediatric
Clavicle Fractures” for an overview of the sub-
classifications).

TREATMENT—MIDSHAFT FRACTURES
The periosteum is much thicker, stronger, and less readily
torn in a child than in an adult and continuity of the
periosteum determines whether or not a fracture displaces.
When displacement occurs, the intact hinge of periosteum
can help or hinder reduction.

Infant
Infant clavicular fractures can be treated by pinning the
shirtsleeve to the shirt (Fig. 6-6) or loosely wrapping the
arm to the body with an elastic bandage for 2-3 weeks. This
treatment provides some immobilization and pain relief and
reminds people not to pick the baby up by the arm.
Infantile fractures tend to heal well regardless of
treatment. The associated injuries including brachial plexus
palsy require more focused attention; however, these are
difficult to evaluate until the fracture heals and motion can
be better assessed.

Figure 6-6 An infant with a clavicle fracture can be treated by

pinning the sleeve (of the injured side) to the body of the garment. A
second option: wrap the limb to the trunk gently with an ACE
bandage.

Children and Adolescents

Current trends in orthopedic care suggest that treatment
selection for mid shaft clavicle fractures has become more
controversial. Historically, indications for surgical fixation
were relatively limited including open fractures and
severely displaced fractures with significant skin tenting or
neurovascular compromise.

With the publication of several randomized controlled trials

in adult populations showing faster healing rates, lower
non-union rates, and better functional outcomes with
surgical intervention, many surgeons have been applying
these “adult principles” to adolescent and pediatric
patients. Currently, the literature is unclear as to which
adolescent clavicle fractures should be fixed. As an
institution, we trend toward non-operative treatment for
the vast majority of clavicle fractures.

Nearly all minimally displaced clavicle fractures can be

treated with a sling or a figure-of-8 brace (Table 6-2). A
theoretical advantage of the figure-of-8 is that it potentially
pulls the shoulders back minimizing fracture fragment
overlap. A practical advantage is that it frees the extremity
making simple daily tasks such as computing easier.
Practical advantages of the sling, on the other hand,
include its ease of use, ubiquitous availability, and cost
effectiveness.

“Currently the literature is unclear as to

which adolescent clavicle fractures need
to be fixed. As an institution, we trend
toward non-operative treatment for the
vast majority of clavicle fractures.”

Many clinical trials failed to show significant outcome

differences between slings and figure-of-8 braces. As a
result, there are regional preferences for one or the other.

“While surgical fixation may return

athletes with displaced fracture to sport
faster, we do not believe that the four to
six weeks gained justifies the vastly
greater treatment costs, risks of
surgery, and likely need for implant
removal (that will take them out of
sports again) for most amateur
athletes”
 Table 6-2 Classic Dilemma: Sling versus
Figure-of-8 Brace
Advantages Disadvantages
Sling Very inexpensive No ability to pull
Easy to put on fracture to length

No pressure over fracture Hand is not free

A few sizes fit all

Figure-of-8 Can hold fracture better Harder to put on

reduced (in theory) Focal pressure over
Hands free for activities fracture site
Need to keep multiple
sizes in stock

When a non-operative approach is utilized, the fracture is

protected for 4-6 weeks, with contact sports avoided for
another 6 weeks. As in most simple injuries, half the
treatment consists of educating the parents about the
normal course. An unsightly lump may appear with fracture
healing (callus) and will potentially persist for a year while
remodeling progresses (we tell parents that the lump may
be the size of a walnut or an egg—Fig. 6-7).
 Figure 6-7 Significantly overlapped midshaft clavicle fracture in a
teenager. We warn patients that the resulting callus may be the size
of a walnut (or even an egg in a teenager). With time, most fractures
remodel nicely.

Although x-rays of a fracture healing in bayonet opposition

may frighten the parents, studies have shown that a
significant amount of angulation and overlap can be
accepted. Once the fracture is non-tender and there is
radiographic healing, the patient may slowly return to
 sports. Final x-rays are usually obtained at 4-6 weeks after
injury; if there are concerns of a developing non-union,
longer follow-up becomes necessary.

Surgical Reduction?
There are four primary concerns that drive patients and
their families toward surgery:

1. Concern that a malunion will lead to functional deficits

2. Concern about developing a non-union
3. The cosmetic concerns discussed previously
4. The concern that a non-operative approach will take longer
to heal

Concerns over a symptomatic malunion are possibly the

strongest indication for surgery, but still not well validated
in the pediatric or adolescent literature. Various criteria for
surgery have been proposed including complete
displacement, greater than 2 cm of shortening, and
comminuted fracture patterns. Our institution, as well as
Boston Children’s Hospital, have published studies showing
that patients treated non-operatively (even with significant
displacement and shortening) have no significant functional
deficits and are able to return to high levels of overhead
sport. Taking into consideration that the rare established
symptomatic malunion can still be managed with late
surgery with good outcomes, nearly all of these fractures
can be treated without surgery.
 Figure 6-8 Although rare, clavicle nonunions can occur in children.

Although non-unions have been reported in as many as 15%

of completely displaced clavicle fractures in the adult
population, they remain an extremely rare complication in
pediatric patients with less than a dozen cases having been
reported in the literature (Fig. 6-8). Over the last 10 years,
our institution has treated hundreds of midshaft clavicle
fractures and we have only observed three non-unions all of
which were successfully managed with local bone graft and
plate fixation. We, therefore, do not believe that non-union
concerns in adolescent patients, even with displaced
fracture patterns, justify acute surgery.

Although surgical fixation may return athletes with

displaced fracture to sport faster, we do not believe that
the 4-6 weeks gained justifies the vastly greater treatment
costs, risks of surgery, and likely need for implant removal
(that will take them out of sports again) for most amateur
athletes.

For the rare midshaft clavicle fracture requiring surgery,

plate fixation can be used for all fracture patterns. The
rigid construct enables early mobilization and a rapid
return to sports. Some centers are now using
intramedullary stabilization with elastic nails for non-
comminuted fracture patterns (Fig. 6-9); this minimizes the
scar that results from open treatment. To date, no study
has compared the results of plate fixation to intramedullary
fixation in the pediatric population.
 Figure 6-9 Intramedullary devices offer an alternative to plate
fixation for the rare surgical fracture. (Image courtesy of Chris Souder,
MD.)

TREATMENT—LATERAL FRACTURES
Dameron and Rockwood suggest that Type I, II, and III
distal clavicle fractures will heal and remodel without
intervention. Reduction and fixation of these lateral-sided
injuries is only necessary for Types IV, V, and VI that have
a severe and fixed deformity. Distal clavicle injuries in
pediatric patients are usually transphyseal fractures and
not true AC separations (as seen in adults). The intact
periosteum allows children to heal and remodel with few
complications without operative intervention.

Most lateral clavicle fractures are adequately treated with

a sling or figure-of-8 brace for 3 weeks followed by an
additional period in which contact sports are avoided. Early
range of motion should be started as soon as pain allows.
Complex harness/brace devices designed to reduce clavicle
fractures (Kenny Howard type harness) are rarely used in
children.

Figure 6-10 Posteriorly displaced medial clavicle fracture with the

medial end of the clavicle driven posteriorly into the chest.

When surgical fixation is potentially required (Type IV, V,

or VI injuries), controversy exists as to the optimal fixation
technique with some favoring Kirschner wires, others hook
plates, pre-contoured lateral clavicle plates,
coracoclavicular fixation devices, or a combination thereof
(Table 6-3). In the rare circumstance where pin fixation is
used, we advocate significantly bending the pin outside the
skin to minimize wire migration and weekly clinical
evaluations until the pins have been removed (typically 3-4
weeks). The literature indicates that there can be
significant complications from pin migration, including
death. We believe each of these cases must be approached
on an individual basis based on the size and comminution of
the fracture fragments.
 Table 6-3 Surgical Options for Lateral
Clavicle Fractures
Standard Plate

Plate & Coracoid Fixation Device

K-wire
Hook Plate
TREATMENT—MEDIAL FRACTURES
Almost all medial clavicle fractures in patients under age
18 years appear to be SC dislocations, but in fact, most are
transphyseal injuries. As noted earlier, the epiphyseal
ossification center does not appear until age 18 years and
may fuse as late as age 25 years. If the shaft displaces
anteriorly, the chances of remodeling are excellent, with
minimal risk to vital structures.

If the clavicle displaces posteriorly, the mediastinal

structures are at risk (Fig. 6-10). These fractures may be
difficult to recognize (the patient may complain of medial
clavicle or sternal pain with difficulty swallowing or
breathing). In suspected cases, a CT scan is necessary for
diagnosis. If the study shows any impingement, or vascular
compromise, the fracture should be reduced under general
anesthesia with a vascular surgeon available.

“Open reduction should be performed if

stable reduction cannot be achieved”

Reduction of a posteriorly displaced medial fracture can

usually be accomplished in a closed fashion. A bolster
placed between the shoulder blades elevates the anterior
chest. In thin patients, the surgeon can place his/her
fingers behind the clavicle. Upward pressure with the arm
abducted, externally rotated, and extended can relocate the
displaced clavicle (Fig. 6-11).

If closed reduction fails, or the reduction is unstable, open

reduction should be performed. A strong #5 suture through
the medial clavicle and sternum anteriorly in a figure-8
fashion is usually adequate to stabilize the SC joint. It is
prudent to have a trauma or thoracic surgeon available
during stabilization in case of hemorrhage; this is a rare
complication but is life threatening if inadequate resources
are available to stop and correct the blood loss.

SUMMARY
The vast majority of pediatric clavicle fractures can be
treated conservatively, but the surgeon must recognize the
few fractures that will benefit from open reduction.
 Figure 6-11 A. A 14-year-old male who sustained a posteriorly
displaced medial clavicle fracture. B. The plain radiograph suggests
injury. C. A CT scan confirms posterior displacement (arrow). D. In
thin patients, the clavicle can sometimes be reduced using manual
manipulation with traction on the arm. Closed reduction was
successful in this patient. He was then placed into a figure-of-8 brace.

SUGGESTED READINGS
Andersen K, Jensen PO, Lauritzen J. Treatment of clavicular fractures. Figure-
of-eight bandage versus a simple sling. Acta Orthop Scand. 1987;58(1):71–74.

Bae DS, Shah AS, Kalish LA, et al. Shoulder motion, strength, and functional
outcomes in children with established malunion of the clavicle. J Pediatr
Orthop. 2013;33(5):544–550.

Caird MS. Clavicle shaft fractures: are children little adults? J Pediatr Orthop.
2012;32(Suppl. 1):S1–S4.

Chalmers PN, Van Thiel GS, Ferry ST. Is skin tenting secondary to displaced
clavicle fracture more than a theoretical risk? A report of 2 adolescent cases.
Am J Orthop (Belle Mead NJ). 2015;44(10):E414–E416.

Ersen A, et al. Comparison of single arm sling and figure of eight clavicular
bandage for midshaft clavicular fractures: a randomized controlled study. Bone
Joint J. 2015;97-B(11):1562–1565.

Hagstrom LS, Ferrick M, Galpin R. Outcomes of operative versus nonoperative

treatment of displaced pediatric clavicle fractures. Orthopedics. 2015;38(2):
e135–e138.

Jensen PO, Andersen K, Lauritzen J. [Treatment of mid-clavicular fractures. A

prospective randomized trial comparing treatment with a figure-eight dressing
and a simple arm sling]. Ugeskr Laeger. 1985;147(25):1986–1988.

Masnovi ME, Mehlman CT, Eismann EA, et al. Pediatric refracture rates after
angulated and completely displaced clavicle shaft fractures. J Orthop Trauma.
2014;28(11):648–652.

McCandless DN, Mowbray MA. Treatment of displaced fractures of the clavicle.

Sling versus figure-of-eight bandage. Practitioner. 1979;223(1334): 266–267.

Meisterling SW, Cain EL, Fleisig GS, et al. Return to athletic activity after plate
fixation of displaced midshaft clavicle fractures. Am J Sports Med.
2013;41(11):2632–2636.

Randsborg PH, Fuglesang HF, Røtterud JH, et al. Long-term patient-reported

outcome after fractures of the clavicle in patients aged 10 to 18 years. J Pediatr
Orthop. 2014;34(4):393–399.

Rapp M, Prinz K, Kaiser MM. Elastic stable intramedullary nailing for displaced
pediatric clavicle midshaft fractures: a prospective study of the results and
patient satisfaction in 24 children and adolescents aged 10 to 15 years. J
Pediatr Orthop. 2013;33(6):608–613.

Robinson L, Gargoum R, Auer R, et al. Sports participation and radiographic

findings of adolescents treated nonoperatively for displaced clavicle fractures.
Injury. 2015;46(7):1372–1376.

Schulz J, Moor M, Roocroft J, et al. Functional and radiographic outcomes of

nonoperative treatment of displaced adolescent clavicle fractures. J Bone Joint
Surg Am. 2013;95(13):1159–1165.

Studer K, Baker MP, Kried AH. Operative treatment of congenital

pseudarthrosis of the clavicle: a single-centre experience. J Pediatr Orthop B.
2017;26(3): 245–249.

Tan L, Sun DH, Yu T, et al. Death due to intra-aortic migration of kirschner

wire from the clavicle: a case report and review of the literature. Medicine
(Baltimore). 2016;95(21):e3741.

Tepolt F, Carry PM, Taylor M, et al. Posterior sternoclavicular joint injuries in

skeletally immature patients. Orthopedics. 2014;37(2):e174–e181.

Waters PM, et al. Short term outcomes after surgical treatment of traumatic
posterior sternoclavicular fracture—dislocations in children and adolescents. J
Pediatr Orthop. 2003;23(4):464–469.

Yang S, Werner BC, Gwathmey FW Jr. Treatment trends in adolescent clavicle

fractures. J Pediatr Orthop. 2015;35(3):229–233.

Zember JS, Rosenberg ZS, Kwong S, et al. Normal skeletal maturation and
imaging pitfalls in the pediatric shoulder. Radiographics. 2015;35(4):1108–
1122.
 7
Shoulder and Humeral
Shaft

Vidyadhar Upasani
Maya Pring
Assessing the Patient
Radiographic Issues
Newborn Fractures
Shoulder Dislocation
Proximal Humerus
Humeral Shaft
Scapula

“Taking care of children has nothing to

do with politics”
— Audrey Hepburn

INTRODUCTION
Fractures of the proximal humerus and humeral shaft are
common during birth and childhood. These fractures have
an amazing potential to remodel as they heal, and
frequently little intervention is necessary. Of course, as
children get older, their remodeling potential diminishes
and more anatomic reduction is necessary.

Scapula fractures that do not involve the glenoid also heal

with little help from a surgeon; however, the associated
injuries must be recognized and treated.

ASSESSING THE PATIENT

Localization of a shoulder fracture, especially in infants,
may be difficult. They may present with what appears to be
a brachial plexus palsy as pain will keep them from moving
the arm. You may not be able to determine whether there is
a neurologic deficit until the fracture has healed. Other
conditions in your differential should include a septic
shoulder joint or a clavicle fracture.

Older children are more cooperative with a neurologic

exam. The brachial plexus may be disrupted or stretched by
a shoulder injury. The axillary nerve is easily damaged by
fractures or dislocations of the shoulder and can be
checked by testing sensation over the deltoid. Rare cases
may also have an arterial injury.

Scapula fractures are typically the result of great violence

and associated injuries are common. Be sure to look for
life-threatening injuries (closed head injury, thoracic
trauma, spine fractures, etc.).

Anatomy
The proximal humeral ossification center appears at
approximately 6 months of age. Those for the greater and
lesser tuberosity appear around 2 years, and 4-5 years,
respectively.

The shoulder has a healthy blood supply from the axillary

artery, and AVN is rarely a concern.

The shoulder does not have inherent bony stability (as the
hip does) and relies on the capsule and surrounding
muscles to maintain its integrity.
The relationship of the bony anatomy of the shoulder to the
brachial plexus must be understood.

Figure 7-1 AP and axillary view of the proximal humerus. The

triangular shape of the physis makes reading x-rays more difficult.

RADIOGRAPHIC ISSUES
Obtaining orthogonal x-rays (two views at right angles) of
an injured shoulder is difficult. In most emergency
departments, an injured shoulder is studied with an AP and
axillary view of the shoulder (Fig. 7-1). However, an
axillary view is often not possible if the child is unable to
elevate the arm, and moving the arm may further displace
the fracture. In such cases, you should consider a “clear
view,” transthoracic lateral, or a scapular Y view in
addition to the AP to properly and safely evaluate shoulder
fractures (Table 7-1). The transthoracic view is difficult to
read as the ribs are in the way.

If the joint is involved (either the glenoid fossa or the

humeral epiphysis), a CT scan will give a clearer picture,
allowing you to better evaluate the joint surface.

Ultrasound of the shoulder girdle can help to identify

fractures in infants without the risk of radiation and is a
better study if you are concerned about epiphyseal
separation when the head is not yet ossified. It can also be
used to assess for a shoulder effusion, which may require
aspiration to rule out an infectious process.
Table 7-1 Views to Assess the Child’s
Shoulder
AP w/ IR

AP w/ ER

Axillary
Transthoracic

Scapular-Y
 Clear View

The “clear view” is a true orthogonal to the AP view. It allows accurate

visualization with decreased radiation compared to the transthoracic lateral
view. The combination of an AP in internal rotation and a clear view may offer
the best combination of views for reducing radiation exposure, improving
patient comfort, and increasing accuracy in measuring fracture translation
and angulation.

NEWBORN FRACTURES
Separation of the proximal humeral epiphysis frequently
occurs during difficult deliveries when the shoulder
becomes lodged in the pelvic outlet or when the arm is
used to assist in extraction of the infant. The fracture is
often difficult to localize and is frequently confused with a
brachial plexus injury until abundant callus formation is
palpable or noted on x-ray. Clinically, the infant may have
an asymmetric Moro reflex as the only sign of injury or may
refuse to move the arm at all. It is often impossible to sort
out neurologic injury versus immobility secondary to the
pain of an acute fracture (“pseudoparalysis”).

The vast majority of shoulder girdle fractures sustained

during delivery (Fig. 7-2) can be treated by simply pinning
the infant’s shirt sleeve to the shirt or using an elastic
bandage around the body to immobilize the injured upper
extremity for 2-3 weeks (Fig. 7-3). Reduction and/or
surgery are almost never required in this age group. Birth
fractures heal extremely quickly with abundant callus
formation and remodel leaving little or no residual
deformity. Once the fracture has healed, a better
neurologic exam can be completed to evaluate for brachial
plexus injury that may have occurred simultaneously.
Figure 7-2 Infant humerus fractures are often sustained during
difficult deliveries. They are easily treated with a few weeks of
immobilization.
 Figure 7-3 This patient was diagnosed with a humeral fracture by
the pediatrician. The father used tape to secure the child’s sleeve to
the trunk prior to being seen by orthopedics.

SHOULDER DISLOCATION
Traumatic dislocation is typically seen in adolescents after
the epiphyses have closed or are closing (Fig. 7-4).
Shoulder dislocations can result in a Hills-Sachs lesion
which is an indentation of the articular surface of the
humeral head (Fig. 7-5) or a Bankart lesion which is an
avulsion of the anterio-inferior glenoid labrum. This is the
primary lesion in reccurent anterior instability.
 Figure 7-4 Traumatic dislocation is typically seen in older
adolescents after the physes have closed. This should be treated as
an adult injury with relocation and immobilization followed by
rehabilitation for first-time dislocators.

This should be treated with relocation and immobilization

followed by rehabilitation. Closed reduction in the
emergency department can be performed with intravenous
sedation or with intra-articular lidocaine. Although the
intra-articular anesthetic has been associated with lower
complication rates and shorter emergency department
stays, there is some concern for chondrotoxicity associated
with the injection.
Anterior dislocations should be immobilized in a shoulder
immobilizer, but the duration is controversial with some
favoring a few days and others preferring 4-6 weeks.
Posterior dislocations are rare and often require a gun-
slinger splint or spica to maintain the shoulder in external
rotation and abduction for 4-6 weeks.

Recurrent dislocation has been reported to be as high as

100% following traumatic dislocation in young patients
(Rowe), and many articles report an incidence of 50%-90%
regardless of treatment following the first dislocation.
 Figure 7-5 This is a patient with recurrent anterior dislocations who
developed both a Hills-Sachs and Bankart lesion. The MRI and
arthroscopic images on the left show a Hills-Sachs lesion. The MRI
and arthroscopic images on the right show a Bankart lesion.

Although conservative treatment for adolescents with a

first-time dislocation is still the gold standard, there has
been increasing interest in surgically stabilizing the
anterior structures, especially in high-risk active patients
who seek to return to competitive contact sports. Although
many surgical interventions have been described for adults,
there are very few reports of long-term outcomes following
surgical intervention in children and adolescents. A recent
comparison of open and arthroscopic Bankart repairs in a
pediatric cohort found an 86% 2-year survival and a 5-year
survival of only 49%. Any surgical intervention will require
long-term rehab with progressive physical therapy starting
with gentle pendulum exercises and advancing to active
motion and eventually strengthening.

“Party trick” dislocation or voluntary dislocation occurs in

children with increased joint laxity and typically is not
related to an injury. These patients are treated with
strengthening exercises, and surgical intervention should
be avoided. Often these loose-jointed children have
difficulty with sports that stress the shoulder (swimming,
throwing—overhead sports).

PROXIMAL HUMERUS
The proximal humerus has a tent-shaped growth plate and
very thick posterior periosteum (Fig. 7-6). The proximal
physis contributes 80% of the growth of the humerus.
Force on the shoulder in pediatric patients typically
produces a physeal fracture instead of dislocation as is
seen in skeletally mature patients. A direct blow to the
posterior shoulder or a fall on the outstretched hand
frequently result in proximal humeral fracture.
 Figure 7-6 Tent-shaped physis of proximal humerus. This pattern
often makes reading of x-rays difficult.

Classification
Proximal humerus fractures are broken down into physeal
fractures (usually Salter-Harris I in patients up to age 5
years and Salter-Harris II in older patients), metaphyseal
fractures, and fractures of the greater or lesser tuberosity.

Neer and Horowitz have classified the degree of

displacement into four grades:

I. Less than 5 mm displacement

II. One-third displacement
II. Two-thirds displacement
V. More than two-thirds displacement

About 70% of patients have Grade-I or Grade-II

displacement and require no more than a sling or shoulder
immobilizer. Several methods of treatment have been
advocated for the more severe grades of displacement.

Chronic proximal humerus separation has been reported in

gymnasts, baseball pitchers, patients previously treated
with radiation, and children with metabolic abnormalities.
Repetitive motion with distractive forces can lead to
physeal stress injuries or separation.
 Figure 7-7 Pitchers and gymnasts may distract their proximal
humeral physis from repetitive stress—these x-rays show a
comparison between the dominant throwing shoulder of a pitcher
compared to his normal left proximal shoulder; note widening of the
proximal humeral physis on the right.

Treatment
Stress injuries to the physis (and the very rare slipped
epiphysis) heal with rest in a sling or shoulder immobilizer
for 4 weeks. The most important and most difficult part of
the treatment is to stop the child from continuing the
damaging activity (gymnastics or pitching) while the physis
heals (Fig. 7-7).
Salter-Harris I fractures can be treated with gentle
manipulation with traction, abduction, and flexion followed
by short-term immobilization (3-4 weeks).

Adolescent Salter-Harris II injuries may be difficult to

reduce and maintain; however, good results are the rule
when these fractures are treated conservatively. About
70% of patients have mild to moderate displacement and
require no more than a sling. As 80% of the humeral
growth comes from the proximal physis, this region has a
great capacity for remodeling. The shoulder has a thick
muscle cover, and malunions tend not to be a cosmetic
problem.
TECHNIQUE TIPS:
Closed Reduction and Pinning of Proximal
Humerus Fractures
For significantly displaced proximal humeral fractures in patients with little
remodeling potential (teenagers), closed reduction and percutaneous pinning
is recommended.

A sheet is placed around the body to provide countertraction. Care must be

taken to protect the head and neck. While maintaining traction, the arm is
brought out into abduction and flexion.

Fluoroscopy can be used to check AP and axillary views. If the reduction is

unstable, pins can be inserted from the lateral cortex (avoiding the axillary
nerve) and into the humeral head.

We often use threaded tip guide pins for cannulated screws as the threaded
tip prevents early back-out of the pins. The pins are bent and cut outside the
skin, to be pulled out in 3 weeks.

Amazingly, even severely displaced fractures can remodel

in young children (Fig. 7-8).
 Figure 7-8 This 1-year-old patient presented with this severe
proximal humeral fracture. Over the next 9 months, the fracture
remodeled.

Risk for Malunion—Need for Reduction

Although young children have excellent remodeling
potential, less deformity can be accepted in a teenager
(Fig. 7-9). If the fracture heals with anterior bowing,
shoulder flexion and abduction will be blocked. With little
time remaining for remodeling, the patient will be left with
a permanent loss of full shoulder motion.

Closed reduction followed by traction or casting with a

Statue of Liberty cast has been described but is mainly of
historical interest.
Closed reduction and percutaneous pinning permits the
arm to be brought down to the side, whereas reduction is
maintained.

Open reduction is rarely necessary but can be used for

fractures that are irreducible into an acceptable position
secondary to interposed soft tissue (usually the biceps
tendon) or periosteum. A deltopectoral approach gives
adequate exposure for proximal humeral fractures; screw
or pin fixation will then maintain the reduction.
Intramedullary elastic nails can be used with distal
insertion (at the lateral epicondyle). The flexible rods can
assist with reduction as well as maintenance of alignment.

Figure 7-9 This teenager with a proximal humerus fracture and

apparent mild displacement on x-ray healed with a mal-union that
slightly decreased her range of motion such that she was unable to
play volleyball at a competitive level.

Other Fractures of the Proximal Humerus

Greenstick fractures are common and can be treated
symptomatically. Completely displaced metaphyseal
fractures are more difficult than physeal injuries. The shaft
may penetrate the deltoid to lie subcutaneously. A short
incision may be required to disengage the distal fragment
and push it back into the soft tissue sleeve. This is typically
a stable reduction in a sling without internal fixation.
Greater tuberosity fractures are almost never seen in
children; on the rare occasion that one is encountered, it
can be treated non-operatively if minimally displaced. If
there is marked displacement, open reduction and internal
fixation (ORIF) should be considered as with adult
fractures.

Lesser tuberosity fractures are also rare and can usually be

treated symptomatically. Athletes who require significant
subscapularis strength (competitive swimmers) may
require ORIF to reattach the subscapularis insertion.

The majority of proximal humerus fractures in skeletally

immature patients can be treated non-operatively as there
is an amazing potential for remodeling and excellent
outcome despite significant angulation and displacement
(Fig. 7-10). Surgery should not be the first line of treatment
but is an option for some severe fractures and special
situations as discussed in this chapter.
 Figure 7-10 Fractures near the physis in a growing child have an
amazing potential to remodel.

HUMERAL SHAFT
Transverse humeral shaft fractures are the result of a
direct blow. Spiral fractures are produced by a twist; even
muscular violence will do this (Fig. 7-11). These fractures
are easily treated because they reduce themselves under
the influence of gravity. The only important part of
treatment is to maintain good public relations with the
family.

There are many ways of treating the fracture. We often use

a hanging arm cast to allow gravity to help reduce the
fracture. Sarmiento braces are an excellent choice for
midshaft fractures.

For a week, an attempt should be made to prop the child up

at night for sleep. Bayonet apposition is satisfactory
because overgrowth of about 1 cm can be expected. Varus
angulation is common, especially in over weight children,
as the arm tends to bow around the body. This can be
prevented with a well-molded cast and abduction pillow at
the elbow. The more distal the fracture is, the more
clinically evident the deformity will be. Varus greater than
20 degrees will need to be corrected. This may be
accomplished with cast manipulation, or with surgery.

Figure 7-11 Transverse humeral shaft fractures are usually the result
of a direct blow. Spiral humeral fractures are often sustained after
twisting or throwing.
TECHNIQUE TIPS:
Immobilization Methods for Humeral Shaft
Fractures and Shoulder Injuries
Hanging Arm Cast

To supply traction to align humeral shaft fractures.

Sarmiento Brace

Sarmiento brace for stabilization of humeral shaft fractures.

Shoulder Immobilizer
Most commonly used brace for shoulder and humerus injuries.

Although non-operative treatment is successful in the vast

majority of patients, external fixators or elastic
intramedullary nails can be used to allow faster
mobilization or weight bearing in polytrauma patients.
Other relative indications for operative stabilization include
unstable proximal-third fractures in children nearing
skeletal maturity, unstable meta-diaphyseal junction
fractures, ipsilateral both-bone forearm fractures (floating
elbow), and stabilization for pathologic fractures through a
diaphyseal bone cyst. A recent study from France
demonstrated excellent subjective and radiographic
outcomes in 38 pediatric patients treated with elastic nails
with a mean follow-up of 30 months.

Open fractures with bone loss at the lower end may not
unite. Grafting and compression plating may be required
and should be carried out before the elbow becomes stiff.

Pitfalls—Humeral Shaft Fractures

The radial nerve wraps around the humerus and may be
injured by the fracture or the reduction. Radial nerve palsy
is particularly likely to occur in fractures at the junction of
the middle and lower thirds of the shaft. The nerve may
become trapped between the fracture fragments. If a nerve
palsy is present at presentation, watchful waiting is usually
recommended. Spontaneous recovery can be expected; look
for this first in the brachioradialis. If the fracture remains
separated by soft tissue interposition, or if a radial nerve
palsy follows manipulation, one can consider acute
exploration of the nerve. However, most of these nerve
palsies recover within 3 months. If there are no signs of
recovery at 3 months, consider EMG and surgical
intervention. Surgery at the time of injury has not been
shown to change the outcome when the nerve palsy is
present before reduction attempts.

SCAPULA

Classification
There are many classification schemes for scapula
fractures; however, none are specific to pediatric patients.
The important things to understand and describe are the
location of the fracture within the scapula (body, neck,
coracoid, acromion, or glenoid), associated fractures of the
clavicle or AC joint that destabilize the shoulder, and
amount of displacement.
 Figure 7-12 This 16-year-old boy was in a motocross accident and
sustained a scapular body fracture. Scapular fractures are typically
nondisplaced and heal with little intervention. Treatment is
symptomatic.

Treatment
Fortunately, scapular fractures in children are rare and
almost never require surgical treatment. Scapular body
fractures tend to heal in adequate alignment regardless of
treatment as the muscular envelope maintains the shape of
the scapula (Fig. 7-12). Isolated body fractures can be
treated symptomatically with a sling or shoulder
immobilizer.

Scapular neck fractures in isolation typically do not require

anything beyond symptomatic treatment; however, if there
is an associated clavicle fracture or AC dislocation, the
shoulder joint becomes destabilized and may require
intervention. In the case of unstable fractures, some
recommend open reduction and fixation of the clavicle to
maintain the suspensory function of the scapulo-clavicular
complex. Others recommend ORIF of both the scapular
neck and clavicle fracture.

Coracoid fractures with minimal displacement are treated

conservatively. Again, if there is an associated clavicle
fracture, some authors recommend ORIF of at least the
clavicle fracture.

Acromial fractures are typically physeal fractures in the

pediatric patient, and the vast majority can be treated
symptomatically with excellent results. Os acromiale can be
a normal finding on x-ray and may be difficult to distinguish
from a fracture. X-rays of the contralateral shoulder will
help to differentiate fracture from a normal anatomic
variant.

Glenoid fractures are the scapular fractures most likely to

lead to arthritis and disability later in life. As with most
joints, a step-off greater than 2 mm is not well tolerated
and every effort should be made to obtain anatomic
alignment. The glenoid is very difficult to approach through
an open incision, and internal fixation is difficult given the
anatomy of the scapula with its paper thin body; so many
surgeons prefer non-operative methods when possible.
Skeletal traction can be used or early range of motion to
attempt to recontour the glenoid during the early healing
process. If the equipment and expertise are available,
glenoid fractures can be reduced and fixed
arthroscopically.

SUMMARY
Fractures about the shoulder joint and of the humerus are
common during childbirth and through childhood. At time,
making a diagnosis is the most difficult part of
management (as in infancy when the proximal humerus
epiphysis is not yet ossified). Most injuries can be treated
conservatively, and the proximal humeral physis growth
predominance provides excellent remodeling. In older
children, more complex injury patterns may require open
reduction.
SUGGESTED READINGS
Beringer DC, Weiner DS, Noble JS, et al. Severely displaced proximal humeral
epiphyseal fractures: a follow-up study. J Pediatr Orthop. 1998;18(1):31–37.

Bishop JY, Flatow EL. Pediatric shoulder trauma. Clin Orthop Relat Res. 2005;
(432):41–48, Review.

Breslin K, Boniface K, Cohen J. Ultrasound-guided intra-articular lidocaine

block for reduction of anterior shoulder dislocation in the pediatric emergency
department. Pediatr Emerg Care. 2014;30(3):217–220.

Canavese F, et al. Evaluation of upper-extremity function following surgical

treatment of displaced proximal humerus fractures in children. J Pediatr
Orthop B. 2014;23(2):144–149.

Chaus GW, Carry PM, Pishkenari AK, et al. Operative versus nonoperative
treatment of displaced proximal humeral physeal fractures: a matched cohort. J
Pediatr Orthop. 2015;35(3):234–239.

Kelly DM. Flexible intramedullary nailing of pediatric humeral fractures:

indications, techniques, and tips. J Pediatr Orthop. 2016;36(Suppl 1):S49–S55.

Khan A, et al. Functional results of displaced proximal humerus fractures in

children treated by elastic stable intramedullary nail. Eur J Orthop Surg
Traumatol. 2014;24(2):165–172.

Marengo L, et al. Displaced humeral shaft fractures in children and

adolescents: results and adverse effects in patients treated by elastic stable
intramedullary nailing. Eur J Orthop Surg Traumatol. 2016;26(5): 453–459.

Markel DC, Donley BG, Blasier RB. Percutaneous intramedullary pinning of

proximal humeral fractures. Orthop Rev. 1994;23(8):667–671.

Masquijo JJ, Baroni E, Miscione H. Continuous decompression with

intramedullary nailing for the treatment of unicameral bone cysts. J Child
Orthop. 2008;2(4):279–283.

Pahlavan S, Baldwin KD, Pandya NK, et al. Proximal humerus fractures in the
pediatric population: a systematic review. J Child Orthop. 2011;5(3):187–194.

Popkin CA, Levine WN, Ahmad CS. Evaluation and management of pediatric
proximal humerus fractures. J Am Acad Orthop Surg. 2015;23(2):77–86.

Shore BJ, Hedequist DJ, Miller PE, et al. Surgical management for displaced
pediatric proximal humeral fractures: a cost analysis. J Child Orthop.
2015;9(1):55–64.

Shrader MW. Proximal humerus and humeral shaft fractures in children. Hand
Clin. 2007;23(4):431–435, vi, Review.
Shymon SJ, Roocroft J, Edmonds EW. Traumatic anterior instability of the
pediatric shoulder: a comparison of arthroscopic and open bankart repairs. J
Pediatr Orthop. 2015;35(1):1–6.

Wang X, Shao J, Yang X. Closed/open reduction and titanium elastic nails for
severely displaced proximal humeral fractures in children. Int Orthop.
2014;38(1):107–110.

Wegmann H, Orendi I, Singer G, et al. The epidemiology of fractures in infants

—Which accidents are preventable? Injury. 2016;47(1):188–191.

Zember JS, Rosenberg ZS, Kwong S, et al. Normal skeletal maturation and
imaging pitfalls in the pediatric shoulder. Radiographics. 2015;35(4):1108–
1122.
 8
Elbow—Distal Humerus

Maya Pring
Vidyadhar Upasani
Anatomy
Assessing the Patient
Radiographic Issues
Transphyseal Distal Humerus Fractures
Supracondylar Fractures
Lateral Condyle Fractures
Medial Condyle Fractures
Medial Epicondyle Fractures
Lateral Epicondyle Fractures

“Learning is not attained by chance, it

must be sought for with ardor and
attended to with diligence”
— Abigail Adams

INTRODUCTION
In our hospital, it is rare to get through a call night without
at least one supracondylar fracture that needs to be fixed.
The goal of this chapter is to help you recognize and treat
pediatric elbow fractures while avoiding the complications
that are abundant. In this chapter we will concentrate on
distal humerus fractures and dislocations and in Chapter 9
will explore proximal radius and ulna fractures and
associated dislocations.
ANATOMY
The elbow is a sophisticated joint composed of three
separate articulations: radio-capitellar, proximal
ulnohumeral, and radio-ulnar. The spiral orientation of the
trochlea allows flexion and extension about an oblique axis,
which brings the forearm from a position parallel to the
humerus in full flexion to a valgus carrying angle of
approximately 15 degrees in extension (Fig. 8-1). The
carrying angle has evolutionary significance, presumably to
allow the upper extremity to carry an item with clearance
of the pelvis as the arm swings.
 Figure 8-1 The trochlea has a spiral orientation, which brings the
forearm from in-line with the humerus in flexion to a carrying angle of
15 degrees valgus in extension.

Elbow motion also permits pronation and supination about

the long axis of the forearm, allowing one to position the
hand in space with close to 180 degrees of rotation. Morrey
had previously shown that an arc of 100 degrees of flexion-
extension and 100 degrees of pronation-supination
provided a functional range of motion for an adult.
However, more recent studies show that more motion may
be necessary to complete normal 21st century tasks. Loss
of rotation can significantly affect function: pronation is
necessary for use of a computer keyboard, and supination
allows talking on a cell phone in addition to self-care,
feeding, and toileting (Fig. 8-2).

Figure 8-2 Loss of rotation can significantly affect function.

These complex motions require maintenance of the

anatomic relationship between all three articulations.
Fracture management requires an understanding of not
just the bony anatomy that is visualized on the x-ray but
also the ligaments, capsule, muscles, and neurovascular
structures around the elbow. Unfortunately, anatomic
reduction and union of the bones does not guarantee good
post-injury motion and function. The elbow, more than most
other joints, can become stiff following injury or surgery,
and the surgeon must make the difficult decision of early
motion (and risk for non-union) versus cast immobilization
(and possible stiffness).

The brachial artery runs across the anterior aspect of the

elbow and can be injured by the bone spikes of a distal
humerus fracture. There are 2 main sources of blood supply
to the trochlea. The lateral vessels are intra-articular and
the medial vessels are extra-articular—there is not a good
anastomosis between the vessels. The blood supply is
important to understand as supracondylar fractures and
lateral condyle fractures can lead to avascular necrosis
(AVN) even if the fracture is well aligned, as noted by Etier
et al. (in Suggested Readings at the end of the chapter).

In addition to complex design issues, there are multiple

growth plates near the elbow that fractures may disrupt,
leading to growth arrest and deformity (Fig. 8-3).

Figure 8-3 Anatomy of the elbow.

ASSESSING THE PATIENT

In the busy season, we may see 50 injured and/or swollen
elbows each week. As a note of caution, on the initial exam,
it may be difficult to distinguish between an occult fracture
and an infected elbow in a young child. At least twice a
year, we see a child with a history of trauma and a swollen
elbow who turns out to have a septic joint. If you do not see
a clear fracture on x-ray, don’t assume there is an occult
fracture until you have ruled out infection. A “soft” history
of trauma may lead a young resident away from suspecting
infection (a “soft” history may consist of an unwitnessed
fall, “she falls a lot,” “…fell yesterday and woke up with
pain this morning,” etc.).

There is immediate pain with a fracture; the timing of a

fracture should not be unclear. The questions regarding the
injury must be precise. “Did the child cry in pain
immediately?” “Who observed this?” If there is no definitive
association between a witnessed fall and pain, order a
complete blood count (CBC), sedimentation rate, and C-
reactive protein to rule out infection before you send the
child out in a cast. If a patient diagnosed with occult
fracture comes back with pain in the cast, re-assess: occult
fractures typically do not hurt once they are immobilized;
infections do.

Like a good radiologist reviewing a chest x-ray, start your

exam away from the area of concern: the contralateral
elbow should be examined to determine the normal
carrying angle and the child’s natural ligamentous laxity or
ability to hyperextend. Once you know the child’s normal
anatomy and have narrowed down where and what the
problems are, gently move to the injured elbow. Carefully
examine the skin to rule out an open fracture. Check areas
where the skin is tented or at-risk; the sharp bone ends of a
displaced supracondylar fracture can easily penetrate the
skin; a closed fracture may be only a cell layer or two from
an open fracture. Use a single finger to palpate medial and
lateral humerus, olecranon, and radial head to try to
localize the fracture so that you can get the best x-rays for
the suspected fracture(s).

Check the joint above (shoulder) and the joint below (wrist)
for associated injuries. Next, proceed with vascular
assessment; radial pulses should be symmetric and
capillary refill less than 2 seconds. If pulses are not
palpable, a Doppler can be used to check for blood flow to
the hand. A dysvascular hand represents an emergency and
should be immediately reduced. A compartment syndrome
can also impede blood flow and must be addressed
immediately (see Chapter 19).

Older children can comply with a neurologic exam (Table 8-

1). Test the radial nerve by asking the child to extend the
thumb. Anterior interosseous nerve testing includes flexion
of the distal interphalangeal joint of the index finger and
the interphalangeal joint of the thumb. The ability to grasp
indicates median nerve function, whereas finger spread
and ability to cross the fingers indicate ulnar nerve
function. Test sensation to 2-point discrimination on the
radial and ulnar sides of each digit and over the dorsum of
the thenar web; light touch sensation is not sensitive
enough to detect a nerve injury (Fig. 8-4). Caution: if the
median nerve is compromised, the child will not feel the
pain of compartment syndrome and you lose pain as an
indicator of impending disaster; for severe injuries, it is
important to document 2-point discrimination in the median
nerve distribution.

Table 8-1 Quick Motor Nerve Testing for

the Upper Extremity
“Thumbs up” “OK”

Radial nerve—Extension of wrist and Ulnar nerve—Abduction of digits 3-5

thumb Anterior interosseous nerve—Flexion
Median nerve—Flexion of digits 2-3 of index and thumb DIP
 Figure 8-4 Sensory nerve distribution of the hand.

If a young injured child is not capable of complying or

willing to comply with a neurologic exam, avoid
documenting that the patient is “neurovascularly intact”
(NVI) unless each test has been successfully performed.
Document only what you can effectively test; if the patient
has a nerve palsy post-operatively and someone wrote
“NVI” on the initial exam sheet, it may be difficult to prove
that the nerve injury was not caused by the reduction (or
surgery). The neurovascular status of the upper extremity
must be monitored carefully until definitive treatment is
completed, and for at least 24 hours and sometimes even
48 hours following treatment.
 Figure 8-5 “Loser’s view”—with the elbow flexed it may be difficult
to get a true AP of the distal humerus or proximal forearm.

RADIOGRAPHIC ISSUES
Obtaining true AP and lateral x-rays in the injured child can
test even the best radiology technician. Some radiology
techs will capture a “loser’s” view (Fig. 8-5), an AP view of
an elbow flexed about 90 degrees, which makes accurate
diagnosis difficult. Don’t be bashful about insisting on a
true AP of the distal humerus and of the proximal forearm,
even if two or more views must be taken. Correct diagnosis
is everything.

Although many fractures are obvious on the AP and lateral

x-ray, some are not. Occult fractures may be detected only
by clinical suspicion and a careful study of the soft tissue
on x-ray. The displacement of lateral condyle fractures is
best seen on an internal oblique x-ray.

The displacement of a medial epicondyle fracture is best

seen on the axial view described by Edmonds (Table 8-2).
Ordering the correct views to best evaluate the fracture is
very helpful in determining if surgery should be offered or
if casting is adequate treatment.

Growth plates and ossification centers cause much

confusion for those who do not regularly evaluate and treat
children’s fractures. Fortunately, the opposite elbow can be
radiographed as a control, which is very useful in
determining the normal anatomy for a particular child.
Understanding the timing of growth center ossification and
fusion helps the orthopaedic surgeon in evaluating an
elbow injury but is generally not part of a primary doctor’s
training (Fig. 8-6).
 Table 8-2 The Distal Humerus Axial View
for Assessment of Medial Epicondyle
Fractures

A sawbones model was created with 10-mm anterior displacement of the

medial epicondyle. The distal humerus axial view was found to be more
accurate and more reproducible than traditional x-ray views.

Figure 8-6 Age at ossification of the distal humerus growth centers

for males and females. (Adapted from Haraldsson.)

Even for the experienced pediatric orthopaedist, there are

times when the exact diagnosis remains elusive. Ultrasound
is becoming a more common tool for evaluating fractures in
young children in whom much of the elbow remains as
radiolucent cartilage (Fig. 8-7). An arthrogram and
magnetic resonance imaging (MRI) study can also be useful
but may require general anesthesia in a younger child.

Figure 8-7 An ultrasound can be used to evaluate displacement of a

lateral condyle fracture in young children. The top image indicates the
fracture (arrow), the bottom is the contralateral normal elbow with
intact cartilage.
X-ray Landmarks
Several x-ray landmarks help in evaluating an injured
elbow: Baumann’s angle on the standard AP view assesses
the angulation of the physeal line (below the lateral
condyle) in relation to the long axis of the humeral shaft. A
normal Baumann’s angle is approximately 20 degrees with
a decrease in Baumann’s angle (0 degree for example)
suggesting cubitus varus.

The anterior humeral line on the lateral view passes

through the middle third of the ossification center of the
capitellum for most normal elbows. The anterior humeral
line of an extension-type supracondylar fracture will
intersect the capitellum more anteriorly or may not
intersect it at all. In a very young child, in whom much of
the distal humerus remains cartilaginous, this is a less
accurate test. Also, in the lateral view, the shaft-condylar
angle should be about 40 degrees. A decrease in this angle
suggests hyper-extension through the fracture site (Table
8-3).
In the fat pad sign (often referred to as a sail sign), a small
amount of fat overlies the elbow joint both anteriorly and
posteriorly. With injury (or sepsis) and elbow swelling, the
fat is pushed away from the bone and may be visible on a
high-quality lateral view. A small anterior fat pad is a
normal finding on many pediatric elbow x-rays, while a
posterior fat pad sign often indicates an occult fracture
about the elbow (Table 8-4).
 Table 8-3 X-ray Landmarks

With a posterior fat pad sign and no obvious fracture,

oblique x-rays should be obtained to help identify medial or
lateral condyle fractures as these may displace in a cast.
Skaggs and Mirzayan prospectively examined a group of
children with acute elbow trauma and a posterior fat pad
sign without a visible fracture on AP and lateral x-rays. At 3
weeks, new radiographs were taken and were evaluated for
signs of fracture healing; they found that 34 out of
45 patients (76%) had evidence of an elbow fracture. These
included the following:

Supracondylar fracture—53%
Proximal ulna fracture—26%
Lateral condyle fracture—12%
Radial neck fracture—9%

A more recent study from Denmark (Al-Aubaidi) showed

that 73% of patients with a positive fat pad sign had only a
bone bruise on MRI and not a true fracture, indicating that
a positive fat pad sign may not always indicate occult
fracture. However, treatment recommendation remains the
same—a short period of immobilization (3 weeks) will allow
both a bone bruise and a non-displaced fracture to heal
without too much risk of elbow stiffness.

Table 8-4 Distal Humerus Fat Pad Sign

(Sail Sign)
A posterior fat pad or so-called sail sign strongly
suggests an occult elbow fracture. You may not know
what type of fracture for 10-14 days when callus
appears
 Figure 8-8 Transphyseal fracture sustained during delivery healed
with significant callus at 3 weeks. At follow-up, the patient had full
range of motion at the elbow.

TRANSPHYSEAL DISTAL HUMERUS FRACTURES

Separation of the distal humeral physis in an infant with an
nonossified epiphysis can look like a dislocation on x-ray
(Fig. 8-8). Remember that dislocation of the elbow without
an associated fracture is very rare in children.
Transphyseal distal humerus fractures are frequently
associated with child abuse and warrant further
investigation. They occur in young children and may also be
secondary to birth trauma or a fall from a height.

Typically, the distal fragment displaces posteriorly and

medially, so the alignment of the proximal radius and ulna
are no longer in line with the distal humerus. In
comparison (although extremely rare in young children),
elbow dislocations usually have posterolateral displacement
of the proximal radius and ulna (Fig. 8-9). If there is
inadequate ossification to evaluate the fracture on plane
films, an ultrasound study or arthrogram can help to clarify
the diagnosis.

Many of these injuries have a small piece of the distal

metaphyseal bone attached to the physis and are thus
technically a Salter-Harris II fracture pattern. Radiographic
evidence of this small Thurston-Holland triangular
fragment plus posteromedial displacement of the proximal
radius and ulna helps to confirm the diagnosis.
 Figure 8-9 Transphyseal fracture.

Classification—Transphyseal Fractures
DeLee classified transphyseal fractures based on age of the
child and ossification of the epiphysis (see Table 8-5).

Treatment—Transphyseal Fractures
If the fracture is diagnosed early (less than 5 days), closed
reduction is recommended. Arthrogram or ultrasound is
very helpful to visualize alignment, as the epiphysis may
not be ossified. If the reduction is stable, casting may be
adequate, or pin fixation can stabilize the reduction until
there is adequate callus (3 weeks)—the technique of
pinning will be reviewed later in this chapter with
supracondylar fractures. It is not uncommon for
transphyseal fractures to heal in varus. Although flexion
and extension deformity will often remodel, varus and
valgus do not remodel as well except in the very young
infant where more initial deformity can be accepted.
 Table 8-5 DeLee Classification of
Transphyseal Fractures
Group A: 0-12 months

No ossification of lateral condyle; usually SH I

Group B: 1-3 years

Ossification of lateral condyle; can be SH I or SH II with small metaphyseal

fragment

Group C: 3-7 years

Ossification of lateral condyle; usually SH II with large metaphyseal fragment

If the fracture is diagnosed late (which is common in child

abuse cases), closed reduction should not be attempted, as
the physis will be further injured. Allow the fracture to
heal, and treat the resultant deformity with a
supracondylar osteotomy when the child is older.
 Figure 8-10 The olecranon forms a fulcrum in the supracondylar
region, which causes a fracture when the elbow is forcibly
hyperextended.

Pitfalls—Transphyseal Fractures
Recognizing the injury as a “classic sign” of child abuse
and completing a social work-up prior to discharge may be
may be the most important issue for future safety of the
child. Cubitus varus is the most common deformity
following under-treatment of transphyseal fractures. Also,
AVN of the trochlea or medial condyle and physeal
bar/growth inhibition can be caused by displaced
transphyseal distal humerus fractures.

Frequently, children are brought in late with transphyseal

fractures (particularly if they are secondary to child abuse);
if the fracture is more than 5 days old, or there is periosteal
new bone noted on x-ray, the fracture should probably not
be reduced because the reduction maneuver may cause
further damage to the physis. Such fractures should be
splinted or casted for comfort, and often adequate
remodeling occurs in infants. If there is not sufficient
remodeling, a later osteotomy can be done to correct
alignment when the child is older.

SUPRACONDYLAR FRACTURES
Supracondylar fractures represent the most common elbow
fracture seen in children. The bone is quite thin in the area
of the olecranon fossa, making this a weak point in the
upper extremity. A fall onto an outstretched hand causes
the olecranon to act like a fulcrum, snapping the distal
humerus into two (Fig. 8-10). This fracture is more common
in children who are “loose jointed” and can hyperextend
their elbows. The posterior periosteum may remain intact
when the force is pure hyperextension; however, when the
fracture is forcibly rotated, the periosteum is torn,
permitting gross displacement (Fig. 8-11). With
progressively more force, the sharp spikes of the proximal
fragment can tear the brachialis, injure the neurovascular
structures, and, in rare cases, come through the skin (open
fracture).

Classification—Supracondylar Fractures
Most commonly, the distal fragment of supracondylar
fractures go into extension (capitellum behind the anterior
humeral line); only approximately 5% are in flexion. The
Gartland classification of extension type supracondylar
humerus fractures initially included Type I (non-displaced),
Type II (extended with posterior hinge intact), and Type III
(completely displaced). This classification has been
modified by several authors. Extension fractures can be
further subdivided as described in Table 8-6.
Figure 8-11 Rotation through the fracture may cause the sharp
anterior spike to tear through the brachialis and skin.
 Table 8-6 Classification of Supracondylar
Fractures
Modification of Gartland Classification

Nondisplaced, no varus or valgus.

Displaced with angulation, posterior cortex intact—no rotation.

Displaced with angulation and rotation, posterior cortex intact.

Completely displaced, no cortical contact. Medial periosteal hinge intact.
Distal fragment displaces posteromedially.

Completely displaced, no cortical contact. Lateral periosteal hinge intact.

Distal fragment displaces posterolaterally.

No periosteal hinge. Multidirectional instability.

Treatment—Supracondylar Fractures
Prior to definitive management, the elbow should be
splinted in a position of comfort—usually about 30 degrees
 of flexion. Flexing a displaced supracondylar fracture in a
splint tends to compress the neurovascular structures.
Also, splinting in full extension may damage the
neurovascular structures (via spicules of the fractured
distal humerus). It is foolish to have a child waiting for
radiographs with an ischemic limb. For severely displaced
fractures, one can put the splint on before the radiographs
are taken to keep the technician from twisting the arm
through the fracture.

Specific treatment of this injury has two goals:

1. Avoiding neurologic and vascular problems

2. Preventing angular (usually cubitus varus) and extension
deformity

The AAOS has developed appropriate use criteria for the

management of pediatric supracondylar humerus fractures.
A web-based app has been developed to help residents and
surgeons determine the recommended treatment for a
specific child. This chapter will review the recommended
treatments for each type of fracture, but for more specific
and complete recommendations, we recommend using the
app: http://www.orthoguidelines.org/auc.
TECHNIQUE TIPS:
Reducing Supracondylar Fractures
The majority of supracondylar fractures displace in a posteromedial direction
and can be reduced in a reproducible fashion.

Position patient supine with arm board.

Fluoro (from head of bed and parallel to bed).
Monitor (easy for surgeon to see without turning head).
We do not recommend using the C-arm receiver as a table as this significantly
increases the radiation exposure to the surgeon and child
Milk soft tissue out of fracture.
Initially, keep the elbow extended and supinated.
Under image control, align the fracture on AP with traction and varus or
valgus pressure.

Only after the AP is aligned should flexion be attempted.

Maintain traction (anesthesia can help with a sheet around the chest for
countertraction).
Flex elbow up with thumb gently behind olecranon (do not overreduce and
convert to a flexion-type fracture!).
Gradually pronate the arm as you flex it.

The elbow is flexed to ~130° with full forearm pronation.

If the fracture is unstable, the fluoro should be rotated while maintaining
elbow position to avoid loss of reduction when obtaining the lateral x-ray.

Type I Supracondylar Fractures

Most Type I supracondylar fractures can be treated by cast
immobilization with the elbow at 90 degrees of flexion and
neutral pronation/supination for about 3 weeks. During the
period of cast immobilization, it is important to monitor
radiographically to ensure that the fracture does not
displace into further extension or varus. Active children
with short, thick arms can be very difficult to hold in a cast
—as the swelling comes down, the cast may slide off. If it
only partially slides off, it will displace the fracture and
create a malunion.
 Figure 8-12 For Type I supracondylar fractures the cast can be
molded gently with your thumb to prevent extension of the fragment.
Be careful not to over mold and create skin necrosis. (Method of Klaus
Parsch—Stuttgart, Germany.)

Type II Supracondylar Fractures

Some argue that Type IIA fractures can be treated with
gentle reduction and casting—the cast should not be flexed
greater than 90 degrees as hyper-flexion increases the risk
of compartment syndrome. A gentle mold just above the
olecranon may prevent the fracture from displacing and
keep the cast from sliding off (Fig. 8-12). Prior to deciding
on conservative management, the contralateral elbow
should be checked for hyper-extension. If the patient
naturally has significant laxity and hyper-extension (as
determined by examining the normal elbow), even a mild
increase in this extension due to a slightly extended
supracondylar fracture can lead to significant deformity.
Thus the more naturally lax the child, the greater the
indication for reduction and pin fixation.

Most recommend closed reduction and pin fixation of Type

IIB fractures to prevent hyper-extension and angular
deformity of the elbow. Although closed reduction can be
maintained with casting or splinting in hyper-flexion, this
increases the risk of neurovascular compromise and is no
longer recommended in centers where the skills and
equipment are available for percutaneous pinning.

Percutaneous pinning maintains the fracture reduction

while allowing a safe casting position (flexion of less than
90 degrees) The majority of Type II supracondylar fractures
have a posteromedial hinge of periosteum that aids in the
reduction process (Fig. 8-13) and helps to maintain stability
once the reduction is completed.

Silva presented a paper at the 2017 AAOS annual meeting

that indicated that the AAOS guidelines for treatment of
pediatric supracondylar humerus fractures may encourage
surgeons to over-treat Type II fractures. (AAOS AUC
recommendation: “We suggest closed reduction with pin
fixation for patients with displaced [Gartland Type II and
III, and displaced flexion] pediatric supracondylar fractures
of the humerus.”) Silva shows good evidence that many
Type II fractures can be treated successfully in a cast
without internal fixation. His indication for non-operative
treatment includes fractures without rotation and a shaft-
condylar angle greater than 30 degrees.
TECHNIQUE TIPS:
Pathway—Pinning Supracondylar Fractures
Following reduction, hold the humerus parallel to the floor with the elbow
flexed to 130°.
Start the first pin just lateral to the olecranon through the capitellum.
Aim at ~45° toward the medial metaphyseal cortex.

Aim the second pin more proximally and diverge from the first.
Aim toward the medial diaphyseal cortex.
Make sure all pins penetrate the medial cortex.
If reduction is not stable, consider a third lateral or medial pin.

For medial pin, palpate the ulnar nerve with thumb and push nerve
posteriorly.
Extend the elbow and insert pin anterior to thumb.

Bend the pins to a 90° angle as close to the skin as possible.

Cut the pins ~2 cm distal to bend.
Place felt over the pins to protect the skin.
Cast the elbow with <80° of flexion and split the cast to allow for swelling.
 Figure 8-13 The periosteum usually remains intact on one side of
the fracture, allowing it to act as a hinge for reduction. In most
supracondylar fractures the distal fragment displaces medially and
the medial hinge is intact. This allows a repeatable sequence for
reduction with the elbow extended and supinated; then gentle flexion
and pronation typically reduces the fracture.

Type III Supracondylar Fractures

Reduction and internal fixation is recommended for all
Type III and IV fractures. Frequently, reduction can be
done in a closed fashion with associated percutaneous
pinning, as with Type III fractures, but the reduction is
much more challenging without the periosteal hinge to help
guide and maintain reduction. At the level of a
supracondylar fracture the bone is extremely narrow; there
is often a rotational component that when added to the
complete displacement can make reduction very difficult.

Prior to attempting reduction of a Type III fracture, “milk”

the soft tissues down the arm by squeezing proximally and
then maintaining circumferential pressure around the arm
and sliding your hand toward the elbow; this may pop the
interposed tissue out of the fracture site. Puckered skin on
the anterior aspect of the elbow indicates soft tissue
interposition and on occasion brachial artery entrapment in
the fracture (Fig. 8-14).
 Figure 8-14 “Puckered” skin on the anterior aspect of the elbow
indicates soft tissue entrapment.

Several other techniques have been reported to help with

closed reduction:

Herzog et al described using a diaphyseal Schanz pin as a

joystick to help the surgeon gain control of the proximal
fragment.
Pei recommends leverage-assisted closed reduction.

If closed reduction techniques fail, or the hand is

dysvascular following reduction and fixation, open
reduction is required (the pulseless extremity will be
discussed later in this chapter). The incision for opening
supracondylar fractures depends on the fracture; the most
direct approach is directly over the prominent bony spike.
Whether it is anterior, medial, or lateral, the spike is
usually where most of the soft tissue injury has occurred
and where the periosteum is completely stripped off of the
metaphyseal fragment and may be blocking reduction. If
the incision is anterior, we recommend a lazy S across the
elbow flexion crease; if medial or lateral, an incision over
the spike in line with the longitudinal axis of the humerus
works well. Care needs to be taken to protect the brachial
artery and median, ulnar, and radial nerves during the
exposure and reduction.

Flexion Type Supracondylar Fractures

Although they are the least common type of supracondylar
fracture (approximately 5%), flexion type fractures are the
most likely to have nerve compromise. The ulnar nerve can
get entrapped in the fracture site and prevent anatomic
reduction. If persistent medial fracture gap remains, or you
can close the gap but it bounces back open, the surgeon
should consider making an incision rather than repeatedly
grinding the bone ends against a nerve, vessel, or other
interposed soft tissue. Because the posterior periosteal
hinge is disrupted in flexion-type supracondylar fractures,
they can be more difficult to reduce than extension
fractures, and pinning is more difficult as the fracture is
reduced with extension (you lose the bony landmarks for
pinning that you have when the elbow is hyper-flexed).
Pinning Patterns
Debate remains as to the optimum number and
configuration of K-wires; two or three pins can be used to
stabilize most supracondylar fractures. Traditionally, cross-
pinning (one pin from medial and one from lateral) was
performed, but this technique has been shown to have a
higher incidence of ulnar nerve injury. Currently, most
surgeons use two or three lateral pins to avoid ulnar nerve
injury. The pins enter the capitellum, cross the fracture,
and engage the medial metaphyseal cortex. Typically two
pins are adequate for Type II fractures and three pins may
be needed to stabilize Type III fractures.

Pins should diverge to create maximum space between

them at the fracture site; they should not cross at the
fracture site as this creates a rotationally unstable
configuration. A good goal is to have one pin crossing the
fracture medial to the olecranon fossa and one lateral to
the olecranon fossa to stabilize both columns of the
humerus and prevent rotation (Table 8-7). We recommend
placing two lateral pins, and, if the reduction is felt to be
unstable, a third lateral or medial pin can be added. There
are some fracture patterns that are not well fixed with only
lateral pins. If the fracture exits very low on the lateral
side, there may not be enough room for 3 good lateral pins;
it is important to be comfortable using a medial pin when
necessary.

When using a medial pin, one must protect the ulnar nerve.
This pin should never be placed with the elbow flexed as
flexion moves the ulnar nerve anteriorly, putting it closer to
the entry site of the K-wire. Once you have 2 pins entering
from the lateral side, there should be enough stability to
extend the elbow, palpate the ulnar nerve (which usually
lies behind the medial epicondyle), keep your thumb on the
nerve, and insert the K-wire anterior to your thumb into the
medial epicondyle. Some surgeons recommend making a
small incision to visualize the ulnar nerve, but even in a
very swollen elbow, the nerve is usually palpable and can
be protected during percutaneous pinning if you use the
technique noted above.
 Table 8-7 Acceptable Configuration of K-
Wires for Supracondylar Fractures
Divergent—2 pins

Two lateral pins adequate for most fractures.

Divergent—3 pins

Three lateral pins for very unstable fractures.

Crossed
 Traditional fixation puts ulnar nerve at risk.

Crossed and Divergent

A third pin can be added for unstable fractures. If necessary, the medial pin
can be removed once the cast is on.

With a three-pin technique that includes a medial pin, if

two lateral pins are in place and the patient wakes up with
an ulnar nerve palsy, the medial pin can be removed
through a window in the cast and the fracture will likely
remain stable. If there is only a single lateral pin, this is not
enough to maintain the reduction if the medial pin has to
be removed.
Post-operative Care
Following closed reduction and percutaneous pinning of a
supracondylar fracture, always check to ensure you have a
good radial pulse before you continue. The type of
immobilization will depend on the amount of soft tissue
injury and risk of swelling. Type II fractures with mild to
moderate swelling, for which surgery did not significantly
add to the trauma (i.e., few attempts at reduction and
pinning), can be placed in a cast flexed to about 80 degrees
at the elbow, as long as the cast is split (univalved). The
cast can be tightened and overwrapped in 1 week. Three
weeks of casting time is usually adequate. Mandating a
sling minimizes motion and the associated risk for pin/skin
issues.

For Type III fractures, it is even more important to confirm

that there is a radial pulse before any dressings are put on.
If there is no pulse, see the pulseless hand section below. If
there is significant swelling, consider a splint or bivalved
cast. (A roll may need to be split as well as it can cause
compression.) Do not flex the elbow past 80 degrees—start
with the elbow in extension and slowly flex the elbow, and
when the flexion crease in the cubital fossa starts to
wrinkle, back off a little with the flexion and splint or cast
in a position that minimizes compression by the soft tissues
around the elbow. (This may be at only 60 degrees of
flexion.) As you are wrapping the cast padding, be sure not
to change the flexion at the elbow—if the elbow is slowly
flexed as the cast is put on, you will end up with a
compressive roll in the elbow crease that can compromise
the blood flow in a swollen elbow.
 Figure 8-15 A cast with a window that allows access to monitor the
radial pulse and was split to allow for swelling.

We often cut a window in the cast over the radial artery at

the wrist so the pulse can be easily monitored overnight
(Fig. 8-15). A pulse oximeter on one of the fingers is also
helpful to ensure the hand is getting adequate perfusion.
Careful monitoring is critical for the first 24 hours
following a Type III or IV fracture to ensure that any
neurovascular compromise is recognized and treated early.
Remember that if the children have median neuropathy, he
or she will not complain of pain if compartment syndrome
develops; frequent and consistent exams are the only way
to identify neurovascular problems.

A sling will slip off if the cast has less than 90 degrees of
flexion; a cuff and collar or fiberglass loop on the cast with
a strap around the neck will provide better control of the
arm at discharge (Fig. 8-16). If the fracture was splinted,
due to concerns for swelling or a compartment syndrome, a
long arm cast can be applied at the 1 week follow-up visit.
 Figure 8-16 A sling will slip off a cast if it is at less than 90 degrees
of flexion. A loop can be added to the cast so that a strap can be
attached.

Three weeks following surgery, the cast can be removed

and the percutaneous pins can be removed in the clinic—
sedation is not necessary. In the majority of cases, there is
adequate healing to begin motion at this time. A few
fractures will remain clearly visible with little callus and
require a second cast for 1-2 weeks after pin removal. This
is in contrast to lateral condyle fractures, which take longer
to heal and may go on to non-union.

Physical therapy is rarely needed to regain elbow motion in

children. If flexion is limited, it is usually secondary to bone
malunion with the fracture in extension. Flexion/extension
deformities may remodel over time, although it has been
shown that varus/valgus deformities of the distal humerus
do not remodel. Zionts looked at the return of elbow motion
following closed reduction and pinning of supracondylar
fractures and found that 6 weeks post-op, children had
approximately 72% of their elbow motion back, and by 6
months, 94% of the motion had returned. There was
continued improvement up to 1 year following surgery.

The Pulseless Hand

Few cases raise the new-to-practice orthopaedist’s stress
titer more than a severe supracondylar fracture with
vascular compromise. Although the incidence of vascular
complications has decreased with early recognition,
advanced techniques for closed reduction and
percutaneous pinning, and avoidance of hyper-flexion, we
still see an occasional supracondylar fracture that requires
the assistance of a vascular surgeon despite our best
orthopedic treatment. In the literature, up to 20% of
displaced supracondylar fractures may have vascular
compromise. There is little controversy regarding
treatment of a dysvascular hand, but there is debate as to
the best treatment of a pink but pulseless hand. It is
valuable to remember Rang’s advice: the main
consideration when taking care of children who have a
perfused hand but no palpable radial pulse in association
with a supracondylar humeral fracture is to “avoid
catastrophe.”
TECHNIQUE TIPS:
Vascular Assessment and Management

An algorithm has been developed to aid in treating these

fractures based on vascularity of the hand (see Technique
tips). If a child comes in with a dysvascular hand, reducing
and fixing the fracture emergently is mandatory—this is not
a fracture that can wait until morning. The pulse often
returns once the fracture is reduced. Following closed
reduction and pinning, immediately reassess the vascular
status. If there is no pulse by palpation or Doppler, but the
hand is perfused, the arm can be monitored for 24-48 hours
to see if brachial artery spasm resolves. We recommend not
sending the child home without, at minimum, a Doppler
 signal or confirmation of a patent brachial artery with
ultrasound or angiogram.

If there is no pulse and the hand appears dysvascular,

ultrasound or angiogram and compartment pressures need
to be checked, preferably before leaving the operating
room. Do not watch a white hand, it needs to be treated
emergently. If angiogram shows a thrombus, this can be
treated with thrombolytics. More often, the artery is caught
in the fracture. Opening the fracture site anteriorly with a
gentle S incision over the antecubital fossa will allow
exploration of the artery. If it is caught in the fracture, back
the pins out to the fracture to allow the fracture to gap
open. Carefully remove the soft tissues from the fracture,
and then re-reduce and pin the fracture. The artery will
likely be in spasm; Lidocaine or papavarine can help reduce
vasospasm. If there is still no blood flow to the hand, a
vascular surgeon may be needed for reconstruction.

Many good articles discuss treatment of the pulseless

extremity following supracondylar fracture fixation with
varied recommendations. In 2015, Badkoobhei et al.
reviewed the literature on the pulseless supracondylar
humerus fractures and came up with the following advice
(graded by level of evidence):

1. Management of a pulseless limb following supracondylar

humeral fracture should be based on the perfusion status
of the extremity. Grade of Recommendation: B.
2. In the setting of a poorly perfused, pulseless limb following
supracondylar humeral fracture, emergency operative
reduction and fixation should be performed. If perfusion to
the extremity does not improve after reduction, immediate
open vascular exploration and possible reconstruction is
indicated. Grade of Recommendation: B.
3. If there is still no pulse after untethering the brachial artery
from the fracture fragments, the brachial artery may be in
vasospasm. Increasing the temperature of the operating
room or application of topical lidocaine or papaverine may
relieve arterial spasm. Grade of Recommendation: B.
4. Urgent operative reduction and stabilization is indicated for
the well-perfused, pulseless limb following supracondylar
humeral fracture, that is, the pink but pulseless limb. The
pulse may return after reduction. Grade of
Recommendation: B.
5. If the extremity remains pulseless but is still well perfused
after fracture reduction, either immediate vascular
exploration or inpatient observation for 24-48 hours with
frequent neurovascular monitoring may lead to satisfactory
clinical outcomes. If perfusion becomes compromised
during observation, vascular exploration is necessary.
Grade of Recommendation: C.
6. Supracondylar humeral fractures with an absent radial
pulse and a median nerve injury should raise suspicion for
associated vascular injury and compartment syndrome.
Grade of Recommendation: B.

Pitfalls—Supracondylar Fractures
The goal of treatment is safe anatomic reduction and
avoidance of residual varus and extension deformities that
are common complications following supracondylar
fractures. Malunion of a supracondylar fracture may lead to
a “gunstock deformity” that consists of varus, medial
rotation, and extension, best visualized by having the
patient extend the arms fully and parallel to the ground
(Fig. 8-17). With residual posterior displacement, the bony
deformity causes a block to motion that cannot be regained
with physical therapy. There may be some remodeling in
the flexion/extension plane over time, but varus/valgus at
the elbow does not remodel. Cubitus varus predisposes the
elbow to subsequent refracture (especially lateral condyle
fractures of the same elbow), so osteotomy may be
warranted to correct malunion even if there is not an
apparent functional deficit.

Nerve injury is one of the most serious complications of

supracondylar fractures and their treatment. The more
severe the fracture, the higher the risk of nerve injury.
Many are transient stretch injuries that resolve within a
few months. A meta-analysis by Babal et al. reviewed 5,184
patients; anterior interosseus nerve injury was most
common in extension-type fractures and ulnar neuropathy
in flexion-type fractures. Many authors have shown that
there is a higher risk of iatrogenic nerve injury when using
a medial pin for fixation; however, we hope that after
studying this chapter, you can safely insert a medial pin
when necessary for fracture fixation.

Figure 8-17 Gunstock deformity: This boy has residual varus and
extension of the right elbow following non-operative treatment of a
supracondylar fracture.

Obesity has also been shown to be a risk factor for loss of

reduction (falls into varus) and for pin site infections.
 Figure 8-18 Lateral condyle fractures can be produced from a fall on
an outstretched hand.

LATERAL CONDYLE FRACTURES

Lateral condyle fractures can be quite tricky; they may go
on to delayed union or non-union, progressive cubitus
valgus, and tardy ulnar nerve palsy despite anatomic
alignment and fixation. The mechanism of injury is thought
to be a varus force on an extended elbow with the trochlear
ridge on the ulna acting as a fulcrum for avulsion of the
lateral condyle by the lateral ligaments. The bone
separates, but the articular cartilage may remain intact as
a hinge making the fracture easier to reduce (when varus
angulation is corrected). But with a greater angular force,
the cartilage hinge tears, and the fracture displaces. The
fragment can displace in the sagittal plane, sometimes
rotating nearly 180 degrees (Fig. 8-18).

Classification—Lateral Condyle Fractures

There are many proposed classifications of lateral condyle
fractures in the literature. Milch described the most
commonly cited classification; it is useful for determining
prognosis of the fracture, or risk of growth arrest, but does
not help the surgeon develop a treatment plan. It is based
on whether or not the capitellar ossification center is
disrupted by the fracture line. Milch Type I fractures are
much less common but can lead to worse long-term
prognosis as the ossification center is disrupted, which may
cause growth arrest; the fracture begins in the metaphysis,
crosses the physis in an oblique fashion, and then traverses
the capitellar ossification center. The more common Milch
Type II fracture traverses through the metaphysis, crosses
the distal physis, and extends to the unossified trochlea
without interrupting the capitellar ossification center (Fig.
8-19).
 Figure 8-19 Milch classification of lateral condyle fractures (Type II
are the most common).

Wiess presented a classification that better aids in

determining if surgery is needed and planning surgical
technique. A Type I fracture is displaced less than 2 mm.
Type II fractures have ≥2 mm of displacement with intact
articular cartilage, as demonstrated by arthrogram. Type
III fractures have ≥2 mm of displacement and the articular
surface is not intact. The risk of complication was more
than 3 times as likely to occur in Type III fractures when
compared to Type II fractures, so this classification has
prognostic significance as well (Table 8-8).

To best understand how much a lateral condyle fracture

has displaced, an internal oblique x-ray is important as this
view will show the maximum displacement (Fig. 8-20).
Ultrasound is being used more commonly to image
displacement and joint congruity or cartilage hinge that
may prevent displacement of the fracture (Fig. 8-21). If it is
still unclear, arthrogram or MRI can be used, but both of
these modalities require anesthesia.
 Figure 8-20 AP, lateral, and internal oblique views are needed to
identify a lateral condyle fracture.

Treatment—Lateral Condyle Fractures

Lateral condyle fractures with maximum displacement less
than 2 mm on every x-ray view (including internal oblique)
are often treated in a long arm cast. However, Bakarman
indicates that this cutoff may leave some fractures
undertreated as a significant number of lateral condyle
fractures initially thought to have minimal displacement did
displace in a cast and required open reduction—delayed
treatment may have less than optimal results. If non-
operative treatment is chosen, we recommend obtaining
AP, lateral, and internal oblique x-rays every week for 3
weeks to ensure that the fracture does not displace. Once
one discovers the tension, time, and energy required to
assure healing with non-operative treatment, many
surgeons choose K-wire fixation for the borderline case.
 Figure 8-21 Ultrasound used to determine displacement in lateral
condyle fractures.

Pennock et al. showed that if the joint surface is intact, but

lateral gap is 2-5 mm, reduction can often be obtained in a
closed fashion by extending and supinating the elbow and
then applying a valgus force to close the fracture gap,
relying on the medial cartilage hinge for anatomic
reduction. Percutaneous K-wires can then be used to
maintain reduction. An arthrogram can help to confirm
joint reduction. This technique had fewer complications
than did open reduction in this series, and all had good
clinical/radiographic results.
 Table 8-8 Weiss Classification of Lateral
Condyle Fractures
Type I

<2 mm of displacement
Type II

≥2 mm of displacement with intact articular hinge

Type III
≥2 mm of displacement with complete disruption of the articular surface

Joint surface disruption should be anatomically reduced

and fixed; this is typically done with arthrogram or open
reduction for good visualization of the joint surface to
ensure there is no joint step-off or incongruity. There are
also reports of arthroscopic reduction, which may decrease
trauma to the elbow while giving good visualization of the
joint surface. For open reduction, a lateral approach to the
elbow can be used. In an acute fracture, the soft tissues are
often disrupted and hematoma is encountered as soon as
the incision is made—the fracture has often already done
the soft tissue dissection. Remember that the blood supply
to the capitellum comes from posteriorly, so avoid
iatrogenic disruption of the posterior soft tissues. Consider
using a headlamp to see into the incision (the surgeon’s
head tends to block the OR lights). Place a retractor that
allows you to see the entire joint surface from lateral to
medial. Using a K-wire as a joystick may help reduce the
fracture (see Technique Tips lateral condyle fracture
fixation).
Gilbert showed that screw fixation of lateral condyle
fractures led to fewer non-unions and faster time to union
when compared with K-wire fixation, but they required a
second surgery to remove the screw. If K-wires are used,
they should be left in longer than those used for
supracondylar fractures as lateral condyle fractures have a
tendency for non-union. We recommend 4 weeks of
immobilization with pins in place followed by an additional
2-4 weeks of casting or splinting (until callus is visible
crossing the fracture site). Every year we see 2 or 3 lateral
condyle fractures where the original treating surgeon (from
the infamous “Elsewhere General Hospital”) correctly
diagnosed, reduced, and pinned a lateral condyle fracture,
but then removed the pins at 2 or 3 weeks and allowed
early motion with subsequent non-union.

Pitfalls—Lateral Condyle Fractures

The classic severe complication of non-union with late
severe cubitus valgus and tardy ulnar nerve palsy is now
almost never seen in developed parts of the world where
early diagnosis and pin stabilization are standard. The most
common problems in advanced centers are now more
subtle.

As discussed above, delayed union or non-union is not

uncommon. Wadsworth has observed that premature
growth plate closure may occur, even in nondisplaced
fractures. This can lead to a progressive valgus deformity
of the elbow joint requiring later supracondylar osteotomy.
Another problem is cubitus varus due to growth stimulation
of the lateral portion of the physis, likely secondary to
increased blood flow in the area of the fracture. This mild
deformity is not progressive.
TECHNIQUE TIPS:
Pinning Lateral Condyle Fractures

1. OR set up—patient should be positioned supine on the OR table with the

arm on a radiolucent arm board. Sterile tourniquet should be used. The
surgeon should wear a headlamp for better visualization into the joint.
Standard or mini C-arm can be used intra-operatively.
2. A lateral incision is made along the anterior third of the capitellum; often
once you get through the skin, the fracture has done much of the soft
tissue dissection already.
3. The joint capsule needs to be elevated off the anterior distal humerus to
allow good visualization of the joint surface to ensure anatomic reduction.
Do not dissect posteriorly as you risk disrupting the blood supply to the
capitellum. Use a retractor that goes all the way across the joint to elevate
the soft tissues.
4. The fracture can be reduced using a dental pick under direct visualization.
Flexing and pronating the elbow will also help with reduction.
5. Two or three 0.62 K-wires can then be used to secure the reduction. If the
surgeon places his or her finger on the medial epicondyle, most surgeons
can drill the first pin from the capitellum to their finger. The second pin
should be angled up approximately 45 degrees and capture the medial
cortex of the distal humerus.
6. Pins are then bent outside the skin, incision closed with absorbable suture.
7. A long arm cast with a loop to secure the arm to the body is better to
minimize motion and use of the arm. Most children remove a sling.

Because the lateral condyle is directly subcutaneous, even

with perfect reduction, the healed lateral condyle fracture
commonly results in a “bump” on the lateral aspect of the
elbow. This is seen in fractures treated with closed
reduction and percutaneous pinning as well as those
treated with open reduction. This is not a functional
problem, but some patients and parents are bothered by
the prominence.
 Figure 8-22 The “fish tail” deformity is a result of AVN of the
trochlea.

“Fish-Tail” Deformity
The trochlear notch may appear deepened on the AP x-ray
at later follow-up despite adequate reduction and union,
because of focal avascular necrosis. The so-called fish-tail
deformity pattern should be recognized, but there is no
good treatment for AVN of the trochlea (Fig. 8-22).

Delayed Diagnosis Cases

Occasionally a child presents after several weeks with a
displaced fracture of the lateral condyle. Should this be
accepted or surgically reduced? In such cases, the results
of surgery are less satisfactory because of the increased
risk for physeal arrest and avascular necrosis. In most
cases of early non-union, even with significantly delayed
presentation, we recommend carefully opening the
fracture, removing the evolving callus, getting the joint as
congruent as possible and pinning the fracture. In late non-
union, one can consider Flynn’s “metaphysis to
metaphysis” fixation, allowing the distal growth centers to
grow as two separate centers (avoiding progressive
valgus). The long term results of an incongruent joint are
unsatisfactory. If the fracture has healed with malunion,
the literature is not clear as to the long term prognosis of
intra-articular osteotomy to re-align the joint versus
metaphyseal osteotomy to align the arm.
 Figure 8-23 Medial condyle fracture.

MEDIAL CONDYLE FRACTURES

Medial condyle fractures (Table 8-9, Kilfoyle classification)
are very rare (Fig. 8-23). As it is an intra-articular fracture,
a neglected fracture of the medial condyle has the same
poor prognosis as a neglected fracture of the lateral
condyle. The medial condyle or trochlea ossifies between
the ages of 7-11 for girls and 8-13 for boys. The unossified
medial condyle in a young child casts no shadow and
avulsion is a matter of conjecture. A common mistake is to
confuse a condylar fracture with an epicondylar fracture as
the epicondyle ossifies earlier (between 5 and 9 years). It
may be possible to avoid this mistake in children who have
soft-tissue swelling on the medial aspect of the joint by
examining the elbow with ultrasound or arthrogram. A
medial condylar fracture is often associated with instability
of the elbow, and posteromedial subluxation of the elbow.

Table 8-9 Kilfoyle Classification of Medial

Condyle Fractures
Type I Type II Type III

Extends from medial Extends across the Condylar fragment is

condylar metaphysis to physis but is minimally rotated and displaced
physis (not into the displaced
joint)

Cast Closed reduction and Open reduction and pin

pin fixation fixation

If non-operative treatment is chosen, it is important to

check x-rays regularly during the healing process to ensure
the fragment does not displace. Similar to lateral condyle
fractures, union may be slow as a good portion of the
fracture is through cartilage, so pins should be left in place
4 weeks, and the elbow casted until good callus is noted on
x-ray.

Pitfalls—Medial Condyle Fractures

Failure to recognize a displaced medial condyle fracture
can lead to non-union and cubitus varus. Avascular necrosis
can occur if the blood supply to the trochlea is disrupted
either by dissection or the original trauma.

MEDIAL EPICONDYLE FRACTURES

The medial epicondyle of the distal humerus ossifies
between the ages of 5 and 9 years and can be avulsed by
valgus stress and contraction of the flexor muscles. We
frequently see this injury in young gymnasts and baseball
pitchers who repetitively put a forceful stress on the medial
epicondyle through the flexor-pronator muscles that
originate from the medial epicondyle and valgus stress; this
can be a chronic, acute on chronic, or acute injury.
Fractures can also be classified as minimally displaced,
rotated, trapped or dislocated (Table 8-10, Classification of
medial epicondyle fractures).

Traumatic elbow dislocation is often accompanied by

medial epicondyle fracture, the avulsed fragment can
become entrapped in the joint. In children under the age of
9, the clinical signs of hematoma may be more obvious than
the radiographic ones. If the epicondyle is ossified, a film of
the opposite elbow may help to clarify the normal position
of the epicondyle. If it is unossified, MRI may be necessary
to fully understand the fracture and degree of
displacement.
 Table 8-10 Classification—Medial
Epicondyle Fractures
Minimally Displaced

Rotated
Trapped
Dislocated
Adequate imaging of the elbow must be obtained to
determine displacement of the medial epicondyle. Even
with good x-rays, it is often difficult to establish the true
fragment displacement on plane radiographs. The axial
view, described by Edmonds, better shows the anterior
displacement of this fragment; however, axial images on a
CT scan may be required to quantify the displacement (Fig.
8-24). It is important to recognize the presence of other
associated injuries such as fracture of the radial neck and
injury of the ulnar nerve, which lies close by.

Figure 8-24 The “distal humerus axial view” was developed to

determine anterior displacement of medial epicondyle fractures.
Treatment—Medial Epicondyle Fractures
There is significant debate as to the amount of
displacement that is acceptable for normal elbow function
with a medial epicondyle fracture. If a medial epicondyle
fracture is allowed to heal in a significantly displaced
position, the flexor-pronator origin is moved distally and
anteriorly. Theoretically, this may lead to elbow weakness
or valgus instability, which aids in the argument to reduce
and fix displaced medial epicondyle fractures, but again,
there is no rule for how much displacement is acceptable
(or which images should be used in making the
measurement).

If it is an acute fracture with no signs of chronic injury, and

the fracture has minimal displacement (less than 5 mm in
any plane) and minimal soft tissue swelling, cast
immobilization alone can be considered. However, if it is an
acute on chronic avulsion-type injury in the dominant arm
of an athlete who plans to return to the same sport,
conservative treatment may not be adequate, even for
minimally displaced fractures. When the children returns to
sport they are likely to re-avulse the fragment if they
continue with the same arm mechanics. So there is a
tendency (although not fully supported in the literature) to
fix medial epicondyle avulsions in high-demand athletes
(gymnasts, pitchers, volleyball players, etc.).
 Figure 8-25 Medial epicondyle fractures with a small or comminuted
bone fragment can be fixed with a suture anchor.

If the child presents with a dislocated elbow and a medial

epicondyle fracture, the elbow should be emergently
reduced to assist the circulation and relieve pain. If the
medial epicondyle remains trapped in the joint following
reduction, it can sometimes be extricated by applying a
valgus stress and supinating the elbow while milking the
tissues out of the joint; however, the fragment rarely
returns to its bed. Open reduction should be performed in
these cases.

Open reduction: The patient can be positioned supine with

the arm externally rotated on an arm board. A small
incision is centered at the level of the bed of the epicondyle
in line with the posterior border of the humerus (remember
that the medial epicondyle is a posterior structure).
Hematoma is usually encountered just under the
subcutaneous fat and leads to the fracture bed.

Figure 8-26 Medial epicondyle fractures with larger fragments can

be fixed with a screw—be careful to avoid the olecranon fossa.

The ulnar nerve must be identified and protected—with

elbow flexion it tends to get pulled into the fracture bed.
Fixing the fragment with the nerve entrapped can cause
significant ulnar nerve injury. The fragment, along with the
flexor-pronator origin, can then be milked proximally up
into the incision with the forearm pronated to relax the
volar musculature. Now the orientation can be visually
determined and the fragment replaced into its anatomic
position. A towel clip will secure the reduction while
fixation is placed.

In younger children, a smooth K-wire can maintain the

reduction. If the fragment has only a small amount of bone,
a suture anchor can be used (Fig. 8-25). In older children,
if there is a large enough piece of bone for a screw, the
medial epicondyle can be fixed with a single cancellous
screw starting in the fragment and continuing up the
medial column of the distal humerus (Fig. 8-26). If a screw
is likely to fragment the avulsed fragment, we recommend
suture anchor fixation. Post-operatively the patient is
casted at 90 degrees of elbow flexion and pronation to relax
the flexor-pronator group for 3 weeks, and then range of
motion is begun.
 Figure 8-27 Medial epicondyle fracture with elbow dislocation.

Pitfalls—Medial Epicondyle Fractures

Missing a medial epicondyle that is entrapped in the joint
can lead to significant loss of motion and disability (Fig. 8-
27). The ulnar nerve may be irritated or stretched at the
time of injury, reduction, or surgery; this ulnar neuropathy
is usually transient. Some patients develop a late ulnar
neuritis, likely secondary to irritation by callus or a chronic
valgus instability.

Non-union is common in displaced fractures treated non-

operatively; however, this only occasionally leads to clinical
problems (with the possible exception of late ulnar
neuritis). Even with anatomic healing, the elbow may
become stiff following healing of a medial epicondyle
fracture especially when associated with elbow dislocation;
so early motion is important, and these patients often need
aggressive physical therapy.

LATERAL EPICONDYLE FRACTURES

The center for the lateral epicondyle ossifies late (age 8-13)
and is often irregular, causing beginners to confuse it with
a fracture (Fig. 8-28). The extensor muscles originate on
the lateral epicondyle and may be responsible for avulsion
injuries. Very few true fractures of lateral epicondyle are
seen; therefore, there is no consensus on the need for or
type of treatment. Minimally displaced fractures can be
casted for 4 weeks.
 Figure 8-28 Normal ossification of the lateral condyle in a 9-year-old
male.

SUMMARY
Distal humerus fractures come in many varieties that
change as the child grows and growth centers appear.
Establishing the correct diagnosis is required to expect a
good outcome. Contralateral x-rays, ultrasound, a CT study,
or even an MRI study may be required in difficult cases.
Treatment options vary based on the type of fracture and
age of the patient. It is important to not only understand
each fracture and its associated complications but also
have a thorough knowledge of normal elbow development
and anatomy to allow each child to return to full function.

SUGGESTED READINGS
Al-Aubaidi Z, Torfing T. The role of fat pad sign in diagnosing occult elbow
fractures in the pediatric patient: a prospective magnetic resonance imaging
study. J Pediatr Orthop B. 2012;21(6):514–519.

Babal JC, Mehlman CT, Klein G. Nerve injuries associated with pediatric
supracondylar humeral fractures: a meta-analysis. J Pediatr Orthop.
2010;30(3): 253–263.

Badkoobehi H, Choi PD, Bae DS, et al. Management of the pulseless pediatric
supracondylar humeral fracture. J Bone Joint Surg Am. 2015;97(11):937–943.

Beck JJ, Bowen RE, Silva M. What’s new in pediatric medial epicondyle
fractures? J Pediatr Orthop. 2016. [Epub ahead of print].

Brighton B, Abzug JM, Ho CA, et al. Current strategies for the management of
pediatric supracondylar humerus fractures: tips and techniques for successful
closed treatment. Instr Course Lect. 2016;65: 353–360.

Davids JR, Maguire MF, Mubarak SJ, et al. Lateral condylar fracture of the
humerus following posttraumatic cubitus varus. J Pediatr Orthop.
1994;14(4):466–470.

Delee JC, et al. Fracture-separation of the distal humeral epiphysis. J Bone Joint
Surg Am. 1980;62:4–51.

Gilbert SR, MacLennan PA, Schlitz RS, et al. Screw versus pin fixation with
open reduction of pediatric lateral condyle fractures. J Pediatr Orthop B.
2016;25(2):148–152.

Kim HT, Song MB, Conjares JN, et al. Trochlear deformity occurring after distal
humeral fractures: magnetic resonance imaging and its natural progression.
J Pediatr Orthop. 2002;22(2):188–193.

Lee SS, Mahar AT, Miesen D, et al. Displaced pediatric supracondylar humerus
fractures: biomechanical analysis of percutaneous pinning techniques. J Pediatr
Orthop. 2002;22(4):440–443.

Pennock AT, Salgueiro L, Upasani VV, et al. Closed reduction and percutaneous
pinning versus open reduction and internal fixation for type II lateral condyle
humerus fractures in children displaced >2 mm. J Pediatr Orthop.
2016;36(8):780–786.

Skaggs DL, Mirzayan R. The posterior fat pad sign in association with occult
fracture of the elbow in children. J Bone Joint Surg Am. 1999;81(10):1429–
1433.

Souder CD, Farnsworth CL, McNeil NP, et al. The distal humerus axial view:
assessment of displacement in medial epicondyle fractures. J Pediatr Orthop.
2015;35(5):449–454.

Spencer HT, Dorey FJ, Zoints LE, et al. Type II supracondylar humerus
fractures: can some be treated nonoperatively? J Pediatr Orthop.
2012;32(7):675–681.
Weiss JM, Graves S, Yang S, et al. A new classification system predictive of
complications in surgically treated pediatric humeral lateral condyle fractures.
J Pediatr Orthop. 2009;29:602–605.
 9
Elbow—Proximal Radius
and Ulna

Maya Pring
Vidyadhar Upasani
Pulled Elbow Syndrome (Nursemaid’s Elbow)
Dislocations—Elbow Joint
Proximal Radius 151
Proximal Ulna—Olecranon Fractures
Proximal Ulna—Coronoid Fractures
Monteggia Fracture/Dislocation

“Once you stop learning, you start

dying”
— Albert Einstein

INTRODUCTION
For the purposes of this book, we have divided “elbow
fractures” into those above the elbow (distal humerus—
Chapter 8) and those below the elbow (proximal radius and
ulna—this chapter). Although fractures of the proximal
radius and ulna are less frequent than supracondylar
fractures in young children, their prevalence increases with
age as does severity of the fractures.

Many of these fractures and dislocations can be treated in

a closed or percutaneous fashion, but caution is warranted
as there is risk of poor outcomes if radial head dislocations
are undertreated, and at the opposite extreme, there can
be significant complications and poor outcome following
open reduction of more severe radial head and neck
fractures.

Anatomy
The elbow does not have inherent bony stability; it depends
on the ligaments and capsule to maintain alignment of
three joints: the ulnohumeral joint (stabilized by the ulnar
collateral ligament and the lateral ulnar collateral
ligament), the radio-humeral joint (stabilized by the radial
collateral ligament), and the proximal radio-ulnar joint,
stabilized by the annular ligament and the interosseous
membrane. The three joints of the elbow allow motion in
several dimensions: flexion, extension, pronation, and
supination (Fig. 9-1).
Figure 9-1 The capsule and ligaments give stability to the elbow.
Elbow x-rays can be difficult to read in young children as
the radial head ossification center isn’t visible until around
age 3, and the olecranon not until around 8 years in girls,
10 years in boys—fractures or physeal injury can be easily
missed on x-ray. Ultrasound is being used more commonly
for evaluation and treatment of pediatric elbow fractures as
it does not expose the child to radiation and can give a
better picture of unossified bone (Fig. 9-2). MRI
arthrogram can also better delineate fractures and
displacement around the elbow.

Figure 9-2 Lateral condyle fracture in a 5-year-old child. Ultrasound

was used to determine the amount of displacement.

In children, the proximal radial physis is intra-articular;

fractures that are bathed in synovial fluid typically take
longer to heal and may go on to non-union even if
adequately reduced. The physis is also at risk for
premature closure secondary to fracture, fracture
reduction, and/or fixation that crosses the physis.

The olecranon has an apophysis at its proximal end that

may develop chronic traction injuries in athletes. The
triceps tendon, with or without the apophysis, can be
completely avulsed with forceful triceps contraction (Fig. 9-
3).

It is also important to note that the blood supply to the

radial head is mainly from the periosteal blood vessels
running from distal to proximal—this tenuous blood supply
may be disrupted by fracture or surgical dissection, leading
to avascular necrosis (AVN), which can have a long-term
deleterious effect on elbow function and growth of the
radius. Repetitive trauma to the elbow, as is seen in
pitchers and gymnasts, can also disrupt radial head blood
supply and cause abnormal growth of the radial head and
an incongruent joint.

Figure 9-3 Triceps avulsion treated with a suture anchor.

The brachial artery, median nerve, and radial nerve

anterior to the elbow joint are at risk for stretch injury with
a proximal forearm fracture or elbow dislocation. The ulnar
nerve, running medially just behind the medial epicondyle,
may be stretched, torn, or entrapped in the joint at the time
of injury or during reduction. The posterior interosseous
nerve, coursing anterior to the radial head and
anterolateral to the radial neck, can easily be injured when
the proximal radius is fractured or dislocated (Fig. 9-4).

Figure 9-4 Cross-section at the level of the elbow.

Initial Exam
As discussed in the prior chapter, it can sometimes be
difficult to distinguish between an injured and infected
elbow in a young child. Be wary if you do not see a clear
fracture but there is a “sail sign” or fluid in the joint on x-
ray (Fig. 9-5). This may indicate an occult fracture, but the
fluid creating the sail sign may also be a sign of infection
(pus) in the joint. If there is any question, check bloodwork:
CBC, sedimentation rate, and C-reactive protein. Putting an
infected elbow in a cast for 3 weeks has resulted in
disaster.
 Figure 9-5 Anterior sail sign with no obvious fracture.

Once the area of concern is identified, a skin exam will rule

out an open fracture, with the standard neuro-vascular
exam then performed (see Chapter 8 for details). Do this
portion of the exam before you touch the elbow; if the child
starts screaming, the rest of the exam is very difficult if not
impossible (Fig. 9-6). In a relaxed child, the fracture
location can be estimated by gentle palpation and
pronation/supination of the forearm.

Because additional fractures in the same limb are common,

always check the joint above and below the area of
concern. The contralateral elbow should be examined to
determine the normal anatomy and motion for each
individual. A child who has a more cubitus valgus due to
normal anatomy or prior fracture is more likely to sustain a
proximal radius fracture whereas a child with a varus
carrying angle is more prone to lateral condyle fracture.
 Figure 9-6 Examining an injured child can be very difficult.

Radiographic Issues
Radiographs of the flexed elbow often represent
compromised views of the upper forearm and the distal
humerus (referred to as the “loser’s view” by Rang—see
Chapter 8) but are the usual starting point. Well centered
AP and lateral views of the proximal forearm and distal
humerus may be required to better identify a puzzling
fracture. Also, an accurate assessment of angulation and
shift can only be measured on films taken at right angles to
the plane of fracture angulation.

As previously discussed, a fat pad or “sail sign” may be the

only x-ray indication of a pediatric elbow fracture. The
actual location of these occult fractures is often not
determined until follow-up x-rays show callus formation.
Olecranon and radial neck fractures are the most common
occult fractures of the proximal forearm (supracondylar
fracture most common in the distal humerus).
 Figure 9-7 The radial head should point directly at the capitellum on
both the AP and lateral views.

Plastic deformation or greenstick fractures of the ulna (and

occasionally the radius) may cause a radial head
dislocation, so it is important to obtain x-rays of the entire
forearm including the wrist and elbow when there is a
forearm fracture. A line drawn down the center of the
proximal radial shaft should pass near the center of the
ossification center of the capitellum on both AP and lateral
views (Fig. 9-7); if not, the radial head is subluxed or
dislocated and must be reduced (Fig. 9-8).

PULLED ELBOW SYNDROME (NURSEMAID’S

ELBOW)
A pulled elbow is a common early childhood injury. The
clinical picture is characteristic; a child between 1 and 4
years suddenly refuses to move an arm and holds the elbow
slightly flexed with the forearm pronated. Often parents
think the arm is paralyzed or broken, and they rarely
mention that the problem began as the child was pulled
along or lifted by the wrist— the usual cause in our fast-
paced culture (Fig. 9-9). It is remarkable that all children
do not experience a pulled elbow!

Figure 9-8 Normal radial head position compared to abnormal

anterior dislocation of the radiocapitellar joint.

Salter and Zaltz found that when longitudinal traction is

applied to the arm (with the forearm in pronation) the
annular ligament partially tears at its attachment to the
radius, allowing the radius to move distally, slipping under
the annular ligament. When traction is released, the
ligament is carried up and becomes entrapped between the
radius and capitellum (Fig. 9-10). After the age of 5 years,
the attachment of the annular ligament to the neck of the
radius strengthens and prevents displacement and radial
head subluxation. Enlargement of the proximal radial
epiphysis with growth may also improve stability.

“After the typical reduction, the child

often stops crying, seems more
comfortable, and starts to move the arm
within a minute or two”

Figure 9-9 The usual mechanism of a radial head subluxation in a

fast-paced culture.

The diagnosis of nursemaid’s elbow is now well recognized

by most primary care providers and is quickly treated in
the office—rarely requiring referral to orthopedics.
However, this condition may be confused for more complex
problems. Conditions that we have had referred to our
clinic that were initially treated with multiple attempts at
reduction of a pulled elbow include

Figure 9-10 With longitudinal traction the annular ligament can

partially tear allowing the radial head to move distally.

Septic elbow
Olecranon fracture
Radial head or neck fractures
Supracondylar fracture
Septic wrist

The child with a simple pulled elbow should have no

swelling on presentation and should have immediate relief
following reduction. If there is not relief following one
attempt at reduction, another cause of elbow pain should
be sought. X-rays of a pulled elbow are usually normal, but
x-ray can rule out effusion, fracture, and true dislocation.
CBC, CRP, and ESR can help rule out infection. Once the
child is referred to orthopedics, pulled elbow should be a
diagnosis of exclusion.
 Figure 9-11 Nursemaid’s elbow reduction maneuver.

Treatment—Pulled Elbow
Fortuitous reduction can occur when the x-ray technician
supinates the arm to obtain an AP x-ray. Because the x-rays
are usually normal, you must rely on the history and your
exam to reach the diagnosis. The classic teaching is to
reduce by supinating the flexed elbow and you will feel a
click as the subluxed radial head reduces. Often the elbow
must be flexed above 90 degrees with firm supination to
achieve reduction (Fig. 9-11). There are four “low quality”
studies reviewed by Krul in the Cochrane Database of
Systematic Reviews that looked at flexion and hyper-
pronation of the pulled elbow as a less painful and more
effective reduction technique; however, better studies need
to be done before this becomes standard of care.

After the typical reduction, the child often stops crying,

seems more comfortable, and starts to move the arm within
a minute or two. No immobilization is required, but the
parents should avoid pulling the child or lifting them by the
arm for the next several years.

Recurrence is relatively common, and a child may have

repeated subluxations in the first 3-4 years of life. Repeat
injuries are treated in the same fashion as first-time
subluxations, with the problem gradually disappearing by
age 5 years; the younger the child, the greater the risk for
recurrent subluxation.

Pitfalls—Pulled Elbow
A few times a year, one is faced with a case that does not
seem to reduce despite ruling out other causes and utilizing
the correct reduction maneuver. When convinced that we
have a true unreducible nursemaid’s elbow (not an occult
septic elbow or fracture), our approach includes casting the
child in a position that technically will reduce the
subluxation (elbow flexed to 100 degrees, full supination)
for 3 weeks. This usually solves the problem.

Figure 9-12 Apparent “dislocation” with transphyseal fracture seen

on arthrogram.

There have been a few case reports in the literature of

pulled elbows that were completely irreducible with closed
means. In these cases, surgical exploration demonstrated
that the annular ligament had slipped past the equator of
the radial head and become trapped in the radiocapitellar
joint. We have no experience with such cases.

DISLOCATIONS—ELBOW JOINT
Dislocations are rare in young children, becoming more
common as they start doing more aggressive contact
sports. If the distal humerus is not yet ossified, beware—a
transphyseal fracture will look like a dislocation on x-ray. In
children under 2 years, consider non-accidental trauma and
use ultrasound or arthrogram to determine if there is a
transphyseal fracture (Fig. 9-12).

In children, elbow dislocations without a fracture are

uncommon. Whenever you encounter an elbow dislocation,
assume an associated occult fracture (which may prevent
reduction). The most common example is a medial
epicondyle fracture, which frequently becomes entrapped
in the joint (discussed in Chapter 8). The articular surface
of the ulna or radial head can also fracture and prevent
concentric reduction. A flap of articular cartilage and
subchondral bone lifted off the articular surface may be
barely perceptible on the x-ray. Crepitus and a restricted
range of motion following reduction should alert you to
possible osteochondral fragments in the joint.

“Do not mistake a transphyseal fracture

for an elbow dislocation in a young
child!”

A non-concentric reduction on x-ray should alert the

examiner to a trapped fragment, which may be cartilage in
younger children (the medial epicondyle ossifies around
age 7 years), or bone in the adolescent (Fig. 9-13).
Ultrasound, arthrogram, and MRI are useful diagnostic
tests for locating a displaced fragment that is not yet
ossified. If the fragment is ossified but it is unclear where it
came from, contralateral elbow x-ray is very useful.
 Figure 9-13 A, B. Child with elbow dislocation reduced elsewhere
and referred to us for ulnar nerve palsy. The lateral view suggests
non-concentric reduction. C, D. After open reduction, which revealed
the ulnar nerve was trapped in the joint and was blocking reduction.

More obvious fractures associated with elbow dislocation

include medial and lateral condyle, olecranon, coronoid,
and radial head/neck injuries; these are easily identified on
x-ray and are more straightforward in terms of
management.

Dislocation puts the neurovascular structures, muscles,

collateral ligaments, and capsule on extreme stretch and at
risk of injury/tearing. Reduction of a dislocated joint should
be done emergently to take tension off the soft tissues.

Classification—Elbow Dislocations
Elbow dislocations are described by the position of the
radius and ulna in relation to the distal humerus (anterior,
posterior, medial, or lateral). They are further classified
based on whether or not the proximal radio-ulnar joint
remains intact (Table 9-1). Posterolateral dislocations, by
far the most common in reported series, are thought to be
caused by a fall on the outstretched hand with the elbow
extended. Typically the radio-ulnar articulation remains
intact with only rare instances of divergent dislocation
(radius and ulna separated).
 Table 9-1 Classification—Elbow
Dislocation
Type I
Proximal radio-ulnar joint intact

Most common—posterior Can also dislocate anteriorly, laterally, or medially

Type II
Proximal radio-ulnar joint disrupted

Anteroposterior divergent
Mediolateral (transverse) divergent

Radio-ulnar translocation

Treatment—Elbow Dislocations
The dislocation should be reduced as soon as possible to
relieve pain and improve circulation. Conscious sedation
helps to relax the muscles adequately for an atraumatic
reduction. An easy method for reduction includes placing
the child prone with the elbow flexed over the edge of the
bed so that the forearm hangs vertically downward. When
the child relaxes, a little pressure over the olecranon with
correction of any sideways displacement usually reduces
the elbow (Fig. 9-14).

Figure 9-14 An elbow dislocation can be reduced by applying

traction to the forearm while simultaneously applying a force on the
proximal forearm that is aimed away from the humerus.

This is a gentle maneuver that does not require the force

required for some orthopedic reductions. Avoid
hyperextending the elbow prior to reduction as this may
further injure the brachialis and neurovascular structures
anteriorly. Immediate pain relief can be expected. If there
is no associated fracture, the elbow can be splinted or
casted for 2-3 weeks to allow soft tissue healing. Some
advocate a hinged brace set to keep range of motion with in
the “safe zone” determined at the time of reduction. This
allows immediate motion and may prevent stiffness;
however, children are notoriously good at removing braces,
so we tend to use a cast. Casting longer than 3 weeks
should be avoided as the risk of stiffness increases with
time in the cast.

Immediate post-reduction x-rays should be performed to

assess reduction and concentricity of the joint and to look
for the medial epicondyle. If the medial epicondyle is
separated and outside the joint, it can be treated by casting
alone if minimally displaced. If markedly displaced, it
should be surgically reduced and fixed within a few days. If
trapped in the joint, prompt open reduction is required. The
medial epicondyle can be fixed with suture anchors if the
fragment is small or mostly cartilage; larger bone
fragments can be fixed with K-wires or screw fixation.

Once the joint is concentrically reduced, fractures can be

treated in the standard fashion (reviewed elsewhere in this
chapter), which may include casting, closed reduction and
percutaneous pinning, or open reduction and internal
fixation.

Pitfalls—Elbow Dislocations
Do not mistake a transphyseal fracture for an elbow
dislocation in a young child! These children need to be seen
by social services and potentially child protective services
as this fracture can be caused by non-accidental trauma.

Failure to recognize an entrapped fragment in the joint can

lead to destruction of the articular cartilage, non-
concentric wear, and early osteoarthritis (Fig. 9-15). In the
rare cases of dislocation without fracture, the collateral
ligaments of the elbow may be disrupted, and even in
children this can occasionally lead to instability and require
reconstruction following bone healing (ligament
reconstruction is not done acutely as most will heal and not
cause long-term problems).

Congenital Radial Head Dislocations

This child presented to the ER after a fall on outstretched hand. He was seen
by a junior resident, and a forearm film was ordered. The child was found to
have a radial head dislocation, so elbow films were ordered. The resident
made several attempts to reduce the radial head before calling the attending
staff, who informed the resident that this was not an acute occurrence.

Nerves and vessels may be stretched and develop a

temporary palsy or spasm, but most resolve with time.
However, neurovascular entrapment following reduction
can lead to disability if not noted and treated promptly.
Entrapment of the ulnar nerve is most common with radial
and median nerve entrapment occurring occasionally. It
may be very difficult to determine if the nerve was only
stretched or if it is truly trapped in the joint. A slightly non-
concentric reduction on x-ray should alert one to the
possibility of soft tissue entrapment that requires surgical
intervention. If there is any concern, MRI is a good
diagnostic study to better evaluate the soft tissues that are
not visible on x-ray.

Figure 9-15 Elbow dislocation with non-concentric reduction due to

entrapped medial epicondyle.
Heterotopic ossification can develop in the ligaments and
capsule following injury but usually does not cause
disability. In rare cases, myositis ossificans develops in the
muscles surrounding the elbow, leading to significant loss
of joint motion.

“A slightly non-concentric reduction on

x-ray should alert one to the possibility
of soft tissue entrapment that requires
surgical intervention”

PROXIMAL RADIUS
Radial Head and Neck Fractures
The majority of radial head and neck fractures are due to a
valgus force, some associated with a posterior dislocation
of the elbow. Other fractures around the elbow are present
in nearly half of the children with displaced radial-neck
fractures; look carefully for associated olecranon, coronoid,
or distal humerus fractures. Younger children tend to
sustain radial neck fractures with radial head fractures
becoming more common in adolescents.

Because the annular ligament holds the radial metaphysis

to the shaft of the ulna, when the neck is fractured, the
displaced radial head is not only angulated but also shifted
laterally as the shaft shifts medially. Pronation and
supination depend on the relationship of the radial head to
the capitellum and ulna. Significant translation of the radial
head separates the center of rotation of the head from that
of the shaft, creating a cam-type deformity that inhibits
pronation and supination (Fig. 9-16). No available study
clarifies how much pure translation is acceptable for later
elbow function; therefore we try to minimize translation
and do not accept more than 2 mm in any direction.
The cartilaginous head of the radius fits the metaphysis like
a bottlecap. For this reason, the majority of fractures are
metaphyseal; only a few are epiphyseal separations.
Epiphyseal separations, when they occur, put the radial
head at risk for osteonecrosis as the blood supply is
disrupted (the blood supply ascends from a distal source,
similar to that of the femoral head; thus physeal fracture
has high risk for AVN). The usual level of injury through the
metaphysis is just distal to the entry of the vessels, but the
blood supply may still be disrupted with significant
displacement.
 Figure 9-16 If the radial head is not centered on the shaft, pronation
and supination will be affected.

Classification—Radial Head and Neck Fractures

Radial neck fractures can be angulated, translocated, or
completely dislocated and can be classified with the Judet
classification (Fig. 9-17).

With high-level sports and repetitive motions such as

pitching or gymnastics, stress injuries are becoming more
common. Repetitive compressive forces to the radial head
and neck may cause osteochondritis dissecans of the radial
head or capitellum, or may injure the physis, creating an
angular deformity of the radial neck (Fig. 9-18).

Figure 9-17 Judet classification for radial neck fractures. Type I: non-
displaced. Type II: less than 30 degrees angulation. Type III: 30-60
degrees angulation. Type IV: greater than 60 degrees angulation.
Treatment—Radial Head and Neck Fractures
Tilt of the radial head is better tolerated than translation.
Therefore, minimally angulated fractures (up to 30
degrees) do not need to be reduced as they will remodel
with growth. We usually protect the elbow in a long arm
cast for 3 weeks followed by encouragement of early
motion. Moderately angulated fractures (more than 30
degrees) need to be reduced; if there is still good contact
with the shaft, reductions can be done in the ED with
conscious sedation. Once there is no contact between the
radial head and shaft, reduction is better done in the OR
with general anesthesia and the ability to open the fracture
to get acceptable reduction if closed techniques are
unsuccessful.

Several published methods for closed radial head reduction

are reviewed in the following technique tips. Knowledge of
each method may save you from opening a radial neck
fracture, which increases the risk for elbow stiffness or, at
worst, AVN of the radial head. However, it should be noted
that multiple attempts at closed reduction may do more
damage than careful dissection and reduction. Although
many studies show worse outcomes with open reduction,
the fractures that are opened tend to be more severe and
often have multiple attempts at reduction prior to opening.
 Figure 9-18 Gymnasts can develop OCDs of the elbow.

If the radial head cannot be reduced to less than 30

degrees of angulation and less than 2 mm of translation, a
percutaneous pin (under image intensifier guidance) can
often be used to lever the head back on to the shaft (Fig. 9-
19). Gentle pronation and supination with direct thumb
pressure on the radial head may then improve translation.
Occasionally the radial head can be reduced to the
capitellum, but the radial shaft still sits medially preventing
normal pronation and supination. A percutaneous
technique can be used to reduce the ulnar translation of
the radial shaft to the radial head. A small incision is made
on the posterior surface of the proximal forearm at the
head of the bicipital tuberosity and a blunt tipped elevator
(“Joker”) is passed between the radius and ulna. The radius
can then be gently levered laterally while maintaining the
position of the radial head with the thumb. The reduction
may be stable or can be fixed with a percutaneous K-wire.
We have not experienced AVN or synostosis with this
technique (See Technique Tips: Radial Neck Fracture
Reduction).

Since his initial description in 1993, the Métaizeau

technique has been shown by multiple authors to be
successful at reducing and fixing radial neck fractures. A
flexible nail is inserted into the distal radius intra-
medullary canal. The nail is passed to the fracture site
proximally, and the curved tip of the nail is used to reduce
the fracture and maintain reduction. This avoids opening
the elbow, which is thought to increase the risk of stiffness
and AVN.
Figure 9-19 A K-wire or Steinmann pin can be used as a joystick for
percutaneous closed reduction.
TECHNIQUE TIPS:
Radial Neck Fracture Reduction

The Columbus (Ohio) technique. Neher and Torch have described a technique
of closed reduction that requires two people to manipulate the head back
onto the shaft. A varus force is maintained, and the radial shaft is pushed
laterally while the radial head is pushed back onto the shaft. (Drawing based
on Neher and Torch.)
An Esmarch bandage can be wrapped tightly from distal to proximal. The soft
tissues help push the radial head back into place.

A K-wire or Steinmann pin can be used as a joystick to aid in closed reduction.

The modified percutaneous technique described by Wallace utilizes a joker
between the radius and ulna to lateralize the radial shaft while the radial head
is reduced by thumb pressure or K-wire.

If attempts at closed reduction and percutaneous reduction

fail to give adequate alignment, open reduction should be
carried out because late corrective surgery for malunion of
the radial neck is very difficult and results are poor.

For open reduction, the Kocher approach is used: the elbow

joint is entered laterally between the extensor carpi ulnaris
and anconeus. The dissection is kept above the annular
ligament and the arm pronated throughout the procedure
to protect the posterior interosseous nerve.

The joint is inspected, and if any soft tissue remains

attached to the radial head, extreme caution should be
used to maintain them to protect the blood supply. The
radial head can then be manually placed on the shaft. The
annular ligament may need to be repaired. Stability should
be checked with pronation and supination while directly
visualizing the reduction.

Figure 9-20 If the reduction is found to be unstable, it can be

secured with percutaneous K-wires.

Once reduced, these fractures are often stable and do not

require internal fixation. If instability is noted
intraoperatively, one or two smooth K-wires can be inserted
from the lateral proximal radius, just lateral to the articular
cartilage, crossing the fracture and engaging the medial
metaphyseal or diaphyseal cortex (Fig. 9-20). The pin
should not enter the capitellum or fix the radiocapitellar
joint. A cast should be used to prevent motion while the pin
is in place with the pin removed early to start motion and
prevent stiffness (we recommend removing the pins at 3
weeks).

Intrarticular radial head fractures may require open

reduction and internal fixation to maintain joint congruity
(gap or intra-articular step off of more than 2 mm) CT
scans may be needed to accurately assess displacement
(Fig. 9-21A-C). The fragments need to be fixed
anatomically. Screws and/or K-wires can safely be inserted
through the safe zone described by Smith and Hotchkiss
(Fig. 9-21D).

All efforts should be made to avoid removing the radial

head. In growing children if the radial head is removed, the
radius migrates proximally, which destabilizes the distal
radio-ulnar joint and can cause wrist and elbow pain. This
is also a problem if the proximal radial physis closes
because of the injury—growth needs to be monitored
carefully.

Figure 9-21 A-D. Screws and K-wires may be necessary to fix an

intra-articular radial head fracture. These should be inserted through
“safe zone” described by Smith & Hotchkiss. (Illustration based on
Smith & Hotchkiss.)

Pitfalls—Radial Head and Neck Fractures

Stiffness is a common sequela of radial head and neck
fractures. Pronation and supination are most commonly
compromised but flexion and extension may be as well.
Therapy may help with soft tissue scarring/contracture, but
some children never regain full motion. In 1981, Morrey
described functional motion of the elbow as 30-130 degrees
of flexion, 50 degrees of pronation, and 50 degrees of
supination; however, with increasing need to use computer
keyboards and cell phones, Sardelli et al. have shown that
in today’s world, adults need more flexion and more
pronation to complete these daily tasks.
 Figure 9-22 Cubitus valgus following a left radial neck fracture with
malunion/physeal closure (proximal radius) that occurred at a young
age.

Though rare, synostosis is a hazard on occasion, even with

closed reduction. The clearance between the proximal
radius and ulna is small, and the torn periosteum may
create a bridge that allows cross union between the two
bones. Not only does synostosis block rotation, but also it
may result in cubitus valgus.

Heterotopic ossification may develop following open

reduction of radial neck fractures (often seen in the vicinity
of the biceps tendon) and correlates with loss of rotation.

Part or all of the radial head may develop AVN. Irregularity

of the head and premature closure of the growth plate may
occur. The carrying angle is often increased in children
because of premature physis closure (Fig. 9-22).

Non-union is rare but disastrous. This may be due to closed

reduction where the head is relocated upside down so that
the articular cartilage prevents healing. Even if the head is
correctly positioned, periosteal or annular ligament
interposition may prevent adequate healing.

Figure 9-23 This is a normal olecranon apophysis and should not be

confused with a fracture.

PROXIMAL ULNA—OLECRANON FRACTURES

The child’s olecranon structure differs from that of an adult
with more spongy bone, making the fracture line more
difficult to identify. The layer of articular cartilage is thick,
allowing occasional osteochondral fractures. The proximal
apophysis (appears around age 8 in girls, 10 in boys) is
often irregular and may be interpreted as a fracture (as in
many other instances, a contralateral lateral x-ray may help
clarify this) (Fig. 9-23).

Repetitive stress injuries can cause apophysitis and rarely

avulsion of the olecranon apophysis (seen in pitchers and
gymnasts). While solitary fractures of the olecranon are
seen, always look for other injuries as olecranon fractures
are commonly associated with fractures of the radial neck,
medial or lateral condyle of the humerus, and distal radius.
An isolated olecranon apophysis fracture may indicate
decreased bone quality as seen in patients with
osteogenesis imperfecta.

Classification—Olecranon Fractures
Evans and Graham presented a comprehensive
classification of pediatric olecranon fractures that outlines
all of the considerations when evaluating this type of elbow
fracture. This leads nicely into their associated treatment
algorithm (see Table 9-2).
 Table 9-2 Classification—Olecranon
Fractures in Children
(Evans MC, Graham HK. Olecranon fractures in
children: Part 1: a clinical review; Part 2: a new
classification and management algorithm. J Pediatr
Orthop. 1999;19(5):559–569)
A. Anatomic site
1. Epiphyseal (apophyseal)
a. Extra-articular, olecranon-tip fracture
b. Intra-articular
2. Physeal (Harris-Salter equivalents)
3. Metaphyseal
a. Juxtaphyseal
b. True metaphyseal
4. Combined olecranon-coronoid process injury
B. Fracture configuration: This is the angulation of the fracture line to
the long axis of the ulna in degrees
1. Transverse (<30 degrees)
2. Oblique (30-60 degrees)
3. Longitudinal (>60 degrees)
C. Intra-articular displacement
1. <2 mm displacement
2. 2-4 mm displacement
3. >4 mm displacement
D. Associated injuries (ipsilateral elbow and upper limb)
1. Radial head/neck fracture
2. Radial head dislocation/subluxation (Monteggia variant)
3. Lateral humeral condylar physeal injury
4. Medial humeral condylar physeal injury
5. Supracondylar humeral fracture
6. Distal radius/ulna fracture
Treatment—Olecranon Fractures
The majority of pediatric olecranon fractures are
nondisplaced and require only a cast. A cast in extension
will reduce the pull of the triceps. When the periosteum is
torn, the fragments may separate; therefore if the fracture
does not reduce by extending the elbow, there may be
interposed periosteum or bone fragments that require open
reduction to realign the joint surface.
 Figure 9-24 Displaced olecranon fractures are best treated with
ORIF. This shows the classic fixation with two K-wires and a tension
band.

Displaced fractures are treated with open reduction and

internal fixation. The incision should be made just lateral to
the subcutaneous border of the proximal ulna and should
stay lateral to the tip of the olecranon (avoid putting
incisions directly over any subcutaneous bone or in an area
that will frequently experience pressure). Keeping the
incision a little lateral allows a soft tissue layer between the
incision and the bony prominence of the olecranon.

Once the fracture is irrigated with any interposed bone

fragments removed, most fractures easily reduce with
elbow extension and can be held with a towel clip while
fixation is placed. The joint should be checked through a
small lateral arthrotomy to ensure a smooth joint surface
with no step offs or gaps; this also allows the joint to be
irrigated to avoid leaving loose bodies that could further
damage the articular surface. Two smooth K-wires and a
tension band wire technique provide excellent fixation of
the fracture fragments (Fig. 9-24). In young children,
suture or suture anchor is sometimes used instead of a wire
tension band; however, for older children, the strength of
suture is not adequate and they can pull the construct
apart (Fig. 9-25).

Figure 9-25 Some young children can be treated with K-wires and a
suture tension band. However, this x-ray is a good example of what
can occur if the child is stronger than the suture. The x-ray taken 1
hour later shows a 2-cm separation due to pull of the triceps. Wire
should be used in older children (larger olecranon).

For more comminuted fractures, a contoured plate and

screws often give better fixation. A 1/3 tubular plate can
easily be contoured to the olecranon, and pre-contoured
plates are available for near adult size patients (Fig. 9-26).
 Figure 9-26 A 17-year-old male with comminuted olecranon fracture
treated with a pre-contoured plate.

Pitfalls—Olecranon Fractures
Regardless of type of fixation, anatomic reduction of the
joint surface is critical. Over compression or bone loss will
create a non-congruent joint with limited range of motion.
Comminution at the joint surface or joint malreduction may
lead to early arthritis. The pull of the triceps tends to pull
olecranon fractures apart, especially if casted in flexion;
this can lead to poor motion and function because of
malreduction. There are reports of non-union, but this is
rare in children. Transient neuropraxia of the ulnar nerve
may occur secondary to irritation or stretch of the nerve. If
the fracture is treated with a cast alone, x-rays should be
checked weekly for the first 2-3 weeks to ensure proper
healing without late fracture line widening.

“The majority of pediatric olecranon

fractures are nondisplaced and require
only a cast”

PROXIMAL ULNA—CORONOID FRACTURES

The coronoid process remains cartilagenous until the age of
6 years. Most fractures of the coronoid occur in association
with elbow dislocation or are associated with other
fractures about the elbow.

Classification—Coronoid Fractures
Regan and Morrey classified coronoid process fractures
based on the size of the fragment (Table 9-3).

Treatment—Coronoid Fractures
Treatment of coronoid fractures is based on the degree of
displacement and the instability of the elbow. A CT scan
will help accurately study the injury. Type I and II fractures
in children, without associated injuries, can be treated with
casting for 3 weeks followed by early motion. Casting
should be done with the forearm supinated and the elbow
flexed to 90 degrees.
 Table 9-3 Regan and Morrey
Classification—Coronoid Fractures
Type I

Avulsion of the tip of the coronoid

Type II

A single or comminuted fragment involving 50% of the coronoid process

Type III
A single or comminuted fragment involving 50% of the coronoid process
 Table 9-4 Classification—Monteggia
Fracture/Dislocations
Type I
Radial head dislocated Anterior

Ulna-metaphysis or diaphysis
Type II
Radial head dislocated Posterior

Ulna-metaphysis or diaphysis
Type III
Radial head dislocated Lateral
Ulna-metaphysis
Type IV
Radial head dislocated Any direction

Radial and ulnar-diaphysis

Type III fractures typically cause instability of the elbow

and require fixation for stabilization. In children, suture
fixation through drill holes is typically adequate fixation if
the fragment is anatomically reduced (Fig. 9-27). Again, a
short time in a cast should be followed with early motion.
 Figure 9-27 Type III coronoid fracture partially hidden by the radial
head in this x-ray, indicated by the arrow in this fracture, resulted in
instability of the elbow and was treated with open reduction and
suture anchor fixation.

Pitfalls—Coronoid Fractures
Non-union of Type III fractures can lead to chronic elbow
instability and recurrent episodes of dislocation. This is
rare in children.

MONTEGGIA FRACTURE/DISLOCATION
Radial head dislocation is almost universally accompanied
by an ulna fracture or bow in children (Table 9-4). Giovanni
Monteggia gave his name to the injury pattern after
missing the diagnosis in a young girl in 1814. Lincoln and
Mubarak reviewed so-called isolated anterior radial head
dislocations and found that each case included a subtle
greenstick fracture or plastic deformation of the ulna,
suggesting that the term isolated radial head dislocation is
a misnomer in children. Most are actually subtle variations
of a Monteggia fracture. Straightening the ulna is
important to stability of the radio-ulnar joint because even
a slight ulnar bow can push the radial head out over time
(if not immediately) (Fig. 9-28).

Giovanni Battista Monteggia

1762-1815

Monteggia was born at Lake Maggiore, Italy. He studied in Milan where he

became professor of surgery. He is particularly remembered for his
description of the forearm fracture that he described in 1814, the same year
that Colles described his fracture.
 Figure 9-28 Subtle ulnar bow in a Monteggia fracture. There should
be no space between the ulna and the yellow line.

Confusion may arise when a child with a pre-existing

congenital dislocation falls on the elbow, which the ensuing
radiographs read as an acute injury. In puzzling cases,
examine and radiograph both elbows. The diagnosis of
congenital dislocation can be made (a) if the condition is
bilateral or (b) if unilateral, when the affected radius is
longer, the radial head misshapen, the capitellum
hypoplastic, the distal humerus grooved, and/or ossification
more advanced than on the opposite side (Fig. 9-29).
 Figure 9-29 Congenital dislocations of the radial head have a
different appearance than acute dislocation. This is a severe example;
rarely will it be so obvious.

Treatment—Monteggia Fracture/Dislocation
The three critical elements required to treat radial head
dislocations include

1. Straightening the ulna

2. Reducing the radial head
3. Minimizing forces that will re-dislocate the radial head

Even a slight ulnar bow can keep the radial head

dislocated, and therefore, the ulna needs to be corrected to
its anatomic position. Greenstick ulna fractures or an ulna
with plastic deformation can often be straightened in a
closed fashion and maintained with a cast alone; however,
this reduction may require general anesthesia as it takes a
significant amount of force to reshape a bent ulna. Perfect
alignment may require the completion of a greenstick ulna
fracture (a somewhat daunting prospect).

Experienced surgeons can often reduce and maintain

Monteggia fractures using closed methods (Fig. 9-30).
Maintaining anatomic alignment of the ulnar fracture
sometimes requires open reduction and fixation with a
plate and screws or an intramedullary pin. An ulna fracture
extending through the olecranon, disrupting the joint
surface, usually requires open reduction to restore the joint
surface plus either K-wires and a tension band or a
contoured plate and screws.
 Figure 9-30 This Monteggia fracture was treated with closed
reduction and casting. The patient went on to have complete healing
and normal motion.

The radial head is usually easily reduced once the ulna is

straight. For Type I anterior dislocations, your thumb can
be positioned directly over the radial head to guide it into
place as the elbow is pronated and supinated. Anterior
dislocations are best held reduced with a cast in flexion and
supination. Lateral and posterior dislocations tend to
require a cast in extension to maintain the reduction.

There are several case reports in the literature of

irreducible radial head dislocations that require open
reduction (reduction can be blocked by the brachialis,
biceps tendon, annular ligament, etc.); however, the
majority of pediatric radial head dislocations associated
with the Monteggia pattern can be treated with closed
methods (although the ulna fracture may have to be opened
and fixed).
TECHNIQUE TIPS:
The Missed Monteggia Fracture

Missed Monteggia with positive ulnar bow sign

Cresentic osteotomy is slid until radial head is reduced

Image depicting Freer elevator through the intact annular ligament

After plate application

Approach
One incision—lateral approach through Kocher interval
Osteotomy through extension of this incision to include the ulna
No bone graft
Annular Ligament
First try reduce into the intact annular ligament
Dilation with internal pie crusting
 If apparent that it will not reduce, then incise and repair annular
ligament around the radial neck
Prefer using the old annular ligament. If not able to retain reduction,
may add triceps fascia.
Ulnar Osteotomy
Acute correction of gradual bow in our osteotomy
Usually use crescentic osteotomy to increase bony contact
No lengthening osteotomy—just angular correction is needed
Typically do not include bone grafting
Post-operative Protocol
We apply an LAC for a total of 6 weeks
– At 6 weeks we remove the cast and start ROM
– Continue activity modification for 4-6 months based off of healing
Do not remove the plate unless the plate is prominent and causing
pain/symptoms
If we do remove the plate we wait at least 6 months prior until it is
removed

The Kocher posterolateral approach is recommended for

the rare occasions in which open reduction of the radio-
ulnar joint is needed. The forearm should be kept in
pronation during the exposure to prevent injury to the
posterior interosseous nerve. The annular ligament may
need to be repaired or reconstructed to maintain the
reduction.

Following reduction of anterior dislocations, the forearm

should be immobilized in 90-100 degrees of flexion with
near full supination to keep the radial head reduced while
the ulna fracture heals. Flexion minimizes the pull of the
biceps, which is the major deforming force in anterior
dislocations. Supination gives maximum stability to the
joint, reducing the force of the supinator muscle, which
may deform the proximal ulna. Check films are taken in 7-
10 days to confirm maintained alignment.

Pitfalls—Monteggia Fracture/Dislocation
Failing to recognize a subtle radial head dislocation can
lead to catastrophe. Late reconstruction is often difficult
with less than perfect results. For persistent
subluxation/dislocation or delayed diagnosis cases, several
operative methods have been proposed to reduce the radial
head. Bell-Tawse proposed annular ligament reconstruction
with a strip of triceps tendon. Other surgeons have used
material such as lacertus fibrosis, forearm fascia, palmaris
longis, or fascia lata to reconstruct the annular ligament.
An ulnar osteotomy with or without annular ligament
reconstruction may be necessary to keep the radial head
reduced. Motion following surgery may be limited by
stiffness. Every effort should be made to make the correct
diagnosis early. Always look at the radial-capitellar joint
first when assessing an arm or elbow x-ray!

“Failing to recognize a subtle radial

head dislocation can lead to
catastrophe”

SUMMARY
Proximal forearm fractures and dislocations can be very
complex in terms of both diagnosis and treatment. Subtle
fractures are easily missed and can lead to long-term
disability. Even in the best surgeon’s hands, many proximal
forearm fractures lead to stiffness and pain.

SUGGESTED READINGS
Braithwaite KA, Marshall KW. The skeletally immature and newly mature
throwing athlete. Radiol Clin North Am. 2016;54(5):841–855.

De Mattos CB, Ramski DE, Kushare IV, et al. Radial neck fractures in children
and adolescents: an examination of operative and nonoperative treatment and
outcomes. J Pediatr Orthop. 2016;36(1):6–12.

Eckert K, Ackermann O, Schweiger B, et al. Ultrasound evaluation of elbow

fractures in children. J Med Ultrason (2001). 2013;40(4):443–451.
Gutiérrez-de la Iglesia D, Pérez-López LM, Cabrera-González M, et al. Surgical
techniques for displaced radial neck fractures: predictive factors of functional
results. J Pediatr Orthop. 2017;37(3): 159–165.

Kozin SH, Abzug JM, Safier S, et al. Complications of pediatric elbow

dislocations and monteggia fracture-dislocations. Instr Course Lect.
2015;64:493–498.

Krul M, van der Wouden JC, van Suijlekom-Smit LWA, et al. Manipulative
interventions for reducing pulled elbow in young children. Cochrane Database
Syst Rev. 2017;(7):CD007759.

Little KJ. Elbow fractures and dislocations. Orthop Clin N Am. 2014;45:327–
340.

Metaizeau JP, Lascombes P, Lemelle JL, et al. Reduction and fixation of

displaced radial neck fractures by closed intramedullary pinning. J Pediatr
Orthop. 1993;13(3):355–360.

Morrey BF Askew LJ, Chao EY. A biomechanical study of normal functional

elbow motion. J Bone Joint Surg Am. 1981;63:872–877.

Murphy RF, Vuillermin C, Naqvi M, et al. Early outcomes of pediatric elbow

dislocation—risk factors associated with morbidity. J Pediatr Orthop. 2015.
[ePub ahead of print].

Sardelli M, Tashjian RZ, MacWilliams BA. Functional elbow range of motion for
contemporary tasks. J Bone Joint Surg Am. 2011;93(5):471–477.

Skaggs DL, Mirzayan P. The posterior fat pad sign in association with occult
fractures of the elbow in children. J Bone Joint Surg Am. 1999;81(10):1429–
1433.

Smith GR, Hotchkiss RN. Radial head and neck fractures: anatomic guidelines
for proper placement of internal fixation. J Shoulder Elbow Surg. 1996;5(2 pt
1): 113–117.

Souder CD, Roocroft JH, Edmonds EW. Significance of the lateral humeral line
for evaluating radiocapitellar alignment in children. J Pediatr Orthop.
2017;37(3):e150–e155.

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pediatric radial neck fractures. J Bone Joint Surg Am. 2013;95(20):1825–1832.
 10
Radius and Ulna

Vidyadhar Upasani
Henry Chambers
Radiographic Issues
Distal Fractures—Physeal
Distal Fractures—Above Physis
Midshaft Fractures
Remodeling
Refracture
Malunions

“Learning is not attained by chance, it

must be sought for with ardor and
attended to with diligence.”
— Abigail Adams

INTRODUCTION
Forearm fractures, especially about the wrist, are among
the most common pediatric injuries. When a child falls off a
bike, scooter, or skateboard, the upper extremity bears
most of the force, particularly the forearm and wrist,
because the arms are often used to brace one’s fall: this is
a variation of the parachute reflex (Fig. 10-1). The
parachute reflex protects the vital organs, often at the
expense of the forearm.
In many ways, these fractures are different from those of
adults:

Shattering injuries of the articular surfaces of each end of

the radius are less common.
The bones may bend or plastically deform without a
complete fracture.
Non-union is rare.
Fractures of the shafts of both bones of the forearm can
usually be managed closed, therefore requiring reduction
and casting skills.
Forearm fractures in children have remodeling potential,
which does not exist in adult forearm fractures.
 Figure 10-1 Children of every age enjoy a variety of sports. This
junior bull rider suffered bilateral distal radius fractures from this fall.
(Photo courtesy of R. Knudson.)

Anatomy and Pathology

The forearm bones are subcutaneous in the lower half of
the forearm. The quality of reduction can be appreciated,
not only by the surgeon but also by the patient when the
cast comes off.

Forearm rotation has a range of 180 degrees, perhaps the

greatest range of rotation of any joint in the body. Although
a decrease of rotation by 50% may go unnoticed for most
activities, fractures should be reduced well so that patients
will re-gain adequate rotation.
Fractures have been produced in cadavers and plated with
various types of malunion to determine the effects of each.

Ten degrees of malrotation limits rotation by 10 degrees

(Fig. 10-2).
Ten degrees of angulation limits rotation by 20 degrees
(Fig. 10-3).
Bayonet apposition does not limit rotation.
Pure narrowing of the interosseous distance is important in
proximal fractures. (Narrowing impedes rotation by causing
the bicipital tuberosity to impinge on the ulna.)
Malalignment of fractures of the ulnar metaphysis
increases the tension on the articular disc so that the head
of the ulna is not free to rotate (Fig. 10-4).
 Figure 10-2 Malrotation limits movement. Ninety degrees of
pronation deformity, as shown here, limits pronation to the
midposition, because the proximal radioulnar joint has reached the
limit.

Clinical Examination
Some injuries to the forearm are more obvious than others.
First observe the extremity to see how the child holds it
and if there is deformity. With severe deformity, the child
will be difficult to examine due to pain and/or fear. The
joints above and below the suspected site of injury are
examined to rule out other injuries. The Monteggia injury
should not be missed. Supracondylar fractures are often
seen along with a distal radius fracture.

Figure 10-3 Angulation malunion limits rotation, because the

interosseous membrane cannot widen and narrow.
 Figure 10-4 Angulation of the distal ulna prevents rotation of the
ulna.

Distal pulses, nerve function, and forearm compartment

status are noted. As always, it is important to only
document what you can confirm. Look at the forearm in its
position of displacement. You should be able to tell from
the shape of the arm how the distal fragment lies in
relation to the proximal part.

It sometimes helps if first part of the arm below the

fracture is blocked off from vision with a hand and then the
part above. If the upper part of the arm lies in supination,
and the distal part looks as if it is pronated, a simple
supination force on the hand will reduce the fracture. The
first person who sees the child has a great advantage,
because he or she are the only one who can see the limb as
it lies (Fig. 10-5). Prior vigorous splinting may make this
analysis problematic.
 Figure 10-5 Typical deformity in a forearm fracture. A fracture with
this deformity (apex dorsal, ulnar angulation) often is most easily
reduced by supination.

The skin exam is critical. Often there is a small puncture

wound where a bone end stuck through the skin and then
retracted back. The spike of bone may have pulled debris
and bacteria back inside with it. If you can visualize
subcutaneous fat or express hematoma through a puncture
hole, it should be considered an open fracture and treated
appropriately.

Despite the presence of closed fascial spaces in the

forearm, the risk of ischemic contracture is low if a well-
padded splint or split cast is used. Nerve injuries are also
rare but can occur from stretch or laceration.

RADIOGRAPHIC ISSUES
Standard AP and lateral views of the forearm are the usual
films performed when a child has a forearm injury. A
separate elbow film may be needed to evaluate the
relationship between the radial head and the capitellum
(Monteggia injury). Beware the forearm film that does not
clearly show the radial head-capitellar relationship or
because the x-ray technician has placed the name-plate
over this vital area.

Figure 10-6 A change in the diameter of the radius, the width of the
cortex, and the smooth curve of the radius indicate malrotation.

Radius
The radius is a curved bone that is pear-shaped in cross
section. Malrotation of the radius is recognized by a break
in the smooth curve of the bone and by a sudden change in
the width of the cortex (Fig. 10-6).

Angulation
Angulation that produces a volar apex or prominence is
conventionally described as volar angulation or bowing.
Some describe the distal fragment as being dorsally
displaced or tilted. If the distal fragment is tipped in the
palmar direction, a dorsal angulation is created. This is
worth stating clearly because telephone conversations
about fractures are often plagued by semantic ambiguities.

Rotation
X-rays are two-dimensional, so it is difficult to recognize
and understand rotational deformity. A supination or
pronation force causes most fractures. For example, when
a child extends the hand to break a fall, the pronated
thenar eminence hits the ground first and an immediate
supination force is applied. The radiographic appearance of
this fracture seems to be apex volar angulation, but the
displacement is usually rotational. Test this for yourself
with a strip of paper, as shown in Figure 10-7. If the
surgeon considers only the angulation and corrects it, the
rotational deformity will remain uncorrected. An apex volar
fracture is often more accurately reduced by applying a
pronation force to the hand, whereas an apex dorsal
fracture is usually better reduced with a supination force to
the hand. It may help to remember that when reducing
these fractures, the thumb is rotated toward the apex of the
deformity.

Figure 10-7 Angulation is usually associated with rotation. Use a

strip of paper to prove this yourself.

Position of Bicipital Tuberosity

The bicipital tuberosity is a good landmark for
understanding rotation. It normally lies medially when the
arm is fully supinated, posteriorly in mid-position, and
laterally in full pronation (Fig. 10-8). This method is better
applied in older children who have a more prominent
tuberosity.

Figure 10-8 The bicipital tuberosity as a guide to the rotation of the

proximal radius. If you cannot remember where the bicipital
tuberosity should be, put an ink mark on your palm at the site
indicated. The prominence of the tuberosity always points in this
direction.

In complete fractures, the rotational position of the

proximal fragment can be identified by this method to aid
in reduction. The distal fragment is lined up in the same
degree of rotation as the proximal fragment, which usually
maintains its normal position.

Application
The above theories must be applied when reducing forearm
fractures. Although useful in achieving reduction, casting
in distorted positions of rotation makes x-ray analysis
difficult. Except for extreme cases (Monteggia or Galeazzi
fractures), we apply a long arm (above elbow) cast with the
forearm in neutral rotation (after using rotational theory to
achieve reduction). Follow-up x-rays are much easier to
analyze (clear AP and lateral views).

Ultrasound Assisted Management

Point-of-care ultrasounds are gaining popularity in
assessing pediatric forearm fractures. This has been
considered as a potential alternative that avoids exposure
to ionizing radiation. A prospective, nonrandomized,
interventional diagnostic study was recently completed
demonstrating that after a short training program,
inexperienced physicians could appropriately diagnose
pediatric forearm fractures with ultrasonography. Although
this technique has been popularized by emergency
department physicians, it will likely take time to infiltrate
orthopedic offices that are more comfortable with
traditional radiographs.

DISTAL FRACTURES—PHYSEAL

Salter-Harris Type I Injuries

Type I injuries are seen in younger children, are seldom
much displaced, and are diagnosed on clinical suspicion
more than by radiographic findings (Fig. 10-9). Swelling
and tenderness at the growth plate, despite normal
radiographs, are grounds for making the diagnosis. The
radiograph may demonstrate a slight widening of the
physis. Protection for 3 weeks in a cast or removable splint
provides adequate treatment. You may consider this over-
treatment, but the entity is common, real, and painful. A
cast relieves the symptoms and stops the parents worrying.
On follow-up exam, callus formation may be seen on the
radiograph confirming the diagnosis. In general, only cases
with more severe trauma would have follow-up to rule out
occult physeal injury.

Figure 10-9 Typical SH I fracture. A. Diagram illustrating bleeding

and swelling but without displacement. B. X-ray at injury (normal). C.
Treatment—either a cast or splint (if patient is cooperative) can be
used.
Salter-Harris Type II Injuries
Type II injuries are the most common, usually associated
with posterior displacement (volar angulation) and are
frequently accompanied by a chip off the ulnar styloid (Fig.
10-10).

This angulation pattern is often referred to as a Colles type

fracture (although Colles described it in adults). For typical
volarly angulated Type II fractures, wrist flexion alone may
not maintain the reduction, because the wrist joint flexes
easily to 80 degrees before the capsule tightens enough to
exert any influence on the distal fragment. Thus, in addition
to moderate wrist flexion, three-point molding must be
optimized.

Several studies have evaluated long arm (above elbow)

versus short arm casts to manage these fractures,
demonstrating minimal differences in clinical outcome. At
our institution, a well-molded (excellent molding required—
Fig. 10-11) short arm cast is usually selected to maintain
alignment yet allow early elbow motion (if the fracture is in
the distal third of the forearm). Exceptions include severely
displaced fractures and “chubby forearms” that pre-dispose
to a cast “sliding off.”
 Figure 10-10 The typical SH II fracture of the distal radius can be
reduced with a hematoma block or conscious sedation.

Distal physeal fractures can also be seen with anterior

displacement (dorsal angulation—Smith variant) because of
a fall from a bike, scooter, etc. These Smith-variant
fractures are easily reduced by direct pressure (with
appropriate anesthesia). The reduction maneuver and
molding are reversed (from Colles pattern) when the cast is
applied (Fig. 10-12).

In 4-6 weeks, the fracture will be united and the cast can
be removed. If a reduction was performed, the child should
return to clinic in 1 week for an x-ray check to ensure
maintenance of reduction. Severe loss of reduction, up to
10 days after the original injury, is usually re-reduced
under general anesthesia. If more than 10-14 days past
injury, this re-reduction may damage the physis; thus, the
fracture is left in its mal-reduced position with hope for
remodeling. In rare cases, a late osteotomy will be
required.

Figure 10-11 Hyndman et al. studied the ratio of the cast width for
maintaining fracture reduction. The lateral diameter (A) must be
significantly less than the AP diameter (B) to maximize molding and
stability.

It is important to discuss the risks of physeal closure with

the family. We follow these children at 6 months and even 1
year after the fracture has healed to assess for premature
closure. X-rays of both wrists are taken at follow-up visits,
and if there is suspicion of early closure, a CT or MRI can
help to further evaluate possible closure.

Salter-Harris Type III and IV Injuries

Injuries that involve the joint surface are less common in
children and can be difficult to see on the radiograph. For
these injuries, the stepoff, depression, or gap at the joint
surface as well as physeal congruity are best evaluated
with a CT scan.

If significant displacement is seen (greater than 2 mm in

any direction), reduction is required to minimize joint
incongruity and risk for physeal closure. This can be
performed arthroscopically, or more typically with a dorsal
or volar incision, depending on where the joint damage is
located. Plan your incision to get maximum exposure of the
joint injury. When possible, we try to minimize internal
fixation and use percutaneous pins that are removed after
3-4 weeks, prior to starting motion. If more permanent
fixation is required to maintain the reduction, all fixations
must be countersunk (or very low profile) to prevent injury
to the tendons as they glide over the implants.
 Figure 10-12 Smith variant fractures with anterior displacement of
the distal fragment are common following falls from scooters. This is
also a Salter-Harris Type II injury.

Growth
The distal end of the radius is a classic site for growth
disturbance owing to bridging of the physis. Thus, all
physeal fractures must be followed closely. With radial
physeal closure and ulnar overgrowth, a deformity may
begin to appear (Fig. 10-13). These children should be
radiographed every 3-6 months for signs of a bony bridge
(so that prompt resection, or distal physeal closure, can be
carried out).
 Figure 10-13 Following a severe Type II injury of the right distal
radius, this patient had a physeal closure and a resulting wrist
deformity. Earlier recognition could have allowed better treatment.

DISTAL FRACTURES—ABOVE PHYSIS

Buckle or torus fractures are common and usually thought
by the family to be a sprain. When the pain persists for
several days and an x-ray is ordered, the diagnosis is
usually accompanied by guilty feelings on the part of the
parent for not bringing the child in right away. The
radiograph demonstrates a “buckle” or wrinkle in the
cortex of the radius (Fig. 10-14). Buckle fractures can be
treated either with a below-elbow cast or Velcro splint,
depending on the child’s age and activity level.
 Figure 10-14 The classic buckle fracture of distal radius is often best
noted on lateral view.

Minimally angulated fractures require casting, with either

a hematoma block or no anesthesia. Fractures that are
apex volar in angulation require a three-point flexion type
mold as shown in Figure 10-15. These should be followed in
7-10 days to assure alignment.

Fractures with apex dorsal angulation require an extension

type mold. These also should be followed within 7-10 days
(Fig. 10-16).

Also be wary of nondisplaced fractures that are complete

through the volar cortex. These fractures may tip into apex
volar angulation; therefore, a cast should be applied with a
flexion type mold. A follow-up x-ray should also be obtained
in 7-10 days. We have seen these fractures angulate in the
cast.
Figure 10-15 Fractures with volar angulation (Colles pattern) can be
reduced and maintained with a three-point mold.

Figure 10-16 For a fracture with apex dorsal angulation (Smith

pattern), an extension mold maintains the reduction.
 Complete Fracture—Distal, Both Bones
Complete distal fractures of the radius and ulna can be
challenging to manage (Fig. 10-17). Reduction may be
difficult and unstable, particularly in children under 2 years
in proximal fractures, and in those that are comminuted or
oblique. If both bones are overlapping, reduce them by
increasing the deformity as described on the following
page. Charnley analogy to re-engaging a gear is important
in understanding why the deformity must be made worse
before it can be reduced. Simple distal pull or simple
angular forces will not do.

Figure 10-17 Distal both-bone forearm fractures can be reduced by

using the method of Charnley, described on the next page.

There are several general rules to guide you:

1. Good reductions last better than poor reductions,

particularly in a well-molded cast.
2. In young children (less than 10), bayonet apposition is
adequate if rotation is correct, if the interosseous space is
preserved, and if there is no angulation.
3. Immobilize the fracture in the position in which the
alignment is correct and the reduction feels stable.
 Immobilization with the elbow in extension may be the best
position for fractures in the proximal one-third of the
forearm.
4. Minor reduction improvements can be made at 2-3 weeks
when the fracture is sticky (wedging—Fig. 10-18) or change
cast and re-manipulate.
5. Be prepared to carry out open reduction and internal
fixation, particularly in children over the age of 10 rather
than accept a poor reduction.
6. Always warn the parents (before you reduce the fracture)
that re-manipulation may be necessary later and that there
will be a bump when the cast comes off.
Figure 10-18 Loss of reduction in a both-bone forearm fracture can
be corrected with a wedge or recasting. This case was corrected by
wedging (which must be done very carefully to avoid skin necrosis).
 Closed Treatment of Forearm Fractures

John Charnley
1911-1982
John Charnley, one of the most remarkable surgical innovators of the 20th
century, is best known for his work in developing a total hip replacement for
the treatment of degenerative arthritis in adults.

Many young orthopedists do not realize the importance of Charnley’s work in

fracture treatment. After serving in World War II, Charnley returned to the
Manchester Royal Infirmary where, working with the famed Sir Harry Platt, he
developed an extensive experience in the closed treatment of fractures,
leading to his classic text The Closed Treatment of Common Fractures (see
Suggested Readings).

Fracture fragments locked

 Disengage fragments by increasing the deformity

Reduce the fracture

To reduce a fracture, the fragments must be disengaged

by recreating the injury. This can then be re-engaged in
proper alignment to assist with reduction.
(Source: Charnley J. The Closed Treatment of Common Fractures. Edinburgh: Livingstone; 1980.
[Figures reproduced with permission])

Solitary Distal Radial Fractures

The ulnar styloid is usually avulsed. It may be more difficult
to reduce a fracture of only one bone as the intact bone will
not allow the typical reduction maneuvers. Armed with
strong thumbs and awareness of the periosteal hinge, you
can usually reduce these fractures closed. If the fragments
are still in cortex-to-cortex apposition, repeat the maneuver
with more thumb pressure. Open reduction may be
required to disengage the fragments if closed reduction
fails.

Galeazzi Fracture
The classic Galeazzi fracture (Table 10-1) is a fracture of
the radius (usually at the junction of the middle and distal
thirds) with dislocation of the distal radioulnar joint and is
less common than Monteggia injury. These fracture-
dislocations are often missed because one focuses on the
distal radial fracture and ignores the subluxation or
dislocation of the distal radioulnar joint. On the other hand,
when looking too hard for these injuries, it is easy to
become confused, as a slightly oblique x-ray of a normal
wrist will make the ulna look subluxated. A trick is to look
at the ulnar styloid, and it should be pointing at the
triquetrum on all radiographic views including obliques.
Contralateral radiographs can also be helpful to assess the
distal radioulnar articulation.

Table 10-1 Classification—Galeazzi

Fractures
Type I (Most Common) Type II

Dorsal Subluxation of the Ulna Volar Subluxation of the Ulna

Supination required for reduction Pronation required for reduction

 Riccardo Galeazzi
1866-1952

Galeazzi directed the orthopedic clinic in Milan for 35 years and was a
contemporary of Monteggia. Galeazzi described a fracture of the distal radius
with subluxation of the distal radio-ulnar joint.
Italian eponyms remain among the most popular and most frequently
quoted in contemporary orthopedic discussion. Why? First, Italy has been
(and remains) a center for orthopedic ideas. In addition, Italian names have a
pleasant way of rolling off the tongue, making those who quote them seem a
bit wiser.

MIDSHAFT FRACTURES

Midshaft Greenstick Fractures

Minimally displaced fractures are very common. The
deformity may be corrected with corrective pressure while
the cast is setting. No reduction effort is made as the cast
is applied. Then, as it is setting, a smooth corrective three-
point mold is applied. Without a good mold, the bone may
slowly bend as it heals (Fig. 10-19).

Angulated greenstick fractures of the midshaft require

slight overcorrection to take the spring out of the fracture.
You will often hear a crack as the bony hinge yields. If this
is not done, the deformity may reappear in the succeeding
weeks. On the other hand, a too vigorous maneuver (big
doctor, small patient) may create more severe
displacement. In most cases, the periosteal tube is intact
and will help maintain reduction. Supination injuries are
pronated and then given a push to get rid of the anterior
angulation, at which time a crack is often heard. The cast
should be well molded to prevent further angulation.
 Figure 10-19 This both-bone forearm fracture originally appeared to
have acceptable alignment, but the arm slid up the cast resulting in
unacceptable alignment of the radius and the ulna.

Plastic Deformation
Some fractures do not appear to break any cortex yet the
arm has a bend to it. The radiographs show a bent
appearance of either or both the radius and ulna. These are
difficult injuries to treat, and in severe cases, reduction
should be performed under general anesthesia or deep
conscious sedation in the emergency department. These
fractures may not remodel, and the child can be left with an
angulated and rotated forearm. A large amount of force is
necessary to reduce these fractures, usually over a rigid
object.

Maintaining Reduction
Examine the radiograph to determine the position of the
proximal fragment (use the bicipital tuberosity as a guide).
Try to line the distal fragment up with the proximal
fragment. It is always difficult to hold the limb while the
cast is being applied and two people are required, one to
maintain the reduction and the other to apply a well-
molded cast. Holding the thumb and index finger, with
slight flexion and ulnar deviation often helps. Be very
careful not to bend the elbow during or after applying the
cast—the fiberglass will dig in and produce a sore (Fig. 10-
20).

Figure 10-20 Be careful not to bend the elbow while applying the
cast—the fiberglass will dig in and produce a sore (note arrow—cast
material “kinked” at elbow crease—resulted in skin ulceration in the
antecubital fossa).

Mold the cast well. The cast should have a straight ulnar
border, it should be compressed so the side-to-side
dimension is wider than the dorsal to volar dimension,
there should be a good interosseous mold, three-point
molding at the fracture (Fig. 10-21), and the elbow must be
at a perfect right angle. Supracondylar molding just above
the elbow should prevent the cast from telescoping up and
down the arm. It is difficult to manage all of these factors
at one time, so at least while learning, we recommend
applying the cast in 2 stages, a well-molded short arm cast
can be extended to an above elbow cast.
Formal radiographs should be obtained at the time of
reduction for subsequent comparison. Carefully analyze the
final films. Remember that the quality of reduction that is
accepted is inversely proportional to the difficulties
involved in changing it. If the position is not satisfactory,
try again. In the end, it is better to deal with the issue now
rather than in a high-volume fracture clinic next week.

Figure 10-21 The ability to provide a careful three-point mold with

the cast relatively narrow in its dorsal to volar dimension is critical to
maintenance of forearm fracture reduction.

Other Methods
Other authors advocate an alternative method of reduction
for midshaft fractures: traction is used to reduce and hold
the limb while the cast is applied. Counter traction is
provided by a padded sling around the arm. An assistant
pulls on the hand while the surgeon manipulates the bone
ends.

Finger traps attached to an IV pole can hold the fingers

(Fig. 10-22). The fracture is reduced with traction and
manipulation. The cast is then applied, and the sling is
pulled out. Some object to this method because the intact
periosteum must be stretched to allow the overlapping
ends to jump into end-to-end contact. It is like trying to
force a door shut when something is in the way of the
hinge.

A combination of the two concepts provides a nice

compromise. Finger traps optimize longitudinal traction
while deft thumbs apply an angular and rotational
correction. Clearly, time and experience will be needed for
you to develop your best method. The reduction should be
checked radiographically weekly for 2-3 weeks to see if
there is any loss of reduction.
 Figure 10-22 Finger traps can aid in reduction of forearm fractures.

When is a Closed Reduction Acceptable?

Price tells us that if the child is under 9, then 15 degrees of
angulation can be accepted. Children older than 9 should
not have more than 10 degrees of angulation. Malrotation
of 45 degrees can be accepted in children under the age of
9, whereas only 30 degrees for those older than 9 years.
Shortening is not usually a problem. It is important to
remember that the more proximal the fracture, the less
likely it is to remodel with time. Fractures near the physis
will remodel in the plane of motion, but rotational
deformities do not remodel efficiently.

Figure 10-23 K-wires can be used for intramedullary fixation in

younger children.

Open Reduction
Traditional plate fixation, commonly advised for adults, can
often be avoided in children. Semi-tubular or compression
plates require a large exposure in small arms. They may
require removal, which predisposes the child to refracture.

Most centers now use intramedullary nailing techniques

using a flexible titanium nail system (Metazeau) or
intramedullary K-wires for internal fixation in children with
open, unstable, of otherwise uncastable forearm fractures
(Figs. 10-23, 10-24).

The term “Nancy nail” is commonly used to describe

flexible nailing because the concept was studied and then
widely used and publicized by Metazeau in Nancy, France.
After widespread use in Europe, the method is now
accepted worldwide.

Figure 10-24 In older children, flexible titanium intramedullary nails

provide better fixation.

It remains controversial as to whether it is necessary to fix

both the radius and ulna in a both-bone forearm fracture.
Stability of the forearm is the key to success. If fixation of
one bone gives adequate stability for casting, you may only
need to fix one of the fractures.

Technique—Elastic (Flexible) Nailing of a Forearm

Fracture
Under general anesthesia, the fracture is evaluated under
fluoroscopic control. If there is an open fracture, the bone
ends are debrided in the standard fashion. The fractures
may be reduced, if possible. Sometimes the fracture will
need to be opened to remove entrapped muscle or
periosteum through a small incision.

Do not try to manipulate the fractures over and over again

as we have had a few cases of compartment syndrome after
multiple attempted closed reductions and IM fixation.
Typically after three failed attempts at passing the
implants, the fracture site is opened to reduce the fracture.
Occasionally, it will be difficult to reduce both bones at the
same time, and one is faced with the decision of which bone
to pin first. We usually choose the one that was most
difficult to reduce (often the radius).

Figure 10-25 Fractures at or distal to the metadiaphyseal junction

can be treated with percutaneous fixation (if unstable).

Fractures at or distal to the metadiaphyseal junction can be

treated with percutaneous K-wire fixation (Fig. 10-25) as
intramedullary fixation may cause a significant ulnar
angulation at the fracture site. These fractures are
metaphyseal and heal quickly, so percutaneous pins can be
removed after 3-4 weeks. A recent publication from Korea
demonstrated adequate results with elastic nailing of meta-
diaphyseal junction forearm fracture in adolescents but nail
introduction is difficult. In more distal fractures, it may be
necessary to place the K-wire across the physis (we haven’t
had a physeal closure yet).

Intramedullary fixation is preferred for diaphyseal

fractures. Metazeau has described a technique using
flexible titanium nails to treat diaphyseal forearm fractures;
Steinmann pins may also be used. If the child is small,
intramedullary K-wires may be used. However, diaphyseal
fractures do not do well with percutaneous K-wire fixation.
Complications such as loss of reduction after pin removal
and osteomyelitis are not uncommon with percutaneous
fixation in this area.

The starting point for a radius fracture is distal. If possible,

one should place the pin (or rod) proximal to the distal
radial physis starting on the radial side. Some physicians
use Lister tubercle on the dorsal aspect of the distal radius
as a starting point. A small incision is made carefully
looking for and protecting the superficial branch of the
radial nerve. A drill or awl just slightly larger than the pin
or rod should be used. The pin or rod should be pre-
contoured to make passage down the bone easier. The tip is
curved to bounce off the far cortex after insertion. A gentle
long C-shaped contour improves three-point contact and
reduction stability.

After the pin is across the radial fracture, the ulnar pin can
be placed. It can be placed through the proximal apophysis
or just distal to the apophysis on the lateral aspect of the
ulna. Some authors prefer to place the ulnar pin from
distally because it is easier to view under fluoroscopy. One
must put a smaller bend on the tip, as the ulnar diaphysis
intramedullary space is often fairly narrow. It is important
to bury the pin below the skin, as these fractures often take
longer to heal (especially open factures, fractures that
require open reduction, or diaphyseal fractures). The child
is then placed in a bivalved, long arm cast for 6 weeks.
TECHNIQUE TIPS:
Flexible Intramedullary Nail Fixation of
Forearm Fractures
For the radius, make a small incision on the dorsal-radial aspect of the wrist,
just proximal to the physis. Care must be taken to protect the superficial
branch of the radial nerve.

An oblique hole is made in the dorsal-radial metaphysis with a drill or awl

(only drill one cortex). Gently widen the hole so that it is near parallel to the
shaft.

A pre-bent K-wire or flexible titanium nail is passed to the fracture site. This
must be bent so that on entry, when the far cortex is encountered, the pin
bounces off the cortex and can be directed down the shaft. We recommend a
20-30 degrees bend at the tip and an additional gentle bend 1-2 cm from the
tip.

Fluoroscopy (or direct visualization if the fracture is open) is used during

fracture reduction. The bent tip of the pin can be used to aid the reduction
and the pin is passed into the proximal radius—stopping short of the physis
(usually at the level of the bicipital tuberosity). The pin is cut close to the
bone, leaving enough length to allow for later removal but not so prominent
that the skin will be tented. The skin is closed over the tip.

For the ulna, if the pin is inserted through the tip of the olecranon, one has a
straight shot down the shaft. The prominent pin, with little soft tissue
coverage, is often bothersome to the patient; a lateral starting point on the
olecranon allows the pin to be buried but requires a slight curve at the tip and
may be trickier to pass.

(Variation of technique described by Lascombes, Prevot, Ligier, et al. —see Suggested Readings)

The pins can be removed at 6 months or whenever there is

complete healing of the fractures. A recent study
demonstrated that repeat forearm fractures with retained
elastic nails can be addressed with revision elastic nailing
or plate osteosynthesis without significant difficulty.

REMODELING
Children’s forearm fractures have an amazing capacity to
improve their radiographic appearance with the passing of
time (Figs. 10-26, 10-27). Friberg has shown that fractures
at the distal end of the radius will correct at a rate of about
1 degree per month or 10 degrees a year as a result of
epiphyseal realignment. But diaphyseal malunion is
unforgiving. The bone may round off on radiographs so that
the site of the fracture disappears, but the arm looks just as
crooked and lacks just as much rotation as when the cast
was removed. This should be described as “rounding off”
rather than “remodeling.”
 Figure 10-26 John Poland’s classic 1896 text included this illustration
of a boy whose fracture remodeled (pre x-ray era).

A few rules may help:

1. Only crude predictions can be made about remodeling.

2. Perfect function can only be promised when the fracture
remains perfectly aligned.
3. Bayonet alignment or overlapping may be unstable but can
be compatible with acceptable alignment.
4. Realignment of a malunited fracture occurs as a result of
epiphyseal growth. The malunion does not straighten. For
every 10 degrees of metaphyseal malunion, a year’s
growth should lie ahead for correction.
5. Diaphyseal malunion that blocks more than 50% of rotation
and looks ugly should be treated by osteoclasis, not benign
neglect.
 Figure 10-27 Distal fractures with residual angulation have good
potential for remodeling if the patient has remaining growth.

REFRACTURE
A small proportion refracture within a few months. They
are more difficult to manipulate and may require general
anesthesia to achieve reduction (Fig. 10-28). Late
refracture (up to 1 year post injury) may be seen. One can
try a protective splint post-casting, but it is rarely used for
more than a few weeks. The risk for re-fracture must be
explained to the family so that the responsibility for
guarded activity is theirs.

Price has noted that late re-fractures are more common

when the initial reduction is less adequate with residual
angulation. The physically dynamic patient requires the
most perfect reduction.
 Figure 10-28 Forearm fractures that heal with residual deformity are
at high risk of refracture.

MALUNIONS
Fractures of the forearm and wrist are the most common
injuries in childhood. Although the majority are easily
treated, the occasional case will be underestimated or the
patient will miss follow-up appointments and return with
poor result.
 Figure 10-29 Malunions with resultant loss of function are best
treated with osteoclasis or osteotomy and internal fixation.

So what should you do with the child who presents with

malunion a few weeks after the cast has been removed at
Elsewhere General Hospital? Angular deformity at the
distal end in a young child always improves. Rotational
deformity at the distal end, midshaft deformity, and
deformities in teenagers do not remodel well. It does not
help to send these individuals away with reassuring words.
They must either accept what they have or be corrected.
The parents have already been disappointed once. The
choice of correction lies between:

1. Manual Osteoclasis. Don’t try this. The bone will break at a

distance from the malunion and leave you with a dog-
legged arm.
2. Drill Osteoclasis. This is often the method of choice. Make a
5 mm incision over the malunion. Use a drill guide or a
trocar to protect the soft tissues as you make several holes
in the bone with a powered drill. Drill both the radius and
ulna, keeping away from the nerves. Crack the bone and
immobilize it in a cast, sometimes with the elbow in
extension. Take x-ray films frequently.
3. Osteotomy and plating (Fig. 10-29). Trading a scar for a
deformity is a basic tenet of orthopedics. The cosmetic
disadvantage has lead us to avoid plating in primary
fracture treatment, but it is the most exact method.
Intramedullary fixation is usually not selected for such
cases because maintenance of reduction in an impending
mal-union requires the stability of plate fixation.

SUMMARY
Most forearm and distal radius/ulna fractures can be
treated in a closed manner. Forearm fractures in children
require reduction and casting skills as nowhere else in the
body. It is important to study and understand the
mechanics of fractures and their reduction. These fractures
also need to be followed closely as they may drift in the
cast and cause significant deformity with decreased
function.

SUGGESTED READINGS
Bohm ER, Bubbar V, Yong Hing K, et al. Above and below-the-elbow plaster
casts for distal forearm fractures in children. A randomized controlled trial.
J Bone Joint Surg Am. 2006;88(1):1–8.

Dietz JF, Bae DS, Reiff E, et al. Single bone intramedullary fixation of the ulna
in pediatric both bone forearm fractures: analysis of short-term clinical and
radiographic results. J Pediatr Orthop. 2010;30(5):420–424.

Kelly BA, Shore BJ, Bae DS, et al. Pediatric forearm fractures with in situ
intramedullary implants. J Child Orthop. 2016;10(4):321–327.

Kim BS, Lee YS, Park SY, et al. Flexible intramedullary nailing of forearm
fractures at the distal metadiaphyseal junction in adolescents. Clin Orthop
Surg. 2017;9(1):101–108.

Labronici PJ, Ferreira LT, Dos Santos Filho FC, et al. Objective assessment of
plaster cast quality in pediatric distal forearm fractures: is there an optimal
index? Injury. 2017;48(2):552–556.

Lascombes P, Prevot J, Ligier J, et al. Elastic stable intramedullary nailing in

forearm fractures in children: 85 cases. J Pediatr Orthop. 1990;10(2):167–171.

Price CT, Scott DS, Kurzner ME, et al. Malunited forearm fractures in children.
J Pediatr Orthop. 1990;10:705–712.

Reinhardt KR, Feldman DS, Green DW, et al. Comparison of intramedullary

nailing to plating for both-bone forearm fractures in older children. J Pediatr
Orthop. 2008;28(4):403–409.

Rowlands R, Rippey J, Tie S, et al. Bedside ultrasound vs X-ray for the diagnosis
of forearm fractures in children. J Emerg Med. 2017;52(2):208–215.

Shoemaker SD, Comstock CP, Mubarak SJ, et al. Intramedullary Kirschner wire
fixation of open or unstable forearm fractures in children. J Pediatr Orthop.
1999;19:329–337.
Webb GR, Galpin RD, Armstrong DG. Comparison of short and long arm plaster
casts for displaced fractures in the distal third of the forearm in children. J
Bone Joint Surg Am. 2006;88(1):9–17.

Yuan PS, Pring ME, Gaynor TP, et al. Compartment syndrome following
intramedullary fixation of pediatric forearm fractures. J Pediatr Orthop.
2004;24(4):370–375.
 11
Hand

C. Douglas Wallace
Vidyadhar Upasani
Physical Evaluation
Radiographs/Imaging
Initial Management
Individual Injuries
Phalangeal Fractures
Intra-articular Fractures
Metacarpal Fractures
Thumb Injuries
Carpal Injuries
Crush Injuries—Digits
Nerve and Tendon Injuries

“Most people would succeed in small

things, if they were not troubled with
great ambitions”
— Henry Wadsworth Longfellow

INTRODUCTION
Hand injuries in the pediatric population frequently lead to
an emergency department (ED) visit for evaluation and
management. The mechanisms vary from the proverbial fall
on an outstretched hand to torsional injuries of the digits in
sports, crush injuries from children dropping heavy objects
on their own or others’ hands, plus a myriad of other
causes from the vigorous lifestyle of a normal, active child.

Because of the intricate nature of hand function, attention

to detail is required, and there is debate as to which of
these injuries a “pediatric hand specialist” should manage.
Children are well known for their ability to remodel
fractures that have healed with some angulation. Pediatric
hand fractures are no exception to this; however, certain
limitations exist in the remodeling capacity of a pediatric
hand injury. Similar to forearm fractures, hand fractures
that occur close to a physis have substantially greater
ability to remodel than do those that occur distant to the
physis.

While angular malalignment directly adjacent to a

phalangeal physis may be well tolerated, malalignment
distally in the same phalanx may lead to permanent
deformity and dysfunction. Malrotation has not been
demonstrated to remodel in hand injuries.

This chapter will present only the most common children’s

hand fractures. Many specialized texts are available for
more complex injuries.
 Figure 11-1 Angular malalignment is usually easy to detect with the
digits extended. This patient has a fracture of the little finger proximal
phalanx.

PHYSICAL EVALUATION
Evaluation of a child’s hand injury can be challenging
because children in general fear strangers, particularly
those in white coats. A child with a painful hand injury can
be extraordinarily uncooperative and difficult to evaluate.
Nonetheless, the responsibility falls on the treating
physician to evaluate the child’s hand for important
characteristics that can be gleaned from careful
observation of the child’s hand with minimal contact.

One should look closely at the child’s digits for evidence of

rotatory or angular malalignment (Fig. 11-1). This can
occasionally be seen with observation alone. More accurate
assessments can be made by combining observation with
gentle manipulation of the hand to study the functional
alignment of each joint within the hand. Specific
observation of the rotation of the nail beds with the digits
both extended and flexed aid in determining rotatory
problems.

Angular malalignment is usually easiest to detect with the

digits in an extended position; however, on occasion the
swelling in juxtaarticular fractures can either mask or
create an angular deformity.

When palpating the digits for tenderness, the examiner

should consider the structures that pass beneath the skin
and their potential for underlying damage. Vascular
assessments, specifically the digital Allen test, are more
practical for the older, more cooperative child. Certainly,
capillary refill and digital color can be readily evaluated,
even in a young, screaming child.

Common Abbreviations Used by Hand Surgeons

IP = interphalangeal (finger)
PIP = proximal interphalangeal (finger)
DIP = distal interphalangeal (finger)
MP = metacarpal-phalangeal
CMC = carpal-metacarpal joint
TFCC = triangular fibrocartilage complex (at distal radioulnar joint)
 Figure 11-2 Standard AP, lateral, and oblique plain films are
generally adequate to assess hand injuries.

Neurologic function of an acutely injured digit is difficult to

assess, particularly in the uncooperative child. Sharp/dull
discrimination and two-point discrimination becomes a
reasonable measurement of nerve function beginning at
approximately age 5 years. In younger patients, pin prick
can be used as a gross measure of sensation, though it does
not engender trust of the doctor.
 Figure 11-3 Properly positioned ulnar gutter splint. When
immobilizing the hand, ideally the MP joints should be flexed and the
IP joints extended to avoid contracture of the intrinsic muscle. This is
not so important in children, who rarely get stiff.

RADIOGRAPHS/IMAGING
Standard AP and lateral plain films (plus obliques as
needed) are generally adequate to assess hand injuries
(Fig. 11-2). Oblique views are very helpful to assess carpal
and metacarpal fractures. In the presence of tenderness in
the anatomic snuffbox, a more detailed evaluation of the
scaphoid is warranted and a scaphoid oblique should be
obtained. In cases of ulnar-sided wrist pain, one can
consider an intra-articular contrast MRI in an attempt to
elucidate injury to the TFCC and interosseous ligaments.
INITIAL MANAGEMENT
Following examination and initial imaging studies,
definitive versus temporizing treatment should be
determined and implemented. When immobilizing IP joints,
full extension is the preferred position (unless there are
reasons in regard to correcting an angular or rotatory
deformity to position the digits otherwise). The
metacarpophalangeal joints should be immobilized in
flexion to put the collateral ligaments on stretch and speed
recovery of their flexion/extension (Fig. 11-3). If the nature
of the injury precludes this position, then the bony injury
should be managed primarily with the attention to soft
tissue tensions as a secondary consideration. When
immobilizing a child with a suspected scaphoid injury, a
thumb spica component should be added to the
immobilization device (usually cast—occasionally splint).

INDIVIDUAL INJURIES
The vast majority of pediatric hand fractures can be treated
non-operatively. Injuries frequently requiring surgical
intervention include mallet finger deformities with loss of
articular congruity, phalangeal neck fractures with
extension or malrotation, intra-articular fractures of the IP
joints, and a more generic set of fractures that occur
secondary to a crush injury.
 Figure 11-4 Classic Salter-Harris III type fracture, which leads to a
mallet finger if left untreated. This child was treated with the dorsal
“suspension” splint method.

PHALANGEAL FRACTURES
Distal Phalangeal Fractures
Tuft fractures are frequent, and the vast majority requires
solely symptomatic treatment with protection and splinting
for several weeks to allow early healing of the soft tissue
and osseous damage. The patients may return to activities
when comfortable. Follow-up radiographs are generally not
required and can in fact be worrisome as they often
demonstrate fibrous union of the tuft injury.

Mallet Finger
The pediatric mallet finger (named mallet because of its
appearance if not treated) is important to recognize
because of potential long-term disability from missed
injuries (Fig. 11-4). The mallet finger generally occurs from
a jamming-type injury, axially loading the DIP joint.
There may or may not be a fracture involved. Classically, in
the pediatric population this involves the Salter-Harris III
type injury in which the extensor mechanism is attached to
the epiphyseal fragment that displaces dorsally. Although
this is the most frequent etiology of the juvenile mallet
finger deformity, these can also be due to terminal tendon
disruption with a negative radiograph.

Figure 11-5 Operative intervention is warranted when joint congruity

is lost.

Management of the mallet finger involves extension

splinting across solely the DIP joint. It is important to
assure maintenance of congruity of the DIP joint on the
lateral view. In cases in which the distal phalanx migrates
volarly with loss of the articular congruity with the distal
aspect of the middle phalanx, operative intervention is
warranted (Fig. 11-5). The degree of displacement of the
dorsal fragment in general is not the indication for surgical
intervention. Articular congruity is the more important
indication.
It is also important to stress that splinting should be in
extension, but not hyperextension. Generally, a dorsally
placed splint that extends from the PIP joint to a point
distal to the tip of the finger held on with tape produces
adequate immobilization. Minimal extension may be added
to the splint. A perfect lateral radiograph centered on the
DIP joint should be obtained to evaluate articular
congruity. The splint can be adjusted as necessary to
provide the best closed alignment. With preserved articular
congruity, 6 weeks of uninterrupted splinting should be
adequate to treat this injury.
 Suspension Taping Method for Mallet Finger
Treatment

The longitudinal taping “suspension taping” method of dorsal splinting to

treat a mallet finger.

Modified from Lester B, et al. (see Suggested Readings). Note that Lester
advised leaving the PIP joint free—in children (hand is smaller) we usually
incorporate the PIP joint as well to be sure the splint doesn’t slide off.

At the termination of immobilization at 6 weeks, the splint

can be worn while the child is active for an additional 1-2
weeks, but taken off for bathing and sleeping purposes to
allow gentle reintroduction of motion to the DIP joint.

Indications for surgical intervention in a mallet finger

include volar subluxation of the distal phalangeal fragment.
With loss of articular congruity, long-term function of the
joint cannot be assured. Therefore, closed versus open
reduction and pin fixation is warranted in this instance. A
caveat exists in patients with hyperextensible PIP joints.
They are at risk for developing swan-neck deformity of the
digit due to overpull of the central slip with either a bony or
soft tissue mallet injury. Evidence of early asymmetric
swan-neck appearance of the digit may warrant early
surgical management even in cases with maintenance of
articular congruity.

In addition to this, a Salter-Harris I versus II fracture of the

base of the distal phalanx (Seymour fracture) with
significant angulation will have the appearance of a typical
mallet finger deformity but can be associated with a nail
bed disruption and open injury. In these instances, the
fingertip droops with bleeding from the eponychial fold.
Radiographs typically demonstrate an intact epiphysis;
however, the metaphyseal component is angulated.
Treatment includes recreating the deformity for exposure,
irrigation and debridement of any foreign material from the
fracture site, careful reduction of the nail back into the
eponychial fold, and fracture reduction, often with K-wire
fixation across the DIP joint. This procedure can be
performed under a digital block in the ED; however, we
often take younger patients to the operating room.
 Figure 11-6 Kirner deformity—This congenital deformity of the distal
phalanx of the 5th finger can be confused with a fracture.

A congenital deformity that can mimic a mallet deformity

and present as such is called a Kirner deformity. A Kirner
deformity of the distal phalanx is formed in a hooked
configuration, which gives the finger the appearance of a
drooping tip (Fig. 11-6). This has been known to be
overlooked until the child has an injury to the digit, the
parent’s attention focuses on this, and they are brought in
for evaluation of the finger injury. A lateral radiograph
generally will establish the diagnosis because of the
characteristic curved growth pattern of the distal phalanx.
 Figure 11-7 Angulated and unstable phalangeal neck fracture
requiring reduction plus percutaneous K-wire fixation.

Phalangeal Neck Fractures

The pediatric phalangeal neck fracture can be a diagnostic
dilemma in a very young child. In general, these injuries
tend to have the distal fragment pushed into an extended
position (with apex volar angulation). In the older child,
this is obvious on x-ray because the volar subcondylar fossa
has been obliterated by the extension and dorsal
translation of the condyles. In the young child with
nonossified condyles, it can be extremely difficult to detect.
The only indication may be a swollen IP joint with some
malalignment of the phalangeal shafts, which is visible on
plain films. Even then, it may not be apparent on plain
radiographs.

Management of these injuries often entails reduction and

pin fixation with cross K-wires (Fig. 11-7). The key is to
restore adequate flexion to the digit. As the distal condylar
fragment extends, the fossa into which the articulating
phalanx should enter disappears. A resultant loss of flexion
with abutment of the base of the next phalanx on the neck
of the more proximal phalanx can result in a permanent
loss of flexion. While children can remodel a portion of this
deformity over time, it may be necessary in cases of
delayed diagnosis to perform an osteoplasty to recreate a
phalangeal neck volar fossa to allow flexion of the IP joint.
The key is to catch this when the fracture is fresh, reduce
the extension with direct pressure and/or flexion, and cross
pin the condyles into position.

Figure 11-8 Assessment of fingernails with digits extended suggests

malrotation of the ring finger.
 Figure 11-9 Drawing dots on the palm at the point where the flexed
fingertips reach the palm helps to detect malrotation. The left hand is
normal. The ring finger is malrotated in the right hand.

In addition to extension deformities, translation and

angular deformities can also be seen with phalangeal neck
fractures. A phalangeal neck fracture with mild angulation
can often be reduced under digital block anesthesia and
with careful taping to the adjacent digit, hold the fracture
in a corrected position that is reasonably stable, allowing
closed treatment. If this proves inadequate, pin fixation can
be added to manage the injury.

“Rotatory malalignment must be treated

to prevent permanent deformity”

Phalangeal Shaft Fractures

Phalangeal shaft fractures are common in adolescents who
are involved in more vigorous sporting activities. These
patients must be evaluated for rotatory and angular
malalignment. Again, special attention paid to alignment of
the fingernails with fingers extended is helpful in
determining rotatory alignment (Fig. 11-8).

In addition to this, careful closing of each individual digit

should show a consistent pattern of the finger aiming
toward the scaphoid tubercle volarly. One can place a dot
in the palm at the center of the nail on the uninjured hand
to show the normal alignment, then flex the fingers of the
injured hand individually placing a dot at the center of the
nail on the palm to indicate the rotatory alignment of the
digits (Fig. 11-9). Rotatory malalignment must be treated
to prevent permanent deformity.

Proximal Phalangeal Fractures

A fracture at the base of the small finger proximal phalanx,
which results in excessive abduction of the digit, is known
as an “extra-octave” fracture (Fig. 11-10). These are
usually Salter-Harris II fractures, which can be managed
simply with digital anesthesia block and gentle reduction
consisting of flexion at the metacarpophalangeal joint with
concomitant adduction of the small finger toward and
under the ring finger. Placing a pencil between the ring
and small fingers provides an efficient fulcrum (Fig. 11-11).
Placing the MP joint in flexion tensions the collateral
ligaments, which allows reduction of the shaft to near
anatomic reduction. This can be immobilized in intrinsic
plus position with the involved digit and the adjacent digit
carefully protected in a cast. Radiographs are difficult to
interpret 1 or 2 weeks out, especially in the cast, so if a
persistent or recurrent deformity is identified after 4 weeks
of casting, the child may require osteoclasis and pinning or
delayed osteotomy in the operating room.
Figure 11-10 The so-called extra-octave fracture of the 5th finger.
Left untreated, the child could have a greater hand span at the piano.
 Intrinsic Plus and Position of Function

Intrinsic Plus
The wrist is held at approximately 10 degrees less than maximum extension.
The MCP joints are in flexion, and the IP joints are in full extension.
 Position of Function
The wrist is held at approximately 30 degrees extension. The MCP joints are
held at approximately 50 degrees of flexion, and the IP joints are in 10-30
degrees of flexion.

Figure 11-11 Placing a pencil between the ring and 5th finger and
then applying a brisk adduction force to the small finger provides
efficient reduction of an “extra-octave” fracture.
INTRA-ARTICULAR FRACTURES
Another fracture requiring special attention is the
phalangeal intracondylar-intra-articular fracture. Minimal
depression of phalangeal condyle will result in obvious
angular deformity as well as possible premature joint
degeneration due to incongruity of the joint surfaces.
Anatomic reduction of the joint surface is critical for proper
management of these injuries. Even a millimeter of
displacement can lead to angulation and some degree of
loss of ultimate function.

In fresh injuries, reduction can be accomplished with a

digital block, use of ligamentotaxis for reduction of the
fracture, and pin fixation utilizing smooth K-wires (Fig. 11-
12). In a cooperative adolescent patient, this can be done
with local anesthesia in the clinic/small procedure room
setting, using a portable fluoroscopy imaging device. A
battery-operated pin driver is an excellent tool for simple
management of these fractures.

If anatomic reduction is not attainable in a closed setting,

then open reduction with as anatomic as possible
restoration of the joint surface is indicated. The K-wire
fixation used in the vast majority of phalangeal fractures
should be left in place 4-6 weeks, followed by a gentle
motion program.
 Figure 11-12 Intra-articular phalangeal condyle fracture. Treatment
by closed reduction and percutaneous K-wire fixation.

METACARPAL FRACTURES
Metacarpal fractures can occur at the head and neck
region, shaft, or base, similar to phalangeal fractures. The
most common metacarpal neck fracture involves the distal
end of the small finger metacarpal (Fig. 11-13). This is
commonly called a boxer’s fracture, although in the modern
world it seems more commonly due to punching a wall
rather then punching a human (“normal” adolescent
frustration).

While significant angulation can be tolerated in this region

because of the mobility at the base of the small finger,
metacarpal reduction is often indicated to improve
alignment and minimize the need for remodeling. Be aware
that a moderately angulated metacarpal neck fracture, with
longitudinal growth over the years, may become an
angulated diaphyseal deformity. The general guidelines for
management of adult metacarpal neck fracture, as a rough
rule can also be applied to children (Table 11-1).

Figure 11-13 Typical 5th metacarpal (boxer’s) fracture in an

adolescent. This injury occurred when the child punched a door.
Metacarpal shaft fractures occur more commonly with
torsional injuries and are often seen in contact sports when
players collide with an oblique blow that is transmitted to
the metacarpal shaft. These tend to be spiral fractures.

Alignment is key, and assessment of alignment should be

performed with the digits both extended and flexed at the
metacarpophalangeal joint. In theory, metacarpophalangeal
joint flexion to the intrinsic plus position should maintain
rotational alignment of the fracture (Fig. 11-14). In those
instances, controlling anterior/posterior angulation is all
that should be necessary with reduction and casting. Hand-
based thermoplastic splints have been found to result in
improved early range of motion and grip strength in a
prospective randomized trial.
Figure 11-14 This 4th metacarpal fracture was treated with closed
reduction and casting.
 Table 11-1 Guide for the Treatment of a
“Boxer’s” Fracture
(as measured from an oblique hand x-ray)
Normal

0-30 Degrees Angulation

Cast only
30-50 Degrees Angulation

Inject local—attempt reduction

>50 Degrees Angulation

Concerted effort to reduce

Open reduction and internal fixation are rarely indicated
with the exception of poor rotatory control, entrapment of
the extensor mechanism of the fracture spike, and inability
to control alignment, particularly in a transverse fracture
(Fig. 11-15).

Figure 11-15 Fracture of both the 4th and 5th metacarpals in a

teenage male. Fracture reduction could not be maintained; therefore
open reduction plus internal fixation was performed.

Several metacarpal base fractures are of note in the hand.

The small finger metacarpal may sustain a fracture
dislocation at the carpometacarpal level. These may be
treated with reduction and immobilization if the reduction
is stable. If not, they require closed versus open reduction
with pin fixation across the CMC joint, and potentially
between the metacarpals as well to maintain length and
rotational control.
In some instances, intra-articular comminution is present at
the base of the small finger metacarpal. The degree of
comminution may be difficult to assess without the
assistance of a CT scan for both severity assessment as well
as preoperative planning (if necessary).

THUMB INJURIES
Several injuries are unique to the thumb metacarpal and/or
have enough attention paid to them to warrant separate
discussion.

Base of Thumb Metacarpal

Injuries to the thumb carpometacarpal region occur in
children as well as in adults. Bennett fractures (intra-
articular fracture of the CMC joint) tend to occur in the
adolescent to young adult population. These require
treatment similar to that in adults to stabilize the CMC
level with accurate closed, occasionally open reduction and
pin fixation.

Extra-articular fractures are more common. These tend to

occur in younger children as a Salter-Harris II versus
metaphyseal injury. While some remodeling is possible, an
accurate reduction is optimal. Often, this can be obtained
with a local anesthesia block, and gentle manipulation
consisting of traction with direct pressure volarly over the
apex of the deformity with support under the
metacarpophalangeal joint (Fig. 11-16). Care must be taken
not to hyperextend the metacarpophalangeal joint in the
process.
 Figure 11-16 Base of metacarpal thumb fracture with moderate
angulation; the joint was not involved. Slight reduction was gained,
and the final result was satisfactory.

A thumb spica cast with careful molding to hold the

position of the fragments is applied. In the cases of severity
deformity, loss of reduction, or inability to attain adequate
reduction, pin fixation should be performed. Generally, this
can be performed percutaneously.

Gamekeeper’s Thumb
Metacarpophalangeal joint injuries, relatively common in
the teenage population, are often associated with contact
sports. A bony or soft tissue gamekeeper lesion can occur
in this group. The diagnostic dilemmas in the adult
population are also seen in the young adult/adolescent
population. When tenderness is identified at the
metacarpophalangeal joint level of the thumb, radiographs
should be obtained prior to stressing the ligaments because
a bony gamekeeper lesion may be present and further
displacement of the fragment should be avoided. Surgical
criteria are similar to those in the adult population.
Accurate reduction of the volar/ulnar portion of the
proximal phalanx of the thumb is important for ligamentous
stability (Fig. 11-17).

Figure 11-17 This teenager sustained a gamekeeper’s thumb and

was treated surgically.

Dislocations
Metacarpophalangeal joint dislocations are reported in the
pediatric population. The proximal phalanx usually
displaces dorsally on the metacarpal head and neck region.
There are both reducible and irreducible forms.

In general, the more easily reducible form demonstrates

hyperextension at the metacarpophalangeal joint with mild
proximal migration of the base of the proximal phalanx on
the dorsum of the metacarpal. Dislocations less amenable
to closed management also tend to be dislocated dorsally;
however the phalanx and metacarpal shafts are colinear.
When reducing a metacarpophalangeal joint dislocation
(after obtaining radiographs to rule out fracture
component), one must be careful to not distract the
metacarpophalangeal joint. Rather than distraction, the
reduction maneuver entails gentle translation of the base of
the proximal phalanx along the dorsum of the metacarpal
head and neck region to bring it back onto the distal aspect
of the metacarpal (Fig. 11-18). By preventing distraction,
one may avoid entrapping the volar plate between the
metacarpal and proximal phalanx. Immobilization should be
with the metacarpophalangeal joint in a gently flexed
position for approximately 4 weeks. Occupational therapy is
often necessary to regain motion in this joint.

Figure 11-18 Typical thumb MP joint dislocation. A translational force

(not distraction) allowed closed reduction.

CARPAL INJURIES
Scaphoid (carpal navicular) fractures are often seen in
vigorous, athletic, adolescent males and occasionally in
females. This is generally from sport or fall on an
outstretched hand. Not uncommonly, there is a delay in
presentation, particularly if the child is hesitant to report
the injury to the family.

The Boat-Shaped Bone

A navicular bone (shaped like a boat—from Latin navis = ship, navicular =

small boat, skiff) is found in both the hand and the foot. Rather than requiring
one to clarify the hand navicular as “carpal” navicular, most use the term
scaphoid (from Greek—scapho = something dug or scooped out).

At presentation, the classic tenderness in the anatomic

snuffbox region (Fig. 11-19) should be evaluated. AP,
lateral, and scaphoid oblique views are helpful to clarify the
diagnosis. Scaphoid waist fractures certainly occur in the
older child and adolescent population. In addition, distal
pole fractures are more common than in adults.
 Figure 11-19 The so-called anatomic snuffbox is formed by the
extensor and abductor tendons of the thumb. The scaphoid bone lies
just under the center of the triangle. A patient with a scaphoid
fracture will likely be very tender in this area.

Distal pole fractures can be treated in a below-elbow thumb

spica cast for approximately 6-8 weeks and then gentle
return to activities.

Waist fractures are a bit more precarious (Fig. 11-20). If

there is no displacement, the injury appears stable, and
swelling is mild to moderate, an above-elbow thumb spica
cast can be applied for 4 weeks followed by radiographs,
then recasting for an additional 4 weeks in a below elbow
thumb spica. If there is minimal displacement or a question
of stability, a long arm thumb spica cast should be applied
for the first 6 weeks followed by a short arm thumb spica
cast for an additional 4 weeks. The ability of the child to
cooperate with their care and anticipated activity level can
enter into considerations of length of immobilization.
 Figure 11-20 Delayed union—scaphoid waist fracture in a 17-year-
old.

In cases of delayed presentation, the scaphoid fracture

anatomy is critical in determining treatment. Despite
having mild to moderate cystic changes in a scaphoid
fracture in a teenager, closed management can be
successful with a nondisplaced scaphoid nonunion.

A CT scan is helpful in determining the anatomy of the

scaphoid to look for a humpback or flexion deformity. If the
osseous alignment appears appropriate, a course of closed
management can be attempted prior to considering open
management.
 Figure 11-21 This teenager had a serious fall in sports with a
scaphoid fracture plus carpal dislocation. Treatment included open
reduction, stabilization of the dislocation with K-wires, and fixation of
the scaphoid fracture with a screw.

Surgical treatment is indicated for a delayed union that

shows no evidence of healing, a displaced scaphoid
fracture, and a scaphoid fracture that are associated with
carpal instability/ligament injuries (Fig. 11-21). The
current method of choice for fixation of scaphoid fractures
appear to be a variable pitch screw that provides
compression as the screw is placed. This can be a
cylindrical or tapered design. In cases in which there is
delay in presentation and collapse of the scaphoid, bone
grafting may be necessary to restore scaphoid anatomy.
This can be obtained from the iliac crest or the distal radius
deep to the pronator quadratus with care to avoid injury to
the distal radial physis. Even in the adult population, the
role of vascularized grafts is in question.

Ligament Injuries
Although scapho-lunate injuries are not impossible, they
are exceedingly rare in children. On the other hand,
injuries such as the transscaphoid perilunate dislocation
have been reported in this age range.

On rare occasions, in conjunction with other injuries of the

distal radius or wrist region, ulna-sided wrist pain
develops. This can be related to an ulnar styloid nonunion,
though complaints from this are rare.
Triangular fibrocartilaginous complex (TFCC) injuries
occur in older children. In cases of ulna-sided wrist pain
with an unclear diagnosis, an arthrogram contrast MRI of
the wrist may help delineate the pathology. This can be
particularly helpful in evaluating the TFCC. TFCC injuries
may be amenable to arthroscopic evaluation and
debridement versus repair, depending upon the nature of
the injury.
Figure 11-22 This 18-month-old child had a 45-pound weightlifting
plate fall on his hand. He underwent partial amputation of his index
finger.
CRUSH INJURIES—DIGITS
Crush injuries to the hand or digits can be difficult and
challenging to treat. The severity of injury can range from
the simple soft tissue contusion and/or tuft fracture up
through virtual or complete amputation of the digit (Fig.
11-22). The crush-injured digit tends to heal less well and
over a longer period of time than does the digit that
sustains an injury with a less severe mechanism. The
crushing force appears to damage the microvasculature,
resulting in an avascular zone. For comminuted fractures,
open reduction and internal fixation may be necessary.

One should anticipate a delay in healing and the need for

pin placement for a prolonged period of time—at least 6
weeks. The family should be counseled regarding the long-
term prognosis and outcome from crush injuries. These
include poor nail development, stiffness, and/or angular
deformity. Proper counseling of the family should be
undertaken preoperatively. Crush injuries to the entire
hand can also occur, and management is similar to what is
done for adult injuries. Release of compartments may be
required in severe cases.

Nail bed injuries can be classified into subungual

hematomas, simple or stellate lacerations, crush injuries, or
avulsions. Subungual hematomas and lacerations can be
treated with trephination of the nail plate and Dermabond
using the nail plate to protect the bed as it heals. More
significant injuries should be treated with a formal
irrigation and debridement to explore the wound, repair
the nail bed, and address associated physeal fractures or
tendon injuries.

NERVE AND TENDON INJURIES

Both nerve and tendon lacerations can and do occur in
children. The mechanism tends to be from grasping and/or
playing with sharp objects. Certainly, in the older child,
altercations with knives can be implicated. Halloween is a
particularly risky time of the year (pumpkin carving is a
slowly acquired skill) (Fig. 11-23).

Figure 11-23 We see an increase in hand lacerations during the

month of October due to pumpkin carving activities. (Image by Jerry
https://www.flickr.com/photos/way2go/3001355114.)

Tendon repairs should be performed primarily within the

first 7-10 days after injury, although a recent study
demonstrated acceptable long-term functional and
subjective outcomes even after a 2-stage flexor tendon
reconstruction. When the profundus and superficialis
tendon are disrupted, often only repair of the profundus is
indicated. Early occupational therapy is indicated in the
older child (perhaps age 6-8). In younger patients we use, a
mitten-type cast with the wrist flexed 30 degrees, with the
hand carefully positioned as if holding a ball but with
nothing actually within the hand. In such a cast, the child
can volitionally wiggle the fingers within the cast, though
not generating any force of significance. Because of age,
detailed occupational therapy is not an option. Hence, the
need to allow some motion yet casted to avoid stressing the
repair.

SUMMARY
Hand injuries in childhood are common, and many of the
principles learned in treating adult injuries can be applied.
Most common injuries can be treated by the well-trained
general orthopedist with certain more complex injuries
benefitting by referral to a children’s hand specialist.

SUGGESTED READINGS
Abzug JM, Dua K, Bauer AS, et al. Pediatric phalanx fractures. J Am Acad
Orthop Surg. 2016;24(11):e174–e183.

Boyer JS, London DA, Stepan JG, et al. Pediatric proximal phalanx fractures:
outcomes and complications after the surgical treatment of displaced fractures.
J Pediatr Orthop. 2015;35(3):219–223.

Davison PG, Boudreau N, Burrows R, et al. Forearm-based ulnar gutter versus

hand-based thermoplastic splint for pediatric metacarpal neck fractures: a
blinded, randomized trial. Plast Reconstr Surg. 2016;137(3):908–916.

Gholson JJ, Bae DS, Zurakowski D, et al. Scaphoid fractures in children and
adolescents: contemporary injury patterns and factors influencing time to
union. J Bone Joint Surg Am. 2011;93(13):1210–1219.

Karl JW, White NJ, Strauch RJ. Percutaneous reduction and fixation of
displaced phalangeal neck fractures in children. J Pediatr Orthop.
2012;32(2):156–161.

Lester B, Jeong GK, Perry D, et al. A simple effective splinting technique for
mallet finger. Am J Orthop. 2000;29(3):202–206.

Matzon JL, Cornwall R. A stepwise algorithm for surgical treatment of type II

displaced pediatric phalangeal neck fractures. J Hand Surg Am.
2014;39(3):467–473.
Mintzer CM, Waters PM. Surgical treatment of pediatric scaphoid fracture
nonunions. J Pediatr Orthop. 1999;19(2):236–239.

Patel L. Management of simple nail bed lacerations and subungual hematomas

in the emergency department. Pediatr Emerg Care. 2014;30(10):742–745; quiz
746–748.

Piper SL, Wheeler LC, Mills JK, et al. Outcomes after primary repair and staged
reconstruction of zone I and II flexor tendon injuries in children. J Pediatr
Orthop. 2016. [ePub ahead of print].

Reddy M, Ho CA. Comparison of percutaneous reduction and pin fixation in

acute and chronic pediatric mallet fractures. J Pediatr Orthop. 2016. [ePub
ahead of print].

Reyes BA, Ho CA. The high risk of infection with delayed treatment of open
seymour fractures: Salter- Harris I/II or juxta-epiphyseal fractures of the distal
phalanx with associated nailbed laceration. J Pediatr Orthop. 2017;37(4):247–
253.
 12
Pelvis and Hip

Andrew Pennock
Vidyadhar Upasani
James Bomar
Hip Dislocations
Hip Fractures
Pelvic Fractures
Acetabular Fractures

“We can be absolutely certain only

about things we do not understand”
— Eric Hoffer

INTRODUCTION
The osteoporotic bone of an elderly lady is very different
from the tough, growing bone of a child. Therefore, greater
energy is required to produce a hip or pelvic fracture in a
child, and many of these injuries occur as the result of
high-speed motor vehicle accidents. Patient age, size, and
skeletal maturity also contribute to the various fracture
patterns with an example being trochanteric fractures,
which tend to occur as a result of “bumper” injuries in
children aged 6-7 years, the age when the greater
trochanter is at the level of a car bumper (Fig. 12-1).
It is misleading to apply the mass of information about
adult fractures to children, and the small number of papers
that relate specifically to children present widely varying
statistics that are almost impossible to compare. If this
were a more common injury, perhaps we would all know
more about the best methods of treatment.

“Pelvic fractures may be accompanied

by genitourinary and/or gastrointestinal
injury”

Figure 12-1 Age determines the site of a bumper fracture.

Initial Exam
Occasionally a child will fall from a counter top or the back
of a couch and strike the floor in just the right way,
sustaining an isolated sub- or inter-trochanteric femur
fracture. However, more commonly, hip and pelvis
fractures in children are the result of high-energy
mechanisms and are associated with other injuries. In
these cases the initial exam needs to concentrate on
identifying any life-threatening injuries including head,
spine, thoracic, abdominal, pelvic, neurologic, and vascular
trauma. A coordinated plan to care for each injury must be
established. The hip exam itself must be gentle to avoid
further disruption of blood supply (especially femoral
neck).

Associated Injuries
Pelvic fractures may be accompanied by genitourinary
and/or gastrointestinal injury. It is important to look for
blood at the urethral meatus, and check for hematuria; a
retrograde urethrogram/cystogram should be obtained if
clinically indicated (Fig. 12-2). Abdominal, vaginal, and
rectal exams are performed by or together with the general
surgery team; blood at the anus suggests injury to the
lower GI tract, which can contaminate a pelvic fracture and
which can be problematic if missed. The rectal exam can
also identify a displaced prostate, indicating transection of
the urethra.
 Figure 12-2 This child was run over by a truck. Cystogram and
retrograde urethrogram show complete disruption of the urethra
(arrows) and elevation of the bladder. Always remember to check for
GI and GU injuries when the pelvis is fractured.

Specific Exam
Instability of the pelvis can often be felt with a compression
test, testing for both lateral and anteroposterior instability.
This test should not be repeated by multiple examiners as
there is risk for compounding the damage already done by
the fracture. Feel the pulses and test active movements in
both legs. Subtle neurologic injuries are easily missed—
always test sacral sensation. When the SI joint is
dislocated, the lumbosacral trunk, superior gluteal nerve,
and obturator nerve are at risk. However, as will be
described later, children rarely have true SI joint
disruption; typically they fracture through the physis
adjacent to the SI joint. Sacral fractures can rupture the
sacral roots, or the foramina can be compressed causing
compression of the sacral roots.

Figure 12-3 Top. In this young child, note the ischium and pubis
beginning to fuse. Bottom. This is the same child 3 years later; the
synchondroses had an almost expansile appearance. This is a normal
finding and should not be confused with a fracture. These
synchondroses may close asymmetrically, adding further confusion.

Blood Loss
In the field, prior to arrival at the hospital, hemorrhage
from a pelvic fracture can often be partially controlled by
binding the pelvis with a sheet wrapped tightly around the
patient at the level of the AIIS. This will close down
fractures and tamponade the bleeding during transport or
until further treatment can be rendered.

Extraperitoneal hemorrhage to some degree is common

and in most cases is allowed to tamponade with blood
transfusion given as needed. In a few instances, bleeding
can be massive and well concealed. An arteriogram may be
required to identify the site of bleeding, and coils can be
placed by the interventional radiologist.

Reading Pelvic X-rays

The pelvis is a very complex three-dimensional structure,
and analyzing films can be difficult. Fractures are difficult
to see and can occur through growth areas such as the tri-
radiate cartilage, which makes x-ray interpretation difficult.

The ischio-pubic synchondrosis is even more puzzling, and

may mimic a fracture (Fig. 12-3). This syndesmosis often
fuses asymmetrically, making interpretation difficult.
Further complexity is added by Ogden’s noting that in very
rare instances this syndesmosis can be the site of a stress
fracture in a young jogger.
 Figure 12-4 This child dislocated his hip during a simple slip and fall.
Reduction was easy and protected with a hip spica for 4 weeks.

HIP DISLOCATIONS
Dislocation is more common than femoral neck fracture in
childhood, and fortunately carries far fewer risks for
complications than does adult dislocation (Fig. 12-4). This
is likely due to hip joint laxity in the child as well as the fact
that the acetabular growth cartilage (adjacent to labrum) is
not yet ossified, with the true socket not as deep as in the
fully ossified adult. The hip of a child under the age of 5 is
usually dislocated by a fall with minimal trauma. As age
increases, the degree of trauma required to dislocate the
hip escalates (age 6-10—athletic injuries, automobile
accidents thereafter). A more violent dislocation is more
likely to be associated with fracture of the acetabulum or
femur and sciatic nerve damage.
 Table 12-1 Hip Dislocations
Anterior

Hip extended abducted and externally rotated

Posterior

Hip short, flexed, and internally rotated

Obturator
Hip flexed, abducted, and externally rotated

A recent traumatic dislocation can hardly be confused with

a long-standing paralytic dislocation for which the
treatment is entirely different. On the other hand,
recurrent dislocation of the hip in Down syndrome may be
confusing. The bone looks normal, and only the appearance
of the face clarifies the diagnosis.
 Figure 12-5 MVA resulting in a proximal femur fracture and posterior
hip dislocation with acetabular fragments.

Classification
The femoral head can be dislocated either anteriorly or
posteriorly, or rarely into the obturator foramen (Table 12-
1). A hip is most commonly dislocated posteriorly (Fig. 12-
5) causing the limb to be held in a shortened, flexed,
adducted, and internally rotated position. Anterior
dislocations cause the limb to extend, abduct, and
externally rotate. Traumatic obturator dislocations (or
intrapelvic dislocations) are very rare in children but have
been reported. The hip tends to be held in flexion,
abduction and external rotation, but this is more variable.

Treatment
It is not merely kind to reduce a dislocated hip as soon as
possible; early closed reduction will almost always succeed
whereas each passing hour makes the need for open
reduction more likely (Fig. 12-6). Prompt reduction also
reduces the incidence for avascular necrosis (AVN)
(although the incidence of AVN is much lower in children
as compared to adults; less than 5% compared to as high as
43% in adult Type V posterior dislocations).

Figure 12-6 Complications recognized after reduction. An acetabular

fragment or avulsion from the femoral head may block complete
reduction. A Type I injury to the physis may become evident.

Reduction of anterior and posterior dislocations are easy if

adequate muscle relaxant is used. A posterior dislocation is
reduced by flexing the hip and the knee to 90 degrees and
applying traction while the leg is externally rotated.

Anterior dislocation is best reduced by pulling the leg in

extension, abduction, and internal rotation. After reduction,
the hip should move freely without crepitus. A post-
reduction pelvis x-ray and CT scan should be obtained to
confirm that the hip is concentrically reduced without intra-
articular fragments. The x-ray sign of fragment entrapment
may be only a subtle joint space widening when comparing
the injured to the normal hip.

After reduction, we apply a hip spica for 4 weeks to allow

capsular healing in patients under the age of 10 years.
Movement usually returns quickly, and myositis ossificans
is rare in children. Radiographic review should continue for
a year to detect AVN.
Obturator dislocations should be taken to the operating
room for open reduction. They are usually irreducible by
closed methods.

“A trapped intra-articular fragment can

easily be missed if a post-reduction CT
study is not obtained”

Pitfalls
Although complications are unusual, during a reduction
maneuver an unrecognized proximal femoral epiphyseal
separation may become apparent. In such a case the neck,
not the head, reduces into the acetabulum. Such a
circumstance mandates open reduction and pinning.

A trapped intra-articular fragment can easily be missed if a

post-reduction CT study is not obtained (Fig. 12-7). A
fragment in the joint can be removed arthroscopically or
through an arthrotomy where fixation can be performed if
the fragment is large. This can be a posterior acetabular
rim fragment, the ligamentum teres with an avulsed head
fragment, or both.

The overall incidence of AVN in the literature is 10% or

less. Delayed reduction and severe injury are the most
important causes. Recurrent dislocation of the hip is a rare
sequel to traumatic dislocation.
 Figure 12-7 Following reduction, a widened joint space (arrows) is
indicative of a fragment in the joint. This was varified with a post-
reduction CT.

Voluntary Dislocation of the Hip

Some teenaged girls complain that they can feel the hip
dislocate. The usual cause is a snapping hip, in which the
tensor fascia lata jumps across the greater trochanter as
the girl rotates her hip. Once learned, some teenagers
seem to have a morbid preoccupation with repeating the
maneuver. Some very convincingly impress the neophyte
examiner as being a dislocation. Treatment is by stretching
(physical therapy) and only very, very rarely surgery
(incision in tensor fascia). A rare cause is a true voluntary
dislocation, a condition described by Broudy and Scott.
 Figure 12-8 The adult has intraosseus vessels that supply the
femoral head. Children with open physes have a more tenuous blood
supply as vessels do not cross the physis.

HIP FRACTURES
 Anatomy and Physiology—Hip
The following differentiate hip fractures in children as
compared to adults:

1. The periosteal tube in a child is much stronger than in an

adult; many fractures are undisplaced in children.
2. The proximal femoral bone (with the exception of the
physis) is much stronger in children and requires a large
force to break it, whereas the osteoporotic bone in the
elderly is easily fractured with a simple fall.
3. The hardness of a child’s bone and the small diameter of
the femoral neck are often not suited to fixation with
standard adult fixation devices.
4. The proximal femoral physis is a point of weakness in the
skeletally immature child; fractures that cross this growth
plate may lead to physeal arrest, which can cause coxa
breva or coxa vara. Although a fracture heals, deformity
may progress with growth.
5. The blood supply of the head is different (Fig. 12-8). When
the physis is still open, blood vessels do not cross the
physis, so the blood supply to the head is tenuous and
easily disrupted. AVN may result from complete division of
the vessels, kinking of the vessels that remain intact, or
tamponade by hemarthrosis within the hip capsule.

Classification
Pediatric hip fractures (from the femoral head to the lesser
trochanter) have been classified by Delbet (Table 12-2).
More distal fractures of the femur will be discussed in
Chapter 13.
 Table 12-2 Delbet Classification of
Pediatric Hip Fractures
Type IA

Transphyseal—no dislocation
Type IB

Transphyseal—with dislocation
Type II
Transcervical
Type III

Cervicotrochanteric
Type IV
Intertrochanteric

Treatment

Type I Fractures (Transphyseal)

The femoral head separates from the neck through the
physis. In very young children this injury is most likely to
occur when a child has been run over by a car, but it may
also be seen in abused infants. In children, great violence is
required, and there are usually associated injuries. In
adolescents, an acute Type I injury is seen, which is
difficult to differentiate from an acute (unstable) slipped
capital femoral epiphysis (SCFE) (see next section).

Traction has been advised for Type IA fractures with no

displacement in very young children, but in most cases,
spica cast immobilization is used. In displaced fractures in
infants closed reduction is relatively easy, and the
reduction should be held in a one and a half hip spica.
Displacement can occur in the cast, and frequent
radiographs should be taken to detect this. If pin fixation is
required (rare), it should be done with smooth pins because
pinning may aggravate the tendency for premature fusion.

If the head is dislocated (Type IB), urgent open reduction is

mandated (Fig. 12-9). Canale and Bourland describe five
cases of traumatic separation accompanied by dislocation,
and all developed AVN with four of the five developing
degenerative arthritis. The young patients required leg-
length equalization. Traumatic separation of the proximal
femoral epiphysis is a severe injury, and the parents should
be warned that problems are more likely than not.
 Figure 12-9 This 15-year-old boy suffered a severe Type IB injury
with marked head displacement. Despite immediate open reduction,
he developed AVN. Late construction included femoral head contour,
bone grafting, and a shelf acetabuloplasty.

Type II and III Fractures—Transcervical and

Cervicotrochanteric
The perils of these injuries are great, with AVN reported in
up to 50% of cases. Although more common in displaced
fractures, AVN can occur in non-displaced fractures.
Premature closure of the physis can occur as a sequel to
AVN, leading to a short femoral neck and a weak lever arm
for the abductor muscles, a short leg, and limitation of
abduction owing to greater trochanter overgrowth. Delayed
union, nonunion, and drifting into coxa vara are also
common.

Non-Displaced Fractures
Non-displaced neck fractures in young children (less than 4
or 5 years) have some inherent stability, and the safest way
to protect them is in a one and one half hip spica with the
leg held in internal rotation and abduction for 6-8 weeks.
This is only advised for a truly undisplaced injury. The
fracture should be checked frequently for change in
alignment. In older children, pinning is technically easier
and reduces the chances of displacement.

Displaced Fractures
Muscular forces across the hip joint tend to produce coxa
vara in displaced fractures (i.e., fractures in which the
periosteum has been torn). Cast fixation after reduction
does not neutralize these muscular forces, and loss of
reduction in a spica cast is almost certain. Because of this,
the true conservative approach for displaced fractures is
internal fixation (Fig. 12-10). In the classic text “Treatment
of Fractures in Children and Adolescents,” Weber et al.
state “we regard every fracture of the femoral neck in a
child as an emergency situation which requires operative
intervention with a minimum of delay. Rapid action is
essential to allow anatomically precise reduction and
stabilization as well as evacuation of the intracapsular
hematoma.” We adhere to this A-O recommendation for all
displaced femoral neck fractures. Although some surgeons
might try a closed reduction and pinning (as in treating an
elderly patient), we have a low threshold at our institution
for an open approach to more optimally achieve an
anatomic reduction and to decompress the hip capsule (Fig.
12-11).

Figure 12-10 A 13-year-old male who fell off a skateboard and

sustained a fractured femoral neck (see Focal AVN box).
 Focal AVN of the Femoral Head

This book is designed to present straightforward concepts to young surgeons

and medical personnel. This case breaks that rule but is included to catch
your eye and to emphasize the guarded prognosis of a femoral neck fracture.

This 13-year-old male suffered the femoral neck fracture shown in Figure 12-
10. Focal AVN was noted 8 months post initial treatment. At that time the
screws from the original surgery were removed and BMP was placed in the
area of AVN. There was no improvement. The decision was made to salvage
the femoral head using a focal femoral head allograft. At 1 year post allograft
the patient has had significant symptom relief.

The anterolateral or Watson-Jones approach gives excellent

exposure for reduction and fixation of femoral neck
fractures. This approach utilizes the interval between the
tensor fascia lata and gluteus medius, with the abductors
retracted to expose the capsule. The capsule is opened to
release the hematoma and to allow exact fracture
reduction. The fracture can be anatomically reduced with
the aid of a periosteal elevator, traction, and internal
rotation. The fracture is fixed with cancellous screws
avoiding the physis if possible.
Figure 12-11 Weber et al. emphasized the need for urgent open
reduction in this injury. (See Suggested Readings.) An anterolateral
 Watson-Jones approach allows a safe, extensive exposure to the
capsule.

Most authors express a preference for threaded pin or

screw fixation. The metaphysis is composed of hard bone
(unlike the adult metaphysis), providing a “good bite” for
screws or threaded pins. It is usually unnecessary to cross
the physis, but in high fractures do not hesitate to place a
pin (temporarily) across the physis. If pins are placed
across the physis, they should be smooth and be removed
as soon as possible to avoid interfering with growth. There
are also several lag screw-plate systems available now in
children’s sizes. The capsule is loosely closed once fixation
is secure.

A child does not need rapid rehabilitation. Apply a hip spica

for 6-8 weeks to protect the hip (ruptured soft tissues—
capsule, vessels) in hopes of decreasing the chance for
AVN. Remember the load on the hip imposed by straight
leg raising can approach that imposed by walking. A belt-
and-suspenders approach is needed to prevent non-union,
coxa vara, and AVN.

Type IV (Inter-trochanteric Fractures)

Operative treatment used for older children can be
difficult, because considerable comminution or separation
of the greater trochanter may be present without being
obvious on radiographs. Always obtain high-quality films
before starting surgery. Older children usually require
ORIF with a plate and screws or a lag screw with side
plate.
 Figure 12-12 Periosteal stripping is the suggested mechanism for
femoral head AVN secondary to greater trochanteric avulsion.

Avulsion Fractures—Lesser Trochanter

Avulsion fractures of the proximal femur are not included
in the above classification system, but are worthy of
mention in this section. We frequently see avulsion
fractures in young aggressive athletes. Avulsion fractures
of the lesser trochanter can be caused by the pull of the
iliopsoas in sprinters. Conservative treatment typically
leads to osseous union or fibrous healing and does not
result in noticeable hip flexor weakness. Crutch use and
partial weight bearing for 3-4 weeks typically gets athletes
back into competition.
 Table 12-3 Ratliff Femoral Head AVN
Classification
Type I

AVN of the head and neck proximal to the fractures (60%)

Type II

AVN of the head alone (22%)

Type III
AVN of the neck alone (18%)

Avulsion Fractures—Greater Trochanter

The greater trochanter can be avulsed by the abductors,
usually associated with a severe twisting fall (Fig. 12-12).
Although this injury may appear relatively benign, the
posterior circumflex vessels traverse dangerously close to
the fracture plane and may be disrupted at the time of
fracture (probably in relation to associated periosteal
stripping). If the fracture is allowed to heal in a
significantly displaced position, the abductors will be weak
and Trendelenburg limp will result. ORIF is the preferred
method of treatment for displaced fractures; however, the
technique should be cautious to avoid increasing the risk
for AVN of the femoral head (which is substantial) (Fig. 12-
13).

Pitfalls
Ratliff emphasized AVN as the main cause of poor results in
proximal femoral fractures (Table 12-3) MacEwen reports
that Type IB injuries (complete head separation and
dislocation) have the highest rate of AVN (80%-100%),
followed by Type IA and Type II (50%), and Type III (27%).
Type IV (intertrochanteric) fractures have the lowest
reported rate of AVN (14%).

AVN is best detected early with a bone scan (Fig. 12-14) or

MRI but is often apparent radiographically after several
months, and almost always within a year. Radiographs
should be obtained regularly (every 2-3 months) during the
first year. The first x-ray signs of AVN include the
following: the head does not become osteoporotic, the head
does not grow, and the cartilage space becomes wider.
These signs appear long before signs of gross density,
fragmentation, and deformity of the head. Slight
disturbance of circulation produces coxa magna luxans
creating a large head that is poorly covered by the
acetabulum.
Figure 12-13 An avulsion of the greater trochanter can result in AVN
of the femoral head.
Coxa vara is the most common deformity following cast
treatment of proximal femoral fractures; it results in a
shortened limb and abductor weakness and may predispose
to future fractures of the femoral neck.

Nonunion is rare, but when it occurs, bone grafting is

advocated with valgus osteotomy if there is coxa vara.

Figure 12-14 A bone scan can detect AVN of the femoral head
before there are radiographic findings. The arrow points to a dark spot
over the left femoral head, indicating AVN. An MRI study can also be
considered.

SCFE (vs. Transphyseal Fracture)

As noted before, an acute SCFE and a Type IA transphyseal
fracture are similar images by x-ray but occur in different
patient populations. Ratliff noted that acute fractures occur
up until age 8-9 years, and that acute (unstable) slips occur
in teenagers, often with predisposed anatomy (obesity,
retroversion of the femoral neck—Table 12-4). SCFE, a
pathologic process and not necessarily the result of trauma,
will be discussed here because it is within the spectrum of
physeal fractures. In the most basic terms, SCFE is the
result of a “sick” physis that is unable to support the weight
of the child. The femoral neck becomes progressively more
retroverted until the femoral head slides off the neck
through the physis. The trauma that is associated with an
acute SCFE is typically less severe than the trauma
required to fracture a healthy proximal femur.

Classification
SCFEs can be classified based on acuity, severity, or
stability. In current thinking, stability is the most important
of the classification types.

Acuity—Three weeks of symptoms is generally considered

the cutoff between acute and chronic slips. SCFEs
associated with less than 3 weeks of symptoms are
generally considered acute and those associated with
greater than 3 weeks of symptoms are classified as chronic.
Acute on chronic describes a circumstance in which a child
has had hip pain for greater than 3 weeks but has had a
recent incident in which the pain has suddenly increased.

Table 12-4 Differentiating a Fracture

from Slip
(modeled from Ratcliff)
Characteristic Transphyseal Slipped Capital Femoral
Fracture Epiphysis
Age incidence Child under 9 years Child 11-16 years
Onset Sudden, following Gradual or sudden
injury
Mechanism of Severe violence, e.g., No injury or minor violence, e.g.,
injury MVA fall
Endocrine defect Not present Sometimes present
 Slipped Capital Femoral Epiphysis—Pitfalls
Beware the Large Child with Knee Films!

Do not be fooled by knee pain in a large child. A physical exam for knee pain
is not complete until hip range of motion has been evaluated. The danger in a
situation like this is that the child is sent home with a mild stable SCFE and
falls down and comes back to the ER with a severe unstable SCFE with a
much increased risk of avascular necrosis.
This 9-year-old child is overweight, non-verbal and has Down syndrome. He
presented to the emergency room with a 1-day history of a limp, as well as a
cold 1 week prior. There was no history of trauma and the child pointed to his
knee when asked where it hurt. He had slightly elevated inflammatory
markers. Knee films were ordered and a phone call was made to the ortho
resident, who did not go to the ER and examine the child. The resident felt
that it was likely knee synovitis and that the patient should follow up in the
ortho clinic. One week later the child was seen in the ortho clinic and a
physical exam was performed. The child was found to have decreased
internal rotation on the left side. Pelvic films were ordered and a left sided
SCFE was noted.

Severity—Severity is typically determined on the frog

lateral view. It can be evaluated using the Southwick angle
or the epiphyseal slip angle. Generally, a slip is considered
mild when it is ≤30 degrees on either of these
measurements. Moderate slips are defined as 30-
60 degrees, and severe slips are ≥60 degrees (Fig. 12-15).

Figure 12-15 Mild, moderate, and severe SCFE.

Stability—Loder defined stable SCFE as a slip in which the

patient is able to bear weight (with or without crutches) or
the absence of a joint effusion on ultrasound examination.
Unstable slips are those in which the patient is unable to
bear weight, or a joint effusion is noted on ultrasound. The
Loder classification is the most important SCFE
classification in terms of prognosis. Using traditional in situ
pinning methods, approximately 47% of unstable slips go
on to develop AVN.
 Figure 12-16 Bilateral stable SCFE, both treated with in situ pinning.

Treatment—SCFE
In situ pinning with screws or threaded Steinmann pins is
the standard treatment for stable SCFE (Fig. 12-16),
treatment of the unstable injury is more difficult and is
heavily debated. The general approach to the treatment of
SCFE at our institution is that stable slips, regardless of
severity or acuity, are treated with in situ pin fixation.
Moderate to severe stable slips can undergo a triplane
corrective osteotomy once the slip has healed. We typically
perform an Imhauser-type osteotomy (Fig. 12-17). Unstable
slips are considered an emergency and are treated with the
reduction and pinning with capsulotomy to decompress the
joint or with a modified Dunn procedure at initial
presentation (Fig. 12-18). We favor this approach because
the head is anatomically reduced and it appears to
decrease the risk of AVN.
 Figure 12-17 Left stable SCFE pinned in situ at presentation.
Because of the severity of the slip an Imhauser osteotomy was
planned for a later date.

Figure 12-18 Left unstable SCFE treated with the modified Dunn
procedure at presentation.

PELVIC FRACTURES
The pelvis is like a suit of armor: when it is damaged there
is much more concern about its contents than about the
structure itself. The problems for the orthopedic surgeon
are different at each age. Osteoporotic old people sustain
minor fractures in falls that pose neither visceral nor
orthopedic problems. Young adults involved in motor
vehicle accidents suffer fractures that may be difficult to
reduce in addition to life-threatening visceral injuries.
Children’s fractures are seldom displaced much and can
usually be treated with rest and protected weight bearing,
but their other injuries may require much treatment. On
the other hand, teenagers often have more displaced
fractures similar to adult patterns (Fig. 12-19).

Figure 12-19 MVA resulting in a vertical shear injury to the pelvis

fracturing through the SI joint and the pubis.

Radiographic Issues
Avoid ordering a frog view of the pelvis if there is any
concern for a hip fracture. Although this is the lateral view
of the proximal femur that orthopedic surgeons are
accustomed to, placing the child in a frog position risks
further displacement of a hip fracture. Instead, order a
cross table lateral (along with an AP pelvis view) for safe
radiographic evaluation.
 Judet X-rays of the Acetabulum

The Judet brothers of Paris were among the best known 20th century
orthopedic surgeons. They made important contributions to the development
of total hip arthroplasty but in addition were experts in diagnosing and
treating acetabular fractures. Their classic paper introduced English language
readers to the proper radiographs needed to assess acetabular and pelvic
fractures. Much can be learned by analyzing these oblique views (although CT
scans have diminished their mystique).

Pelvic ring fractures are better evaluated with inlet and

outlet x-rays (tube angled 45 degrees caudad or cephalad,
respectively). In addition to the AP view (Fig. 12-20).
Figure 12-20 Inlet and outlet views show any disruption of the pelvic
ring, and they are especially good for seeing movement of the SI
 joint.

Acetabular fractures are initially evaluated with oblique

(Judet) x-rays. The obturator oblique x-ray allows
evaluation of the anterior column and the posterior rim of
the acetabulum. The iliac oblique shows the posterior
column and the anterior rim. However, a 3-D CT scan is
much more accurate and is becoming a standard for
evaluation and pre-operative planning (if surgery is being
considered).

A gonadal shield should not be used when obtaining x-rays

of possible pelvic fractures—the pathology can easily be
concealed by the shield.

MRI studies are rarely needed but when performed have

provided interesting differences in adult versus children’s
SI joint injuries. MRI studies of posterior pelvic injuries
have clarified that the vertical displacement in SI joint
injuries in children occurs through the non-ossified iliac
growth cartilage next to the SI joint and typically does not
tear the ligaments, analogous to what one sees at the ankle
in a child (physeal separation rather than ligament injury).
Thus bony healing is likely in children.

Classification
The most important aspect of understanding pelvic
fractures is whether the fracture is stable or unstable. This
differentiation provides the basis for whether a pelvic
fracture will require operative intervention. A single break
in the pelvic ring typically does not render instability to the
pelvis, two or more breaks in the ring may destabilize it.
Fortunately, because of the relative plasticity of the
growing skeleton, most childhood pelvic fractures are
stable.
 Table 12-5 Torode and Zieg Classification
of Pelvic Fractures
Type I

Avulsion fractures
Type II

Iliac wing fractures

Type III

Simple ring fractures (includes pubic and acetabular fractures)

Type IV
Fractures producing an unstable segment, (includes straddle, Malgaigne, and
other unstable fractures)

Quinby and Rang classified pelvic ring fractures into three

groups:

Group uncomplicated fractures; these are minor and

I: minimally displaced. Signs of abdominal or urologic
injury are absent or settle quickly with non-
operative treatment.
Group fractures with visceral injuries requiring surgical
II: exploration. These are more severe; the patient may
be in shock and require transfusion. The pelvis can
conceal a large amount of hemorrhage before it is
clinically apparent.
Group fractures associated with immediate massive
III: hemorrhage. Hemorrhage may be from visceral
injuries or vascular injury. Even with advanced
trauma life support and aggressive management,
the mortality of these patients is still high.

“The most important aspect of

understanding pelvic fractures is
whether the fracture is stable or
unstable”
Torode and Zieg developed a more detailed classification
system for pediatric pelvic fractures that is summarized in
Table 12-5.

Treatment

Fractures of the Pelvic Ring

Stable fractures of the pelvic ring (rami fractures, iliac
wing fractures, ischial fractures) that do not involve a joint
(acetabulum or SI joint) and are not associated with
hemorrhage can typically be treated with a few days of rest
followed by protected weight bearing until the fracture
heals (usually 4-6 weeks).

Figure 12-21 CT showing SI joint fracture that was fixed with a screw
(arrow depicts joint widening and fracture fragment).
Unstable pelvic fractures can be fixed with an external
fixator or internal fixation. Pin placement for the external
fixator will depend on the location of the fracture and the
unstable segment. All orthopedic surgeons should be able
to quickly apply a stabilizing pelvic external fixator. These
should be positioned to allow access to the abdomen if the
general surgeons are planning surgery for a visceral injury.

Many pelvic fractures are now fixed with percutaneous

screws. These are very useful for fractures involving the
sacroiliac joint, superior rami, and some iliac wing
fractures, but because of the complexity of understanding
the three-dimensionality of the pelvis, this percutaneous
approach is best performed by experts or with CT guidance
(Fig. 12-21).

Figure 12-22 Many muscles originate from the pelvis. With strong
muscle contractures, the origin of the muscles can be avulsed—see
Pelvic Avulsion Fractures box.

Avulsion Fractures About the Pelvis

With today’s aggressive athletics, the muscles about the hip
often overpower the open pelvic apophyses creating
avulsion fractures (Fig. 12-22). Pelvic avulsion fractures
are thought to occur during the interval between
appearance and closure of the secondary ossification
centers. Ischial tuberosity and AIIS avulsions tend to occur
in younger adolescents, whereas anterior superior iliac
spine (ASIS) and iliac crest avulsions tend to occur in older
adolescents.

The ASIS can be avulsed by the sartorius (Type I) or the

tensor fascia lata (Type II). The Type I, ASIS, avulsion is
typically seen in sprinters, whereas the Type II iliac crest
avulsion is often seen in athletes with significant rotational
forces such as baseball batters and tennis players.
The AIIS is avulsed by the rectus femoris (often seen in
soccer and rugby players).
The ischial tuberosity is avulsed by the hamstrings. This
injury is typically associated with a high kicking motion,
most commonly occurring in hurdlers and gymnasts.

The vast majority of these avulsion fractures heal well with

conservative treatment including protected weight bearing
for 3-4 weeks. A very rare patient will develop a painful
nonunion that requires operative fixation or excision of the
fragment. This is more likely to occur with ischial
tuberosity fractures that are displaced greater than 2 cm. It
is not uncommon for patients with AIIS fractures to have
residual hip pain lasting greater than 3 months. This may
be secondary to subspinal impingement, rectus femoris
tendonitis, or an associated labral tear. Fortunately, most
of these patient symptoms will resolve with time, but
families should be counseled accordingly.

“The vast majority of these avulsion

fractures heal well with conservative
treatment”

ACETABULAR FRACTURES
Fractures of the acetabulum in the skeletally immature
patient are extremely rare. When they occur, they are
typically seen as separation through the tri-radiate
cartilage. With minimal displacement, fractures of the tri-
radiate cartilage can be treated with protected weight-
bearing; this fracture risks closure of the tri-radiate growth
center and subsequent hip dysplasia. Fractures with
significant displacement need to be reduced. Smooth pins
can cross the tri-radiate cartilage to maintain reduction and
should be removed once the fracture is healed to avoid
iatrogenic closure.
 Pelvic Avulsion Fractures

Pelvic avulsion fractures are thought to occur during the interval between
appearance and closure of the secondary ossification centers. Closure of
these ossification centers in males tends to lag behind that in females by
about 1-2 years. The adjacent chart indicates the ages at which these
avulsion fractures occur in males and females.
Age at Avulsion
Male Female
ASIS 13-18 years 13-17 years
AIIS 11-16 years 11-15 years
Ischial tuberosity 12-17 years 12-15 years
Once the tri-radiate cartilage closes, fractures of the
acetabulum are classified and treated like adult fractures.
Three-dimensional CT scan is very useful for understanding
the fracture. It is critical to remove any bone or cartilage
fragments from the hip joint to avoid further joint
destruction. Reconstruction of the acetabulum is best left
to the experts; traction is often useful to keep the joint
distracted until the time of surgery.

CONCLUSION
Fortunately, hip and pelvic fractures are relatively
uncommon in children. It is important to understand and
recognize these fractures and their associated injuries. The
more severe fractures are produced by high-energy trauma,
and the associated injuries may be life threatening.
Proximal femoral fractures need to be maintained in
anatomic alignment until the fracture has healed. The risk
of AVN is significant following both closed and open
treatment of proximal femoral fractures. In the rare
instance that a pelvic fracture requires operative
intervention, this may be best left to the experts as the
surgery may be technically difficult and the prognosis is
often poor.

SUGGESTED READINGS
Blasier RD, McAtee J, White R, et al. Disruption of the pelvic ring in pediatric
patients. Clin Orthop. 2000;(376):87–95.

Cheng JC, Tang N. Decompression and stable internal fixation of femoral neck
fractures in children can affect the outcome. J Pediatr Orthop. 1999;19(3):338–
343.

Davison BL, Weinstein SL. Hip fractures in children: a long-term follow-up

study. J Pediatr Orthop. 1992;12(3):355–358.

Haddad RJ, Drez D. Voluntary recurrent anterior dislocation of the hip. J Bone
Joint Surg. 1974;56A:419.
Judet R, Judet J, Letournel E. Fractures of the acetabulum: classification and
surgical approaches for open reduction. Preliminary report. J Bone Joint Surg
Am. 1964;46:1615–1646.

Loder RT, Richards BS, Shapiro PS, et al. Acute slipped capital femoral
epiphysis: the importance of physeal stability. J Bone Joint Surg Am.
1993;75A:1134–1140.

Mehlman CT, Hubbard GW, Crawford AH, et al. Traumatic hip dislocation in
children. Long-term followup of 42 patients. Clin Orthop. 2000;(376):68–79.

Musemeche CA, Fischer RP, Cotler HB, et al. Selective management of

pediatric pelvic fractures: a conservative approach. J Pediatr Surg. 1987;22(6):
538–540.

Ogden JA. Hip development and vascularity: relationship to chondro-osseous

trauma in the growing child. Hip. 1981:139–187.

O’Rourke MR, Weinstein SL. Osteonecrosis following isolated avulsion fracture

of the greater trochanter in children. A report of two cases. J Bone Joint Surg
Am. 2003;85-A(10):2000–2005.

Parvaresh KC, Upasani VV, Bomar JD, et al. Secondary ossification center
appearance and closure in the pelvis and proximal femur. J Pediatr Orthop.
2016 Jul 20 [Epub ahead of print].

Ratliff AHC. Traumatic separations of the upper femoral epiphysis in young

children. J Bone Joint Surg Br. 1968;50B:757.
Schuett DJ, Bomar JD, Pennock AT. Pelvic apophyseal avulsion fractures: a
retrospective review of 228 cases. J Pediatr Orthop. 2015;35(6):617–623.

Silber JS, Flynn JM. Changing patterns of pediatric pelvic fractures with
skeletal maturation: implications for classification and management. J Pediatr
Orthop. 2002;22(1):22–26.

Song KS, Kim YS, Sohn SW, et al. Arthrotomy and open reduction of the
displaced fracture of the femoral neck in children. J Pediatr Orthop B.
2001;10(3): 205–210.

Souder CD, Bomar JD, Wenger DR. The role of capital realignment versus in
situ stabilization for the treatment of slipped capital femoral epiphysis. J
Pediatr Orthop. 2014;34(8):791–798.

Torode I, Zieg D. Pelvic fractures in children. J Pediatr Orthop. 1985;5(1):76–

84.

Weber BG, Brunner Ch, Freuler F. Treatment of Fractures in Children and

Adolescents. Berlin/Heidelberg: Springer-Verlag; 1980.
White KK, Williams SK, Mubarak SJ. Definition of two types of anterior superior
iliac spine avulsion fractures. J Pediatr Orthop. 2002;22(5):578–582.
 13
Femoral Shaft

Maya Pring
Peter Newton
Assessing the Patient
Radiographic Issues
Classification
Treatment
The Non-walking Child
The Walking Child—Age 2-6 Years
Children Age 7-12 Years
Children Age 12 Years and Older

“Live as if you were to die tomorrow.

Learn as if you were to live forever”
— Mahatma Gandhi

INTRODUCTION
The femur is the longest and strongest bone in the human
body, supporting over 11 times the body’s weight during
running. Despite its strength, children find a wide variety
of ways to break the femur. From coming through the birth
canal to extreme sports such as flyboarding and parkour
(Fig. 13-1), different stresses at all stages of development
can cause a wide variety of injuries to the femoral shaft.

Surgeons who treat children’s fractures need to understand

the nature of a femoral fracture in each age group and
master treatment techniques that allow full recovery of
structure and function (Fig. 13-2). Flynn and Curatolo have
outlined five factors to consider and seven treatment
options for pediatric femoral shaft fractures that we will
review in this chapter. (This chapter focuses on femoral
shaft fractures—proximal femur fractures are discussed in
Chapter 12 and distal femur fractures in Chapter 14.)

Figure 13-1 Parkour (from French—parcours—“course or route”) is a

street sport in which the participant performs running, jumping, and
climbing stunts using obstacles in any given environment. (Image by
Cosmin Barbu
https://www.flickr.com/photos/29541676@N06/4086706046.)

ASSESSING THE PATIENT

A femur fracture in a non-walking child should set off
warning bells for potential non-accidental trauma. Experts
have stated that abuse may cause between 10% and 20% of
all fractures in infants and toddlers; approximately 80% of
all fractures caused by child abuse occur in children
younger than 18 months. Be sure you are fully versed in
suspecting and evaluating the potentially abused child (see
Chapter 19).
 Figure 13-2 Each fracture must be treated differently based on the
age of the child and the anatomy of the fracture. A. Spiral fracture in
infancy, easy to hold in a cast. B. Proximal fracture in a 4-year old—
more difficult to hold in a cast. C. Unstable shaft fracture in a
teenager will require intramedullary fixation.

Children who are walking but not yet involved in sports can
fracture their femurs with lower energy twists and falls,
getting the leg caught in a shopping cart, jumping off the
couch, etc. The most common fracture type in this age
group is a spiral fracture secondary to a twisting
mechanism. Full exam should still be done, but the risk of
child abuse and multiple injuries is much lower, and the
child can often tell you a good story so you are not as
dependent on the parents’ story.

Teen and young adult femur fractures often follow motor

vehicle accidents, yet a vast array of extreme sports also
that put them at risk for femur fracture and associated
injuries (see Chapter 20). Deformity of the femur is often
obvious, but it is important not to focus only on the femur
and lose sight of other injuries that result from high-energy
trauma such as spine, head, and internal organ injuries.

The femur fracture is often so painful that it masks other

injuries (a so-called distracting injury). Following the
normal ABCs of a trauma evaluation, a head to toe exam
are critical both at the time of initial evaluation and
following stabilization of the femur fracture. Monitor the
blood pressure; shock is almost never the result of a femur
fracture in childhood and is more likely because of internal
hemorrhage (e.g., a ruptured spleen).

RADIOGRAPHIC ISSUES
Often the initial femur film is not of high quality, being one
of many x-rays taken quickly in the emergency department
as opposed to the more controlled setting of the radiology
suite. Polytrauma patients can be difficult to position, and
there are often more critical life-threatening issues that are
being addressed, so true AP and lateral x-rays in the
trauma bay are unusual. An oblique/rotated film can help
you understand general fracture pattern, but overlap or the
true extent of shortening is difficult to determine (Fig. 13-
3). If the patient comes to the ED in a traction splint, or you
put the patient in traction prior to going to the OR (we
often use Buck or boot traction to keep the child
comfortable), better x-rays may be obtained, although
traction does pull the fracture more out to length making
the initial shortening difficult to determine.
 Figure 13-3 A fracture may appear distracted or overlapping
depending on the angle at which the radiograph is taken.

Before definitive treatment, you must image the hip and

knee to avoid missing a hip dislocation, femoral neck
fracture, or intra-articular knee injury. If there is question
about the femoral neck or knee joint, CT is warranted, as
these fractures even if non-displaced will substantially
change your treatment plan.

Children may also sustain pathologic fractures from

infection, bone cysts, fibrous lesions (Fig. 13-4), and very
rarely malignant lesions. It is important to get a good
history—do they (or anyone in the family) have a known
bone disorder (osteogenesis imperfecta, fibrous dysplasia,
neurofibromatosis), did the child have pain prior to the
 fracture, night pain, fevers, weight loss, etc.? Look at the
child and x-rays carefully to avoid missing an underlying
pathologic cause of the fracture. If there is any question,
advanced imaging such as CT or MRI is warranted prior to
surgical intervention (see Chapter 19).

CLASSIFICATION
In their AAOS Instructional Course Lecture in 2015, Flynn
and Curatolo suggest the following practical classification
of pediatric femur fractures:

1. Fractures that will heal with limited intervention

2. Fractures that should be treated without surgery but must
be watched closely
3. Fractures that benefit from surgical intervention with load-
sharing implants
4. Fractures that may benefit from surgical intervention with
rigid fixation
5. Fractures in a patient with a limb at risk because of
associated injuries (vascular, etc.) that require urgent
treatment precedence
Figure 13-4 Pathologic femur fractures through a unicameral bone
cyst, aneurysmal bone cyst, or fibrous lesions are not uncommon in
children. This spiral fracture begins in a distal femoral lesion.
 Figure 13-5 A deformity of the fracture will be based on the
anatomic location of the fracture.

Femoral shaft fractures can also be classified based on the

following location:

1. Proximal (subtrochanteric)
2. Midshaft
3. Distal third

“We mention traction, although it is

rarely used as a definitive form of femur
fracture management in the USA today”

Depending on fracture level, the forces exerted on the

fragments by the muscles that remain attached can pull the
fracture into varus, valgus, flexion, extension, or rotational
malalignment (Fig. 13-5). These forces must be considered
 and counteracted by the cast, traction, or internal fixation
when planning treatment. Poorly applied treatment of any
type can worsen the initial deformity and create an
unacceptable result.

TREATMENT
The seven options for treating femoral fractures in
children, as organized by Flynn and Curatolo, include the
following:

1. Pavlik harness with or without a splint

2. Walking hip spica cast
3. Standard spica cast with or without traction
4. Elastic intramedullary nailing
5. Submuscular plating
6. External fixation
7. Trochanteric-entry intramedullary nailing.

We mention traction, as noted in (3) above, although it is

rarely used as a definitive form of femur fracture
management in the United States today. However, there
are many parts of the world where traction is the mainstay
of femoral fracture treatment for all ages including adults.
If you do outreach trips to countries that don’t have
advanced resources and equipment, placing a patient in
traction may be safer than implanting metal with the risk
for infection and non-union.
 TECHNIQUE TIPS:
Traction
Skin Traction

1. For patients less than 60 pounds.

2. Apply adhesive to the skin.
3. Pad malleoli and fibular head with cast padding.
4. Apply traction tape (fabric backed foam) down medial and lateral sides of
the legs.
5. Overwrap the tapes from ankle to knee leaving the foot free.
6. Use no more than 5 pounds of weight.
7. Use sling and pillow to support the hip and knee in a slightly flexed position
(20-30 degrees).
8. Check skin regularly, as skin blistering and sloughing can occur.
9. Regular neurovascular checks—nerves and blood vessels can be
compromised.
10. Traction can be used until there is adequate callus for spica.
 Skeletal Traction

1. For patients greater than 60 pounds (can be used on adults as well as

children).
2. The distal femur is preferred for insertion of the Steinmann pin (tibial pins
may sublux the tibia or injure the physes, including the tibial tubercle).
3. Pins may be threaded (better hold) or smooth (easier to insert and
remove).
4. Pins inserted from medial to lateral to protect the neurovascular structures,
entry point is proximal and parallel to the physis in the metaphyseal flare.
5. During pin insertion, hold the leg in the position for traction (usually 90-90)
so the skin and fascia are not stretched after pin insertion.
6. Apply dressing over pins, followed by a traction bow.
 7. A short leg cast with anterior loops allows rotational adjustment and
prevents equinus contractures.
8. Apply enough weight to support the leg, avoid over-distraction at the
fracture site.
9. X-rays in traction should be checked weekly to allow proper adjustment of
weight and position to ensure that there is no distraction at the fracture site
and that alignment remains acceptable.
10. Traction can be used until there is adequate callus for spica (good test: no
pain with thigh motion—usually 3 weeks).
One to three kilograms of skin traction can be used for a
short period of time before placing the child in a spica. If
greater force is required to get an adequate reduction,
skeletal traction should be considered. If the distal femoral
physis is still open, the traction pin must be placed
proximal to the femoral physis to avoid physeal injury.
Skeletal traction can be used for many weeks until the
fracture is healed (see Technique Tips), but if possible, it is
better to get patients out of bed and back to school or
work.
 Figure 13-6 For quick transport of a patient with a femur fracture, a
Hare traction splint can be used to keep the fracture out to length.
These splints cannot be used for more than a few hours, as there is a
risk of skin necrosis and tourniquet effect at the ankle. The proximal
pad pushes against the ischium while traction is pulled through the
ankle cuff.

If a patient comes to the hospital in a traction splint put on

in the field by EMTs (Hare traction splint, Thomas splint,
Sager splint, etc.)(Fig. 13-6), the splint should be removed
as soon as possible. These splints keep the fracture out to
length and decrease discomfort and hemorrhage during an
ambulance or helicopter ride, but they are not meant for
longer-term use. Do not leave a patient in a traction splint
overnight, as there is risk for skin breakdown and nerve
injury.

In addition to available resources, the age of the child,

mobility, weight, fracture “personality” (location, pattern,
and stability), and surgeon skill will all influence the best
treatment for a particular child.

THE NON-WALKING CHILD

Fractures in children under 2 years heal quickly and have
great potential to remodel; a good outcome is almost
certain in very young children regardless of shortening or
initial alignment. Most are classified as Class 1: fractures
that heal with limited intervention. The goal of treatment is
comfort while the fracture heals. Surgery is almost never
necessary (the extremely rare exceptions being an open
fracture or fracture with neurovascular compromise).

A Pavlik harness with a soft wrap around the thigh (we use
cast padding) may be easier for a parent to manage for
diaper changes and nursing than a spica cast and can be
considered for infants up to 6 months of age. This is
particularly useful in the NICU where a spica would make
monitoring and care of the child very difficult (Fig. 13-7).

Figure 13-7 This infant was treated in a Pavlik harness and had quick
healing and remodeling of her fracture.

It is important to remember that the Pavlik does not

prevent motion at the fracture site, so the baby must be
moved very carefully—typically they will not move their
own leg when it hurts, but diaper changes may be quite
painful if the caretakers are not aware and gentle. You
should assess the parents and choose a treatment method
that they can manage. A splint gives a little extra
immobilization and decreases pain; a spica gives excellent
immobilization that makes a femur fracture relatively pain
free while it heals. Three to four weeks of immobilization is
typically adequate for children under 2 years of age.

Figure 13-8 Typical spica cast position for a very young child.

Application of Hip Spica Cast

For children under 2 years, anatomic alignment of the
femur fracture is not critical as they will remodel with
growth. As such, these casts may be put on in a variety of
settings: OR, ED, or clinic, with or without sedation
(although some pain medicine is required). A live (fluoro)
image is not necessary for application of the cast; if the leg
looks straight and in a good position, it will heal and
remodel satisfactorily.

We recommend putting the leg in a position that makes

care of the child as simple as possible. Usually the hip is
flexed and abducted 30 degrees with the knee flexed 30
degrees. The foot can be left out of the cast and a single leg
spica is usually adequate (Fig. 13-8) (see Chapter 5 for
details regarding spica cast application).

Remember that early spica application may prevent overall

inspection of the child (abdomen, pelvis, skin bruising, etc.)
and should be avoided if a child abuse workup is ongoing. A
splint is usually adequate to stabilize the fracture while the
workup is completed.
 Figure 13-9 This child has osteogenesis imperfecta and has been
treated with a Rush rod to prevent recurrent fracture and deformity.

Older non-walking children (with developmental delay,

cerebral palsy, spina bifida, etc.) often fracture with
minimal trauma because of osteopenia. These can typically
be treated in a well-padded single leg spica cast or a splint.
The duration of immobilization should be limited to 3-4
weeks as further immobilization will increase osteopenia
and the risk of fracture when the cast is removed. We
recommend including the foot in the cast if the child is
osteopenic to prevent fracture of the tibia at the lower end
of the cast. Position of the leg should be to make sitting in a
wheelchair comfortable once the fracture heals.
If a child has multiple insufficiency femoral fractures or
fragile bone conditions such as osteogenesis imperfecta,
intramedullary stabilization can be considered to prevent
future fractures. There are small diameter rods that can be
used in these children—Rush rods can be easily exchanged
as the child grows (Fig. 13-9), or a Fassier-Duval nail can
expand as the child grows to minimize surgeries.

“An excellent spica cast is easier to

apply with the patient asleep under
general anesthesia”

THE WALKING CHILD—AGE 2-6 YEARS

Although age guidelines are helpful, you also need to look
at the child when deciding on a treatment plan. A 6-year-
old gymnast who weighs 15 kg is not the same as a 6-year-
old football player who weighs 35 kg. A spica cast is often a
good option in this age group but there are instances where
internal fixation may give a better result.

These fractures are usually classified as Class 2: fractures

that should be treated without surgery but must be
watched closely. Once the child is over 2 years, alignment
in the cast is more important, so the fracture needs to be
reduced and held with a spica cast. If you have an
experienced team, you may consider doing this in the ED,
but we prefer to take these children to the OR for reduction
in a controlled setting, and an excellent spica cast is easier
to apply with the patient asleep under general anesthesia
(see Chapter 5 for spica technique).

End-to-end reduction is not required because the femur

tends to overgrow following a fracture in this age group.
Initial in-cast shortening of 1-1.5 cm is ideal and up to 2-3
cm is often acceptable.

Figure 13-10 A walking spica is much easier for a family to manage

than a traditional spica cast.

For low-energy fractures, with less than 2 cm of shortening

on initial x-ray, Flynn advises a single leg walking spica
(Fig. 13-10) which is much easier for the family to manage
and has been shown by several authors to be as effective as
a double-leg spica in children up to 6 years as long as there
is careful monitoring of the fracture and wedging or change
of cast if alignment is lost. If the foot is left out of the cast,
a waterproof cast can be applied, which increases ease of
care (caution: if the foot is included in the cast, or there is
more than 30 degrees of flexion at the hip or knee, do not
give the waterproof option as water will pool where the
cast is flexed and cause significant skin
problems/sloughing).
For higher-energy fractures, with more than 2 cm of
shortening, a 1½ leg spica cast may better maintain
alignment. A short leg cast should never be applied with
the intent of using the lower leg to apply significant
traction to the thigh as the remainder of the spica cast is
applied. This technique is easily overdone with risk of
compartment syndrome and/or dorsal foot ulceration.

For the first 3 weeks after cast application, weekly x-rays

should be obtained to confirm alignment is maintained. The
best time to wedge a cast is 10-14 days after casting and
should be done only by those who understand the risks of
cast wedging (see Chapter 5).

Figure 13-11 Proximal femoral fractures can be very difficult to hold

in a cast—they tend to get pulled into abduction and external
rotation. The cast needs to be applied to counteract these forces.

Proximal Fractures
Proximal femoral fractures often prove difficult to align in a
spica cast and may require fixation. The strong pull of the
iliopsoas, abductors, and external rotators pulls the
proximal fragment upward and outward (Fig. 13-11). The
spica needs to be applied with the hip in flexion, abduction,
and external rotation to align the shaft with the proximal
fragment (90-90 position with the heel over the contra-
lateral thigh). The parents should be warned at the outset
that treatment may change. If reduction is lost, the patient
may need to be converted to internal or external fixation to
optimize the outcome.

Midshaft Fractures
Midshaft fractures tend to drift into varus and procurvatum
(Fig. 13-12). The cast should be molded to create slight
valgus and recurvatum (Fig. 13-13). It is important to
evaluate rotation of the fracture both clinically and
radiographically as the proximal fragment will tend to
externally rotate.
 Figure 13-12 This child was lost to follow-up for 6 weeks after
placement in a spica cast; the x-ray shows the tendency of midshaft
fractures to drift into varus and procurvatum. Always be ready to
wedge a spica cast to prevent this deformity. Luckily, this child is
young enough that this will likely remodel with time.

Distal Fractures
For distal fractures, the gastrocnemius tends to flex the
distal fragment, causing recurvatum at the fracture site.
Flexing the knee will reduce this deforming force. Distal
femoral fractures can be aligned with a neutral varus-
valgus alignment—with the knee in 10-20 degrees of
flexion. Because of the increased risk for knee
malalignment in distal fractures, x-rays should include the
proximal tibia to ensure proper positioning in the cast.

Duration of Treatment
For children over 2 years, we recommend removing the
spica cast at 6 weeks for x-rays and a decision regarding
subsequent treatment. Usually there is adequate callus to
allow them to stay out of the cast at that time; older
children may need a long leg walking cast for a few more
weeks if x-rays are concerning for inadequate healing.

Figure 13-13 This is a good example of proper cast molding with

slight valgus and recurvatum.

Aftercare
Children just coming out of a spica cast will be reluctant to
weight bear on the leg. Just allow them to increase activity
as tolerated and warn the parents that the child may crawl
or cruise before they start walking. We discourage the
parents from pushing the child to walk quickly—the child
will walk when ready, and this may take several weeks
after cast removal. It is important for the parents to know
that when the child does start walking, they will limp for a
month or 2. Physical therapy is rarely needed. Slowing
them down is better than pushing them to get moving at
this age. Additionally, children under 8 years are usually
not coordinated enough to use crutches—they are more
likely to fall and break something else if this is attempted.

Pitfalls

Loss of alignment will lead to malunion if not caught early

and treated with a cast wedge or cast change at the
appropriate time.
If the fracture is out to length, the femur may overgrow
creating a leg length discrepancy that needs to be
monitored/ treated later in life.
If there is too much overlap, the femur may be short also
creating a leg length discrepancy.
Cast problems/ulcers/rash.
 The Flexible Nail Revolution (The Nancy Nail)
Jean-Paul Metaizeau (Nancy, France) popularized a method called
“L’embrochage centro-médullaire élastique stable” in the early 1980s. This
method, based on principles first developed in Romania, evolved into the
current method known in North America as “flexible nailing,” which has wide
application for treatment of children’s fractures. Lascombe, Parsch, Prevot,
Ligier, Slongo, Heinrich, Rang, and other helped to make this a widely used
method in North America. (Photo courtesy of Pierre Lascombe.)

CHILDREN AGE 7-12 YEARS

Although traction and spica casting are still options in this
age group, it becomes a greater burden for the working
family with a school-age child. Most surgeons in developed
countries select internal fixation in children over 6 years,
or children who are too heavy to easily carry in a spica
cast. Most in this age group are classified as Class 3:
fractures that benefit from load-sharing implants. This will
get the child back to normal activities, school, and sports
much more quickly than treatment in traction or a spica
cast.

Flexible or elastic intramedullary nails are now the

treatment option of choice for children up to 45 kg (100
pounds) with “length stable” femur fractures. The
advantages of flexible nails are that insertion avoids the
risk for femoral head avascular necrosis (seen after
piriformis entry site rigid nails) and avoids injury to the
physes. There is no reaming, so the endosteum remains
intact, which may expedite healing, and they are load
sharing, so the risk of re-fracture following removal of the
nails is not as significant as with other treatment methods.

Elastic nails have been studied extensively, and excellent

results can be obtained with this treatment method. They
can also be used in children younger than 6 years
(literature reports using flexible nails in 4- and 5-year-olds)
if the fracture is difficult to maintain in a cast because of
patient size, polytrauma, fracture instability, or if family
circumstances make spica cast treatment very burdensome.

There are reports of using flexible nails in children over

100 pounds and also achieving good results, but stiffer
stainless steel (rather than titanium) nails should be used,
and the risk of malunion increases as the child gets
larger/heavier.

Long spiral fractures or fractures with significant potential

to shorten may be better treated with other methods. In
general, flexible nails are selected for children age 7-12
years, under 100 pounds, and with length stable diaphyseal
fractures. If these guidelines are extended to heavier
children with unstable fractures, consider the addition of a
spica cast to help maintain alignment for the initial 3-4
weeks after surgery. We also use a supplementary spica in
any circumstance that is less than ideal (“wild child,” or
less than perfect surgical technique).
TECHNIQUE TIPS:
Flexible Intermedullary Nailing

1. Preoperative planning: Measure the narrowest diameter of the diaphyseal

canal. The width of each nail should be approximately 40% of this diameter
(e.g., if the canal diameter is 1 cm, use two 4-mm nails). Larger diameter
nails give better stability and decrease the risk of nonunion, but greater
than 80% canal fill risks additional comminution.
2. For most fractures, an entry point 1.5-2 cm above the distal femoral physis
in the metaphyseal flare is preferred. One nail should enter from the medial
side and one from the lateral side to stabilize varus/valgus angulation. With
distal entry sites, the two nails can both be “C” shaped (to get the medial
nail into the proximal portion, turn the nail into anteversion as it
approaches the femoral neck).
3. For distal fractures, consider a proximal entry point on the lateral aspect of
the femur just below the apophysis of the greater trochanter. The nails
should be pre-bent: One into a “C” shape and one into an “S” shape so that
one ends medially and one laterally in the distal femur.
4. The widest separation of the two nails should be at the level of the fracture.
5. Cut to leave 1.5-2 cm outside the bone for easy removal.

Variation of technique described by Ligier, Metaizeau, Prevot, and Lascombe.

Potential contraindications for use of flexible/elastic nails

or load sharing fixation:

Open, contaminated fractures, limb at risk (consider ex-fix).

Other life-threatening injuries that need to be
assessed/treated before definitive treatment of the femur
fracture (consider ex-fix).
Patients greater than 100 pounds (consider submuscular
plate or rigid antegrade trochanteric entry rod).
Comminuted fractures that are likely to shorten/rotate/lose
reduction with flexible nails (consider ex-fix or submuscular
plate). As flexible nails are not locked, they do not control
length and rotation well.

Flexible nails can be inserted retrograde or antegrade.

Choosing your starting point further away from the fracture
gives better fixation, so start distally for midshaft and
proximal fractures and start proximally for more distal
fractures. Measure the canal diameter on x-ray and plan to
use two rods with diameters that sum to approximately
80% of the canal diameter. Example: if the canal measures
10 mm, use two 4-mm rods (Technique tip box).
 Figure 13-14 Protective end caps are available that can be placed
over the tips of flexible nails to prevent the nails from backing out.

The nails need to be pre-contoured to maximize cortical

contact at the fracture site. If distal insertion is chosen, the
two nails can be contoured into a “C” shape with the
maximum bow at the fracture. One nail is inserted from
medial and one from lateral, above the physis (plan your
entry site so that the physis is not at risk from the drill or
the end of the nail lying against the physis that may disrupt
growth). Both nails should be of similar diameter and
generally pre-bent to a similar degree to avoid varus or
valgus deformity. The bending moments induced by the two
rods’ shape and size should balance each other.
Proximal insertion can be accomplished through a single
lateral incision (just below the greater trochanter
apophysis). Contouring the nails requires more attention
with one “C” shaped and one “S” shaped—to get opposing
bending moments at the fracture site. It is helpful to get an
intra-op x-ray with the rod lying on top of the thigh to
calculate where to place your bends. The “S” is often not
symmetric with the top of the “S” shorter and the bottom
longer.

Aftercare
If there is good fixation with the flexible nails, a cast is not
necessary. We often use a knee immobilizer and crutches
for comfort/support in the early post-op period; children
usually discard the brace when the pain subsides. This
allows the patient to ambulate independently and return to
school within a week.

Pitfalls

Malunion: varus, valgus, rotation, and shortening have all

been reported.
If the fracture is out to length, the fractured femur may
overgrow creating a leg length discrepancy.
Bursitis over the ends of the nails, especially if left “proud”
in the soft tissues.
Difficulty removing the nails if they were tamped in too far
during insertion.
Nails may back out and become prominent distally—end
caps may help prevent this (Fig. 13-14), but the end caps
themselves may be prominent in a small child.

CHILDREN AGE 12 YEARS AND OLDER

The majority of fractures in this age group are Class 4
femoral fractures: fractures that benefit from rigid fixation.
Treatment in this age group still provides treatment
choices. As with all femur fractures, traction is an option,
but surgical fixation is preferred. Locked intramedullary
nails, submuscular plating, and external fixation are good
options depending on surgeon skills and fracture pattern.
The literature has not shown a clear benefit of one method
over another—all can have excellent results if done well,
and each has its own potential complications/downsides
that will be discussed.

Trochanteric Entry Site Intramedullary Rods (See

Technique Tips)
Several companies make intramedullary femoral nails
designed for patients with open growth plates. They have a
lateral entry site (tip of the trochanter) to avoid damage to
the deep branch of the medial femoral circumflex artery in
the piriformis fossa. The risk of damaging this artery is
avascular necrosis (AVN) of the femoral head; risk is
greatest when the physes are still open with limited blood
flow across the open physis. Once the physes close, adult
piriformis entry site nails can be used if the surgeon
prefers this technique.
 Figure 13-15 A solid rod that fills the canal is idea for older children
(left). If there is concern for proximal stability, a “recon” nail can be
used, which allows screws to be placed up the femoral neck (right).

A solid nail that fills the reamed intramedullary canal offers

an ideal solution for the older child; fracture stability is
maximized allowing early weight bearing with no need for
casting or prolonged bed rest. With proximal and distal
locking screws, the fracture will be held out to length and
will not rotate. It is critical to get proper alignment and
rotation before locking the nail as whatever you have when
you leave the OR is the alignment/length you will have
when the fracture heals. There is a “recon” option that
places screws through the nail and up the femoral neck to
stabilize femoral neck or proximal femoral fractures (Fig.
13-15).
TECHNIQUE TIPS:
Interlocking Intermedullary Nailing

1. Pre-operative planning: the narrowest portion of the canal should be

measured on the x-ray to determine nail diameter—the canal should be
filled with the nail. Use contralateral leg to determine length—either a plain
x-ray or fluoroscopy with a ruler will ensure equal leg lengths. Note the
alignment of the uninjured leg to avoid fixing the fractured femur in
malrotation.
2. A fracture table with the leg adducted simplifies fracture reduction,
fluoroscopy, and nail insertion (but this can also be done on a flat,
radiolucent table).
3. The tip of the trochanter is usually palpable even on very large children (if
not, C-arm can be used as a guide); a guidewire can be inserted through
the skin and into the lateral side of the tip of the trochanter prior to making
any incision—this wire should never slip medially into the piriformis fossa
as this puts the vascular supply to the femoral head at risk.
4. A small incision is made, and an opening reamer is used. Then, a long
guidewire is inserted through the trochanter and down to the fracture,
guided by AP and lateral image views. Once the fracture is reduced, the
guide pin can be passed into the distal femur. Stop 1 cm above the physis.
If closed reduction is not possible, a small lateral incision can be made at
the fracture site to aid reduction and passing the guide wire.
5. The canal is sequentially reamed 1.5-2 mm larger than the planned nail
size. The nail is then inserted over the guidewire.
6. The guidewire is removed to allow proximal and distal locking screws to be
placed, which will maintain length and rotation.
There are smaller diameter lateral entry nails that can be
used in younger children—there are reports in the
literature of using a locked nail down to the age of 7 years.

Aftercare
The child can be weight bearing as tolerated—they typically
use crutches for a week or 2. We do not allow return to
contact sports until there is adequate callus noted on x-ray
(usually by 3 months). Locked intramedullary rods do not
need to be removed, but families may choose to have it
removed once the fracture is completely healed. If you are
going to remove the rod, do not wait more than a year. The
growing child may develop bone over the top of the nail
making removal difficult and trying to find the nail risks
disrupting the abductors that attach on the tip of the
trochanter. There will be some abductor disruption at the
time of insertion but trying to find and remove a buried nail
can be much more destructive.

Pitfalls

Heterotopic ossification may form around the entry site of

the nail that can be quite symptomatic and difficult to
treat. Thoroughly washing all reamings out of the
abductors may help prevent this phenomenon.
There may be permanent abductor weakness from
disruption of the insertion site during insertion and more
commonly during removal of the nail.
Bursitis over the tip of the nail.
There is a risk for non-union if the fracture is fixed with a
gap at the fracture site; however, this can usually be
overcome with dynamization of the nail (removing the
distal screw) if necessary.
There is risk of proximal femoral growth disturbance that is
usually not a problem in older children, but using these
nails in very young children may cause issues (Crosby et al.
reported two cases of proximal femur growth disturbance
in children).
Deep infection and malrotation have been reported.
 Figure 13-16 A. Note how distal femoral fractures tend to go into
recurvatum because of pull of the gastrocnemius. B. This cast was
wedged to correct the recurvatum. C,D. Because of continued
rotational malalignment, open reduction and internal fixation were
necessary to obtain and maintain alignment of this unstable fracture.

Submuscular Plating (See Technique Tips)

Minimally invasive techniques of plating the femur
resulting in less soft tissue disruption, no stripping of the
periosteum, and anatomic alignment by an indirect method
are feasible using the submuscular plating method. The
endosteum of the femoral canal is left intact—there is some
concern that reaming the intramedullary canal for a nail
slows healing. This technique has been adapted from adult
fracture management and is being used in younger children
with excellent results in several centers (Fig. 13-16).

This technique has been adapted from adult fracture

management and is being used in younger children with
excellent results in several pediatric centers. Scarring is
minimal, and plates can be removed through the same
percutaneous incisions as long as they are not left in too
long. Bone will overgrow the plate if it is left in longer than
a year in a growing child—we recommend removal at 6-8
months post-op to facilitate removal. As this is a load-
sharing device and not load bearing, the child should not
weight bear until there is visible callus on x-ray; usually 3-4
weeks for children less than 8 years and 5-6 weeks for
children over 8 years. If you have a very reliable child,
some consider no additional immobilization; however, a
cast is beneficial to protect the child while the fracture
heals.
TECHNIQUE TIPS:
Submuscular Plating of Femur Fractures

1. A fracture table or flat radiolucent table can be used.

2. The fracture is aligned using fluoroscopic guidance (reduction does not
need to be perfect as the plate can assist reduction). It is helpful to have
muscle paralysis and bumps to hold alignment if you use a flat table.
3. Determine if the plate will slide along the lateral femur better from proximal
or distal. In this example, the plate is inserted distally and aids in fracture
reduction.
4. Make a small incision through skin and IT band down to bone either 2 cm
proximal to the distal femoral physis or 2 cm distal to the trochanteric
physis depending on the fracture anatomy and where you want to start
sliding the plate.
5. Place a 20-gauge spinal needle at the anterior and posterior border of the
femur to be used as “goal posts” in sliding the plate along the lateral
surface in the submuscular layer.
6. A Cobb elevator or a plate with a contoured tip can be used to create the
path in the submuscular layer. A Kocher, or plate holder for a locking plate,
can be used to slide the plate along the femur to bridge the fracture.
7. Secure the plate proximally and distally with a wire. Confirm position of
plate with fluoroscopy. If reduction needs to be improved, a small incision
can be made at the fracture to aid reduction.
8. Screw placement—2-3 percutaneous bicortical non-locking screws proximal
and distal to the fracture screws are sufficient to stabilize most pediatric
femur fractures.

Operative photos courtesy of Mary Beth Deering, MD, Saint Mary’s Regional
Medical Center, Grand Junction, CO.

External Fixation
For Class 5 femur fractures: fractures in a patient with a
limb at risk and associated injuries that require initial
treatment precedence, external fixation provides a quick
method of stabilizing the fracture temporarily. External
fixation can also be used for definitive fixation, although
typically the external fixator is exchanged for internal
fixation once the patient is stable. An ex-fix allows easier
transport, treatment of life-threatening injuries, soft tissue
coverage, and neurovascular repair. Pins should be placed
away from the fracture, so as not to contaminate the field
for later fixation with a plate or rod.
 Figure 13-17 Airplane transportation is much easier in an external
fixator than a spica cast, which makes this option appealing for
hospitals serving tourist centers.

Airplane transportation is also much easier in an external

fixator (as compared to a hip spica cast). Thus, femur
fractures in the children of tourists at ski areas (who must
fly home after their holiday) are commonly treated with
external fixators (Fig. 13-17).

Half pins should be inserted perpendicular to the femoral

shaft. Keep pins out of the zone of injury. Two pins
proximal and two distal with a lateral bar is generally
adequate. Circular fixators are not usually necessary for
acute femoral fracture care. If the fixator will be left on
more than a week or 2, the IT band may need to be
released to allow knee motion.

Aftercare
Once the patient is stable and the soft tissue injuries to the
extremity have been addressed, the external fixator may be
exchanged for a rod or plate. If the fixator is left on for a
longer duration, the patient is kept toe-touch weight
bearing for 6 weeks. Pin sites need careful attention to
prevent infection.

Pitfalls

Pin tract infections that can contaminate the fracture and

prevent more definitive fixation.
Significant risk of refracture through the incompletely
healed fracture as well as pin tracts following removal of
the fixator (if internal fixation does not replace the fixator).

SUMMARY
There are a number of treatment options that should be in
every orthopedic surgeon’s armamentarium to adequately
treat the wide variety of femoral shaft fractures seen in
pediatric patients. Deciding which treatment is best for an
individual child requires an understanding of the age and
weight of the child, remodeling potential, fracture anatomy,
energy that caused the fracture, associated injuries, the
available resources, and your own skills.

SUGGESTED READINGS
Cage JM, Black SR, Wimberly RL, et al. Two techniques for retrograde flexible
intramedullary fixation of pediatric femur fractures: all-lateral entry versus
medial and lateral entry point. J Pediatr Orthop. 2017;37(5):299–304.

Crosby SN Jr, Kim EJ, Koehler DM, et al. Twenty-year experience with rigid
intramedullary nailing of femoral shaft fractures in skeletally immature
patients. J Bone Joint Surg Am. 2014;96:1080–1089.

Epps HR, Molenaar E, O’connor DP. Immediate single-leg spica cast for
pediatric femoral diaphysis fractures. J Pediatr Orthop. 2006;26(4):491–496.

Flynn JM, Curatolo E. Pediatric femoral shaft fractures: a system for decision
making. Instr Course Lect. 2015;64:453–460.

Flynn JM, Garner MR, Jones KJ, et al. The treatment of low-energy femoral
shaft fractures: a prospective study comparing the “walking spica” with the
traditional spica cast. J Bone Joint Surg Am. 2011;93(23):2196–2202.

Hedequist D, Bishop J, Hresko T. Locking plate fixation for pediatric femur

fractures. J Pediatr Orthop. 2008;28(1):6–9.

Keeler KA, Dart B, Luhmann SJ, et al. Antegrade intramedullary nailing of

pediatric femoral fractures using an interlocking pediatric femoral nail and a
lateral trochanteric entry point. J Pediatr Orthop. 2009;29(4):345–351.

Kong H, Sabharwal S. External fixation for closed pediatric femoral shaft

fractures: where are we now? Clin Orthop Relat Res. 2014;472(12):3814–3822.

Miller DJ, Kelly DM, Spence DD, et al. Locked intramedullary nailing in the
treatment of femoral shaft fractures in children younger than 12 years of age:
indications and preliminary report of outcomes. J Pediatr Orthop. 2012;32:777–
780.

Moroz LA, Launay F, Kocher MS, et al. Titanium elastic nailing of fractures of
the femur in children. Predictors of complications and poor outcome. J Bone
Joint Surg Br. 2006;88:1361–1366.

Shaha J, Cage JM, Black S, et al. Flexible intramedullary nails for femur
fractures in pediatric patients heavier than 100 pounds. J Pediatr Orthop. 2016.
[ePub ahead of print].
 14
Knee

Andrew Pennock
Eric Edmonds
Assessing the Patient
Radiographic Issues
Patellar Instability
Anterior Cruciate Ligament Injuries
Proximal Tibia Fractures
Patella Fractures
Distal Femur Fractures

“Education is what remains after one

has forgotten what one has learned in
school”
—Albert Einstein

INTRODUCTION
With our country’s fascination and enthusiasm for sports,
we are currently observing a dramatic rise in sports-related
pediatric knee injuries. When a child presents to the
emergency department or clinic with a traumatic
hemarthrosis, the most common diagnoses should be
considered a patella instability event, followed by a
ligament tear, although depending on the child’s age, a
fracture or meniscus injury should also be considered. In
these situations, it is important for the clinician to obtain
the correct diagnosis and initiate the appropriate treatment
because if unrecognized or mismanaged, a large number of
these patients will develop future arthritis or have future
disability (regardless of the their ability to return to sport).

Common Abbreviations—Knee
ACL = anterior cruciate ligament
PCL = posterior cruciate ligament
MCL = medial collateral ligament
LCL = lateral collateral ligament

ASSESSING THE PATIENT

An acutely swollen knee in a child may be difficult to
examine. Establishing a good rapport with the patient and
family prior to the examination, as well as distracting the
patient during the examination will assist with this process.
We also advocate examining the uninjured extremity first
so that the patient is more relaxed and comfortable with
you before proceeding with the more painful limb.

One of the most important findings on the examination is

the presence of an effusion, as this points to an intra-
articular source of pain. In a child who has had an injury,
fluid within the joint almost always signifies a severe knee
injury that will need formal treatment (Fig. 14-1). Palpation
is also important to identify the areas of greatest
tenderness. This will be an important clue as to what
anatomic structure was injured. Is the pain located at the
physis suggesting a fracture, or is it over the anterolateral
aspect of the lateral condyle with concomitant pain along
the course of the medial patellofemoral ligament
suggesting a patella instability event?
 Figure 14-1 Impaction injuries on the lateral femoral condyle can
lead to a medial patellar femoral ligament tear and a bone bruise on
the lateral femoral condyle.

The ligamentous exam should assess the medial

patellofemoral ligament with the patella apprehension test,
which is almost always positive in a patient who has
dislocated their patella. The Lachman test is most sensitive
for an ACL tear, but the pivot shift test is more specific. It
is frequently challenging to have a young patient with a
swollen knee relax enough to enable an adequate pivot shift
maneuver to be performed in the clinical setting.

“In a child who has had an injury, fluid

within the joint almost always signifies a
severe knee injury that will need formal
treatment”

The PCL is best assessed with the posterior drawer test,

but this does require one to flex the patient’s knee close to
90 degrees which may be painful and difficult for the
patient in the first hours or days after a knee injury. The
medial and lateral supporting structures of the knee can be
assessed with a valgus and varus stress test, respectively.
Isolated medial instability and gapping with the knee in 30
degrees of flexion is indicative of an isolated superficial
medial collateral ligament (sMCL) injury where as isolated
lateral gapping in 30 degrees of flexion is indicative of an
isolated fibular collateral ligament (FCL).

Figure 14-2 Diagram illustrating the posterior cruciate ligament

(PCL), anterior cruciate ligament (ACL), fibular collateral ligament
(FCL), posterior oblique ligament (POL), superficial and deep medial
collateral ligament (sMCL, dMCL), and popliteus tendon.
TECHNIQUE TIPS:
Test Used for Assessing the Injured Knee
Lachman Test

Knee flexed to 30 degrees. Anterior translation of the tibia indicates ACL tear.
Anterior Drawer Test

Knee flexed to 90 degrees. Anterior translation of the tibia indicates ACL tear.
Quadriceps Active Test
Knee flexed to 45 degrees. Contraction of quads will translate tibia anteriorly
if PCL is torn.
Pivot Shift

Flex knee while applying valgus stress and internal rotation. If ACL is
disrupted, the tibia (which is subluxated in extension) will reduce with knee
flexion.
Posterior Drawer Test
Knee flexed to 90 degrees. Posterior translation of the tibia indicates PCL tear.
McMurray Test

With valgus stress on the knee and external rotation of the tibia, flex and
extend the knee. A torn lateral meniscus will “pop.”
Apprehension Test
Lateral translation of the patella. Patient apprehension indicates patellar
instability.
Varus Stress

Knee flexed to 30 degrees. Opening of lateral joint space indicates LCL tear.
Valgus Stress
Knee flexed to 30 degrees. Opening of medial joint space indicates MCL tear.

Valgus instability in full extension always represents a

more severe injury involving a physeal fracture or a
complete tear of not only the MCL but also the posterior
oblique ligament (POL) and/or the cruciate ligaments.
Similarly, varus instability in full extension represents a
physeal fracture or a severe posterolateral corner injury
involving not only the FCL but also the popliteus tendon,
the popliteofibular ligament, and/or the cruciate ligaments
(Fig. 14-2).

In patients who have sustained high-energy knee injuries,

including knee dislocations and severely displaced physeal
fractures, a comprehensive neurovascular examination
must be performed. Many of these patients will have
traction injuries involving the peroneal nerve and, although
rare, some may have a vascular injury (typically an intimal
tear) of the popliteal artery that if not recognized early can
lead to a dysvascular extremity. In these cases, an ankle-
brachial index (ABI) should be obtained and if a value less
than 0.9 is obtained, further vascular studies should be
obtained, such as an arteriogram.
 Figure 14-3 Unilateral decreased internal rotation can be a sign of
slipped capital femoral epiphysis.

Finally, when assessing patients with knee pain, the hip

cannot be ignored as a possible source of pain. Each year,
we see at least one slipped capital femoral epiphysis
(SCFE) that was initially missed because an outside facility
listened only to the complaint of knee pain (referred) and
did not evaluate hip range of motion (Fig. 14-3).

RADIOGRAPHIC ISSUES
Children with an acute knee injury should have a standard
knee evaluation including an AP, lateral, merchant, and
tunnel view of the knee (Fig. 14-4). The merchant view
frequently is not obtained in primary care physician offices
or emergency departments, but it is often the key
radiograph depicting an avulsion fracture involving the
medial facet of the patella, all but confirming the diagnosis
of a patella dislocation (Fig. 14-5). Likewise, a tunnel view
is frequently the only view that a distal femur physeal
fracture or an osteochondritis dissecans lesion will be
visualized (Fig. 14-6).
 Figure 14-4 The AP, lateral, tunnel, and merchant views are a
common first step to clarify knee trauma.

Contralateral knee radiographs may be very helpful in

detecting more subtle pathology such as asymmetric
widening of the physis indicative of a physeal fracture or
abnormal patellar position that may be indicative of an
extensor mechanism injury. Recent literature suggests that
the presence of an effusion is highly predictive of a
significant knee injury; therefore we routinely obtain an
MRI in these patients.

PATELLAR INSTABILITY
The vast majority of children under the age of 14 who
present with a traumatic knee effusion will have
experienced a patella dislocation. Nearly all of these occur
in a lateral direction, but rarely medial instability can be
seen if the patient has undergone a previous lateral
release, or in patients with connective tissue disorders,
such as Down syndrome or Ehlers-Danlos syndrome.

Figure 14-5 Merchant view depicting a medial patellar femoral

ligament (MPFL) avulsion.

Occasionally patella dislocations will be associated with a

loose body; if this fragment is of substantial size (greater
than 1 cm), it may require arthroscopic removal or open
fixation (Fig. 14-7). Although there is some controversy as
to the optimal management of a first time dislocation, we
typically manage these non-operatively with a brief period
of immobilization (2-4 weeks) in a knee immobilizer
followed by physical therapy to strengthen the hip external
rotators (gluteus muscles) to control hip adduction and
knee valgus moments during activity, thus reducing the
risk for recurrence.
Figure 14-6 The tunnel view is often the only view in which to
discover a femoral condyle osteochondritis dissecans lesion.

Figure 14-7 Patellar instability with patellar fragment that required

open reduction and internal fixation (ORIF).
Yet, recurrent instability is a real concern after a first-time
dislocation and ranges from 14% to 88% depending on the
patient risk factors (Table 14-1). Patients with recurrent
patella instability will likely require surgical stabilization
that may involve a soft tissue procedure such as a medial
patellofemoral ligament reconstruction or a bony procedure
such as a tibial tubercle osteotomy (Fig. 14-8). This is a
very common injury and is what lay people mean when they
say, “my knee dislocated.” The injury is very common in
adolescents and teenagers, but less common in early
childhood. We see many cases in teenage females who are
somewhat loose-jointed, who have upper range genu
valgum (often with increased femoral anteversion), and
who are attempting sports (often not properly conditioned
for it).

Table 14-1 Jaquith and Parikh Predictors

of Recurrent Patellar Instability
Risk Factors Number of Risk Factors and Predicted Risk
of Recurrence
Trochlear dysplasia 0 Risk factors—14% recurrence risk
History of contralateral 1 Risk factor—30% recurrence risk
dislocation 2 Risk factors—54% recurrence risk
Skeletal immaturity 3 Risk factors—75% recurrence risk
Patella alta 4 Risk factors—88% recurrence risk
 Figure 14-8 A. Medial patellofemoral ligament reconstruction has
become the workhorse procedure for patients with patellar instability.
B. Patients with significant bony abnormalities may require a tibial
tubercle osteotomy as well.

ANTERIOR CRUCIATE LIGAMENT INJURIES

Anterior cruciate ligament (ACL) injuries are the 2nd most
common cause of a knee effusion in a child under the age
of 14 and are the most common cause in a teenager greater
than 14 years of age. Historically, ACL tears in the
skeletally immature have been managed non-operatively
and surgery has been postponed until the patient is done
growing.

Recently, there has been a dramatic shift in the

management of these injuries with almost all surgeons now
favoring early reconstruction in a knee with functional
instability (Fig. 14-9). The rationale is that left untreated,
these pediatric knees are at high risk of further meniscus
and cartilage damage. The various techniques for
reconstructing an ACL in the pediatric population are
beyond the scope of this chapter, but most authors will use
autograft tissue taken from the iliotibial band, the
hamstring tendons, or the quadriceps tendon.
 Figure 14-9 Nine-year-old who underwent a physeal sparing ACL
reconstruction.

PROXIMAL TIBIA FRACTURES

Tibial Spine Fractures
Tibial spine fractures have been called the pediatric
equivalent of an adult ACL tear, but we contend that the
pediatric equivalent of an adult ACL tear is a pediatric ACL
tear because we see approximately 5-10 ACL tears for
every tibial spine fracture. Regardless, these injuries
typically occur in the 8 to 14-year-old age group and
frequently occur while kids are skiing, biking, playing
football, or jumping on trampolines.

A CT scan may be helpful for assessing fracture

displacement and comminution. An MRI scan may be an
alternative that may also provide information about the
meniscus, which can be torn in up to 30% of these
fractures. Myers and McKeever originally classified these
injuries, but their classification has been expanded upon
over the years (Table 14-2). Nondisplaced or minimally
displaced fractures (less than 5 mm) respond well to non-
operative treatment including long leg casting in either 30
degrees of flexion or full extension. We will typically cast all
of our tibial spine fractures to see if extension of the knee
will help reduce the fracture; if there is concern about
residual displacement we then obtain a CT scan or MRI.
 Figure 14-10 Type III tibial spine fracture treated with a suture
anchor.

Fractures with residual displacement more than 5 mm

should be reduced and fixed, as these fractures are at
higher risk to have subsequent surgery for impingement
and instability. Surgery can be successfully performed
either arthroscopically or through an open arthrotomy (Fig.
14-10). It is not uncommon for either the meniscus or
intermeniscal ligament to be interposed in the fracture site
preventing reduction of the fracture fragment. Either
suture or screw fixation may be performed based on
surgeon preference and fracture configuration.
Complications are not uncommon with this fracture
including arthrofibrosis (10% incidence) or residual
instability requiring a future ACL reconstruction (10%
incidence). The duration of post-operative immobilization is
related to these complications with prolonged casting
increasing the possibility of stiffness; however, early
mobilization needs to be balanced with the need to protect
the fixation. As in multiple children’s orthopedic conditions,
you will have to “pick your poison”: too short of
immobilization = pseudo-arthrosis and loss of reduction,
too long immobilization = arthrofibrosis.
 Table 14-2 Classification of Tibial Spine
Injuries
Type I

Nondisplaced
Type II

Lifted anterior with posterior hinge

Type III
Complete separation of the spine
Type IV

Complete separation with comminution of spine

 Figure 14-11 Tibial tubercle fractures typically occur as the child is
leaping to take a shot in basketball. The quadriceps fire and avulse
the tubercle prior to “lift off.”

Tibial Tubercle Fractures

Tibial tubercle fractures occur almost exclusively in male
basketball players between the ages of 12 and 16 years.
The injury tends to happen when the quadriceps muscle
eccentrically contracts when an athlete is getting ready to
jump from the ground (Fig. 14-11). This relatively benign
injury mechanism is quite deceiving because extensive soft
tissue damage tends to occur with avulsion of the bone
periosteum and the anterior compartment musculature
(Fig. 14-12).

Upwards of 10% of these fractures will develop a

compartment syndrome; therefore we recommend that
these patients be admitted to the hospital overnight for
neurovascular checks. Although Watson-Jones and Ogden
described three types of acute fractures, we have published
a classification that is guided by patient skeletal maturity
and utilizes four types to help guide management via risk
stratification (Table 14-3). San Diego Types A and D usually
have little need for surgical intervention and can be treated
with immobilization, whereas Types B and C almost always
require surgical correction and fixation. Type B is most
commonly associated compartment syndrome, sometimes
acting like a knee dislocation relative to the neurovascular
posterior structures. Type C injuries require advance
imaging or at least an intra-articular surgical approach to
assess the extent of injury, as they not only involve the
weight-bearing surface of the proximal tibia, but can be
associated with meniscus injury. Nearly all of these
fractures are displaced and require surgical fixation. Two
to four screws are typically sufficient to secure these
fractures. The large surface area of exposed metaphyseal
cancellous bone enables these fractures to heal quickly,
and joint mobilization can normally be initiated 2-4 weeks
after surgery. Although these represent physeal fractures,
premature physeal closure and a resultant angular
deformity are quite rare because these injuries tend to be
“transitional” fractures that occur just prior to the physis
completely closing. Nonetheless, younger patients and their
families need to be counseled of this possibility, and they
should be followed with serial radiographs for a minimum
of 1 year or until skeletal maturity is reached (Fig. 14-13).
Figure 14-12 Tibial tubercle fractures are accompanied by significant
soft tissue damage. This figure illustrates interposed soft tissue being
manually removed.
 Table 14-3 San Diego Classification of
Tibial Tubercle Fractures
Type A—Tubercle Youth

The injury is isolated to the ossified tip of the largely cartilaginous tubercle.
Type B—Physeal
The physis is open. The epiphysis and tubercle fracture as a unit off the
metaphysis without intra-articular involvement.
Type C—Intra-articular

The physis is partially closed. The injury extends into the intra-articular
surface.
Type D—Tubercle Teen
The majority of the physis is closed. The injury is isolated to the distal aspect
of the tubercle.

Figure 14-13 Physeal closure and recurvatum following a tibial

tubercle fracture. The recurvatum required surgical correction.

PATELLA FRACTURES
The patella, an interesting sesamoid bone designed to
improve the lever arm of the quadriceps mechanism, is
initially cartilaginous and ossifies around 3-5 years of age.

Three patella pathologies tend to occur in children, two of

which may mimic an acute fracture (bipartite patella and
Sinding-Larsen-Johansson disease) and are relatively
benign and a third problem (patella sleeve fracture) that
can have devastating consequences for the child, if missed.
A bipartite patella develops when an embryonic growth
center of the patella does not fuse with the rest of the
patella. The resulting fibrous synchondrosis may then be
mistaken for a fracture. The most common bipartite patella
involves superolateral growth center (75%), but less
commonly a lateral secondary center of ossification (20%)
or an inferior bipartite (5%), may be identified (Fig. 14-14).

Figure 14-14 Distribution of common bipartite patellas.

If there is confusion, x-rays of the opposite knee may shed

light on the situation, although some cases are bilateral
(50%). To add more confusion, it should be noted that
although a bipartite patella is usually a normal variant (and
not the cause of pain), in rare cases a fracture may
propagate through the synchondrosis causing motion at
this junction (and symptoms). In rare cases, the secondary
center requires surgical treatment (excision, lateral
release, or fixation and possible bone grafting) (Fig. 14-15).
 Figure 14-15 Symptomatic bipartite patellas can be treated with
excision, lateral release, or fixation and possible bone grafting.

Sinding-Larsen-Johansson is a traction apophysitis of the

distal pole of the patella that is similar to Osgood-Schlatter
disease (a traction apophysitis of the tibial tubercle), which
occurs in a slightly younger age group 7-12 years old. With
repetitive trauma typically from running or jumping, the
cartilaginous portion of the inferior patella becomes
irritated and potentially fragmented (Fig. 14-16). In more
severe cases, it may actually be quite challenging to
differentiate SLJ from an acute fracture. The differentiation
is key because treatment of these two entities is completely
different.

On exam, the ability to perform a straight leg raise (even if

painful) more or less rules out a fracture. Once again,
contralateral radiographs may be helpful in this instance as
well if there is concern. Very rarely, an MRI will be
required to clarify the situation. Ultrasound may also be
useful if it is readily available in the clinic to assess for
fracture versus an apophysitis. The treatment for SLJ is
rest, activity modification, stretching, and in rare
circumstances a short course of immobilization.

Figure 14-16 Sinding-Larsen-Johansson

A patella sleeve fracture is extremely rare, but should not

be missed as the patient may be at risk of lifelong disability
(Fig. 14-17). Most patients with this injury will avulse the
inferior pole of the patella during the course of running,
jumping, or kicking, and they will immediately be unable to
bear weight or perform a straight leg raise. The key to
proper diagnosis typically resides on the lateral radiograph
where the patient will have patella alta, and possibly a
small bony avulsion just distal to the main patellar body.
 Figure 14-17 If missed, a patellar sleeve fracture can lead to lifelong
disability. The key is recognizing patella alta.

When displaced (which it nearly always is), the treatment is

surgical, because often a significant portion of the articular
surface is involved with the avulsion. Suture fixation, screw
fixation, and/or Kirschner wire fixation is possible
depending on the fragment size. A missed diagnosis leads
to chronic dysfunction of the knee extensor mechanism that
may be challenging to reconstruct in a delayed fashion
(Fig. 14-18).

Figure 14-18 A missed patellar sleeve fracture that required surgical

repair.
As an aside, transverse fractures through the substance of
the patella are uncommon in pediatric patients, but rarely
will occur in older teenagers. When widely separated, they
are best treated by the AO technique (parallel Kirschner
wires and a tension band); however, many are not
sufficiently displaced to require surgery and can be treated
with cast or knee immobilizer. Occasionally marked
patellar overgrowth can occur following patellar injury in
infancy.

Figure 14-19 Salter-Harris II distal femur fracture treated with screw

fixation.

DISTAL FEMUR FRACTURES

As previously discussed, the physis is a point of weakness
in the growing child. The distal femoral physis may be
disrupted in several ways as described by Salter and Harris
(see Chapter 2). Salter-Harris I type fractures are often not
visible on x-ray but can be suspected by a careful exam
(tenderness directly over the physis). True type I injuries
are rarely displaced and are well treated in a long leg cast
for 4 weeks. In many cases, with localized physeal pain
(and normal x-rays), you are not certain of the diagnosis. If
suspected in a younger patient, one could order an MRI, or
an alternative and more cost-effective treatment is to treat
them with a long leg cast for 2 weeks and then repeat the
x-rays out of cast. If callus is noted and a fracture is
confirmed, the child is casted for 2 or 3 more weeks.
 Figure 14-20 Salter-Harris III distal femur fracture treated with screw
fixation.

Salter-Harris II injuries of the distal femur (Fig. 14-19) are

common and are concerning because of their tendency to
produce physeal closure. Riseborough reported that 11 out
of 25 patients with distal femoral Salter-Harris II injuries
experienced subsequent physeal closure and leg length
discrepancy greater than 2.4 cm. X-rays often demonstrate
a large Thurston-Holland fragment; the fracture often
reduces easily with varus or valgus force depending on the
injury. Following anatomic reduction, these fractures can
be placed in a hip spica or long leg cast. If the reduction is
unstable, percutaneous pinning should be performed. A few
require open reduction secondary to entrapped periosteum.

The issue of cast type following closed reduction merits

discussion. A long leg cast alone will not assure
maintenance of reduction in a rowdy teenage male.
Bending the knee to 90 degrees and adding a pelvic band
provides more stability. If K-wires are used, a long leg cast
should be enough. It should be noted that these K-wires, in
their trans-cutaneous nature, are at risk for propagating an
infection into the joint that may predispose to joint sepsis.
Consideration may be given to burying these wires under
the skin and removing them at a later time once the
fracture has healed. Finally, the family must be made
aware of the high risk for physeal closure and the patient
followed accordingly.

Salter-Harris III injuries are a relatively rare fracture

pattern that typically involve the medial femoral condyle
(MFC) and typically occur in teenage male football players.
This injury, which has been called a football “clipping
fracture,” normally occurs after the shoulder or helmet of
an opposing player collides with the lateral aspect of the
knee creating a valgus moment. The MCL, which is
stronger than the physis in these adolescent athletes, then
avulses the MFC.
Like most type III injuries (e.g., Tillaux), these fractures
tend to occur as the physis is closing, so the risk of
deformity or leg length discrepancy following this injury is
less likely. We have found that these injuries can be initially
missed on presentation 39% of the time, often because of
their subtle appearance on x-ray. This has important
implications because if missed and left untreated, these
fractures are susceptible to late displacement. Although
some have advocated treating these fractures non-
operatively, we favor surgery because it allows early
mobilization, avoids the issues of late displacement, and
has good outcomes. Be aware that over 10% of these
injuries will be associated with other intra-articular injuries
(most commonly a tear of the ACL) (Fig. 14-20).

Figure 14-21 10% of Salter-Harris III and IV fractures will be

associated with other intra-articular injuries, most commonly an ACL
tear.
Type IV injuries are the least common distal femur physeal
fracture and may involve either the MFC or the lateral
femoral condyle. Because these fractures tend to occur
from high-energy mechanisms such as motor vehicle
accidents, pedestrian versus automobile accidents, and
bike injuries, they are at high risk of premature physeal
closure especially in the younger age groups (females less
than 12 years of age and males less that 14 years of age)
(Fig. 14-21). Similar to Salter-Harris III fractures, anatomic
reduction is required to minimize the chances of a
premature physeal closure and to prevent arthritis (by
anatomic joint surface reconstruction).

SUGGESTED READINGS
Abbasi D, May MM, Wall EJ, et al. MRI findings in adolescent patients with
acute traumatic knee hemarthrosis. J Pediatr Orthop. 2012;32(8):760–764.

Anderson AF. Transepiphyseal replacement of the anterior cruciate ligament

using quadruple hamstring grafts in skeletally immature patients. J Bone Joint
Surg Am. 2004;86-A(Suppl 1, Pt 2):201–209.

Askenberger M, Arendt EA, Ekström W, et al. Medial patellofemoral ligament

injuries in children with first-time lateral patellar dislocations: a magnetic
resonance imaging and arthroscopic study. Am J Sports Med. 2016;44(1):152–
158.

Crawford EA, Young LJ, Bedi A, et al. The effects of delays in diagnosis and
surgical reconstruction of ACL tears in skeletally immature individuals on
subsequent meniscal and chondral injury. J Pediatr Orthop. 2017. [ePub ahead
of print].

Edmonds EW, Fornari ED, Dashe J, et al. Results of displaced pediatric tibial
spine fractures: a comparison between open, arthroscopic, and closed
management. J Pediatr Orthop. 2015;35(7):651–656.

Flynn JM, Skaggs DL, Waters PM. Rockwood and Wilkins’ Fractures in
Children. 8th ed. Philadelphia, PA: Wolters Kluwer; 2014.

Kocher MS, Micheli LJ, Zurakowski D, et al. Partial tears of the anterior
cruciate ligament in children and adolescents. Am J Sports Med.
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Mubarak SJ, Kim JR, Edmonds EW, et al. Classification of proximal tibial
fractures in children. J Child Orthop. 2009;3(3):191–197.
Nguyen CV, Farrow LD, Liu RW, et al. Safe drilling paths in the distal femoral
epiphysis for pediatric medial patellofemoral ligament reconstruction. Am J
Sports Med. 2017;45(5):1085–1089.

Pandya NK, Edmonds EW, Roocroft JH, et al. Tibial tubercle fractures:
complications, classification, and the need for intra-articular assessment. J
Pediatr Orthop. 2012;32(8):749–759.

Shea KG, Styhl AC, Jacobs JC Jr, et al. The relationship of the femoral physis
and the medial patellofemoral ligament in children: a cadaveric study. Am
J Sports Med. 2016;44(11):2833–2837.

Vander Have KL, Ganley TJ, Kocher MS, et al. Arthrofibrosis after surgical
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fractures in children-38 patients with a minimum follow-up of 1 year. J Orthop
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 15
Tibia and Fibula

Andrew Pennock
Maya Pring
Assessing the Patient
Anatomy
Radiographic Issues
Classification
Proximal Metaphyseal Fractures
Diaphyseal Fractures
Distal Metaphyseal Fractures

“The beautiful thing about learning is

nobody can take it away from you”
— B.B. King

INTRODUCTION
Tibia and fibula shaft fractures heal so much more readily
in children than in adults that they should be a joy to treat.
The majority of children have a cast applied and only
require a cast shoe and a note for school outlining their
limitations.

Most tibial fractures in children are stable, and the child

can soon be weight bearing in an above knee (long leg)
cast. However, there is more variation to these fractures
than is generally realized. If foresight is to be used to
prevent problems in treatment, the characteristics of the
fracture should be well understood. In this chapter, we will
present tibia and fibula shaft fractures and discuss common
variations according to their anatomic location. Proximal
tibia epiphyseal fractures including tibial tubercle fractures
are discussed in Chapter 14, and distal tibia epiphyseal
fractures are discussed in Chapter 16.

Figure 15-1 Congenital pseudoarthrosis of the tibia and fibula. This

should not be confused with an acute fracture.

ASSESSING THE PATIENT

A non-walking child with a tibia fracture should always
alert you to think about non-accidental trauma or child
abuse. Make sure the described mechanism is consistent
with the fracture. If there is any concern, have social work
evaluate the child and family.

Evaluate the x-rays carefully as pseudoarthrosis of the tibia

may be seen in very young children with no trauma—this
can indicate underlying pathology such as
neurofibromatosis. Look for tapered bone ends,
smooth/sclerotic non-healing ends of the bone (Fig. 15-1).

Toddlers often have a twist and fall and sustain low-energy

non-displaced spiral fractures. The child with a fracture will
be exquisitely point tender at the location of the fracture
and usually will not walk. A child that will crawl but will not
walk likely has pathology below the knee. X-ray may not
show the fracture initially, so a careful exam is important.
If there is not a clear fracture on x-ray, think about
infection as metaphyseal osteomyelitis is not uncommon in
children. Leg pain is also a classic presenting complaint for
children with undiagnosed leukemia. Do not assume there
is a fracture just because there is a history of fall—if you
don’t see it, consider labs including CBC with differential,
CRP, and ESR.

As children get older and become adolescents, more force

is necessary to fracture the tibia and soft tissue injury
becomes more of a concern. For high-energy injuries,
monitoring for compartment syndrome is critical. We admit
all tibia fractures over the age of 6 for monitoring following
reduction. One of the predictors of compartment syndrome
after tibial fracture is age of the patient. In a study of 1,388
patients, McQueen showed the highest prevalence of
compartment syndrome was between 12 and 19 years of
age—youth was the strongest predictor of developing
compartment syndrome.
 Figure 15-2 Neurovascular anatomy inferior to the knee joint.

ANATOMY
The tibia is subcutaneous for most of its length, so
displaced fractures can be easily identified. Because of the
lack of soft tissue over the medial face, open fractures are
more common than with other bones with a good soft tissue
envelope; look carefully for the grade I open inside to
outside fracture. Even if the fracture is not open, the skin is
easily compromised and may subsequently necrose, so we
recommend reducing a displaced tibia fracture sooner
rather than later to protect the soft tissues.
 Figure 15-3 The four compartments of the lower leg.

The popliteal artery trifurcation is firmly adherent to the

posterior aspect of the proximal tibia and is at risk of injury
with more proximal fractures. The anterior tibial artery
passes over the proximal edge of the interosseous
membrane into the anterior compartment and is closely
applied to the tibia. Because of this fixed position, the
artery may be compressed, stretched, or torn. The peroneal
nerve wraps around the proximal fibula and is at risk of
injury with proximal fibula fractures (Fig. 15-2).

There are four muscle compartments in the leg: anterior,

lateral, posterior superficial, and posterior deep (Fig. 15-3).
The leg is the most common site to develop compartment
syndrome following injury including tibia and fibula shaft
fractures—see Chapter 19 for more information on
identifying and treating compartment syndrome.
RADIOGRAPHIC ISSUES
Rotation of a spiral fracture may be difficult to judge on x-
ray, so clinical exam is very important. Know the rotation of
the contralateral foot compared to the knee before you
start your reduction as rotational deformity does not
remodel and is more difficult for the child to compensate
for.

Figure 15-4 Pathologic fracture through tibial non-ossifying fibroma.

AP and lateral x-rays are critical; sometimes oblique x-rays

help better define the fracture pattern. Evaluate carefully
for a pathologic fracture. It is not uncommon to have a non-
ossifying fibroma that weakens the bone. Other cysts and
malignant tumors can also cause fracture and need to be
treated appropriately (Fig. 15-4). If there is significant
comminution, or concern for pathologic fracture, CT may
be helpful.

CLASSIFICATION
Physeal and intra-articular fractures at the knee and ankle
are reviewed in Chapters 14 and 16 respectively. The
majority of tibial fractures are isolated; 30% will have an
associated fibula fracture. Tibia and fibula shaft fractures
in children are classified by location (proximal—
metaphyseal, shaft, distal—metaphyseal), and type of
fracture (buckle, greenstick, spiral, oblique, transverse,
comminuted) (see Chapter 1).

Lewis Cozen
1911-2001

Cozen was born in Montreal, Canada, but moved to Los Angeles at age 11.
He received his certification from the American Board of Orthopaedic Surgery
in 1940 and joined the military soon after. He was stationed in England during
D-Day and treated many of the soldiers that were wounded on the beach in
Normandy.
In 1971, Cozen wrote a paper describing progressive genu valgum following
proximal tibial metaphyseal fractures in children. This fracture is now
generally referred to as the Cozen fracture.
PROXIMAL METAPHYSEAL FRACTURES
Often masquerading as “innocent little cracks,” neglected
or missed proximal metaphyseal fractures can lead to
significant problems for the patient. Two distinct types of
fracture occur in this region, each with its own distinct set
of complications.

Cozen Fracture
Metaphyseal greenstick fractures in children between the
ages of 3 and 10 years are known as Cozen fractures. A
valgus-directed force causes the medial cortex of the
proximal tibia to open slightly. The x-ray angulation is
typically unimpressive, and most of these fractures are
accepted and are casted in situ following the adage that
children’s fractures, particularly in younger children, can
be expected to remodel and do not require exact angular
correction. When the cast is removed, the child holds the
leg flexed making it difficult to see hip to ankle alignment,
so it is difficult to know if the leg is in valgus to start and/or
if the leg subsequently grows into valgus (Fig. 15-5). It may
be a combination of these two factors, but it is important to
remember (and warn the parents) that Cozen fractures are
known for late valgus deformity. Luckily, this usually
resolves without intervention, but the broken leg may
appear more knock-kneed for a year or two, which can be
quite upsetting to the parents. If the deformity does not
resolve with growth, these fractures happen in a young
enough age group that guided growth is an option for
correcting valgus before skeletal maturity. Very rarely,
osteotomy of the tibia may be needed to restore alignment.
 Figure 15-5 Progressive deformity following a Cozen fracture.

Why Progressive Valgus?

Several studies have suggested that the valgus was due to
overgrowth of the medial tibia because of fracture
hyperemia while the intact fibula acted as a tether. Aronson
found that dividing the periosteum around the medial half
of the proximal tibia in animals produced valgus deformity.
This may be due to mechanical release of the restraint the
periosteum imposes on the growth plate. Likely the
mechanism is multifactorial.

It has been our experience that if the fracture is

anatomically reduced, significant late valgus is less likely.
Sometimes anatomic reduction requires completing the
fracture, and on occasion, the medial gap cannot be
reduced by closed manipulation because of soft tissue
interposition. Both the lower part of the pes anserinus and
the thick periosteum avulsed from the lower fragment can
be entrapped (Weber). In this instance, open reduction is
needed to ensure reduction. Once open reduction is
performed, the fracture is usually pinned to maintain
reduction.

Complete Proximal Tibia Metaphyseal Fractures

The anterior tibial artery passes over the proximal edge of
the interosseous membrane into the anterior compartment
and is closely applied to the tibia (Fig. 15-6). Because of
this fixed position, the artery may be compressed,
stretched, or torn. The initial sign of vascular damage may
be a cold, pale, pulseless leg that in about an hour becomes
anesthetic and paralyzed, but often the findings are more
subtle and appear slowly. Muscle ischemia alone is less
dramatic; warm skin has misled many.

With a proximal fibular fracture, the temptation to blame

calf and foot neurologic signs of ischemia on local peroneal
nerve damage should be resisted. Arterial compromise
and/or compartment syndrome must be suspected.
Reduction is urgent because correction of the displacement
and angulation may restore the circulation. An arteriogram
or MR angiogram may be helpful but should not overly
delay intervention. If an arterial repair is performed or
compartment syndrome is diagnosed, four compartment
fasciotomies should be performed with internal fixation of
the fracture to protect the soft tissues (including the
vascular repair) from further trauma.
 Figure 15-6 Proximal tibial metaphyseal fractures put the anterior
tibial artery at risk.

DIAPHYSEAL FRACTURES
Toddler’s Fracture
Children under the age of 2 years may present with a
painful limp or refusal to walk because of an occult tibia
fracture. The injury may or may not have been witnessed.
Toddlers often fall, and a rotational stress can cause an
oblique distal tibia fracture or spiral non-displaced shaft
fracture.
For a limping child with a suspected toddler’s fracture, the
examination should start on the uninvolved side to provide
a comparison for the symptomatic extremity. Examine the
area you think is broken last — once you make the child
cry, the rest of the exam is very difficult. Gently palpate the
foot and examine for any swelling or ecchymosis. Palpate
the knee and thigh and log roll the hip; if you grab the tibia
to rotate the hip, you will cause pain and may mistakenly
think the problem is more proximal.

AP and lateral radiographs of the tibia and fibula should be

obtained but are often normal. The fracture may not be
visible on the initial radiographs especially if the injury is
less than a week old.

If a toddler’s fracture of the tibia is suspected but the x-ray

is normal, we usually get a CBC with differential, ESR, and
CRP to rule out infection and leukemia. If the laboratory
studies are normal we then apply a walking cast for 3
weeks. Repeat radiographs in 3 weeks will often show
periosteal new bone formation, which helps to confirm the
diagnosis (Fig. 15-7).
 Figure 15-7 Toddler’s fracture. The oblique fracture line on the injury
film is very hard to see. The child was treated with a long leg cast.
Three weeks later, the presence of healing callus confirms the
diagnosis.

Diaphyseal Fractures in the Child and Adolescent

With an intact fibula, a tibia fracture may go on to varus
deformity with posterior bowing unless the cast is molded
into valgus with added posterior molding to prevent
recurvatum (Fig. 15-8). The bowing may not be apparent
on initial films but commonly develops in the course of 2 or
3 weeks if the cast is not suitably molded. It is a deformity
more easily prevented than corrected.
Displaced mid shaft diaphyseal fractures are common;
however, a distinction should be made between low- and
high-energy trauma to predict the extent of soft tissue
injury. In the majority of cases, the fibula is intact. In
children these fractures are often stable and minimally
displaced because of the more resilient periosteum,
whereas in adolescents these fractures are frequently
displaced and need more aggressive treatment.

In a child, the recoil of the intact periosteum holds the

fracture in good position. Displacement is much more
common when both bones are fractured than when the
fibula is intact.

Cast Immobilization
Low-energy, nondisplaced fractures are immobilized in a
long leg cast applied in two segments with the child’s leg
hanging over the side of the bed. The leg-calf segment
should be applied with the limb in a vertical position to
ensure the best possible reduction. Casting with the patient
supine may lead to posterior angulation (recurvatum
deformity) due to the effect of gravity (Fig. 15-8). In the
“two-segment” application method, good padding is
required at the juncture (felt is ideal). The knee is then
extended with the remainder of the cast applied.

The knee is then flexed 10-15 degrees and the ankle casted
in neutral flexion, if possible, to allow for early weight
bearing in stable fractures. It is important to mold the cast
at the fracture site and also at the foot arch and over the
tendo Achillis to minimize loosening of the cast, avoid
fracture displacement, and prevent heel pressure sores
(see Chapter 5).

If you wish to prevent walking on an unstable fracture,

consider flexing the knee beyond 60 degrees. Note—Most
energetic children will still walk on the cast with less
flexion (less than 45 degrees). There are only two rational
choices (15 degrees knee flexion—walking OK and greater
than 60 degrees flexion—can’t walk). X-rays should be
performed after casting to ensure adequate fracture
position.
 Figure 15-8 Casting a tibia fracture with the patient supine may lead
to posterior angulation (gravity effect) (A, B). A better method is to
make the cast in two sections. Apply the short leg last first with the
limb hanging over the edge of the table; then position the patient
supine and complete the long leg cast (C, D).

Fractures Requiring Reduction

Most simple fractures may be reduced in the ED; however,
significantly displaced tibia fractures may be better
managed in the OR setting with ideal analgesia (general
anesthesia), more help, and a regular image intensifier.
What is an acceptable position? Rotation should be
accurate because the knee and ankle are hinge joints and
residual rotation will be noted by the patient. Rotational
malalignment does not remodel. If the child is under 8, the
goal is to obtain at least 50% apposition of the tibia and
less than 10 degrees of angulation in the coronal plane, less
than 15 degrees in the sagittal plane. As patients get closer
to skeletal maturity, less than 5 degrees of coronal
angulation is accepted, but 10 degrees of sagittal
angulation is still acceptable in adults.

The cast is univalved to allow for swelling (bivalved in

severe fractures). Most significant tibial fractures are
admitted overnight to monitor for swelling and signs of
compartment syndrome. The leg should be elevated for 3-4
days.

Monitoring Reduction
Fracture alignment must be monitored closely during the
first 3 weeks after reduction. Occasionally, a full cast
change either in clinic or under general anesthesia is
required 2-3 weeks after injury to realign the fracture. Or
the surgeon may choose to proceed with internal fixation if
the cast is not holding the reduction adequately.

Some advocate wedging the cast in the clinic during the

first 2-3 weeks to correct angulation (see Chapter 5).
However, it is important to remember that the tibia does
not have a good soft tissue envelope like the femur does.
The parents should be made aware of the potential for skin
necrosis and compartment syndrome after wedging of leg
casts. When the opening wedge is created, the cast will
buckle on the contralateral side—if this buckle is over the
medial subcutaneous tibia, it can quickly cause skin
necrosis. This will be very painful for an hour or two, but
then the skin dies and is no longer sensate—you may not
know until you remove the cast that a full-thickness ulcer
has been created. By then you may have associated
infection and exposed bone. Wedging must be done with
extreme caution. Those in our practice who wedge casts
typically perform an opening wedge correction at about 2
weeks post fracture when callus has begun to form (this
initial stickiness minimizes the chance for recurrence of
angulation).
 Figure 15-9 There is an increased risk for skin complications when
wedging the tibia. Pay close attention that a kink does not occur in
the cast.

First, a transverse cut is made opposite the apex of the

fracture (perpendicular to the long axis of the tibia). A
small segment of the cast is left intact directly over the
apex of the angulated tibia utilizing two longitudinal stress
relief saw cuts. A cast spreader is placed into the cast
opposite the apex of the bone, and the cast is opened. A
plastic block of appropriate size (usually 1-2 cm) is placed
into the opened segment, and the cast is initially wrapped
with tape (for x-ray alignment check) and then over-
wrapped with casting material (Fig. 15-9).

In the presence of a stable fracture pattern, the patient is

allowed to start weight bearing with the help of a cast shoe
once the cast is overwrapped (univalve closed 7-10 days
post fracture). If the fracture is unstable, weight bearing is
delayed for 4 weeks until early callus is present.
In infants, the bone unites in 3 weeks. In older children the
initial cast is usually removed after 4-6 weeks. but some
teenagers will take 10-12 weeks or longer to heal. In such
cases, after 6 weeks, the patient is transitioned into a
patellar-tendon-bearing cast, short leg (below knee)
walking cast, or fracture brace.

When the cast is removed, young children may revert to

crawling for a week or two and should be allowed to
ambulate as tolerated. Children over 8 are typically
coordinated enough to use crutches if needed (we typically
do not trust children under 8 to maintain balance and
safety with crutches). A limp owing to calf wasting and
stiffness will persist for several months after the cast is
removed. Warn the parents about this to save many anxious
phone calls.

“A limp owing to calf wasting and

stiffness will persist for several months
after the cast is removed. Warn the
parents about this to save many anxious
phone calls”

Adolescents Require More Attention

A recent analysis of our institution’s experience with
adolescent patients with displaced tibia fractures requiring
a closed reduction under anesthesia or conscious sedation
showed that the majority of fractures could be managed
non-operatively. Ultimately though, 40% of patients went
on to surgical intervention with the placement of an
intramedullary nail. Risk factors for loss of reduction
included fractures with an associated fibula fracture and
fractures with initial tibial displacement greater than 20%
of the width of the tibia. Although we still favor an attempt
at non-operative treatment for these patients, families need
to be counselled accordingly and patients need to be
observed closely in the first few weeks after their injury.

Operative Treatment
As mentioned above, unstable fractures of the tibia and
fibula may require operative reduction and stabilization,
especially in older adolescents. Open fractures, obese
patients, segmental fractures, poly trauma, and floating
knees are also typically treated surgically. Methods of
fixation include percutaneous K-wires, external fixation,
plates and/or screws, intramedullary flexible nails, and
rigid intramedullary nails. Indications for operative
treatment include irreducible fractures, fractures that
cannot be maintained in a reduced position, fractures
associated with compartment syndrome, open fractures,
multiple system injuries and the so-called floating knee
(fracture of both the tibia and femur in the same limb).
 Figure 15-10 This child had a distal third tibia fracture that was
treated with K-wire fixation and casting.

K-wires
In patients younger than 6 years with open or unstable
fractures, percutaneous K-wire fixation can be used in
conjunction with a long leg cast (Fig. 15-10). This is usually
best for metaphyseal fractures that heal quickly and not
diaphyseal fractures. The K-wires are usually left outside
the skin with felt over the pins to protect the skin and
prevent movement of the pin inside the cast. The pins are
removed no later than 4 weeks after surgery. Pins left in
longer than this may increase the chance of infection.

Flexible Nails (See Technique Tips)

In patients older than 6 years of age with wide-open growth
plates, flexible intramedullary nails are the current
preferred method for stabilization of fractures requiring
operative intervention (Fig. 15-11). The nails are inserted
from the proximal metaphysis of the tibia below the physis.
Two “C-shape” nails are typically inserted, one from the
anteromedial aspect and the other from the anterolateral
aspect of the metaphysis. An alternative is to insert one “C-
shape” and one “S-shape” nail both from the anteromedial
aspect of the metaphysis. If the fracture cannot be reduced
by closed manipulation, the fracture site is exposed
through a small incision to facilitate passage of the nails.
The nails vary in diameter between 2 and 4 mm and should
be selected so that each fills 40% of the medullary canal
diameter measured at the isthmus of the tibia (2 nails will
fill 80% of the canal diameter).

Figure 15-11 In skeletally immature patients older then 6 years,

flexible intramedullary nails are the current preferred method for
stabilization.
In the older adolescent with open physes and wider
intramedullary diameter, it may be necessary to stack the
nails by using two “C-shape” nails inserted anteromedially
and two “C-shape” nails inserted anterolaterally to provide
sufficient fracture stability. Bauer showed good results with
this quadruple Elastic Stable Intramedullary Nailing (ESIN)
technique.
TECHNIQUE TIPS:
Flexible Intermedullary Nailing

1. Patient is positioned supine on the operating room table ensuring that C-

arm can be brought in easily. The surgeon should be able to see the pre-op
and intra-op x-rays easily.
2. A small vertical incision is made distal to the physis on the medial and
lateral aspects of the metaphysis.
3. A drill hole is made on either side of the proximal tibia taking care to avoid
the tibial tubercle.
4. The nails are pre-bent to have maximum convexity at the fracture site.
5. Nails are inserted to the fracture; the fracture is reduced.
6. Nails are passed into the distal tibia stopping just above the physis with one
tip medial and one lateral.
7. The nails are cut proximally so that the cut end lies against the metaphysis
—it should not rest on the physis as this may injure the perichondrial ring.
8. A splint is applied for soft tissue rest; this can be removed at the first post-
op visit if the nails provide good stability to the fracture.

Pitfalls of Flexible Nails

Similar to femur fractures, anatomic alignment of tibia
fractures in young patients can lead to overgrowth and
resultant leg length discrepancy. Heavier patients may be
at risk of malunion with flexible nails; however; Goodbody
showed that with skilled insertion and post-op care, elastic
nails can be used for tibia fractures of older/heavier
patients with good results. Pandya et al. showed a high risk
of compartment syndrome (20%) after flexible
intramedullary nailing of pediatric tibial shaft fractures
with both open and closed injuries. Those who developed
compartment syndrome were heavier (greater percentage
over 50 kg) and were more likely to have
comminuted/complex fracture patterns.

Plate Fixation
An alternative treatment strategy in these skeletally
immature patients is plate fixation (can be inserted
percutaneously and submuscularly) or lag screw only
fixation. These techniques work particularly well for
oblique fracture patterns especially if the fracture site is
already open. If three lag screws can be placed, a plate is
not necessary. If a plate is used, if placed anterolaterally on
the tibia underneath the anterior compartment
musculature, it is less likely to be symptomatic (Fig. 15-12).
 Figure 15-12 Plate fixation is an alternate treatment strategy in the
skeletally immature patient with a tibia fracture. Note: This
anteromedial plate is subcutaneous—a lateral submuscular plate may
be less symptomatic.

Rigid Intramedullary Nails

In patients with closed physes or very near skeletal
maturity, rigid, interlocking nails provide excellent stability
and may alleviate the need for post-operative
immobilization (Fig. 15-13). This can be done with an
infrapatellar or suprapatellar approach. If the guidewire
cannot be passed into the distal fragment, a small incision
can be made to aid with fracture reduction and passage of
the IM nail.

Open Fractures
Approximately 10% of pediatric tibia fractures are open.
Most are grade I, but knowing how to treat limb
threatening grade II and III fractures is critical. Open
fractures may be the result of being hit by a car, fall off a
dirt bike, or other motorized vehicle accidents. These are
high-energy fractures. The wounds are often small and
represent a puncture wound from within. They should be
treated with thorough operative debridement and internal
fixation in a timely fashion.

Figure 15-13 In adolescents with closed physes, rigid interlocking

nails provide excellent stability.

In the emergency department, the patient’s tetanus status

is updated as necessary and antibiotics are started.
Antibiotic coverage and duration depends on the grade of
the open fracture and presence or absence of gross
contamination. Almost all patients are taken to the
operating room for irrigation and debridement. However,
several centers are now studying the concept of treating
grade I fractures with ER cleansing plus intravenous
antibiotics. Great experience and judgment are required to
elect this course. As an institution, we still favor surgical
debridement for all cases that are clearly open.

In the OR, clean grade I and II open fractures can be

stabilized with percutaneous pins or intramedullary nailing
after the initial irrigation and debridement. External
fixation is often used for grade III fractures and grossly
contaminated grade II and III fractures. In the presence of
more extensive wounds or contaminated wounds, repeat
debridement should be performed every 48-72 hours until
the wound is clean. Laine et al. developed a good algorithm
for the management of severe open tibia fractures (see
Technique Tip).

TECHNIQUE TIPS:
Pathway—Open Tibia Fractures

Modified from Laine JC et al. The management of soft tissue and bone loss in type IIIB and IIIC
pediatric open tibia fractures. J Pediatr Orthop. 2016;36(5):453–458.

Soft tissue coverage within 1 week is recommended. A

study by Nandra et al. discouraged the use of plate fixation
for open tibial fractures in children given the increased
incidence of deep infection in their study. They also
advocate early definitive combined orthopedic and plastic
surgery in order to stabilize the fracture and get good soft
tissue coverage.

In cases with significant soft tissue loss or degloving, we

consult our plastic surgeons early so that they can be
involved in the decision making process and can assess
whether skin grafting or tissue flaps will be necessary.

Figure 15-14 The term floating knee has been proposed to describe
the very unstable circumstance in which both the tibia and the femur
have complete fractures in the same limb.

The Floating Knee

The term floating knee has been proposed to describe the
very unstable circumstance in which both the tibia and
femur have complete fractures in the same limb (Fig. 15-
14). The usual mechanism of injury involves a pedestrian
struck by a car or a motor vehicle accident.

General treatment considerations include age, polytrauma

injuries, closed or open fracture, and the physician’s
experience. Operative intervention is recommended once
the child is medically stabilized. These severe injuries may
be associated with closed head injuries and chest and spine
trauma. Splint or consider temporary external fixation until
the child can go to the OR for definitive treatment. The
nature of each fracture needs to be assessed, and
appropriate fixation for each fracture is chosen. As the tibia
fracture is usually higher risk for compartment syndrome,
consider fixing this first to minimize twisting through the
fracture during surgery and creating more soft tissue
injury. It is difficult to reduce a femur fracture with an
unstable tibia. Don’t hesitate to open the fractures if
pulling on one risks the other; open reduction is usually
more straightforward. If there are associated upper
extremity injuries that will preclude crutch use, consider
more secure fixation to allow early weight bearing (solid
intramedullary fixation if the child is old enough, or
potentially plate fixation in younger children).
 Figure 15-15 A child with osteogenesis imperfecta has had many
tibia fractures leading to a significant bow. A Fassier-Duval nail is used
for realignment and to prevent recurrent fracture while the child
grows.

Fractures in Children with Osteopenia

Tibial fractures are not unusual in children with bone
fragility due to neurologic conditions (cerebral palsy,
muscular dystrophy, spinal bifida, spinal cord injury). In
this population, tibia fractures are usually nondisplaced
and result from relatively minor trauma (such as a fall from
a wheelchair). They are also common after cast
immobilization for reconstructive surgery (due to
preexisting osteopenia made worse by casting), and in
children with osteogenesis imperfecta. Minimally displaced
fractures can be splinted for 2-3 weeks. Displaced fractures
are treated with reduction and immobilized for 3-4 weeks.
Casting should be minimized because these children are at
risk of becoming even more osteopenic with prolonged
immobilization. In the face of severe osteopenia or
repetitive insufficiency fractures, patients should be
referred to endocrinology for consideration of medical
therapy. Consider intramedullary fixation to minimize
recurrent fractures. The canal diameter may be very small
so that only a rush rod will fit in the canal. The Fassier-
Duval nail is also an option for the growing osteopenic child
(Fig. 15-15).

Stress Fractures
Stress fractures are often associated with poor conditioning
prior to sport activity; a sudden change in distance
running; and tight heel cords, hamstrings, and quadriceps
(Fig. 15-16).
 Figure 15-16 Stress fractures occur when normal bone is subjected
to repetitive microstresses below the usual threshold needed to cause
an acute fracture. In this case, diagnosis was delayed and moderate
anterior bowing occurred. Often stress fractures can be treated with a
decrease in activity.

Stress fractures occur when normal bone is subjected to

repetitive microstress below the usual threshold needed to
cause an acute fracture. In this setting, osteoclastic bone
resorption exceeds osteoblastic activity and bone
deposition. Most tibia stress fractures occur in the proximal
third with a peak age incidence between 10 and 15 years.
In contrast, stress fractures of the fibula are frequently
seen in children between the ages of 2 and 8 years.

If not readily apparent on plain radiographs, an MRI can be

ordered to facilitate the diagnosis. Treatment can begin
with activity restriction if the patient is very compliant.
Other treatment modalities may include protected weight
bearing with crutches and immobilization in a walking
brace or cast for 4-6 weeks.

Figure 15-17 The Gillespie fracture is a potential source of grief.

Casting the fracture with the ankle at neutral causes unacceptable
angulation (recurvatum). To avoid this, the cast must be applied with
the foot in equinus.

A gradual return to activities is then recommended with a

lower extremity strengthening and stretching program.
Although rare, nonunions of stress fractures typically in the
middle third of the tibia may occur. If decreased activity is
not adequate, there are several options for treatment
including electromagnetic stimulation, iliac crest grafting,
and intramedullary fixation or compression plating.

Girls with stress fractures should be assessed for the

female athlete triad (disordered eating, menstrual
disturbances, and bone loss) because these individuals are
at increased risk of future osteoporosis and fractures as an
adult. Additionally, there is now increased awareness of
vitamin D deficiency in patients with stress fractures and
supplementation should be implemented if identified.

DISTAL METAPHYSEAL FRACTURES

Distal metaphyseal buckle fractures are common in
children and are usually treated with a cast for 3-4 weeks
with low risk of complication.

Gillespie Fracture
This little-known fracture is worth recognizing, as it is a
potential source of grief. The injury appears to result from
landing on a dorsiflexed foot. The anterior border of the
tibia is crumpled while the posterior surface opens,
producing posterior angulation. Robert Gillespie of the
Hospital for Sick Children—Toronto described this pattern
(Fig. 15-17). Seemingly innocent at first, by the time the
cast is removed the angulation has increased to an
unacceptable degree. Cast the leg with the foot in equinus
for the first 4 weeks to prevent this problem. The cast can
then be changed to one with a more neutral ankle position
until the fracture heals.

Distal tibia physeal injuries are also very common and are
presented in Chapter 16.

Maisonneuve Fracture
A proximal fibula fracture with distal tibia fracture
indicates disruption of the interosseous membrane and
syndesmosis. It is important to get anatomic reduction of
the distal tib-fib joint and consider fixation of the joint with
a syndesmotic screw or other fixation device (tight-rope)
(Fig. 15-18).

SUMMARY
Tibia and fibula shaft fractures are common in the pediatric
population and in the younger age group can usually be
treated with a good cast and close monitoring. Fractures in
older children and adolescents are more likely to be
sustained with high-energy injuries and are more prone to
loss of reduction, compartment syndrome, and need for
surgical intervention. There are many options for fixation
including K-wires, lag screws, sub-muscular or open
plating, flexible intra-medullary nails to protect the physis,
solid intramedullary nails for more skeletally mature
patients, and external fixation. Becoming skilled with all of
these techniques and knowing which is best suited for the
specific fracture you are treating is a critical part of
orthopedic training.

Figure 15-18 Maisonneuve fracture—high fibula fracture with

disruption of the syndesmosis.
SUGGESTED READINGS
Aronson DD, Stewart MC, Crissman JD. Experimental tibial fractures in rabbits
simulating proximal tibial metaphyseal fractures in children. Clin Orthop Relat
Res. 1990;(255):61–67.

Aslani H, et al. Treatment of open pediatric tibial fractures by external fixation

versus flexible intramedullary nailing: a comparative study. Arch Trauma Res.
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 16
Ankle

Andrew Pennock
Maya Pring
Anatomy
Assessing the Patient
Radiographic Issues
Classification
Non-articular Fractures of the Tibia
Articular Fractures of the Tibia
Fibula Fractures
Distal (Epiphyseal) Fibular Avulsion Fractures
Adolescent Fibula Fractures
Syndesmosis Injuries
Ankle Sprains

“Education is the most powerful weapon

which you can use to change the world”
— Nelson Mandela

INTRODUCTION
In 1898, John Poland wrote Traumatic Separation of the
Epiphyses and noted that ankle injuries in children differed
from those in adults in three important ways:

1. The growth plate forms a plane of weakness directing

fracture lines in patterns different from those of adults.
2. Ligaments are stronger than bone so that ligamentous
injuries are less common in children.
3. Certain injuries will affect growth.

Figure 16-1 Ankle anatomy. AITFL, anterior inferior tibiofibular

ligament; ATFL, anterior talofibular ligament; ATTL, anterior talotibial
ligament; CFL, calcaneofibular ligament; PITFL, posterior inferior
tibiofibular ligament; PTFL, posterior talofibular ligament; PTTL,
posterior talotibial ligament; TCL, tibiocalcaneal ligament; TNL,
tibionavicular ligament.

ANATOMY
The ankle joint is composed of the talus, which articulates
with the ankle mortise (formed by the distal tibia, the
lateral and medial malleolus). The three major groups of
ligaments (deltoid, tibiofibular, tibiotalar) originate on an
epiphysis (Fig. 16-1) and provide stability for the
articulation.
Figure 16-2 Progression of normal distal tibial physeal closure at
puberty. A. Begins centrally. B. Spreads medially. C. Then laterally. D.
Until complete closure.
 Mortise Joint

French = “mortaise”
Spanish = “mortaja”
Arabic = “al-mortáz”

A cavity, socket, groove, slot, or hole. Usually rectangular into which is

received a structure of complementary shape to form a joint.

Source: Diab M. Lexicon of orthopaedic etymology. Amsterdam, The Netherlands: Harwood

Academic Publishers; 1999.
 Kump’s Bump

Warren Kump, a Minneapolis radiologist, first described the mound-shaped

medial undulation on the distal tibial physis, now referred to as “Kump’s
bump.” Kump noted that natural physeal closure begins “medio-centrally” in
this area. The medial physis closes earlier than the lateral, predisposing to
the Tillaux-type fracture.
Others believe that this prominence may be prone to shear injury with a
physeal fracture, predisposing to premature physeal closure.

The distal tibia physis closes around the age of 14 years in

girls and 16 in boys. The asymmetric closure of the physis
is responsible for many of the fractures that will be
discussed in this chapter (Fig. 16-2). Closure proceeds in
two directions from an initial site in the near central area,
which has been coined “Kump’s bump” after W. Kump’s
1966 paper on the topic. This is followed by fusion of the
posteromedial and finally the anterolateral segments of the
growth plate. The distal fibula physis closes approximately
1 year later.

When the foot is forced into an abnormal position, tension

and compression forces are generated across the ankle.
The structure of the ankle appears to permit tension
injuries most frequently with the result that avulsion
injuries of the epiphyses are common. Compression
fractures are relatively unusual except with axial loading,
which can be seen when a child jumps or falls from a
height.

ASSESSING THE PATIENT

Gross deformity of the ankle (dislocation) should be
reduced before sending a patient to the x-ray suite or
transferring the patient to another facility. In-line traction
will usually realign severe deformity quickly, improve
patient comfort, allow for better x-ray assessment of the
fracture anatomy, and will decrease the risk of
neurovascular problems by taking tension off the
neurovascular bundles (Fig. 16-3).
 Figure 16-3 Do not transfer a patient with a dislocated joint; this
fracture dislocation was sent from another facility, leaving the ankle
dislocated for greater than 6 hours.

There may be significant swelling with ankle fractures and

dislocations, although this swelling is distal to the muscle
compartments of the leg, swelling under the extensor
retinaculum as is frequently seen with Salter-Harris
injuries can cause numbness in the first web space and loss
of extensor hallucis longus (EHL) and extensor digitorum
communis (EDC) function; this indicates need for urgent
surgical release of the extensor retinaculum.
Neurovascular exam is critical when evaluating an ankle
fracture.

There is minimal soft tissue padding around the distal tibia

and fibula; the medial and lateral malleoli are
subcutaneous, so it is important to check the skin carefully
for signs of open fracture.
Always palpate the proximal tibia and fibula and examine
the knee. It is easy to focus on the ankle fracture and miss
the high fibula fracture indicating a syndesmotic injury
(Maisonneuve fracture).

Figure 16-4 This fracture is much more visible in the mortise view
than the AP view. The mortise view shows a Type IV fracture that will
require surgical reduction.

RADIOGRAPHIC ISSUES
Many people assume that there is no fracture if the x-ray
appears normal. However, nondisplaced physeal
separations may reveal no fracture lucency. The clinical
signs and localized soft tissue swelling on the x-ray should
be sufficient to lead to the correct diagnosis. On occasion,
there may be widening of the physis when comparison is
made with x-rays of the uninjured ankle.

Fractures about the ankle can be missed when only two

views of the ankle are obtained (Fig. 16-4). We feel strongly
that a mortise view should always be performed (Table 16-
1). The term mortise describes the fitting of the talus into
the “socket” formed by the distal fibula and medial
malleolus. The mortise x-ray is taken from anterior to
posterior with the foot internally rotated 20 degrees; on
this view, the outline of the talus is visualized with a
symmetric space around it. Asymmetry indicates
ligamentous injury and ankle instability.
 Table 16-1 The Mortise X-ray
Mortise

The mortise should be congruent and parallel to each surface of the talus.
Tilt of the Talus

Talar tilt in the mortise can indicate instability. In lax individuals, this may be
normal.
Talocrural Angle
Talocrural angle is normally 8-15 degrees. <8 or 2 degrees difference from the
other side indicates fibular shortening.
Clear Space/Tib/Fib Overlap

Clear space <6 mm is normal.

Overlap >1 mm is normal.

X-ray measurements of the tibiofibular line, talocrural

angle, talar tilt, medial clear space, and tibia-fibular
overlap can be made from the standard mortise view to
help determine stability and plan treatment.

CLASSIFICATION
The pattern of injury to the ankle depends on many factors,
including the age of the patient, the quality of the bone, the
position of the foot at the time of injury, and the direction,
magnitude, and rate of the loading forces. In children, the
Salter-Harris method still remains the most widely
accepted classification system for ankle fractures (Table
16-2).
 Table 16-2 The Salter-Harris
Classification
SH I

Fracture through the physis

SH II

Fracture through physis extending through the metaphysis

SH III
Fracture through physis extending through the epiphysis
SH IV

Fracture through the epiphysis and the metaphysis

SH V
Compression fracture through the physis
SH VI

Perichondral ring injury (lawn mower)

Much of our current understanding of the mechanisms of

ankle injury (Fig. 16-5) is derived from the work of Lauge-
Hansen who emphasized the influence that the position of
the foot (supination or pronation) and the direction that the
deforming forces (adduction, external rotation, or
abduction) have on the fracture pattern. These adult
descriptions are often used to describe children’s fractures
(with only partial success—the terminology appears to be
too complex for everyday use).

Figure 16-5 Supination and adduction of the foot causes the top
injury. Pronation and external rotation causes the bottom injury.

An alternative classification scheme that may be used in

older adolescents is the Danis-Weber system (Fig. 16-6),
which classifies the distal fibula fracture based on its level
relative to the ankle joint and provides information
regarding the stability of the syndesmosis.

NON-ARTICULAR FRACTURES OF THE TIBIA

Salter-Harris Type I Injury of the Distal Tibia

Salter-Harris Type I injuries are usually non-displaced;
diagnosis is based on clinical exam more than x-ray. The
child will have tenderness and swelling directly over the
physis. Sometimes the injury cannot be recognized on
radiographs until subperiosteal new bone appears after 3
weeks. If you do not see a fracture on x-ray, rule out
infection before placing the child in a cast. Once you are
convinced that the pain is just a Salter-Harris I fracture, a
short leg walking cast for 3-4 weeks will allow healing of
the fracture. X-rays are typically taken when the cast is
removed, but often no callus is noted. The true incidence of
Salter-Harris I fracture versus ligament injury is poorly
understood. A simple walking cast treats either nicely.
 Figure 16-6 The Danis-Weber classification is based on the
relationship between the fibular fracture and the mortise.

The rare displaced fracture requires reduction and a longer

period of immobilization (up to 6 weeks), and we will
typically limit any weight bearing for the first 3-4 weeks.
 Figure 16-7 Salter-Harris II injury of the distal tibia treated with open
reduction and K-wire fixation.

Salter-Harris Type II Injury of the Distal Tibia

Type II injuries typically result from higher-energy
mechanisms; the force is most commonly supination-
plantar flexion or abduction (Fig. 16-7). Gross displacement
sometimes produces ischemia of the foot, which should be
relieved, prior to transfer or definitive treatment, by
partially reducing the fracture with the help of longitudinal
traction and splinting. Usually this initial step leads to
improved circulation to the foot with pulses evaluated by
finger palpation or Doppler exam.

Treatment
The rare non-displaced type II fracture can be treated in a
below-knee walking cast for 4-6 weeks. Patients are
followed with x-rays at 6 and 12 months post fracture to
rule out physeal arrest (Fig. 16-8).

Closed reduction of Salter-Harris II fractures of the tibia

can be done either in the emergency department using
conscious sedation or in the operating room (OR) under
general anesthesia. Greater muscle relaxation with general
anesthesia and superior imaging capabilities in the OR
often facilitate the reduction and reduce the number of
attempts made at reduction, perhaps decreasing the
chance for physeal arrest.

Figure 16-8 This is the same patient from Figure 16-7 at 6 months
post-op. Note the symmetric Harris growth line, which confirms
physeal growth.

As described for reduction of tibia shaft fractures,

reduction of an ankle fracture is often made easier with the
knee flexed over the end of the bed. First, the force of
injury is recreated with plantar flexion and supination or
abduction. Longitudinal traction is then applied to the foot
and ankle with an assistant providing countertraction at the
knee. Although maintaining traction, the reduction is
achieved by bringing the foot around and into a neutral
position. Internal rotation will help to keep the fracture
reduced. The adequacy of the reduction is checked initially
by fluoroscopy and any adjustments are made. Frequently,
complete reduction of Salter-Harris II fractures of the tibia
is limited by entrapped soft tissues (usually periosteum) at
the fracture site; this is identified when the physeal gap is
wider than on the contralateral x-ray (Fig. 16-9).

If the reduction is deemed adequate, a long leg cast is

applied in two stages, then split to allow for swelling.
Anteroposterior, lateral, and mortise x-rays of the ankle are
then obtained in cast to document the reduction. Ankle x-
rays should be obtained rather than x-rays of the entire
tibia/fibula as they demonstrate the reduction more
accurately. For comparison, the opposite ankle may be
imaged so that precise measurement of the difference in
physeal gap or step-off can be evaluated. The length of time
in the cast is usually 6 weeks with weight bearing
restricted for the first 3-4 weeks.
 Figure 16-9 Periosteal entrapment can block reduction in a Salter-
Harris II distal tibia fracture. It may need to be removed surgically as
seen here.

There is current debate regarding whether open reduction

of this fracture with removal of entrapped soft tissues and
stabilization of the fracture with either crossed K-wires or
screws can decrease the incidence of physeal arrest (Fig.
16-10).

In the previous edition of this book, we advocated acutely

removing any interposed tissue that was preventing an
anatomic reduction in a child with more than 2-3 years of
growth remaining. Recent data from our institution suggest
that removing this entrapped soft tissue does not alter the
natural history of these physeal injuries (see later
discussion in this chapter). We now only recommend
surgery to remove this tissue if an acceptable alignment
cannot be achieved with a closed reduction (typically we
accept up to 5 degrees of angular deformity).
 Figure 16-10 Salter-Harris II injury of the distal tibia treated with
screws.

Salter-Harris Type VI Injury of the Distal Tibia

Lawn-mower and degloving injuries may remove the
perichondrial ring. Lipmann-Kessel has shown that this
allows a callus bridge to form between the epiphysis and
metaphysis with resulting varus deformity and failure of
growth. The severity of this injury may be missed on initial
x-rays. These are open fractures that invariably require
surgical debridement. The need for surgical stabilization
with screws and/or K-wires depends on the fracture pattern
and stability of the fracture. Some authors have advocated
placing fat graft, bone wax, or even bone cement into the
growth plate defect to lessen the possibility of a premature
physeal closure, but to date, this approach is largely
theoretical.

Pitfalls—Non-articular Distal Tibial Fractures

Premature physeal closure frequently occurs after Salter-
Harris I and II fractures of the distal tibia. A study by
Mubarak and Rohmiller et al. of 147 skeletally immature
patients with distal tibia Salter-Harris I/II fractures found a
38% incidence of physeal arrest overall. Upon further
analysis of the direction of the force at the time of injury, it
was found that supination-external rotation (SER) injuries
have a slightly better prognosis than abduction-type
injuries. SER and abduction injury patterns can be
classified based on the initial injury radiographs with SER
injuries having more fracture displacement anteriorly
(visualized on the lateral radiograph), whereas abduction
injuries have more displacement medially, evaluated best
on the AP view.

The rate of physeal closure after a displaced abduction-type

injury has been reported to range from 50% to 60%,
whereas the closure rate ranges from 30% to 40% for SER
injury types. One possible explanation for this is that the
abduction injuries represent higher-energy shearing forces
to the physis with probable disruption of Kump’s bump at
the time of injury. Regardless of treatment method,
patients with Salter-Harris injuries to the distal tibia
require close follow-up with x-rays for a minimum of 1 year
after injury to follow the growth of the physis.

If premature physeal closure is documented by x-ray, the

patient’s Tanner stage should be documented. If the patient
is female, menarcheal status (pre- or post-) should be
noted. Consider obtaining a left hand for bone age x-ray
and a scanogram to determine the current length of both
lower extremities (sometimes the injured leg was longer to
start with which would influence planned treatment). A CT
or MRI can document more precisely the extent and
location of the physeal arrest to determine if physeal bar
excision is possible. Depending on the size of the bar,
growth remaining, leg length discrepancy, and any
deformity, treatment of premature physeal arrest may
consist of the following:

Close observation with serial x-rays if the patient is close to

skeletal maturity
Excision of the physeal bar with interposition material if
there is significant growth remaining
Epiphysiodesis of the remaining open distal tibia and
fibular physes on one or both sides
Corrective osteotomy if deformity has already developed
 Figure 16-11 This patient had a Salter-Harris II distal tibia fracture
that was pinned. Postoperatively the child had extensor hallucis
weakness and pain with toe movement. The child was taken back to
the OR, the compartment under the extensor retinaculum was
measured, and the decision was made to release the extensor
retinaculum.

Extensor Retinaculum Syndrome

The extensor compartment of the ankle, deep to the
retinaculum is vulnerable to increased pressures in
association with distal tibia physis fractures. This often
occurs when the foot is caught between the ground and the
pedal of a bicycle or motorbike causing a distal tibia
fracture with apex anterior angulation. Structures that
travel within the extensor compartment include the long
toe extensors, the anterior tibial artery, and the deep
peroneal nerve.

Signs of extensor retinaculum syndrome include severe

pain and swelling of the ankle, hypoesthesia or anesthesia
in the web space of the great toe, weakness of EHL and
EDC, and pain on passive flexion of the toes, especially the
great toe. A high index of suspicion is required (Fig. 16-11).
If suspected, the extensor compartment pressure should be
measured. Interpretation of elevated pressure is similar to
that described for compartment syndrome. If the measured
pressure is elevated, surgical intervention is warranted
with release of the superior extensor retinaculum and
stabilization of the fracture.

The Tillaux Fracture

Paul Jules Tillaux

1834-1904
Tillaux, a Parisian surgeon, is credited with first understanding this fracture.
His description was originally drawn on a scrap of paper. The drawing was
found after he died by Chaput, who made the best of the ambiguous sketch.

Anatomy of the Tillaux fracture. Characteristically, the fracture is difficult to

see.

ARTICULAR FRACTURES OF THE TIBIA

The Tillaux Fracture (Salter-Harris Type III)
The Tillaux fracture almost always occurs in the adolescent
within a year of complete closure of the distal tibial physis
(Fig. 16-12). The central and medial aspects of the physis
have closed, leaving the anterolateral aspect open and
vulnerable to injury. An external rotation force on the foot
may avulse the anterolateral quadrant of the tibial
epiphysis, which is bound to the fibula by the strong
anterior inferior tibiofibular ligament, resulting in a
rectangular or pie-shaped fragment being broken off of the
anterior distal tibial epiphysis. A mortise view is essential
with this fracture as the fibula may obstruct visualization.

Non-displaced fractures are treated in a non–weight-

bearing above-knee cast for 3-4 weeks, followed by a
below-knee walking cast for another 3-4 weeks. When
displacement is present, an initial attempt at closed
reduction may be performed in the emergency department
under conscious sedation. The reduction maneuver consists
of internal rotation and supination of the foot and thumb
pressure over the displaced anterolateral fracture
fragment.
 Figure 16-12 This 15-year-old male sustained a Tillaux fracture that
was treated with open reduction and screw fixation.

An above-knee cast is applied in two stages with the foot in

supination and internal rotation. Postreduction x-rays (AP,
lateral, mortise) are taken to assess the adequacy of the
reduction. If the amount of residual displacement remains
in question after review of the x-rays, a CT scan of the
ankle is helpful. If greater than 2 mm of articular
displacement is present, open reduction and internal
fixation are preferred through an anterolateral approach.
After reduction, fixation is achieved using one or two
cancellous screws; crossing the fracture line in a
perpendicular fashion, the screw can cross the physis
because the physis is in the process of closing.

“The triple fracture classically appears

as a Salter-Harris III injury on the AP
view and a type II injury on the lateral
view”

The Triplane Fracture (Salter-Harris Type IV)

The tibial triplane fracture is a complex fracture defined by
sagittal, transverse, and coronal components, which
courses in part along and in part through the physis and
enters the ankle joint or exits through the medial malleolus.
As pointed out by Von Laer, these fractures with their
complicated course of fracture lines in different planes,
challenge the imagination of the surgeon. The triplane
fracture also occurs as a result of the special anatomic
circumstances surrounding the nature of closure of the
distal tibial growth plate. Most fractures are the result of
an external rotation of the foot on the leg. Less commonly
an internal rotation force can produce a medial triplane
fracture.

Classically, this fracture appears as a Salter-Harris type III

injury in the anteroposterior x-ray and as a Type II injury
on the lateral view. Radiographs are frequently hard to
interpret. A CT scan is an invaluable tool in defining the
fracture configuration and the amount of intra-articular
displacement (Fig. 16-13).
 Figure 16-13 Triplane fracture.

Most classification systems are based on three factors: (a)

medial or lateral, (b) number of parts, and (c) intra- or
extra-articular. Fractures of the fibula may be seen with
any triplane fracture. Not uncommonly, triplane fractures
can be seen in conjunction with ipsilateral tibial shaft
fractures.

Fortunately, neurovascular compromise and compartment

syndrome are rare after these injuries. Occasionally, in
widely displaced fractures, tenting of the skin over the
fracture fragment may lead to skin necrosis if reduction is
not carried out expediently. Accurate closed reduction is
the usual mainstay of treatment.

Reduction is performed either under conscious sedation or

general anesthesia for optimal relaxation and is achieved
by traction and internal rotation of the foot, usually with
the foot in plantar flexion. The exception is the rare medial
fracture, which may require external rotation. Overly
aggressive internal rotation and forceful dorsiflexion before
the distal fragment is reduced can fracture the
anterolateral beak of the epiphysis, which then converts a
two-part fracture into a three-part fracture.

Once closed reduction is achieved, a long leg cast is

applied with the foot in internal rotation (not varus). The
patient is kept non-weight bearing for about 3-4 weeks, and
then transitioned into a short leg or patellar tendon weight-
bearing cast for an additional 3-4 weeks.

Once again, similar to a Tillaux fracture, maximum

acceptable residual displacement is 2 mm at the articular
surface. For the extra-articular variant, less stringent
requirements may apply. Open reduction is often necessary
for medial fractures and some three- and four-part
fractures (Fig. 16-14). CT scans are extremely helpful in
planning operative intervention. Typically, the lateral
triplane fracture is approached using an anterolateral
incision for the free anterolateral epiphyseal fragment. A
second posteromedial or posterolateral incision may be
necessary depending on the fracture configuration.
Interfragmentary screws are usually used for fixation with
occasional plating of displaced fibular fractures.

Figure 16-14 Two, three, and four fragment triplane fractures.

The Medial Malleolus Fracture

Nearly all medial malleolus fractures represent Salter-
Harris III or IV fractures of the distal tibia. Occasionally,
these injuries are non-displaced and must be distinguished
from normal variations of ossification. In our experience,
most of these fractures will be displaced and require open
reduction and internal fixation. Blumetti et al. showed that
this injury is frequently sustained when multiple children
are jumping on a trampoline at the same time. Failure to
correctly treat the fracture may result in medial physeal
closure (with resulting ankle varus) or non-union.

Of note, these injuries are rarely isolated, and the

possibility of a nondisplaced lateral injury such as a
Maisonneuve proximal fibula fracture should be
considered. Isolated fractures are treated closed if they are
non-displaced, involve the distal portion of the malleolus, or
can be anatomically reduced by manipulation. A CT scan
may be necessary to ensure that the joint surface is not
disrupted if closed management is chosen.

Fractures with residual displacement greater than 2 mm

should be anatomically reduced and fixed. In skeletally
immature patients, reasonable efforts should be
undertaken not to cross the open physis. This can often be
accomplished with two transepiphyseal cannulated or
cancellous screws (Fig. 16-15). On occasion, the
metaphyseal portion of the fracture is large enough to
accommodate a transmetaphyseal screw. When
transepiphyseal fixation is not possible because of the
location of the fracture, it may necessary to use smooth K-
wires across the physis.
 Figure 16-15 Medial malleolus fracture in a skeletally immature
patient.

Reduction may be hindered by trapped, loose fragments

that will require removal. In skeletally mature patients,
medial malleolus fractures are stabilized using two
cancellous or cannulated screws inserted perpendicular to
the fracture in the classic adult fashion.

In a patient with substantial growth remaining, it is not

uncommon for a medial malleolus fractures to have a
premature physeal closure. In these instances, the ankle
tends to grow into varus. These patients should be followed
at 6 months and 1 year postinjury with radiographs of the
involved ankle so that diagnosis and treatment of physeal
closure can occur before deformity becomes symptomatic.
 Figure 16-16 This child was treated with a cast for a Salter-Harris I
distal fibular fracture. Eight months later, the child returned to clinic
with ankle and knee pain. Distal fibular physeal closure was noted,
and the child was scheduled for distal tibial epiphysiodesis to prevent
further deformity.

FIBULA FRACTURES

Salter-Harris Type I and II Fractures of the Fibula

Salter-Harris Types I and II are common injuries to the
fibula. They are recognized by swelling and tenderness
over the growth plate. In a type I injury, the radiographs
are usually normal. Again, rule out fibular osteomyelitis
before placing the child in a cast if you do not see a
convincing fracture. It should be noted that a study by
Hofsli looked at MRIs of patients with suspected Salter-
Harris I fractures of the distal fibula and found no true
fractures in the group they looked at indicating a high
false-positive rate based on exam.

Figure 16-17 Salter-Harris III fracture of the distal fibula treated with
closed reduction and percutaneous pin fixation.

Treatment
The majority of Salter-Harris type I distal fibular fractures
are minimally displaced and can be treated in a walking
cast for 3 weeks to allow comfortable healing. If no cast is
applied, the injury will heal, but the parents, watching their
child hop around on crutches, will be an endless source of
trouble to you because of their unrelieved concern and the
very small chance that the fracture will displace. When the
cast is discontinued, movement quickly returns, and
sequelae are uncommon. In rare cases, the distal fibula can
close after a fibular physeal fracture (Fig. 16-16) leading to
ankle valgus. Displaced Type II injuries (rare) may be more
prone to physeal closure.

Displaced Salter-Harris I and II fractures require reduction.

Definitive treatment usually depends on the presence of
other associated ankle fractures and the quality of the
reduction. In widely displaced fractures, there may be soft
tissue interposition (peroneal tendons or periosteum)
blocking adequate reduction. In this instance, open
reduction and internal fixation with cross or longitudinal K-
wires is helpful. Fixation of the fracture with a K-wire may
be required after closed manipulation if the reduction is
unstable (Fig. 16-17).

DISTAL (EPIPHYSEAL) FIBULAR AVULSION

FRACTURES
In a young child, the distal fibula epiphysis is incompletely
ossified, and the cartilaginous portion can be avulsed by
the anterior talofibular ligament (ATFL), the
calcaneofibular ligament (CFL), or a combination thereof.
Initially, there is just swelling, and radiographs are normal.
After a month or more, the cartilage ossifies and a bony
ossicle subsequently becomes visible (Fig. 16-18). This
injury pattern is the childhood equivalent to an adult
ligament rupture. In general, these injuries can initially be
managed with a brief period of immobilization (2-6 weeks)
and progressive return to activities. When the original
injury occurs at a young age (age 4-10 years), the patient
may present later in life with symptoms of pain and
recurrent instability and x-rays showing a bony ossicle just
distal and anterior to the tip of the fibula. This condition is
often confused with a normal ossification variation (Os
subfibulare). When patients remain persistently
symptomatic, the painful ossicle can be excised and the
ligament repaired or reconstructed.

“Ankle swelling usually peaks between

day one and seven, and operative
treatment is best done before the period
of maximal swelling or after the initial
swelling has resolved”

ADOLESCENT FIBULA FRACTURES

Most displaced fibula fractures in an adolescent patient
warrant an attempt at closed treatment. Provided one has a
good understanding of the mechanism of injury and
inherent stability of the injury, closed reduction can be
attempted for displaced fractures under oral or intravenous
analgesia and/or sedation. Closed reduction is obtained by
reversing the mechanism of injury to the ankle and then
bringing it into a reduced position while maintaining
traction on the foot. Postreduction x-rays are essential to
assess stability and the quality of the reduction. The
majority of adolescent fibular fractures can be treated with
casting.
 Figure 16-18 The distal tip of the fibula may be avulsed by the
attached ligament.

Operative treatment of ankle fractures is recommended

when:

Closed reduction fails

Maintaining closed reduction requires forced, abnormal
positioning of the foot, such as forced plantar flexion and
inversion
There is displacement of the talus or widening of the
mortise greater than 1-2 mm
Displaced fractures involve the articular surface
The fracture is open
The timing of the surgery is dependent on evaluation of the
entire patient, the condition of the soft tissues, and the
amount of swelling present. Initially, the ankle should be
gently reduced and immobilized in a padded splint to
prevent further soft tissue injury and decrease swelling. Ice
and elevation are used to reduce swelling until operative
treatment can be safely performed. Ankle swelling usually
peaks between day 1 and 7, and operative treatment is best
done before the period of maximal swelling or after the
initial swelling has resolved. The “wrinkle” test is
commonly used to determine if swelling is likely to prevent
skin closure following surgery.
 Figure 16-19 Medial malleolar and fibular fracture with syndesmotic
disruption. The syndesmotic injury was treated with a suture
syndesmotic fixation system. ORIF, open reduction and internal
fixation.

If surgery is necessary, the lateral malleolus may be

approached through a lateral incision, which can be
adjusted anteriorly or posteriorly based on the surgeon’s
preference and any associated pathology. Depending on the
skeletal maturity of the patient, there are many options for
fixation. In young children, a longitudinal or crossed K-wire
is sufficient. An oblique fracture that is longer than two
times the diameter of the bone can be fixed with lag screws
alone. For short oblique fractures of the distal fibula at the
level of the syndesmosis, a plate to neutralize the rotational
and axial forces on the fibula is most commonly utilized.
The one-third tubular plate conforms better to the fibula
and has a lower profile than the thicker compression plate.
Fractures above the syndesmosis are stabilized with a one-
third tubular plate with or without lag screws.

In treating deltoid ligament injuries in association with a

fracture of the lateral malleolus, it is generally accepted
that an anatomic reduction of the fibula and talus restores
the medial anatomy and will allow the medial ligamentous
structures to heal without need for operative repair.
Anatomic restoration of the fibula usually restores the talus
to its normal position. If, however, the medial clear spaced
remains widened after reduction of the fibula, or the
reduction of the fibula is blocked, then the medial side
should be explored.

SYNDESMOSIS INJURIES
Fractures associated with syndesmotic disruption
(pronation-abduction/external rotation) are usually
unstable and most require operative stabilization (Fig. 16-
19). The decision to use syndesmotic fixation is based on
the fracture pattern and intraoperative assessment of
stability. Fixation is recommended when:

There is medial ligamentous injury, syndesmotic disruption,

and talar shift without a fracture of the fibula (tibiofibular
diastasis)
When the treatment of a high fibula fracture (Maisonneuve
fracture) is directed primarily at stabilization of the
syndesmosis and ankle mortise
When there is continued evidence of syndesmotic
instability after fixation of the fibula and any avulsion
fracture(s) of the tubercles or medial malleolus
Intraoperative assessment of syndesmotic stability can be
done with fluoroscopy after fixation of the fibula fracture:

Cotton test: place a hook or clamp around the fibula at the

level of the syndesmosis and pull lateral traction.
External rotation stress test: stabilize the tibia and
externally rotate the foot.

If there is widening of the clear space or asymmetry of the

mortise noted on intraoperative x-ray with either of these
maneuvers, this indicates a syndesmotic injury and need for
syndesmotic stabilization.

If indicated, one or two (3.5 or 4.5 mm) cortical screws are

used to hold but not compress the syndesmosis. The screw
is inserted just above the level of the tibiofibular ligaments.
Both cortices of the fibula and either both cortices of the
tibia or just the lateral cortex of the tibia are drilled and
engaged by the screw(s). To date, no definitive advantage
of bicortical versus unicortical fixation of the tibia has been
shown. The intraoperative radiographs must be scrutinized,
and intraoperative CT should potentially be considered to
confirm anatomic reduction of the syndesmosis as multiple
studies have now shown a high rate of surgical
malreduction of the joint.
 Figure 16-20 Stress view indicating ligamentous injury.

Suspensory fixation devices, as an alternative to screws,

have been gaining popularity over the last decade for the
treatment of unstable syndesmotic injuries. Potential
advantages of these devices is that they provide non-rigid
fixation of the tibiofibular joint potentially better restoring
joint mechanics. Regardless of fixation device, patients with
syndesmotic injuries should be kept non-weight bearing for
6-8 weeks. Although controversy exists, if we utilize
screw(s), we favor removal of the implant prior to running
and sports (approximately 3 months post-op), whereas
when we use a suspensory fixation device, we do not
routinely remove the implant

ANKLE SPRAINS
Ankle sprains are very common injuries that result from an
inversion stress to the ankle. The ligaments most commonly
affected are the anterior talofibular ligament and the CFL.
In skeletally immature patients, this injury must be
differentiated from the Salter-Harris I or II distal fibula
fracture. Both present with swelling and ecchymosis over
the anterolateral aspect of the ankle, but the point of
maximum tenderness helps to differentiate these two
injuries.

Ankle sprains are commonly graded according to severity.

A grade I sprain indicates that the ligaments are in
continuity, grade II refers to a partial tear of the ligaments,
and grade III denotes a complete tear of the ligaments with
gross instability. Ankle sprains can be treated in a number
of ways including an elastic bandage, an Aircast, a
posterior splint, or a short-leg cast. With mild and
moderate sprains, the patient is allowed to weight bear as
tolerated with or without the help of crutches depending on
the method of immobilization.

Recurrent ankle sprains may be due to residual ankle

weakness, ligamentous instability, or unsuspected tarsal
coalition. In the non-acute setting, ligament instability can
be assessed on exam by the drawer test and inversion
stress (Fig. 16-20) and by imaging such as stress
radiographs and/or MRI.
Figure 16-21 Recurrent ankle sprains may be due to ankle
weakness, ligamentous instability, or an unsuspected tarsal coalition.
If the patient is found to have decreased subtalar motion, at
some point during the treatment period, one should suspect
a tarsal coalition (difficult to detect at time of injury due to
acute pain) and appropriate images of the foot should be
obtained (AP, lateral, oblique, and Harris axial views). A
talocalcaneal coalition may be difficult to visualize on x-
rays, and a CT scan may be helpful to make the diagnosis
(Fig. 16-21).

SUMMARY
A vast array of injuries occur around the pediatric ankle.
The distal tibia and fibula physes create weak points and
can easily be injured. Young children are more likely to
have physeal injuries than sprains or ligamentous injuries.
As children get closer to skeletal maturity, the weak physes
turn to bone and ligamentous injuries become more
common.

As the ankle is a weight-bearing joint, intra-articular

fractures need to be reduced as anatomically as possible to
protect the joint from posttraumatic arthritis and non-
union. Usually fixing the bone is relatively easy; the art is in
knowing which fractures need to be fixed and how to best
protect the long-term growth and alignment of the lower
extremity.

SUGGESTED READINGS
Barmada A, Gaynor T, Mubarak SJ. Premature physeal closure following distal
tibia physeal fractures. A new radiographic predictor. J Pediatr Orthop.
2003;23:733–739.

Blackburn EW, Aronsson DD, Rubright JH, et al. Ankle fractures in children. J
Bone Joint Surg Am. 2012;94(13):1234–1244.
Boutis K, Plint A, Stimec J, et al. Radiograph-negative lateral ankle injuries in
children: occult growth plate fracture or sprain? JAMA Pediatr. 2016;
170(1):e154114.
Choudhry IK, Wall EJ, Eismann EA, et al. Functional outcome analysis of
triplane and tillaux fractures after closed reduction and percutaneous fixation. J
Pediatr Orthop. 2014;34(2):139–143.

Eismann EA, Stephan ZA, Mehlman CT, et al. Pediatric triplane ankle fractures:
impact of radiographs and computed tomography on fracture classification and
treatment planning. J Bone Joint Surg Am. 2015;97(12):995–1002.

Gourineni P, Gupta A. Medial joint space widening of the ankle in displaced

tillaux and triplane fractures in children. J Orthop Trauma. 2011;25(10):608–
611.

Hofsli M, Torfing T, Al-Aubaidi Z. The proportion of distal fibula Salter-Harris

type I epiphyseal fracture in the paediatric population with acute ankle injury:
a prospective MRI study. J Pediatr Orthop B. 2016;25(2):126–132.

Misaghi A, Doan J, Bastrom T, et al. Biomechanical evaluation of plate versus

lag screw only fixation of distal fibula fractures. J Foot Ankle Surg.
2015;54(5):896–899.

Petratos DV, Kokkinakis M, Ballas EG, et al. Prognostic factors for premature
growth plate arrest as a complication of the surgical treatment of fractures of
the medial malleolus in children. Bone Joint J. 2013;95-B(3):419–423.

Podeszwa DA, Mubarak SJ. Physeal fractures of the distal tibia and fibula
(Salter-Harris Type I, II, III, and IV fractures). J Pediatr Orthop.
2012;32(Suppl 1):S62–S68.
Russo F, Moore MA, Mubarak SJ, et al. Salter-Harris II fractures of the distal
tibia: does surgical management reduce the risk of premature physeal closure?
J Pediatr Orthop. 2013;33(5):524–529.

Shore BJ, Kramer DE. Management of syndesmotic ankle injuries in children

and adolescents. J Pediatr Orthop. 2016;36(Suppl 1):S11–S14.
 17
Foot

Maya Pring
Vidyadhar Upasani
Assessing the Patient
Anatomy
Radiographic Issues
Forefoot Fractures and Dislocations
Midfoot Fractures and Dislocations
Hindfoot Fractures
Subtalar Dislocation
Talar Fractures
Puncture Wounds of the Foot and Pseudomonas
Osteomyelitis

“The thing that’s important to know is

that you never know. You’re always sort
of feeling your way”
— Diane Arbus

INTRODUCTION
Foot fractures account for 5%-10% of pediatric fractures,
and many of these can be treated with benign neglect and
do relatively well. However, a missed midfoot fracture or
hindfoot dislocation can lead to significant long-term
disability. In many cases, the magnitude of the soft tissue
injury may be more significant than the fracture. A
thorough physical exam and careful imaging to evaluate
fractures in three dimensions are needed to ensure you
don’t miss injuries that can lead to problems.

“Check the skin carefully; open foot

fractures may be missed if the
laceration is on the plantar or posterior
aspect of the foot”

ASSESSING THE PATIENT

Knowing the mechanism of injury can improve your
evaluation. Getting the toe caught on the doorframe or a
trip and fall requires a much more limited evaluation than a
motocross injury. For low-energy injuries or occult
fractures, you should be able to localize a fracture with
observation and a single finger to push on the areas
thought to be injured—cuboid fractures are a classic
missed fracture in the foot. Toe fractures usually present
with a very swollen, sometimes crooked toe.

High-energy injuries to the foot may also cause damage to

the ankle, knee, hip, and spine—do not focus on the obvious
distal swelling, instead look for other injuries—it is not
uncommon to find ligament injuries and fractures above.
The foot has very small, tight compartments that do not
tolerate much expansion before developing compartment
syndrome—if you have any concern, measure compartment
pressures.

Check the skin carefully; open foot fractures may be missed

if the laceration is on the plantar or posterior aspect of the
foot. Pulses should be symmetric to the contralateral side,
if you cannot find pulses manually or with Doppler, try to
determine what is compromising blood flow—swelling in
the foot or leg, vascular injury, joint dislocation?
 Figure 17-1 Compartments of the foot.

Open fractures resulting from a lawn mower injury are

relatively common in parts of North America where
children love to play on and around the lawn mower. These
injuries often involve partial amputations and are very dirty
wounds that may require multiple debridements before
getting a plastic surgeon involved for a skin graft or flap.

ANATOMY
Each human foot has 26 bones, 33 joints, and 107
ligaments. There is some debate as to how many separate
compartments there are in the foot: the compartments in
Figure 17-1 should be considered when there is concern for
foot compartment syndrome.
 Figure 17-2 Arches of the foot.

Structural Issues
The arches of the foot must be maintained for shock
absorption and normal foot function (see Fig. 17-2).
Because of the many moving parts and many
physes/apophyses, the opportunities for injury in the foot
are extensive. Because the foot is the base of the lower
extremity and has to support many times body weight with
activities such as running and jumping, it is important to
know which injuries can be treated with benign neglect and
which need more aggressive treatment to restore anatomic
alignment to maintain the foot structure for weight bearing
and to minimize the risk for post injury arthritis.

RADIOGRAPHIC ISSUES
The best foot x-rays are obtained standing; however, a child
with an injured foot will not stand for x-ray so the initial x-
rays tend to be oblique and not of high quality. You do have
the other foot that can be x-rayed for comparison, but if
there is concern for fracture or dislocation that is not well
visualized, a CT scan will give you a better view of the bony
alignment and is also useful for evaluation of pathologic
fractures caused by a bone cyst (Fig. 17-3). If there is
concern for a ligamentous injury such as a Lisfranc
ligament injury, an MRI study may be more useful. An MRI
study is also useful for evaluation of stress fractures when
a fracture line is not seen on plain films.

Figure 17-3 CT can help delineate pathologic lesions that may lead
to fracture. This unicameral bone cyst has a very thin cortex
superiorly with impending fracture.

FOREFOOT FRACTURES AND DISLOCATIONS

Phalangeal Fractures
Modern culture provides a variety of opportunities for toe
fractures ranging from a television falling on a toe to
kicking your sibling (Fig. 17-4). The pain makes shoe wear
very difficult, the x-rays may be uncertain, and the patient
requires your care and attention even though the problem
may seem small to you.

“We don’t recommend taping if the child

is not old enough to take the tape off if
the toes become painful or numb”

Simple phalangeal fractures require protection to allow

healing. This protection may range from simple taping,
taping plus a hard-soled or “post-op” shoe versus a well-
molded short leg (below knee) cast. The choice of
immobilization method is often determined by the patient
and family’s temperament and the child’s response to pain.
For a simple phalangeal fracture treated with taping, follow
up may not be required because post-healing x-rays are
rarely needed. When the toe stops hurting, they can go
back to activities—usually in 3-4 weeks. It is important to
teach the family to check the toes regularly as tape can cut
off the circulation turning a small injury into disaster if it is
not recognized. We don’t recommend taping if the child is
not old enough to take the tape off if the toes become
painful or numb.

On occasion, a toe fracture is significantly angulated

(especially Salter-Harris II fracture—proximal phalanx) and
requires reduction. The “digital block plus pencil as
fulcrum” reduction method used for fingers also works well
for toe fractures. Taping the toe to the adjacent one will
maintain alignment.
 Figure 17-4 These phalanx fractures were treated with a short leg
walking cast.

Some toe fractures are not reducible because of soft tissue

interposition or are very unstable and will not maintain a
reduction; for these fractures and open fractures, a trip to
the operating room may be indicated. Reduction may be
achieved by closed manipulation; sometimes a towel clamp
can be used to aid reduction in a very swollen toe.
Percutaneous K-wire fixation will then stabilize the
fracture. Small, fine K-wires are used to stabilize the
fracture in its reduced position. If the fracture cannot be
reduced by closed means, open reduction is indicated
followed by fixation with fine K-wires.

If the fracture has to be opened, incision should protect the

tendon and neurovascular bundles. The pin can be inserted
through the fracture and driven out distally, then the
fracture is reduced and the pin driven back in a retrograde
fashion. The pin should be cut short and bent outside the
skin for easy removal in clinic—make sure the cast covers
the pin as children may pull the pin out if they can see it.
The child should not bear weight with pins in the foot (the
pins can break) so if they are not trust-worthy, we put them
in a long leg cast with the knee bent to 90 degrees to
protect the foot.

Figure 17-5 Open fracture/crush injury of the great toe involving the
physis.

Problem Fractures—Great Toe

Growth arrest is occasionally seen as a late consequence
after stubbing of the great toe, likely due to an occult
Salter-Harris V physeal injury. Depending on the age of the
child, they may end up with a short great toe which
functionally is not usually a problem, but cosmetically may
be displeasing (Fig. 17-5).
With hyper-flexion (tripping over the toe while running
barefoot), the great toe distal phalanx may sustain an open
Salter-Harris I fracture of the distal phalanx with damage
to the nail bed and matrix. If the proximal part of the nail is
lifted out of the skin fold along with physeal disruption, this
should be considered an open fracture. The nail matrix may
get caught in the fracture and cause poor nail growth. As
with any open fracture, infection may follow without
adequate irrigation and debridement. These fractures
should be recognized as open injuries and carefully
cleaned, nail matrix lifted out of the fracture before
reduction, consider pin fixation and a cast to prevent loss of
reduction, and further injury to the matrix. The patient
should be treated with appropriate antibiotics.

Figure 17-6 This vertical cleft, often seen following a kicking injury,
can be an epiphyseal injury or a normal variant. Contralateral films
may help you decide.
Displaced, intra-articular fractures of the great toe
proximal phalanx, a common injury in soccer and other
sports, are often under-treated. On occasion, there may be
difficulty in determining whether the child has a normal
vertical cleft or a physeal fracture (Fig. 17-6).

All intra-articular fractures have a risk for non-union, and

this important joint is no exception. As in any intra-articular
fracture, a gap of less than 2 mm and no articular step-off
may allow cast treatment only (cast past tip of great toe,
dorsal and plantar, to optimize immobilization— non-weight
bearing for 3 weeks, then weight bearing). Interim x-ray
checks are required to rule out loss of reduction. Fractures
within the gray zone of 2 mm of displacement may need a
fine cut CT scan to make a final decision regarding the
need for operative treatment. With significant
displacement, fixation is recommended (Fig. 17-7).

Old non-unions often persist with symptoms and a

relatively smooth longitudinal line crossing the proximal
phalanx epiphysis. A cast can be tried, but internal fixation
may be needed to achieve union.
 Figure 17-7 Intra-articular Salter-Harris III fractures need to be
anatomically reduced to minimize the risk of metatarsophalangeal
joint arthritis.

Dislocations
The interphalangeal joints and metatarsophalangeal joints
can dislocate with or without a fracture. Most commonly,
these can be reduced in a closed fashion and do not require
open reduction or internal fixation. Very rarely, there is soft
tissue interposition that blocks reduction, and open
reduction is necessary; this can be done with a relatively
small incision medial or lateral to the joint. A “freer”
elevator is used to replace the soft tissue anatomically,
which allows reduction of the joint. The reduction is usually
stable, but the foot should be protected with a cast or hard-
soled shoe for 2-3 weeks (Fig. 17-8).

Metatarsal Fractures
Current childhood culture that includes aggressive
skateboarding, dirt-bike racing, and television inspired
jumps often from dizzying heights makes foot fractures
common, especially metatarsal fractures.

Shaft and Neck Fractures

Minimally displaced metatarsal fractures can be treated
simply by immobilization in a short-leg walking cast for 3-6
weeks depending on the child’s age and activity level (Fig.
17-9). The cast is split widely for the first week to allow for
swelling. In cases with severe swelling, a well-padded
(bulky Jones) splint may be needed for the first week.
 Figure 17-8 Oblique and lateral views may be helpful in diagnosing a
toe dislocation.

If there is significant angulation or translation of a

metatarsal neck fracture, it may require closed versus open
reduction and pin fixation followed by casting. The amount
of acceptable angulation decreases with increasing age as
the potential to remodel decreases. You may accept 45
degrees of angulation in a 4-year-old, but in a teenager,
more anatomic reduction is required.
 Figure 17-9 Initial and 1-year follow-up AP x-rays in a teenage boy
with second and third metatarsal fractures treated in a short leg cast
with toe plate. Remodeling of the fractures has allowed normal
function.

The second metatarsal tends to be the longest metatarsal

and is at highest risk of stress fracture and Freiberg
infraction (Avascular necrosis [AVN] of the metatarsal
head).

Figure 17-10 The compartments of the foot can be released with 3

incisions.

Multiple Metatarsal Fractures

The often high-energy nature of these injuries (as well as
the foot being naturally dependent) may lead to marked
swelling with metatarsal fractures. Compartment syndrome
can involve the interossei and short plantar muscles.
Compartment syndromes of the foot can occur with severe
fractures and must be recognized. There is debate in the
literature as to whether fasciotomies of the foot lead to
better outcomes. As discussed in the anatomy section,
there are multiple foot compartments (±9) that can be
effected. These can be released with two dorsal incisions,
one over the second metatarsal and one over the 4th and a
third incision medial to the calcaneus if needed (see Fig.
17-10). Incisions can usually be closed without skin
grafting once the foot swelling resolves.

However, a recent study by Bedigrew of military injuries

showed that fasciotomies did not prevent neuropathic pain
and deformities in adult patients with compartment
syndrome—it is unclear if these data translates to the
pediatric population as the injuries in children do not tend
to be as high energy as the blast injuries seen in the
military. We still consider fasciotomies for children with
foot compartment syndrome (intracompartment pressure
greater than 30 mm Hg).
 Figure 17-11 Older patients can tolerate less angulation in
metatarsal fractures.

Multiple, displaced metatarsal fractures may require

reduction and fixation depending on the age of the patient
and whether the first and fifth metatarsals are involved. It
is important to maintain the transverse and longitudinal
arches of the forefoot and to align the metatarsal heads to
maintain appropriate forces going through the foot and
prevent transfer metatarsalgia.

If the intermetatarsal ligaments are disrupted, it may be

difficult to maintain alignment of multiple metatarsal
fractures. If the border metatarsals are intact, and there is
no ligamentous injury, the width and stability of the foot
will be maintained even with a fair amount of displacement
of the middle metatarsals. Flexion and extension
deformities tend to remodel better than
abduction/adduction. The abduction deformities can also
widen the foot making shoe fitting more difficult.

In the child nearing skeletal maturity, much less angulation

can be accepted, because abnormal weight bearing will
result with little potential for adequate remodeling. Thus,
in the older age group, the metatarsals should be aligned,
not only to prevent splayfoot deformity but in addition to
prevent asymmetric loading of the metatarsal heads (Fig.
17-11).

In cases requiring reduction, manipulation can be

attempted with traction applied to the corresponding toes
of the fractured metatarsals and counter traction applied to
the distal tibia. Percutaneous K-wire fixation may be
necessary if the reduction is unstable. In this instance, K-
wire fixation may also prevent a non-union from developing
which can result in a short toe and in asymmetric
metatarsal head position with painful metatarsalgia. K-wire
fixation of the first and fifth metatarsal fractures maintains
metatarsal length and assists in preserving reduction of the
other metatarsals.
 Figure 17-12 First and fifth metatarsal fractures need to be
reasonably well aligned to maintain the borders of the foot.

Occasionally, open reduction is necessary for irreducible

fractures. this is performed through a dorsal longitudinal
approach. The K-wire is passed through the medullary
canal of the distal fragment, exiting in a plantar direction
after passing across the metatarsal head. The wire is pulled
through distally to the level of the fracture, and after
reduction, the wire is drilled retrograde into the proximal
fragment and into the midfoot if necessary.

First Metatarsal Fractures

Proximal fractures (Fig. 17-12) may damage the physis
resulting in shortening of the medial side of the foot.
Johnson described a variation of the Lisfranc injury (in
children under the age of 10 years), which causes a
fracture of the proximal first metatarsal physis with
associated medial cuneiform injury.
 Figure 17-13 On the left, x-ray depicts a normal growth center at
base of fifth metatarsal with radiolucent line parallel to shaft. In
contrast, the x-ray on the right shows a transverse fracture at the
base of the fifth metatarsal.

Crush injuries of the first metatarsal may affect its length.

Length can be restored by closed reduction and
percutaneous pinning to adjacent metatarsals.

Fifth Metatarsal Base Fractures

Soccer, football, baseball, and basketball inversion injuries
commonly produce avulsion fractures of the base of the
fifth metatarsal. The avulsion is thought to occur because
of the pull of the peroneus brevis.

The fracture is distinguished from the apophyseal growth

center (os vesalianum) by the direction of the radiolucent
line. The long axis of the apophysis is parallel with the shaft
(a normal finding), whereas a true fracture line is
transverse (Fig. 17-13). The apophysis appears around age
8 and unites to the shaft by age 12 years in girls and 15 in
boys.

Unfortunately, this distinction is clouded by the fact that

the apophysis can be traumatically avulsed, often with little
or no displacement, and the x-ray may seem normal
(longitudinal line) yet the patient has severe pain and
requires treatment. In both true fractures and apophyseal
separation, treatment includes a short-leg weight-bearing
cast worn for 3-6 weeks, depending on the child’s age.

Sir Robert Jones

1857-1933

Robert Jones is a recurring name in British orthopedics. Jones was a founding

member of the British Orthopaedic Society and made many contributions to
our specialty, including a system of organization for the care or orthopedic
patients.

When Jones was 16, he left his home in London to live with his uncle Hugh
Owen Thomas in Liverpool, who sent him to medical school. Jones would later
introduce the Thomas splint to the British Military during World War I, greatly
reducing the mortality rate of gunshot wounds to the thigh.
Jones Fracture
Because of Robert Jones’ intricate description of his own
fifth metatarsal injury, fractures of the proximal diaphysis
of this bone are known as a “Jones fracture.” It is important
to differentiate this fracture from a fracture of the
tuberosity, as the two differ considerably in prognosis and
management. Jones fractures are much more likely to go on
to non-union and cause long-term difficulties. Metaphyseal
fractures on the other hand heal quickly and uneventfully.

The mechanism of injury of a Jones fracture is not thought

to be an avulsion but rather the result of vertical or
mediolateral ground forces on the weight-bearing foot.
Because the blood supply of the proximal diaphysis is
limited compared to that of the tuberosity, healing may be
delayed, especially in athletes. Non–weight-bearing
immobilization is therefore recommended. Some children
will require a long leg cast with the knee bent to 90
degrees to ensure compliance. Repeat fractures or non-
union are usually treated with intramedullary screw
fixation with or without bone grafting. In athletes,
regardless of age, there has been a recent trend toward
immediate intramedullary screw fixation (Fig. 17-14).
 Figure 17-14 There has been a recent trend toward treating Jones
fractures in athletes with immediate fixation.

Stress Fractures
Metatarsal shaft stress fractures are commonly referred to
as “march fractures” because of their high incidence in
military recruits. Athletes frequently sustain these
fractures, but they also can occur in children with cavus
foot deformity and after procedures to correct clubfoot,
hallux valgus, and hallux rigidus, in which the weight-
bearing distribution to the lesser metatarsal heads is
affected. Repetitive micro stresses cumulatively lead to
fatigue fractures of the bone.
Many patients with this injury present with foot pain but
normal x-rays. If there is a high degree of suspicion, a bone
scan or MRI can be obtained to clarify the diagnosis. The
second and third metatarsals are most commonly involved.

Treatment involves activity restrictions and usually

immobilization in a short leg cast for 3-6 weeks. It may be
worth checking a vitamin D level if a child has recurrent or
multiple stress fractures. Subsequent x-rays will show the
periosteal new bone that typifies the fracture (Fig. 17-15).

Figure 17-15 Left—Early on, x-rays of patients with stress fractures

often appear normal. Right—X-ray of same patient several weeks
later after immobilization in cast showing healing 2nd metatarsal
stress fracture.

MIDFOOT FRACTURES AND DISLOCATIONS

Tarsometatarsal Injuries (Lisfranc Injury)

The tarsometatarsal joints can be injured directly or
indirectly with the indirect method being by far the more
common. Forces producing an indirect injury include
violent abduction or forced plantar flexion of the forefoot,
either alone or in combination. Hardcastle and associates
proposed an anatomic method of classifying
tarsometatarsal injuries (Table 17-1).

Although swelling of the midfoot is usual, there may be no

obvious deformity because spontaneous reduction of the
injury to a near-anatomic position commonly occurs. A
fracture of the base of the second metatarsal should raise
suspicion of an associated tarsometatarsal dislocation. The
combination of a fracture of the cuboid with a fracture of
the second metatarsal base also indicates a tarsometatarsal
dislocation.

Radiographic documentation of this injury is difficult, and

oblique views are mandatory. Although stress views have
been suggested, a CT study or MRI is more commonly used.
 Table 17-1 Lisfranc Injury Patterns
Type A

Incongruity of the entire joint

Type B

Partial instability (medial or lateral)

Type C
Divergent with partial or total instability (rare)

Non-displaced tarsometatarsal dislocations can be treated

with elevation and an initial compression dressing initially
followed by a short leg cast to complete 4-6 weeks of
immobilization. Displaced fractures require anatomic
reduction. Manipulative closed reduction is often
successful, however fixation with Kirshner wires, screws or
an endobutton-type device is often required to ensure
maintenance of reduction. The key to reduction is to
stabilize the second metatarsal base to the medial
cuneiform.
 Jacques Lisfranc de St. Martin
(1790-1847)

Jacques Lisfranc was Napoleon’s surgeon (and thus advisor to the French
army). Lisfranc noted a special type of foot fracture which occurred when a
soldier fell from his horse with a foot still fixed in the stirrup (thus the
eponymous Lisfranc fracture).
 Figure 17-16 Type B Lisfranc injury treated with open reduction
internal fixation.

Following fixation, the child is placed in a non–weight-

bearing cast (short cast if they are trust-worthy, long leg
knee bent cast if they are likely to walk on the broken foot.
The foot is immobilized for 4-6 weeks. At the end of 4
weeks, the Kirshner wires are removed often through a
window in the cast (less stressful for the patient). If screw
fixation is used, these can be removed at 3 months (Fig. 17-
16). We do not recommend Lisfranc joint fusion as initial
treatment in children although this is often done in adults

Navicular, Cuneiform, Cuboid Fractures

Isolated fractures of the tarsal bones can be the result of
direct trauma such as an object falling from a height. A
compression fracture of the cuboid bone (nutcracker
fracture) because of a jumping injury or falling down the
stairs is a common injury in the 2 to 6-year-old child and a
common cause of limping child with normal x-rays. The
occult fracture is often seen if x-rays are taken at a follow-
up visit. An astute surgeon will recognize the occult
fracture by the point tenderness over the cuboid (Fig. 17-
17).

Figure 17-17 AP x-ray of a child, who presented with a limp after a

fall. The x-ray shows a subtle compression fracture of the cuboid
(arrow).

Treatment of isolated non-displaced fractures consists of

immobilization in a weight-bearing cast for approximately 3
weeks.

More displaced lesser tarsal fractures are usually only seen

in association with a more severe injury to the foot,
searching for other fractures and soft tissue injuries
becomes more important. It is rare to see significant
displacement of the cuboid and lateral cuneiform; most are
crush injuries that are not very amenable to surgical
fixation but allowed to heal in a cast. And if there is
symptomatic deformity, this can be corrected with an
osteotomy in the future. Navicular fractures may displace
enough to need anatomic reduction and screw or pin
fixation (Fig. 17-18) and may go on to non-union. As this
bone is critical for midfoot and hindfoot motion, anatomic
reduction is recommended.

Figure 17-18 Navicular fracture went on to non-union and required

ORIF and bone grafting.

HINDFOOT FRACTURES

Calcaneal Fractures
Calcaneus fractures in children can be caused by a fall
from a height, dirt bike injuries (usually from putting the
foot out for stability), and we occasionally see pathologic
fractures from cysts in the calcaneus with minimal trauma.
Sagittal plane calcaneus fractures are easily missed if axial
(Harris) views or CT of the os calcis are not obtained. On
the lateral view, Bohler angle (angle formed by a line
parallel to the articular surfaces of the calcaneus with a
line drawn along the superior border of the tuberosity—Fig.
17-19) is measured. Bohler angle is normally 20-40
degrees; depression of the subtalar joint decreases this
angle.

Figure 17-19 Lateral x-ray of the foot illustrating landmarks used to

measure Bohler angle—normal = 20-40 degrees. This angle will be
decreased in compression-type calcaneus fractures.

As in other complex fractures, a CT scan is often required

for a clear understanding of the injury pattern. For intra-
articular fractures, the CT scan clarifies the degree of
subtalar joint incongruity.
Calcaneus fractures are typically classified by the Essex-
Lopresti classification (Table 17-2) or the Sanders
classification (Table 17-3).

Open fractures should be treated with standard irrigation,

debridement, and fixation.
 Table 17-2 Essex-Lopresti Classification
Joint Depression Type

Tongue Type
 Table 17-3 Sanders Classification
Type Radiographic Findings
I All non-displaced articular fractures less than 2 mm
IIA-C Two-part fractures of the posterior facet. A: Primary fracture line
through lateral aspect of facet. B: Primary fracture line through central
aspect of facet. C: Primary fracture line through medial aspect of
facet.
IIIAB, Three-part fractures (often include centrally depressed fragment). AB:
AC, Primary fracture lines through lateral and central aspect of facet. AC:
BC Primary fracture lines through lateral and medial aspect of facet. BC:
Primary fracture lines through central and medial aspect of facet.
IV Four-part articular fractures.

Most fractures of the calcaneus in children involve the

tuberosity and heal uneventfully. Non-displaced fractures
and extra-articular fractures can be treated in short leg
cast, which is initially split widely to allow for swelling. The
cast can be overwrapped once the swelling comes down
(usually 1 week post injury), but the child is kept non-
weight bearing until sufficient healing is visible on x-ray,
usually after 4-6 weeks. There is remodeling potential of
the talus and calcaneus in a growing child, but joint
incongruity is not likely to remodel and should be
corrected.

Extra-articular fractures seem to do well regardless of

treatment, with the possible exception of fractures
involving the anterior process. The anterior process of the
calcaneus is not well seen on radiographs until age 10 and
varies in shape. The distal portion of the fracture fragment
articulates with the cuboid. If articular displacement and
joint depression are evident, open reduction is indicated.

With significant displacement and intra-articular calcaneal

fractures, conservative treatment may not be adequate and
reduction to maintain subtalar joint congruity is important.
This can sometimes be done with closed/joystick reduction
of the fracture fragments and percutaneous fixation with K-
wires or cannulated screws to minimize wound
complications; this technique is nicely described by Feng et
al. Open reduction using a lateral approach and fixation
with plate and screws can also be done (Fig. 17-20).
Figure 17-20 Joint depression type calcaneous fracture treated with
plate fixation. Note improvement in Bohler angle post-op.
SUBTALAR DISLOCATION
Subtalar dislocations are extremely rare in children and
can be associated with talar neck fractures or other
fractures around the foot and ankle. Joint reduction can
usually be accomplished by closed methods and should be
done emergently. A CT can then better assess the
associated fractures, which can be addressed when
swelling comes down. If the joint cannot be reduced in the
ED, the patient should be taken to the OR urgently.

TALAR FRACTURES
Fractures of the talus are unusual in children. The talus,
entirely articular and saddle shaped, is divided into three
parts—the neck, body, and head. Because so much of the
talus is articular, it has a precarious blood supply with few
sites for blood vessel entry. The arterial source enters the
bone on the dorsum of the talar neck in the sinus tarsi and
medially deep to the deltoid ligament (Fig. 17-21).

Figure 17-21 Blood supply to the talus is limited and can be

interrupted by fractures, resulting in AVN—especially of the talar
body.
The most common mechanism of injury is forced
dorsiflexion of the foot. AP, lateral, and oblique radiographs
centered on the hindfoot should be taken. If the nature and
extent of the talus injury remain difficult to define by x-ray,
a CT scan is recommended.

Talar Neck
Talar neck fractures have been classified by Hawkins
(Table 17-4).The majority of talar fractures are non-
displaced neck fractures, which can be treated with
immobilization for 6-8 weeks in a long leg cast with the
knee flexed to prevent weight bearing. At this time, the
fracture is usually united, and the child can be changed to a
short leg walking cast for another 2-3 weeks. Non-displaced
fractures of the talar neck are rarely associated with
osteonecrosis (15%). However, Hawkins II fractures have a
50% risk of AVN, with III and IV having 90%-100% risk of
AVN.

The amount of acceptable displacement of talar neck

fractures in children is not well defined. We consider a
reduction with less than 2 mm of displacement and less
than 5 degrees of malalignment on all views to be
adequate.

Minimally displaced fractures can usually be treated by

closed reduction with the foot in plantarflexion. Depending
on the direction of instability, the hind foot is either
inverted or everted. With a stable reduction, the foot can
be dorsiflexed during immobilization. Otherwise, the foot is
immobilized in plantar flexion for 4-6 weeks. If the
reduction remains unstable despite plantar flexion of the
foot, fixation can be achieved by percutaneous K-wires or
screws.
 Table 17-4 Hawkins Talar Neck Fracture
Classification
Type I

Non-displaced
Type II

Fracture with subtalar dislocation

Type III
Fracture with subtalar and tibiotalar dislocation
Type IV

Fracture with subtalar and tibiotalar dislocation, and talonavicular subluxation

If adequate closed reduction is not possible, open reduction

is necessary. As these fractures are rarely seen by the
pediatric orthopedist, assistance from an adult
traumatologist is prudent. The posterior approach, just
lateral to the Achilles tendon, can be used; it avoids
dissection around the neck with its vulnerable blood
supply. A minimal anterior exposure may be added if
necessary to obtain a satisfactory reduction.
 Figure 17-22 Hawkins Type II talar fracture treated with screw
fixation.

The traditional open reduction has been performed through

a dorsomedial approach staying on the medial side of the
extensor hallucis longus. Care must be taken to avoid
removing any soft-tissue attachments from the bony
fragments. Two 4.0-mm cannulated screws, a single larger
screw or multiple K-wires can be used for fixation (Fig. 17-
22). The child should be monitored monthly for the first 6
months to assess the vascular status of the talus as most
cases of osteonecrosis occur during this time interval in
children. In the absence of complications, talar neck
fractures should be followed for at least 1 year after injury
to monitor for AVN.

Talar Body

Osteochondral Lesions
Trauma can impact or sheer off a corner of the talus, most
commonly on the medial side of the talus, or disrupt the
blood supply to the talus causing an osteochondritis
dissecans type lesion that may not heal without surgical
intervention. For these isolated osteo-articular lesions,
treatment includes arthroscopy to reattach the piece if it is
no longer attached to the talus. Micro fracture or
retrograde drilling of the lesion can be done if the articular
cartilage is intact (Fig. 17-23).
 Figure 17-23 Osteochondritis dissecans lesion of the talus treated
with retrograde drilling.

Lateral Wall Fractures

Lateral wall fracture, probably representing an
osteochondral fragment avulsed by the anterior talofibular
ligament, is rare and seldom recognized initially. The
mechanism of injury is dorsiflexion of the inverted foot.
Persistent pain and point tenderness just in front of the
lateral malleolus should indicate the need for oblique
radiographs or a CT scan to show the small, loose body.
Open reduction and internal fixation versus excision may
be needed.

Os Trigonum
The os trigonum is a normal variant which can sometimes
be confused with a fracture of the posterior process of the
talus (Fig. 17-24). It is an accessory center of ossification
which appears around the age of 8-10 in girls and 11-13 in
boys. Unlike a fracture with sharp, jagged edges, the os
trigonum, appears rounded and smooth. In rare cases, this
center is injured, and chronic movement through the
fibrous union attachment can cause symptoms (especially
in ballet dancers). The work-up is difficult, and in rare
cases, the os trigonum is surgically removed.

Figure 17-24 Os trigonum is a normal variant that may be mistaken

for a fracture.

PUNCTURE WOUNDS OF THE FOOT AND

PSEUDOMONAS OSTEOMYELITIS
The smell of socks and shoes is due to pseudomonas.
Puncture wounds, as a result of a nail penetrating the shoe,
can inoculate pseudomonas and produce osteomyelitis,
septic joint, or soft tissue abscess (Fig. 17-25).

“The smell of socks and shoes is due to

pseudomonas”
 Figure 17-25 Puncture wounds through a tennis shoe may lead to a
pseudomonas osteomyelitis.

Pseudomonas infection becomes apparent a week or two

after the puncture because of increasing pain, swelling, and
erythema. If the joint was punctured, a septic arthritis may
be produced. This is common at the metatarsophalangeal
joint. Radiographic changes may take 3-4 weeks to appear.
A three-phase bone scan or MRI can help make the
diagnosis of osteomyelitis earlier.

Debridement of the area under general anesthetic is

recommended. Antibiotic coverage should initially include a
cephalosporin to cover for staph aureus and an
antipseudomonas drug such as Ciprofloxacin or
Levofloxacin until the organism is identified and the
sensitivities are known. With late presentation, the joint
and physis may be permanently damaged by the infection
(Fig. 17-26).
Figure 17-26 This child had physeal closure secondary to
pseudomonas osteomyelitis of the first metatarsal and a septic TMT
joint.
SUMMARY
Many foot fractures and dislocations can be treated
conservatively with closed reduction and casting or a hard-
soles shoe. Recognizing the injuries that may have a poor
outcome and treating them early and effectively is the
challenge with foot trauma. The more complex calcaneus
and talus fracture/dislocations are rarely seen in a
pediatric hospital, so it may be prudent to get help from an
adult traumatologist when these come through your ED.
The goal is to recreate the natural foot anatomy with the
longitudinal and transverse arches, to avoid AVN, and re-
create a functional pain-free foot. These goals are not
always achievable with high-energy foot trauma.

SUGGESTED READINGS
Bedigrew KM, Stinner DJ, Kragh JF Jr, et al. Effectiveness of foot fasciotomies
in foot and ankle trauma. J R Army Med Corps. 2017. [ePub ahead of print].

Buoncristiani AM, Manos RE, Mills WJ. Plantar-flexion tarsometatarsal joint

injuries in children. J Pediatr Orthop. 2001;21(3):324–327.

Ceroni D, De Rosa V, De Coulon G, et al. Cuboid nutcracker fracture due to

horseback riding in children: case series and review of the literature. J Pediatr
Orthop. 2007;27(5):557–561.

Feng Y, Yu Y, Shui X, et al. Closed reduction and percutaneous fixation of

calcaneal fractures in children. Orthopedics. 2016;39(4):e744–e748.

Hill JF, Heyworth BE, Lierhaus A, et al. Lisfranc injuries in children and
adolescents. J Pediatr Orthop B. 2017;26(2):159–163.

Kim HN, Park YJ, Kim GL, et al. Closed antegrade intramedullary pinning for
reduction and fixation of metatarsal fractures. J Foot Ankle Surg.
2012;51(4):445–449.

Kramer DE, Mahan ST, Hresko MT. Displaced intra-articular fractures of the
great toe in children: intervene with caution! J Pediatr Orthop. 2014;34(2):
144–149.

Lim KB, Tey IK, Lokino ES, et al. Escalators, rubber clogs, and severe foot
injuries in children. J Pediatr Orthop. 2010;30(5):414–419.
Petit CJ, Lee BM, Kasser JR, et al. Operative treatment of intraarticular
calcaneal fractures in the pediatric population. J Pediatr Orthop.
2007;27(8):856–862.

Robertson NB, Roocroft JH, Edmonds EW. Childhood metatarsal shaft

fractures: treatment outcomes and relative indications for surgical
intervention. J Child Orthop. 2012;6(2):125–129.

Smith JT, Curtis TA, Spencer S, et al. Complications of talus fractures in

children. J Pediatr Orthop. 2010;30(8):779–784.

Wu Y, Jiang H, Wang B, et al. Fracture of the lateral process of the talus in

children: a kind of ankle injury with frequently missed diagnosis. J Pediatr
Orthop. 2016;36(3):289–293.
 18
Spine

Vidyadhar Upasani
Burt Yaszay
Peter Newton
Radiographic Issues
Treatment
Cervical Spine Injuries
Thoracic and Lumbar Fractures
Special Conditions

“What people want is not knowledge but

certainty”
— Bertrand Russell

INTRODUCTION
Pediatric spine fractures are rare with only 5% of all spinal
cord and vertebral column injuries occurring in children
age 16 and under. Although uncommon, spine fractures in
children can lead to deformity, instability, and potentially
neurologic sequelae. An extra measure of vigilance is called
for in evaluating spine injuries because both the clinical
and initial radiographic findings can be subtle. Successful
treatment is based on knowledge of the radiographic,
anatomic, and developmental differences between the
pediatric and adult spine.
Etiology
The location, pattern, and etiology of a child’s spine
fracture is primarily dependent on the patient’s age at the
time of injury (Table 18-1) with birth trauma and child
abuse being the most common reason for spinal injury in
children under age 2 years. In patients between the ages of
2 and 8 years, the most frequent mechanisms of injury are
falls, motor vehicle accidents and child abuse. Children
older than 8 years of age are more commonly injured in
motor vehicle accidents, sports, and even gunshot wounds.

Table 18-1 Table 18-1 Spine Fractures in

Children (United States)
Age Most Common Causes
0-2 years Birth trauma
3-8 years Falls, MVA, child abuse
8 years and older MVA, sports (swimming, diving, surfing), gunshot wounds
MVA, Motor vehicle accident.

Level of Injury
The majority of spinal column fractures in childhood occur
in the thoraco-lumbar spine. Cervical spine fractures in
patients age 8 years or younger commonly involve the
upper cervical spine (above C4), most often involving the
occiput—C1-C2 complex and are potentially fatal. Patients
older than 8 more typically sustain injures below C4 with a
much lower fatality rate.

Applied Anatomy
The patterns and types of spine injuries seen in children
reflect unique age-related features of the developing spine.
In children less than 8 years of age, anatomic factors place
the upper cervical spine at greater risk for injury. These
include the relatively large head size compared to the body,
increased ligamentous laxity, relative strap muscle
weakness, and horizontal, shallow facet joints. In addition,
there is increased spinal column elasticity as compared to
older children and adults. Injuring forces are dissipated
over several adjacent motion segments at times exceeding
the elasticity of the spinal cord itself. Spinal cord injury
without radiographic abnormality (known by the acronym
SCIWORA) can occur resulting in both subtle and severe
neurologic abnormalities. An urgent magnetic resonance
imaging (MRI) study is required to identify pathology.

Equally perplexing to the uninitiated are several normal

developmental features that can be misinterpreted as
evidence of injury to the spine. Lateral C-spine views in
children under age 2 years may be hard to interpret
because the anterior ring of the C1 vertebra has not yet
ossified. Thus, the dens-C1 interval cannot be measured.
The dento-central synchondrosis of C2, appearing as a
lucent line below the level of the body-dens interface, does
not usually fuse until about age 6 years and may be over-
interpreted as an odontoid fracture.

Absence of the characteristic normal cervical lordosis with

the presence of frank kyphosis is seen in up to 14% of
patients less than age 8 years. This can be misinterpreted
as representing injury with related muscle spasm. Os
odontoideum, thought to represent either a failure of fusion
of the top of the dens to the body of C2 or non-union of an
occult fracture, can be difficult to distinguish from an acute
fracture. Further evaluation of these patients with
advanced imaging should be undertaken if this condition is
identified on screening trauma radiographs, as fixation or
upper cervical fusion may be required if true pathology is
present.

In infancy, notching of the anterior and posterior vertebral

bodies by vascular channels is common and is sometimes
confused with a vertebral body fracture. The anterior
channel generally disappears by age 1, whereas the
posterior notch persists throughout life. Many issues make
reading infant neck films problematic (Figs. 18-1, 18-2). In
adolescents, the presence of the vertebral body ring
apophysis also presents a challenge in diagnosing spinal
column fractures because the injuring force can traverse
this cartilaginous growth plate, producing deformity that is
unrecognizable on plain films. Normal, somewhat wedge-
shaped vertebrae can be common up to age 8 years and are
distinguished from a compression fracture by noting a
similar appearance in the neighboring vertebrae and the
absence of associated soft tissue findings.
Figure 18-1 Lateral C-spine view in an infant. The odontoid or dens
(green arrow) is identified, but there is no bone noted anterior to it
(black arrow). This is because the anterior ring of C1 has not yet
ossified.
 Figure 18-2 Moderate head tilt and rotation seen in an AP view of
the C-spine in an infant with torticollis.

“By late childhood, the patterns of

spinal injury and healing become similar
to the adult”

After age 8 the spine begins to mature. The ligaments and

facet capsules strengthen, the facets become more
vertically oriented and the vertebral bodies become more
rectangular. By late childhood, the patterns of spinal injury
and healing become similar to the adult.

Further complicating matters include congenital and

syndromic conditions that have associated cervical spine
manifestations. Klippel-Feil syndrome is characterized by
congenital fusion of two or more cervical vertebrae (Fig.
18-3). Given the relative lack of motion segments and
resultant longer lever arm within the cervical spine, these
patients are thought to be at greater risk for fracture, and a
higher level of scrutiny should be given following trauma.
This is also true for Down syndrome (trisomy 21) patients
whose ligamentous laxity may result in upper cervical
instability, potentially causing cervical myelopathy. A
careful instability assessment with lateral flexion-extension
radiographs should be performed when evaluating injury in
these patients.
 Figure 18-3 Klippel-Feil syndrome includes congenital fusion of 2 or
more cervical vertebrae. The AP view is less diagnostic in this case
but does show spina bifida occulta at the C7 level.

Initial Evaluation
Evaluating a child with a suspected spinal fracture,
ligamentous injury, or spinal cord injury (SCI) depends
largely on the setting in which the child is seen. Because
the vast majority of pediatric spinal fractures and spinal
cord injuries are due to motor vehicle accidents, sports-
related injuries and falls. The first orthopaedic evaluation
will occur in the emergency department.

Given the increased participation of children in organized

sports, a physician may, on occasion, be required to
perform an evaluation on the athletic field and to
coordinate the safe handling and transport of the
potentially spine injured child to a medical facility. On the
field, or at the scene of an accident, any children
complaining of neck or back pain, or transient/prolonged
neurologic symptoms, must be treated as though they have
a spinal injury.

Early immobilization will help to prevent further instability

or propagation of an SCI. Because the child’s head is
relatively large in relation to the body, a spine board with
an occipital recess is ideal for transport as this avoids
inadvertent neck flexion (Table 18-2). If this is unavailable,
any rigid platform with blankets placed beneath the
shoulders and trunk will suffice. A pediatric cervical
orthosis and sandbags or towels placed on each side of the
head will limit further motion. Until the cervical spine is
cleared, movement of the patient should only be performed
with in-line traction and a logroll technique.
 Cervical Spine Clearance Options

Clinical exam
MRI
Flexion/extension radiograph (minimum 30 degrees)

Once the airway, breathing and circulation have been

secured, a brief secondary survey can be performed. A brief
history in the awake, alert, and cooperative child is
important. Any history of numbness, tingling, brief
paralysis, or complaint of neck or back pain should alert
the physician to the possibility of a spine injury. Physical
examination begins with inspection of the body for signs of
possible trauma to the spine including obvious or subtle
deformity, abrasions, edema, or bruising.

Inspection for abdominal wall ecchymosis suggestive of a

lap belt injury is important when evaluating a child
involved in a motor vehicle accident. Pain or step-off along
the spinous processes should raise suspicion. Range of
motion of the spine should only be attempted in the awake
and cooperative child in whom there is no suspicion of an
unstable injury.
 Table 18-2 Emergency Transport of an
Infant with Possible Spine Injury
(Herzenberg et al.)
Incorrect

Straight board Neck flexed

Correct

Hole in board to accommodate head Neck now straight

Trunk elevated on pad or blanket Neck now straight

 Figure 18-4 Lateral x-ray of the C-spine.

RADIOGRAPHIC ISSUES
For minor spine trauma, often an AP and a lateral view of
the affected area will be the only x-rays ordered. For more
severe trauma, a more thorough analysis is required.

Great care should be taken in the evaluation of children

who are incapable of verbal communication, who cannot
cooperate with the clinical examination, or who have other
injuries that may divert their attention from concomitant
neck or back pain. These patients should be considered as
having a spine injury until proven otherwise. A diligent
clinical and radiographic search for injury to the axial spine
is required. Similarly, patients with underlying conditions
that increase the risk of cervical spine injuries also require
extra attention.
Typically, the first study in these patients is a screening
cross-table lateral x-ray of the cervical spine (Fig. 18-4). It
is important to personally review this x-ray for technical
adequacy, insuring that the top of the first thoracic
vertebrae is visible. A systematic evaluation of bony
alignment (Fig. 18-5) soft tissue parameters and
relationships between key landmarks is then performed
(Table 18-3).

Any high-risk patient should have x-rays taken of all

symptomatic areas or have a complete spine series if the
examiner is unable to focus the clinical evaluation. A
cervical orthosis and spine board precautions should be
maintained until definitive x-ray or clinical clearance is
obtained. Depending on the institution, guidelines are
typically established for discontinuing spine precautions.
This can be performed by the trauma surgeon, orthopedic
or neurosurgical spine surgeon, and the emergency
medicine staff physician.
 Figure 18-5 Normal alignment of the lateral cervical spine. 1,
spinous process line; 2, spinolaminar line; 3, posterior vertebral body
line; 4, anterior vertebral body line. Space available for the cord is the
distance between 2 and 3.

Table 18-3 Normal Parameters of the

Pediatric Cervical Spine
Parameter Normal Value
C1 facet-occipital condyle distance ≤5 mm
Atlanto-dens interval ≤4 mm
Pseudosubluxation of C2 on C3 ≤4 mm
Pseudosubluxation of C3 on C4 ≤3 mm
Retropharyngeal space ≤8 mm (at C2)
Retrotracheal space ≤14 mm (at C6, under age 15)
Torg ratio (canal to vertebral body) ≥0.8 mm
Space available for cord at C1 ≥14 mm
Modified from Booth TM. Cervical Spine Evaluation in Pediatric Trauma. AJR. 2012;198:W417–W425.

Figure 18-6 Odontoid views—space lateral to the odontoid is

symmetric (normal). Asymmetry of the space lateral to the odontoid
can indicate C1-C2 instability. In this case, the child had only muscle
spasms.

Cervical Spine—Imaging
AP and lateral x-rays of the cervical spine are initially
ordered to rule out most fractures. In some cases, where a
computed tomography (CT) of the cervical spine is planned,
plain films are avoided to minimize radiation exposure. The
open-mouth odontoid view may be a helpful adjunct to
detect odontoid and atlas ring fractures (Fig. 18-6),
although its usefulness and safety has been questioned in
the pediatric population. As mentioned previously, the
treating physician should be aware of anatomic and
physiologic variants unique to the developing cervical spine
in order to correctly interpret the images (Fig. 18-7).

If the child is alert and cooperative in the face of negative

x-rays and complains of neck pain, flexion/extension views
may be considered to identify ligamentous injuries. No
attempt to “assist” the patient to passively increase the
range of motion should be attempted. Acutely, pain often
limits the patient’s ability to fully flex and extend the neck,
making such x-rays of limited value. We commonly delay
flexion-extension films until the first outpatient visit
scheduled 2-3 weeks after the injury (when muscular
soreness has abated) (Fig. 18-8). The patient is maintained
in a Philadelphia type cervical orthosis for comfort and
safety during this period.
 Figure 18-7 Normal findings on a pediatric C-spine film that may be
mistaken for pathology.

When further clarification of a patient’s injury and

immediate decision making regarding treatment is needed,
a CT study is recommended. This study can help to identify
occult fractures or to fully characterize fractures, which
have been identified on plain films.

Given the purely soft tissue nature of man injuries, the use
of MRI for spine injuries is increasingly being utilized. The
length of time needed to complete the test, and the
magnetic environment, limit its use in patients with
hemodynamic instability or critically ill patients. MRI
should be obtained to assess the degree of ligamentous or
SCI in any child, who has neurologic complaints or
symptoms, particularly those suspected of having spinal
cord injury without radiographic abnormality. MRI is also
useful in assessing the extent of soft tissue damage,
especially associated ligamentous and cartilaginous
injuries. MRI should also be used to “clear” the C-spine of
comatose patient where a reliable exam is not feasible.

Figure 18-8 Flexion and extension x-rays are used to evaluate

ligamentous instability. A change in the interval between the dens
(odontoid) and the ring of C1 or a change in vertebral body or
posterior element alignment from C1-C7 can suggest a ligamentous
injury. There is no instability in this patient.

Thoracic/Lumbar Spine—Imaging
Antero-posterior and lateral views of the thoracic and/or
lumbar spine should be obtained in the initial evaluation of
any patient suspected of having a thoracic or lumbar spine
fracture. Computerized tomography is the study of choice
to evaluate bony architecture or to evaluate suspected
injuries to the ring apophysis. As in the cervical spine, an
MRI should be obtained in the face of any neurologic signs
or symptoms to assess the degree of cord injury and is the
imaging modality of choice for suspected cartilaginous and
ligamentous injuries.
TREATMENT
With a few exceptions that will be highlighted, the majority
of fractures in the pediatric spine can be treated non-
operatively. Surgical stabilization should be undertaken in
unstable injuries or injuries associated with SCI.
 Table 18-4 Common Methods to
Immobilize the C-Spine
Soft Collar

Aspen Collar

Philadelphia Collar
Minerva-Type Brace

Most cervical injuries are simple strains and require

generic treatment. Cervical collars are often used and
come in a variety of types with varying capacity for
immobilization (Table 18-4). A halo may be required for a
very serious injury.
For cervical strains, anti-inflammatory medications are
often prescribed, and the patient is followed. Most are
greatly improved or asymptomatic within 1-2 weeks. A few
have more severe injuries that will take weeks or even
months to heal. Confusing the issue are legal cases in
which the patient, parents, and attorneys are monitoring
the outcome. Children often have a hard time recovering
while these stressful events are ongoing.

CERVICAL SPINE INJURIES

Atlanto-occipital Dislocation
Atlanto-occipital dislocation occurs almost exclusively in
younger children and is associated with the highest rates of
closed head injury and mortality in pediatric spine injuries
(Fig. 18-9). These injuries were traditionally fatal because
the high SCI level paralyzes the diaphragm. Modern rapid
rescue methods have led to more survivors. Occipital
condyle fractures are associated with this injury and should
not be overlooked. If the child is neurologically intact, halo
immobilization for 2-3 months may be successful. For
children with persistent instability, an occiput-C1 fusion
may be necessary. Children with atlanto-axial dislocation
associated with SCI require fusion from occiput to C2.
 Figure 18-9 Atlanto-occipital dislocation.

Figure 18-10 This toddler suffered a flexion injury to the C-spine.

The MRI study shows posterior ligamentous injury (yellow arrow) at
the C1-C2 level. She was treated with prolonged immobilization.

Atlanto-axial (C1-C2) Injury

C1-C2 is the most common level of injury in the pediatric
and adolescent spine (Fig. 18-10). Either a fracture of the
odontoid or an atlanto-axial dislocation without fracture
may occur. Atlanto-axial dislocation without fracture is
most likely to occur in children under the age of 13.
Fracture is more common in children older than 13.
Dislocations may be treated with halo immobilization for 3
months, but posterior C1-C2 fusion may be required for
those with persistent instability.

Atlas Fractures (C1 Ring)

Fractures in the “ring” of the C1 vertebra (atlas) are
uncommon in children and are usually the result of a high-
energy mechanism. For stable fractures, immobilization in
a rigid cervical collar for 10-12 weeks allows healing. For
more severe injuries, or for children in whom compliance is
difficult, immobilization in a Minerva jacket or halo for 2-3
months will usually result in complete healing.
Immobilization up to 6 months is sometimes required, and
surgery is rarely indicated.

Atlanto-axial Rotary Subluxation/Fixation

The onset of C1-C2 rotary subluxation is often spontaneous
and manifested by pain, torticollis, and diminished range of
motion. This condition can result from minor trauma or can
be associated with pharyngitis. In the current era, it often
follows ear, nose, and throat procedures and dental
procedures in which the patient’s head was maintained in
an unusual position for a sustained period of time.
 Figure 18-11 Fixed rotary subluxation— C1 on C2. This 6-year-old
developed a fixed rotary subluxation documented by CT scans. The
problem eventually resolved with conservative treatment.

Radiographs, particularly the open-mouth odontoid view,

will reveal a persistent asymmetry of the odontoid in
relation to the atlas. Dynamic CT studies provide the best
method for confirming the diagnosis (Fig. 18-11).

For spontaneous cases, initial treatment consists of a brief

period of immobilization in a soft collar, rest, and
analgesics. For more significant degrees of subluxation, a
brief period of head halter traction accompanied by
systemic muscle relaxants such as diazepam may be
needed until reduction is achieved. For more severe or
long-standing cases in which a fixed subluxation has
developed, halo traction or, in extreme cases, surgical
reduction with fusion may be needed.

Odontoid Fracture
Fractures of the odontoid process are rare in children, and
the incidence of associated SCI is low. Treatment should
consist of reduction and external immobilization in a halo
or Minerva jacket for 3-4 months. Surgical intervention is
rarely required and has been associated with a high rate of
complications.

Figure 18-12 Pseudo-subluxation C2-C3. Many patients have a

normal slight forward positioning of C2 on C3.

Hangman Fracture
This morbid terminology follows an understanding that the
cause of death in successful hanging is not strangulation
but instead traumatic fracture of C2 with associated SCI.
The diagnosis of traumatic spondylolisthesis of the axis
(C2) may be confounded in children by persistence of a C2
pars synchondroses until the age of 7.
Additionally, “pseudosubluxation” of C2 on C3 is common
and may be mistaken for injury (Fig. 18-12). Anterior
subluxation of C2 on C3 of 3 mm or more implies
pathologic subluxation and suggests fracture although a CT
scan will be needed for confirmation. Treatment should
consist of reduction and application of a rigid cervical
collar for 2-3 months. For more significant injuries or for
poorly disciplined families, immobilization in a halo device
(Fig. 18-13) or a Minerva jacket may be necessary.

Middle to Lower Cervical Spine Injuries

Cervical facet dislocations can rarely occur in adolescent
patients. They are often due to a high-energy injury and
most commonly occur at C6-C7. Unlike in adults,
adolescent patients rarely have a cervical disc herniation
associated with this injury. However, many of these
patients will develop a complete SCI with a low rate of
neurologic recovery.
 Figure 18-13 Halo application in an infant. Because the skull is soft,
multiple pins are required and are tightened with a low torque
(initially finger tightened)— then with a torque wrench but not to
exceed 4-5 in.-pounds of torque.

Similar to fractures in the upper cervical spine, unstable

ligamentous injuries in the middle to lower cervical spine
can be successfully treated with external immobilization in
either a halo device or Minerva jacket for 3 months.
Injuries that remain unstable after 3 months may require a
posterior fusion. For acute, unstable fractures, as well as
fractures associated with spinal cord injuries, we often
perform a posterior fusion (Fig. 18-14).
 Figure 18-14 Unstable fracture/dislocation at C6-C7. This injury
warrants internal fixation.

THORACIC AND LUMBAR FRACTURES

Compression and Burst Fractures

In general, the inherent elasticity and mobility of the
pediatric spine protects children from compression and
burst-type vertebral body fracture patterns. As the
pediatric spine matures and becomes more adult-like, the
pattern of injury in adolescents and older children begins to
mirror that is seen in adults, with an increasing incidence
of compression and burst fractures. The patient’s relative
maturity, degree of deformity, instability, and the presence
of SCI are all factors that must be considered in planning
treatment.

A working knowledge of the three-column concept of spinal

stability, developed by Francis Denis, is essential to
correctly identify and treat thoraco-lumbar spinal
instability. He defined three categories of instability (Fig.
18-15; Table 18-5).

Figure 18-15 Denis’ concept of spinal columns. If more than one

column is disrupted, stability is compromised.

Immobilization is better tolerated in children than in adults.

Consequently, stable burst fractures and compression
fractures with less than 20 degrees of kyphosis and less
than 50% loss of anterior column height can be treated
non-operatively. Most children with minor compression
fractures do not require external immobilization and are
symptom free in 1-2 weeks but should refrain from sports
for at least 6 weeks to prevent re-injury. Children with
more significant injuries or symptoms of back pain may be
treated with a 4-6 week period of immobilization in an
orthosis (thoraco-lumbo-sacral orthosis [TLSO] for thoracic
fractures or a Jewett hyperextension orthosis for lumbar
fractures).

Table 18-5 Denis Classification of Spinal

Column Instability
Type Instability Example Risk Treatment
Pattern
1st Mechanical Severe compression Progressive Brace in
degree fracture kyphosis extension
2nd Neurologic Ligamentously stable Neurologic Operative
degree burst fracture injury versus non-
susceptible to collapse operative
from axial load brace
stabilization
3rd Mechanical Unstable burst Progressive Operative
degree and fracture, displacement stabilization
neurologic fracture/dislocation and and
neurologic decompression
injury
Adapted from Denis F. Spinal instability as defined by the three-column spine concept in acute spinal
trauma. Clin Orthop. 1984;189:65–76.

With increasing skeletal maturity, the likelihood of

improving sagittal alignment by subsequent vertebral
growth decreases. For children with multilevel fractures,
marked collapse (greater than 50%), or ligamentous
posterior injury, the development of progressive deformity
in both the sagittal and coronal planes is more likely. For
these patients, posterior instrumented fusion could be
considered. In addition, it has been shown that children
with compression fractures are more likely to develop later
evidence of disc degeneration on MRI; however, the role of
this phenomenon in guiding treatment is unclear at this
time.
As with injuries in the cervical spine, unstable fractures
and fractures associated with SCI should be treated with an
instrumented fusion (Fig. 18-16). The role of
decompression in neurologically compromised patients
remains controversial. Patients with incomplete return of
neurologic status or degrading neurologic function are
candidates for decompression. Evidence suggests that early
decompression may enhance neurologic recovery. In
centers with skilled spine surgeons, decompression and
stabilization (even though classic predictors would not
suggest neurologic recovery) should be considered.

Chance Fractures
Chance (eponym) fractures, or “Chance fracture
equivalents,” are flexion distraction injuries. As in adults,
they may be purely ligamentous, exclusively bony, or a
combination of both types (Table 18-6). Unique to children
is the vertebral apophysis in the anterior column, through
which the fracture frequently traverses. The association
between Chance fractures and lap belt injuries (Fig. 18-17)
in motor vehicle accidents has been well documented. Once
associated intra- abdominal (visceral) injuries have been
ruled out or treated, treatment of the spinal injury may be
planned.

Figure 18-16 L3 burst fracture in a motorcycle racer with incomplete

neurologic injury. Treated with partial corpectomy and anterior
instrumentation L2-L4.
 Table 18-6 Classification of Chance
Fractures
Type A

Bony disruption of the posterior column with minimal extension into the
middle column
Type B

Avulsion of posterior elements with facet joint disruption of fracture and

extension into vertebral body apophysis
Type C

Posterior ligamentous disruption with fracture entering vertebra close to pars

interarticularis and extending into middle column
Type D

Posterior ligamentous disruption with fracture traversing lamina and

extending into apophysis of adjacent vertebral body

Injuries that involve bone (greater chance to heal) may be

treated in a cast or TLSO as long as an adequate reduction
can be obtained and maintained. Purely soft tissue injuries
are less likely to respond to conservative treatment. These
injuries as well as those associated with an SCI are best
treated with a posterior instrumented fusion from one level
above to one level below the injury (Fig. 18-18).

Fractures of the Ring Apophysis

Fractures of the vertebral ring apophysis are unique to the
adolescent spine. Typically, a portion of the ring apophysis
will be retropulsed into the spinal canal along with
herniated disc material. Four age associated patterns have
been described (Table 18-7). Patients will typically present
with back and or leg pain after minor injury. Plain films are
often inconclusive, and MRI or ideally CT should be used to
confirm the diagnosis. Ring apophyseal fracture must be
considered in any adolescent presenting with symptoms of
lumbar disc herniation. Conservative treatment may consist
of rest, analgesics, and physical therapy and bracing. If
ineffective, surgical treatment includes decompression of
all herniated material including excision of the bony and
cartilaginous fragments via wide lamenectomy (Fig. 18-19).
Figure 18-17 Diagram of a child in a seatbelt with a flexion injury,
which can produce a Chance fracture. Associated intra-abdominal
trauma is common.
 Figure 18-18 Chance fracture of the L2 vertebra in a teenager.
Surgical reduction and stabilization was performed.

Spondylolysis and Spondylolisthesis

Sudden acute lumbar back pain in an athlete is a common
presentation in an ER. The “spondy” conditions are often
the cause. A form of “fracture,” the condition is really
developmental. Spondylolysis and spondylolisthesis,
conditions related to weakness and then separation (stress
fracture) of the pars interarticularis, most commonly occur
at the L5 level (Fig. 18-20). Symptoms usually develop
gradually, and the diagnosis is most common in vigorous
young athletes (especially gymnasts). In rare instances, a
child can have an acute injury (or acute onset of pain) and
present as an emergency. A CT scan or MRI can clarify the
diagnosis.
 Table 18-7 Radiographic Classification of
Lumbar Apophyseal Injury
Type Age Radiographic Findings
Group
I 11-13 Separation of the posterior vertebral rim. Arcuate fragment
years without osseous defect
II 13-18 Avulsion fracture of vertebral body, annular rim, and
years cartilage
III ≥18 Localized fracture posterior to endplate irregularity
years
IV ≥18 Defect spans entire length and breadth of posterior vertebral
years margin between endplates
Adapted from Epstein ND, Epstein JA. Limbus lumbar vertebral fractures in 27 adolescents and adults.
Spine. 1991;16(8):962–966.

We often treat these patients with 6 weeks of activity rest

versus immobilization depending on the severity of the
symptoms. This is followed by a formal course of physical
therapy to work on core strengthening and lower extremity
(primarily hamstring) stretches to improve spinal range of
motion. A vast majority of these children can be treated
conservatively with a rare few proceeding to surgical
stabilization.

Various strategies have been described to stabilize a

persistently symptomatic spondylolysis. A pre-operative 3D
CT study is critical pre-operatively to determine the
dimensions of the vertebral anatomy and develop a
stabilization strategy. The options include a direct pars
repair (cannulated screw—Buck’s technique or
compression with a pedicle hook-screw construct) versus a
posterior spinal fusion (L5-S1 fusion for L5 spondy) (Fig.
18-21).
 Figure 18-19 Apophysis fracture treated with decompression.

Figure 18-20 Spondy = spine. Lysis = crack, break. Listhesis = slip

or slide. Acute lumbar back pain is a common reason for a teenage
ED visit. The “spondy” conditions are a common culprit.

SPECIAL CONDITIONS

Non-accidental Trauma—Spine Injuries

Although child abuse is frequently thought of in terms of
long bone injury, injury to the axial skeleton and spinal
cord is well described in this setting. SCIWORA can be
seen as a component of the aptly named “shaken baby
syndrome.” The infant’s large head-to-body ratio and
relatively weak cervical musculature likely predispose the
defenseless child to this injury as a result of repetitive
hyperextension and flexion forces. Evidence of neurologic
deficit should be carefully sought in infants evaluated for
non-accidental trauma, as this condition can be easily
unappreciated in this age group.
 Figure 18-21 Symptomatic L5 pars defect treated with posterior
spinal instrumentation and fusion.

A team approach is essential to thoroughly evaluate these

patients in a comprehensive, systematic manner, with
social services or Child Protective Services notified
immediately. A thorough orthopaedic evaluation, including
a skeletal survey that includes a lateral spine x-ray, is
essential in this setting. Consideration should also be given
to obtaining MRI images of the spinal cord at the time of
intra-cranial imaging if indicated by the clinical
circumstances.

As with long bone fractures, spine fractures at different

stages of healing are highly specific for non-accidental
trauma. Fracture/dislocations and multiple compression
fractures may also be seen. Specific treatment is based on
the injury pattern present.

Spinal Cord Injury

The characteristic patterns of SCI in children are
fundamentally different than that seen in adults. Children
sustain a disproportionately higher incidence of upper
cervical and thoracic spine injuries, a higher proportion of
complete neurologic injuries and a much higher incidence
of spinal cord injury without plain film evidence of spinal
column injury (SCIWORA). In addition, when an injury to
the spinal column occurs in association with SCI, it is often
difficult to detect on a plain x-ray. Most SCI in children less
than age 16 years results from falls and motor vehicle
accidents.

Following the initial trauma assessment and identification

and resolution of life-threatening conditions, a meticulous
baseline neurologic evaluation is performed and
documented. Serial examinations should then be planned in
order to identify neurologic deterioration/improvement
should either occur. In those patients capable of
understanding and communicating with the examiner, a
history of transient paresthesia, numbness, or paralysis
should be sought, as this may be the only clue to an occult
SCI. Immobilization of the spinal column should be
maintained until clinical and radiographic clearance is
obtained.

Figure 18-22 This 8-year-old male presented with complete paralysis

distal to T12 because of fracture dislocation. He was emergently
reduced and stabilized and was walking 4 months post-injury. It is
best to err on the side of overtreatment (surgical reduction) in
children who have great potential for recovery from spinal cord injury.

The efficacy of methylprednisolone in the pediatric patient

remains controversial but may be considered if the patient
arrives less than 8 hours following injury. The prognosis for
children with an SCI is better for incomplete lesions,
although up to 20% of patients with a complete SCI
experience significant recovery.

Three patterns of MRI signal in acute SCI have been

described (Table 18-8). In general, laminectomy alone
should be avoided as this contributes to increased
instability with the subsequent development of localized
kyphosis. Laminectomy, cord decompression, and
instrumented fusion can be considered in cases with
potential for neurologic recovery (Fig. 18-22).

Children who are preadolescents at the time of injury are at

significant risk for developing scoliosis following the injury
(Fig. 18-23). The presence of spasticity is also a significant
risk factor. The development of sagittal plane deformity,
especially lumbar kyphosis, is also common. Initial
treatment should consist of bracing and fabrication of a
wheel chair seating system. The primary goal of treatment
is maintenance of sitting balance in order to prevent
decubitus ulcers and to preserve independent upper
extremity use. Vigilant skin care is essential to avoid
pressure sores from the brace. Instrumentation and fusion
are often needed but ideally should be delayed until closer
to skeletal maturity.
 Figure 18-23 Progressive scoliosis has been reported in children who
sustain an SCI. This child went on to require anterior/posterior spinal
fusion.

Late neurologic deterioration has been reported in children

who sustain an SCI. An MRI should be used to assess for a
post-traumatic syrinx which may be managed by
neurosurgery.
 Table 18-8 MRI Patterns on T2-Weighted
Images of Acute Spinal Cord Injuries
Type Findings

I Decreased signal because of intraspinal hemorrhage

II Bright signal because of spinal cord edema

III Mixed signal: central hypointensity and peripheral hyperintensity

because of contusion

Adapted from Bondurant FJ, Cotler HB, Kulkarni MV, et al. Acute spinal image. Spine. 1990;15:161–168.

Spinal Cord Injury Without Radiographic Abnormality

(SCIWORA)
As originally described, the syndrome of spinal cord injury
without radiographic abnormality is diagnosed in patients
with objective findings of myelopathy following trauma
without evidence of skeletal injury or subluxation on plain
films, tomography, or myelography. The syndrome was
described prior to the use of MRI for diagnosis. The
mechanism of SCI presumably occurs due to the inherent
immaturity and elasticity of the spinal column relative to
the spinal cord.

The condition is most common in children less than 8 years

of age who sustain more serious neurologic damage and
suffer a larger number of upper cervical cord lesions than
older children. Up to half of the patients have delayed onset
of paralysis, occurring as long as 4 days after injury. Of
particular importance to the initial treating physician, most
of these children experienced transient paresthesia,
numbness, or subjective paralysis at the time of injury.
Occult instability with subsequent repetitive insults is one
possible explanation for this phenomenon. Careful
evaluation is therefore critical in this setting to identify the
underlying cord injury and source of instability and to
provide appropriate spinal stabilization to avoid
preventable progression.

“The MRI, which allows assessment for

occult ligamentous and disc injury and
the status of the spinal cord, has served
to invalidate the SCIWORA terminology”

Further evidence for occult instability as a cause of delayed

SCIWORA is the phenomenon of recurrent injury. In one
series, a trivial injury after an initial mild SCIWORA
resulted in a second episode of the condition several weeks
later.

Radiographic evaluation includes initial plain films and an

MRI. The MRI, which allows assessment for occult
ligamentous and disc injury and the status of the spinal
cord, has served to invalidate the SCIWORA terminology
(but as in many medical language issues, the term is still
used because it is widely “understood”).

Clinically, the most reliable predictor of neurologic

outcome is the initial neurologic status. An initial severe
neural injury is almost always associated with a poor
prognosis, whereas an initially mild to moderate injury is
compatible with good recovery. MRI findings are also
highly correlated with prognosis.

The orthopedist’s role is to rule out occult fractures and

subluxation requiring surgical stabilization, identify
patients likely to have delayed deterioration, and prevent
recurrent cord trauma by initiating and rigidly enforcing
strict immobilization. Late instability should be ruled out
with dynamic cervical spine x-rays performed prior to
clearing a patient for return to regular activities (especially
sports).

SUMMARY
A thorough knowledge of the developmental characteristics
of the pediatric spine will greatly assist the treating
physician. An understanding of the differences between the
immature spine and that of the adult is fundamental to
correctly diagnosing and treating pediatric spinal trauma.
Fortunately, childhood spinal trauma is rare and good
outcomes are the rule in these resilient patients.

SUGGESTED READINGS
Adib O, Berthier E, Loisel D, et al. Pediatric cervical spine in emergency:
radiographic features of normal anatomy, variants and pitfalls. Skeletal Radiol.
2016;45(12):1607–1617.

Andras LM, Skaggs KF, Badkoobehi H, et al. Chance fractures in the pediatric
population are often misdiagnosed. J Pediatr Orthop. 2016 Dec 23. [Epub ahead
of print].

Anissipour AK, Agel J, Bellabarba C, et al. Cervical facet dislocations in the

adolescent population: a report of 21 cases at a Level 1 trauma center from
2004 to 2014. Eur Spine J. 2017;26(4):1266–1271.

Baerg J, Thirumoorthi A, Vannix R, et al. Cervical spine imaging for young

children with inflicted trauma: expanding the injury pattern. J Pediatr Surg.
2017;52(5):816–821, pii: S0022-3468(17)30082-9.

Brown RL, Brunn MA, Garcia VF. Cervical spine injuries in children: a review of
103 patients treated consecutively at a level 1 pediatric trauma center.
J Pediatric Surg. 2001;36(8):1107–1114.

Cattell HS, Filtzer DL. Pseudosubluxation and other normal variations in the
cervical spine in children. J Bone Joint Surg. 1965;47:1295–1309.

Cui S, Busel GA, Puryear AS. Temporary percutaneous pedicle screw

stabilization without fusion of adolescent thoracolumbar spine fractures. J
Pediatr Orthop. 2016;36(7):701–708.

Denis F. Spinal instability as defined by the three-column spine concept in

acute spinal trauma. Clin Orthop. 1984;189:65–76.

Farrell CA, Hannon M, Lee LK. Pediatric spinal cord injury without
radiographic abnormality in the era of advanced imaging. Curr Opin Pediatr.
2017;29(3):286–290.

Herzenberg J, Hensinger R, Dedrick D, et al. Emergency transport and

positioning of young children who have an injury of the cervical spine: the
standard backboard may be hazardous. J Bone Joint Surg. 1989;71:15–22.

Moore JM, Hall J, Ditchfield M, et al. Utility of plain radiographs and MRI in
cervical spine clearance in symptomatic non-obtunded pediatric patients
without high-impact trauma. Childs Nerv Syst. 2017;33(2):249–258.

Pannu GS, Shah MP, Herman MJ. Cervical spine clearance in pediatric trauma
centers: the need for standardization and an evidence-based protocol. J Pediatr
Orthop. 2017;37(3):e145–e149.
 19
Fractures in Special
Circumstances
(Vascular-Compartment Problems,
Nonaccidental Trauma, Pathologic
Fractures)

Dennis Wenger
Scott Mubarak
Vascular and Compartment Problems
Compartment Syndromes
Non-accidental Trauma—The Vulnerable Child
Pathologic Fractures
Fractures in Special Groups of Patients
Stress Fractures

“Education is education. We should

learn everything and then choose which
path to follow”
— Malala Yousafzai

VASCULAR AND COMPARTMENT PROBLEMS

On the battlefield, arterial injuries are transported, and the
decision to expose the artery is already partly made. The
amputation rate is low because of prompt expert repair.
For closed fractures with arterial damage, the amputation
rate is often high because of late recognition of the
problem.

Arterial Injury
In fractures with arterial injury, the maximal permissible
interval between injury and repair is 6-8 hours, depending
on the degree of arterial occlusion, the state of the
collaterals, and shock. These 6-8 hours may pass quickly
while the patient is given narcotics and a doctor is found to
split the cast. The doctor often realizes there is trouble but
may fail to act immediately and decisively, hoping that the
situation will miraculously improve.

Slowly the surgeon comes to appreciate that hope is not

enough and calls for an arteriogram or transfers the case to
another hospital. Every minute should count, because
invisible changes are taking place in the muscles and
nerves of the limb. Yet in many patients we have cared for,
hours have been frittered away. Successful care comes
from a high index of suspicion and early arterial repair.
Successful care produces a normal limb and delay a
Volkmann contracture or gangrenous limb.

“Unfortunately, in the emergency

department, a child with a fracture plus
ischemia does not appear startlingly
different from a child with a simple
fracture”

Physical Signs
Unfortunately, in the emergency department, a child with a
fracture plus ischemia does not appear startlingly different
from a child with a simple fracture. A crying child, with his
limb swathed in splints and bandages and surrounded by
distraught relatives is not easily viewed with cool, clinical
detachment. A quick squeeze of a protruding digit or nail
bed for capillary filling is often considered sufficient to
demonstrate an intact circulation. You can demonstrate the
fallacy of this sign the next time you are in the operating
room (OR). Inflate the tourniquet before the limb is
exsanguinated. Squeeze the digits and note that capillary
return is still present. This test only indicates that blood is
present in the limb and not that it is circulating.

In recent years, the guesswork has been taking from these

problems by direct measurement of compartment tissue
pressure and by the use of Doppler pulse meters.

The Three Faces of Arterial Occlusion

If occlusion is not recognized on admission, there is usually
a considerable delay before anyone notices it. A child’s
ischemic pain may be borne stoically by the staff and
attributed to fracture pain or clouded by opiates. Pulses are
hidden by a cast, splint, or traction making observation
difficult. Remember that a splinted limb should be
relatively painless. Pain after reduction should be
attributed to ischemia until proven otherwise. A special
trap is painless ischemia in a child with a nerve palsy.
 Figure 19-1 Volkmann ischemia. Top. Normally the pressure in the
brachial artery is 120 torr. Muscle is perfused at a pressure of 30 torr.
Bottom. Muscle ischemia. If the pressure within the muscle
compartment is raised about 30 torr, muscle will not be perfused, but
the radial pulse is not necessarily occluded.

Complete Arterial Occlusion

The pulse is absent, the veins are empty, and in the course
of an hour or two the limb becomes white and cold. Failure
of nerve conduction produces glove and stocking
anesthesia and paralysis. After a few more hours, rigor
mortis results in the muscles shortening, and attempts to
overcome this are painful. Pain is extreme. Later the skin
becomes marbled, and gangrene follows.
 Figure 19-2 Compartment ischemia may be due to arterial injury
(Type I) or to increased compartment pressure (Type II).

Incomplete Occlusion—Compartment Ischemia

Ischemia of muscle, called Volkmann ischemia (Fig. 19-1),
is compatible with an intact pulse and adequate peripheral
circulation. The first signs are pain in the muscle and pain
on stretching the muscle. For this reason, we do not advise
strong analgesics for children with fractures that have a
reputation for vascular problems. Compartment ischemia
may be a sequel to an arterial injury (Holden Type I) or to
direct compartment injury (Holden Type II) (Fig. 19-2).
Frequently there is sufficient arterial flow to maintain a
pulse and distal circulation, but the muscles and nerves
become hypoxic and damaged. The outcome of muscular
ischemia is a Volkmann contracture. Compartment
syndromes will be described in more detail later in this
chapter.
 Figure 19-3 Compensated occlusion. Anastomotic channels maintain
perfusion at low pressure and sufficient to sustain the tissue but
insufficient to produce a pulse at the wrist. The pulsations have been
abolished, but the flow remains. If an eponym had been attached to
this condition, it would be diagnosed infrequently.

Compensated Occlusion
This is most often seen in the child with a supracondylar
fracture who has an adequate distal circulation but no
pulse (Fig. 19-3). The extremity may be a little cool, but
there are no signs of nerve or muscle ischemia. Despite
occlusion of the major artery, the collaterals maintain an
adequate circulation. The best treatment is immediate
reduction. Apart from worrying and ordering an hourly
check on sensation and movement, there is nothing special
to do. A Doppler can be used to detect a faint pulse.
Arteriography and exploration are usually meddlesome.
Within a few weeks, the pulse returns, and we have yet to
see a child with claudication in this circumstance.

Sites of Fracture Associated with Vascular Damage

Although any fracture carries the hazard of vascular
damage, the problem is most likely in supracondylar
fractures, elbow dislocations, fractures of the shaft of the
femur, especially the distal one-third (Fig. 19-4),
dislocation of the knee, fractures of the proximal tibia
physis, grossly displaced fractures of the ankle and talus,
and midtarsal dislocations.
 Ischemic Muscular Paralyses and Contractures
Richard Volkmann, 1881 (Halle, Saxony, Germany)

“For many years I have been drawing attention to the fact that the paralyses
and contractures of the limbs which sometimes follow bandages applied too
tightly, do not arise, as we assumed, through paralysis of the nerves by
pressure, but through wholesale and swift disintegration of the contractile
substance and the resultant reaction and regeneration. The paralysis and
contracture should be understood to have their origin in the muscle.”

Figure 19-4 In the hour that followed this injury, the leg became
cold, white, anesthetic, and weak. The pulse was absent. After the
fracture was reduced under general anesthesia, the veins became
full, the foot warm and pink. The pulse did not return for several
weeks. The femoral artery passes through the adductor opening at
this site, where it is liable to injury.
Types of Arterial Injury
The incidence of arterial damage, as distinct from ischemia,
in fractures is not known.

Lesions in Discontinuity. There is complete transsection

of the vessel.

Lesions in Continuity. Intimal lesions. Intimal tears and

contusions can only be diagnosed with confidence by
arteriotomy. The distal part of the vessel is empty and
stringlike. The condition is indistinguishable from spasm
until the intima is inspected.

“The most common causes of ischemia

are undoubtedly tight casts and
deformity at the fracture site”

Spasm. Traction has been shown experimentally to

produce spasm. Application of this observation has reduced
the incidence of Volkmann ischemia in fractures of the
femoral shaft. However, in the past, the importance of
“temporary spasm” has been greatly overplayed at the cost
of many limbs.

Compression. The most common causes of ischemia are

undoubtedly tight casts and deformity at the fracture site.
Release the cast or align the limb, and the circulation
comes bounding back. Kinking and stretching of vessels
has been convincingly demonstrated after high tibial
osteotomy.

Thrombosis. Prolonged occlusion owing to any cause will

produce propagating thrombosis.
Aneurysm. After a few days or weeks, the site of the
fracture becomes painful, red, swollen, and warmlike an
infection, but when it is drained, there is a gush of blood.
The aneurysm may be caused by a partial tear of the artery
at the time of fracture; by the end of a pin, drill, or screw;
or by a mycotic infection. Small vessels may be tied off, but
major vessels require a graft.

Whenever you embark on releasing a hematoma, bear in

mind that it may be a false aneurysm. Listen for a bruit;
consider an arteriogram. Check on the whereabouts of your
vascular surgeon before you start, just in case you will need
help.

Prevention
Traction, tight casts, excessive flexion of a swollen elbow,
and hypotension all produce ischemia in the absence of an
arterial injury at the time of fracture. Be vigilant, be quick,
and be decisive. If you are lucky, removing bandages,
bivalving the cast, and placing the limb in a dependent
position may be enough to improve circulation. If you are
the resident, get on and do this; don’t call your chief first,
however precious the patient or the reduction.

Treatment of Limb Ischemia

If the circulation does not improve rapidly, you must make
preparations to take the child to the OR immediately. As
soon as diagnosis of ischemia is reached, it is obviously a
matter of extreme urgency, and you must not be put off by
any other service commitments or by an anesthesiologist
telling you that the child has a full stomach. You should
carry out surgery with the help of a vascular surgeon.
However, in civilian practice, vascular surgeons do not
have much experience with the problem, and you cannot
look to them to make all the decisions. Your hospital or
orthopedic service should maintain a roster of surgeons
who can help you. The growing group of microvascular
surgeons may be your best ally.

Expectations of Arterial Repair for Complete

Ischemia

Treatment Steps—Limb Ischemia

Arteriography. Arteriography is only of value if it can be
carried out immediately: do not waste time rounding up
staff. Arteriography always takes at least an hour, whatever
you are told, and in most cases, this time could be better
spent relieving ischemia. It will demonstrate the site of
occlusion, although it will probably not disclose the type of
lesion. The site of occlusion is usually opposite the fracture
site. In one case, we suspected that the cause of ischemia
may have been tight bandaging; however, the arteriogram
showed an intimal tear opposite the fracture site. Ideally,
arterial damage should be recognized early and repaired
before irreversible complications occur.

Figure 19-5 This girl fell out of a tree. She almost died during the
next 12 hours because of hypotension from a ruptured spleen and a
hemothorax. The fractured femur was placed in skin traction. The
combination of muscle hypoxia owing to hypotension and somewhat
tight bandaging produced a white, anesthetic leg. Arteriogram shows
no damage at the fracture site but complete vascular occlusion
caused by compartment compression. All compartments were
opened, and the arteries were dilated with Fogarty catheters.

Treatment of the Arterial Lesion. Direct inspection is

the only certain way to determine the nature of the lesion.
For this reason, we expose the vessel widely through one of
Henry extensile exposures. The effectiveness of repair can
be judged, the extent of muscle damage can be discerned,
and wide fasciotomy may be carried out.

Lesions in Continuity. When the artery is constricted at

the level of the fracture, an intimal tear or contusion is
most likely. In most cases, a vascular, neurovascular, or
plastic surgeon (with vessel repair training) will be doing
the procedure with you. A segment of artery can be
excised. The proximal end is flushed out. The distal part is
dilated and cleared of thrombus with a Fogarty catheter
and end-to-end suture undertaken if this can be done
without tension; otherwise, a reversed saphenous graft is
often inserted.

Lesions in Discontinuity
Lesions in discontinuity are repaired or grafted.

Fasciotomy. Subcutaneous fasciotomy is quick and easy. It

leaves little scar but does not decompress the deep flexor
compartments (Fig. 19-5). For this reason, open fasciotomy
is mandatory. In the calf, all four compartments must be
opened-anterior, peroneal, superficial, and deep posterior.
In the arm, the deep flexors and extensors require
decompression.

Do not excise any muscle at this time. It is impossible to

distinguish the sick from the dead. After arterial repair and
fasciotomy, distal pulses should become palpable and the
veins should fill. The skin can never be closed after
fasciotomy, because the muscle has swelled. Cover the
extensive wound with a petroleum gauze dressing.

Care of the Fracture. Is internal fixation the ideal

method? The Vietnam experience suggested that it might
add to morbidity because of infection and nonunion. Our
experience is limited, but for children who have not been
injured on the battlefield, we favor internal fixation
whenever possible, because traction may pull the
anastomosis apart. A cast, which prevents examination of
the entire limb, should not be used. External fixation works
well and can be a good choice.

Complications. Because thrombosis affects up to 20% of

repairs, the circulation must be closely watched
postoperatively. If there are signs of failure, the vessel will
need to be explored once again and the thrombus removed.

Note-Keeping and Public Relations. Parents of children

in whom ischemia is noticed late usually believe that this
catastrophe is somebody’s fault. These cases usually go to
litigation. Keep scrupulous notes; every time you see the
child, record your findings and note the time. Put down
everything; nothing is too insignificant. Because the case
may end up in court, you or your colleague will need the
type of help that only pages and pages of detailed
documentation can provide. You must also be aware of
nursing notes—sometimes they contain helpful bits of
information that can help you to better manage the patient.

Request your colleagues’ advice, as needed. Not only may

this be helpful, but their written notes may be useful as
well. If the case is referred to you, you should keep in touch
with the original doctor. Do not jump to the conclusion that
it is their fault. All notes regarding prior care should be
even-handed and not blame anyone for their decision
making.
 Figure 19-6 Mechanisms of compartment hypertension.

The Aftermath. In a few days, you will know whether a

normal limb may be expected or whether amputation or
reconstruction will be required. The reward of early repair
will be a normal limb. Wet gangrene usually requires early
amputation and secondary suture. In children, it is worth
skin-grafting a stump in order to preserve length,
particularly if it allows you to save the knee joint. Similarly,
all efforts should be made to save the distal physis and
joint, no matter what anatomic region is involved (to avoid
“stump overgrowth” of bone).

COMPARTMENT SYNDROMES
A rise in the pressure within a closed compartment may
tamponade the muscles and nerves so that they become
ischemic. Muscles are normally perfused by blood at a
pressure of about 30 torr in a compartment with a tissue
pressure of 3-4 torr. If the compartment pressure exceeds
30 torr, the muscle will receive no blood, but the main
arteries will not be compressed, the pulse will get through
(Fig. 19-6).
In everyday use, compartment pressure often exceeds 30
torr for a few minutes at a time. When making a fist, the
muscle becomes hard, the pressure rises, and the muscle
loses its circulation for a time.

Figure 19-7 Method of measuring intracompartmental pressure. The

anesthesia department can provide an epidural catheter, which has
many small holes in the sidewall of the distal tip of the catheter.

You may have noticed the effects when applying a cast on a

leg. Have you noticed how your assistant, who is grasping
the toes, always drops the leg just before you have
finished? This is because your assistants’ forearm muscles
are somewhat ischemic during the time they grip; when
they reach their limit, they drop the leg.

The science of compartment syndromes has been much

advanced by experimental models. The anterior
compartment of a dog’s leg can be injected with blood to
raise the pressure. Studies of nerve and muscle show that
irreversible changes begin after 6-8 hours of ischemia.
After 24 hours, the muscle shows only slight histologic
changes, despite the fact that it is dead and will undergo
necrosis later. Muscle damage is related to the duration of
ischemia. Nerve damage is related to the compartment
pressure. At first, there is loss of conduction, which quickly
returns when the pressure is lowered, but prolonged
compression causes nerve degeneration.

Compartment pressures may be measured by several

techniques (Fig. 19-7). The wick or slit catheter works well;
however, special catheters are not always available. A very
suitable replacement is an epidural catheter (from the
anesthesia department), which has holes in the sidewall at
the tip. Special patented bedside units have been
developed and are used in some centers.

With a suspected compartment syndrome, we prefer to

have the help of the anesthesia department who routinely
monitor arterial and venous pressures. They have the
equipment. We do this in the ER, OR, or ICU with a large
bone needle inserted into the compartment and an epidural
catheter then inserted within the needle. Anesthesia then
hands you the fluid-filled line, which is attached to their
pressure monitors. You can manually compress the
compartment, with the catheter in place, to show a fluid
wave on the monitoring screen, to assume that you are in
the compartment and that the equipment is functioning.

But, whichever you choose, you should become familiar

with one technique before you are confronted by a problem
case. We usually measure pressure in children under
general anesthesia, but it can be done using local
anesthesia. Do not inject a local anesthetic into the muscle.

Why measure the pressure? If you rely on clinical signs

alone, you will do fasciotomies too late and too
infrequently. Numbers galvanize you into action and will
carry weight in your struggle to get into the OR quickly.
What should you do if you believe that a child has a
compartment syndrome, but the pressure in both deep and
superficial compartments are normal? Check the
equipment. Repeat the test in an hour or two. If technology
continues to contradict common sense, do a fasciotomy,
despite the pressure numbers.
Incisions for Fasciotomies
Differential Diagnosis of a Compartment Syndrome
Fracture pain, a lonely child, an arterial injury, and a nerve
palsy may each resemble a compartment syndrome. A
Doppler pulse measurement and a pressure measurement
will distinguish these.

Care of Compartment Syndrome

On suspicion of a compartment syndrome, the cast and
padding should be split to the skin and spread apart widely
(bivalved). There is a lot to be said for taking the front of
the cast off to be 100% certain that there are no edges
digging in. An acutely flexed elbow should be straightened.
This is a time to forget the reduction. Contact the parents
so that you do not have to hang around waiting for a
consent for the next stage. Elevate the part to the level of
the heart but not above. Does the compartment feel hard?
If after 30 minutes decreased sensation or pain on
stretching muscles remains, plan to measure the pressure
preferably under general anesthesia. Carry out a
fasciotomy if the pressure measured by wick catheter
extends 30 torr.

Upper Limb
The deep flexor compartment is usually affected. The
extensor compartment is affected in 20% of cases. Measure
the pressure in the extensor as well as the deep flexor
compartment. The fasciotomy should extend above the
elbow into the palm; always open the carpal tunnel. Expose
the median nerve and the radial artery. Open the fascia
over profundus and flexor pollicis longus.

Do not try to close the wound—little stitches just cut in. The
edges can be drawn together with Steri-strips or a skin
staple—rubber band weave method. With Steri-strips, the
edges can be pulled further together at 1, 2, and 3 weeks,
by which time closure succeeds. In some cases, the patient
can be taken to the OR for delayed primary closure. Skin
grafts are sometimes needed.

Lower Limb
Use the catheter to decide which compartments need
opening-peroneal, anterior, superficial posterior, or deep
posterior. There are several techniques available. We
prefer a medial and lateral incision; the medial incision
opens the posterior compartments between the tibia and
the gastrocsoleus; the lateral incision opens the anterior
tibial and peroneal compartments. They should be opened
widely.
NON-ACCIDENTAL TRAUMA—THE VULNERABLE
CHILD
Although assault has been a criminal offense for centuries
when directed toward adults, it has only in the last 100
years been considered an offense when directed against
children. The first action brought on behalf of a battered
child took place in New York City in 1870. Mary Ellen was
being beaten daily by her parents. Attempts to correct this
situation by appeals to the police and to the District
Attorney’s office were unsuccessful. Eventually an action
was brought by the American Society for Prevention of
Cruelty to Animals, which succeeded because Mary Ellen
was certainly a member of the animal kingdom and was
being cruelly abused.

Today, child abuse continues to be a major problem. Many

major children’s hospitals now have divisions referred to as
the Center for the Vulnerable Child to provide health care
and counseling for children (and families) from
environments known to negatively affect health (poverty,
drug exposure, abuse, etc.).

“In 1954, Kempe coined the term ‘The

Battered Child Syndrome’ and received
wide medical and lay press exposure,
leading to current understanding of the
disorder”

Two to three percent of abused children die with the

mortality rate of battering equal to or greater than that of
leukemia. Why a parent should want to injure or kill their
own offspring remains a deep philosophical question. Much
thinking has been devoted to the topic. Interestingly,
animals (dogs, lions, domestic cats) sometimes willfully
abandon or kill their offspring. Thus, parental imposed
injury may represent a poorly understood innate biologic
element. In most cases, simple explanations can be found
(high family stress, poverty, poor family support,
separation of parents, psychological or psychiatric
disorders).

The gradual recognition that the cause unexplained

multiple fractures in children were the result of abuse was
slow to penetrate the medical conscience. Prior to 1950,
children with multiple fractures and a subdural hematoma
were thought to perhaps have a metabolic bone disorder
(Caffey). Reading these early descriptions, in the light of
modern understanding, is frightening. In 1954, Kempe
coined the term “The Battered Child Syndrome” and
received wide medical and lay press exposure, leading to
current understanding of the disorder.

Figure 19-8 This infant presented with a history that she slipped off
a bathroom counter while having a bath. She had a humeral fracture,
a tibial fracture (in a later stage of healing), and multiple rib fractures.
This is diagnostic of non-accidental trauma.

Failure to recognize that a fracture in a young child is due

to abuse can be fatal. If the child is treated as a
straightforward fracture and sent home, he/she may be
killed (by the abuser). Each of our orthopedic departments
has suffered through this tragic sequence in our early
years.
 Figure 19-9 Typical “corner fracture” of the distal femur. This is due
to repetitive stress and is almost always diagnostic of child abuse.

Recognition of Abuse
Battered children may come to the hospital with head
injuries, with visceral injuries, fractures, bruises, or with all
of these (Fig. 19-8). Twenty-five to fifty percent of abused
children have fractures. The humerus, femur, and tibia are
the most commonly fractured long bones. The corner or
bucket handle–type fracture was thought to be the most
common pattern, but recent studies suggest a transverse
fracture as the most common (King et al.). In King’s series,
spiral fractures (26%) were much less common than
transverse fractures (48%).

In many cases a “normal fracture” plus a suspicious social

history is all that you have as a lead. If you do not inquire,
that is, the nature of the injury etc., you may miss the
pattern. The typical patterns of child abuse include:
 Figure 19-10 Classic “bucket handle” fracture of the distal tibia in a
very young child. This fracture is common in child abuse.

Multiple Injuries Over a Period of Time. Some fractures

are new and some are old. Infants commonly sustain Type I
epiphyseal separations. If these are manipulated every day,
a characteristic appearance is produced. A skeletal survey
is mandatory; it may show healed rib fractures with more
recent limb injuries. “Corner” fractures (Fig. 19-9) or
“bucket handle” fractures (Fig. 19-10) are commonly seen.
Transphyseal distal humerus fractures are very commonly
related to child abuse (Fig. 19-11).
 Figure 19-11 Transphyseal fracture of distal humerus in a very
young child. One must think of child abuse in such a case. A. At
injury. B. After reduction plus K-wire fixation.

Though these radiographic appearances are diagnostic and

much used as illustrations, it should be realized that they
are unusual. Most battered children have fractures
indistinguishable from those produced in everyday life (Fig.
19-12).
 Figure 19-12 The most common fractures because of child abuse are
also the common fractures that occur in non-abuse childhood. A.
Typical femur fracture—most common children’s fractures are of a
spiral type. Abuse can be determined only by the history. B. Typical
humerus fracture in infancy—does this mean abuse?

Evasive Explanations. “He must have fallen out of his

crib.” “He fell down three days ago.” Considerate parents
bring their children right away when they are hurt, and
they are sure of the cause of injury. In fact, few children
who fall do themselves any harm. Levin studied 100 infants
who fell (and these were only the falls that alarmed
mother) and not one gave cause for concern.

On the other hand, recent experience with large immigrant

families in crowded housing contradicts Levin’s study.
Having five siblings in one family, all under age 6 years,
jumping on a bed or sofa in a tiny apartment commonly
produces a limb fracture in the youngest one. Your
detective work becomes more complex. Hennrikus and
Shaw, in Fresno, have directly refuted Levin’s study.

Lack of Tenderness. Parents are gentle as they handle an

injured child. “Battering” parents sometimes handle the
child roughly and are oblivious of their cries. Once in an
interview, Mercer Rang asked the parents, “Is he a good
boy?” The father replied, “No, he is very bad.” Rang then
asked, “What do you do when he is bad?” Father then
grabbed the boy’s arm–his thumb fitting exactly to a large
bruise on the boy’s arm–and shook his fist at him.

History of Previous Obvious Injuries. Some children are

already known to the social service because of family
problems. Others have been seen in emergency
departments before. This information is difficult to obtain
but sometimes emerges later.
 The Skeletal Survey—When is it Overdone?

This child had a simple ankle fracture but the inexperienced ER doctor wasn’t
clear on the history and called the social service team. A total of 18 films
were taken with little else learned. Although generally indicated, the skeletal
survey produces a great deal of irradiation. Some wonder if there is still a role
for a “babygram” in the “low index of suspicion” case.
Management
A high index of suspicion is warranted. Statistics suggests
up to 10% of all injuries in children under the age of 2
years are due to inflicted injury. A doctor should approach
all fractures in this age group as potential examples of
abuse until they are convinced otherwise. In much of the
Western world, doctors are required by law to inform the
social services whenever there is a suspicion of child abuse.
This law protects not only the child (and siblings) from
further injury but the doctor from legal proceedings.

Whether or not the injury itself demands admission, the

child should be admitted for protection and to provide time
for investigation. The family can be advised that the child
must be examined and tested to determine the cause of the
fracture. Often formal casting can be delayed (use traction
or a splint), while awaiting full social services evaluation.

The doctor may find themself in the strange position of

acquiring evidence against the parents as well as trying to
provide them with counsel. The social worker has much to
offer in these circumstances but needs support from you.
They will be able to alleviate strains on the family by using
community resources, educating the family in child rearing,
perhaps putting them in contact with Parents Anonymous
(originally called Mothers Anonymous), which is an
organization of reformed child abusers. In the future,
parenting courses in schools may help to prevent child
abuse in subsequent generations.

If a child has been seriously injured, the parents may be

charged with child abuse and the child temporarily placed
in a foster home. In the end, a common judicial view is
often taken that the child is better off with his or her own
parents, even in an indifferent home, than in long-term
foster care. Different states (United States) have differing
philosophies in interpreting the rights of the biologic
parents to raise their child versus the states right to be
sure that children are raised humanely. The size of the
adult prison population in North America suggests that no
state has a “clearly just right” philosophy on the matter.

Figure 19-13 The babysitter’s children, age 7, 5, and 2 years, had

produced these symmetrical fractures.

The Battering Child

A 6-week-old child was brought to the emergency
department with symmetrical spiral fractures of the
humerus (Fig. 19-13). The parents thought the arms had
been caught in the sides of the crib–an immediately
suspicious explanation. Instead, the babysitter’s children
were the culprits; whether in play or in malice was never
determined. Adelson has recently described cases where
infants were killed by other children. Some of these killings
were due to sibling rivalry.

Munchausen by Proxy Syndrome

Munchausen syndrome is named after Baron von
Munchausen, a German repeated teller of exaggerated
tales. In the adult medical world, such patients are
characterized by habitual presentation for hospital
treatment of an apparent acute illness, the patient giving a
dramatic and usually medically “correct” history, all of
which in the end is untrue.

In the Munchausen by proxy syndrome, a parent creates

such a disease in their child, mandating unneeded
admissions, extensive work-ups, and unneeded operations.
Orthopedics must be careful of this syndrome. The line
between an overly demanding (but normal) parent and a
Munchausen by proxy parent is sometimes narrow.

Overdiagnosis—Defending Parents
As the child abuse syndrome has become better
recognized, some families end up being falsely accused. For
example, if an infant has one fracture (say humerus or
femur) and the finding of “periostitis of the newborn” (a
known phenomenon), the investigative team can be misled.
Also subtle forms of osteogenesis imperfecta may cloud the
issue.
 Figure 19-14 Midshaft humeral unicameral bone.

Sometimes the orthopedist needs to help educate the social

worker regarding the potential for fracture associated with
rough play. Hennrikus and Shaw have nicely illustrated this
in their important 2003 publication. A team approach is
required to best serve the family.
In some cases, this may be related to misinformation of
bone injury and healing patterns. In some cases, a
children’s orthopedist, with extensive experience and
understanding regarding fracture healing patterns and
remodeling, is in a good position to provide sound advice re
musculoskeletal injury and repair. Sullivan has published
his experience in helping to provide a balanced opinion in
such circumstances (see Suggested Readings).

PATHOLOGIC FRACTURES
By definition, a pathologic fracture is one through weak
bone of abnormal composition. There are multiple causes
as noted below.

Local Bone Lesions

Simple Bone Cyst. Most pathologic fractures in the upper

humerus are caused by bone cysts. (Unicameral bone cyst
[UBC] and simple bone cyst terms are used
interchangeably.) Minimal displacement is the rule.
Diagnosis can be confidently made on the radiologic
appearance alone (Fig. 19-14). Although the term simple
bone cyst is commonly used, it may lead you and the
parents to underestimate the chemistry of the lesion. As
one wit once said, “don’t call it a simple bone cyst until you
have treated ten cases. They are very often not simple (to
manage).”

The presence of the cyst does not interfere with healing,

and the fracture is treated as if the cyst is not present.
However, if nothing is done, refracture is likely.
 Figure 19-15 Nine-year-old boy with a simple bone cyst (UBC). He
has been treated with steroid injection three times. He has developed
a physeal bridge, and his humerus is now 2 cm short.

Neer found that 80% of children had one to three

refractures after the initial injury and that 10% had some
deformity as a result. For this reason, he advocated
treating all cysts.

Bone cysts occasionally produce fractures in weight-

bearing bones such as the neck of the femur. Deformity is
likely. Bone cysts may breach the growth plate. Growth
disturbance and even collapse of the femoral head may
follow. The same (growth arrest) can occur in the proximal
humerus.
 Figure 19-16 Proximal femoral cysts are at risk for intertrochanteric
fracture.

Treatment—Steroid Injection. The treatment of cysts has

been transformed by the discovery that injection with
methylprednisolone will produce healing (Fig. 19-15).
Scaglietti, Marchetti, and Bartolozzi provided details for
performing this procedure.

If the cyst is showing no signs of healing at 3 months, the

injection is repeated and may be repeated again. In 72
cases Scaglietti followed for more than 18 months, the
results ranged from complete healing in 36% to a clearly
positive result in 96%. We continue to use this method for
almost all UBC lesions treated in our hospital. Surgery for
bone cysts is now much less common but is occasionally
required.

Current methods to replace steroid injection with bone

marrow injection and vigorous methods of breaking down
the wall of the lesion with strong, curved needles
(Weintraub) appear to be successful but are more
complicated to perform than steroid injection. We have
tried several new methods but have found them either
unnecessarily complicated or to have not improved the
healing percentage. We have reverted to steroid injection,
which is very effective, providing you are persistent (inject
at least three times in sequence—when needed).

Curettement plus bone grafting may be required in the few

cysts, which are large and recalcitrant. This is most
commonly considered in large proximal femoral cysts,
which risk intertrochanteric fracture (Fig. 19-16) (although
even these lesions can heal with persistent steroid
injections). Any curettement must be delayed until the cyst
has grown away from the physis (otherwise physeal
closure, which sometimes occurs even without
curettement, will be attributed to your industrious
scraping).
 Figure 19-17 Eleven-year-old male with a pathologic fracture of the
tibia. The fracture line spirals through the distal non-ossifying fibroma.

Nonossifying Fibroma. The distal femur, followed by the

distal tibia, are the most common sites of the fracture
through cortical nonossifying fibromas. Centrally placed
lesions do not weaken bone. The risk for fracture is greater
than one might think, especially in the distal femur and
distal tibia (Fig. 19-17).

Most of these fractures are spiral and little displaced.

Healing is accompanied by partial obliteration of the
fibroma. Because the diagnosis is obvious, biopsy is not
required. Refracture is unusual. A small series of large
fibromas has been reported. Some of these were grafted
initially because of their size and risk for fracture or
because of the doubts about the diagnosis. CT scans are
often performed in large lesions to clarify size and fracture
risk (cortical break, cortical thinning).
Miscellaneous. Almost every type of bone lesion has been
associated with a pathologic fracture (Fig. 19-18). Fibrous
dysplasia of the proximal femur is a typical example. Also
congenital pseudarthrosis of the tibia (often in a patient
with neurofibromatosis) may present with pain and a
pathologic fracture.

Figure 19-18 This 8-year-old boy presented with right hip pain and
was found to have a subtle fracture line in a large bone lesion in the
intertrochanteric area. Diagnosis was polyostotic fibrous dysplasia.
The femur lesion was excised and bone grafted and fixed with flexible
nails. The left foot was treated due to recurrent fracture. His other
lesions are being monitored.

General Bone Weakness—Osteopenia

Neuromuscular Disorders. In children, a major cause of

pathologic fractures is osteoporosis resulting from
neuromuscular disorders. Fractures are especially common
in these patients after operation and cast immobilization
(because of joint stiffness and disuse atrophy).

Figure 19-19 Fracture in osteopetrosis in a girl of 8 years. This family

of affected children sustains frequent fractures.

Cerebral Palsy (CP). Fractures in children with cerebral

palsy (CP) are not common in active patient unless the
child is taking anti-seizure medicines, which effect vitamin
D metabolism. Routine care is generally effective. However,
in bedfast patients, particularly those with contractures
and convulsions, fracture are common. Very simple
methods of treatment are needed for these patients,
because pressure sores are difficult to avoid. Referral to
the metabolic bone disease unit may help in patients who
get into a vicious fracture cycle (cast off-refracture-cast off-
refracture again).
Muscular Dystrophy. The policy of keeping children with
Duchenne dystrophy on their feet as long as possible, by
means of surgical releases and bracing, and now steroid
treatment has led to more lower-limb fractures in this
group. Fractures occur at all sites and require typical cast
immobilization. An aggressive approach to encourage
walking as long as possible has been turned down in some
centers, resulting in fewer fractures.

Spina Bifida and Paraplegia. Diagnosis is often delayed

when a fracture occurs in an anesthetic part of the lower
limb. The surgeon is confronted with a swollen, hot, red
limb in a child with a slight fever–symptoms that simulate
acute osteomyelitis especially in physeal fractures, which
present exactly as an infection. We have coined the term
“Charcot physis” to describe the sequence of progressive
pain-free physeal injury with partial healing—then further
damage that can close the physis.
 Figure 19-20 This is an example of a humerus and forearm in a child
with osteogenesis imperfecta after repeat fractures. These patients
will have a great number of fractures over their lifetime. This child has
had 243 x-rays taken to evaluate various fractures throughout the
body.

Other Issues
Fracture is very common after orthopedic operations and
cast immobilization; supracondylar and trochanteric
fractures of the femur are so common after neuromuscular
hip surgery that we warn the parents to expect them. The
incidence is reduced by insisting that the child stand for a
few hours every day while in the postoperative cast.

Rapid healing is the rule for fractures in neuromuscular

conditions. Commonly, hyperplastic callus is seen. There is
no single explanation for the massive volume of callus;
repeated movement, unspecified neural influence on bone
formation, and hyperphosphatemia are possible reasons.
 Figure 19-21 Waddell’s triad of injuries in children.

Treatment should be simple and carefully supervised. An

early return to brace-wearing for the tibia, or a well-padded
weight-bearing cast, is advised in order to prevent further
disuse osteoporosis and a succession of fractures. Growth-
plate injuries may present a diagnostic challenge. We noted
premature growth arrest occurred in five of the nine
patients with neurogenic physeal fracture (Charcot physis)
and advised immobilization with non-weight bearing until
full healing has occurred.

General Bone Disease. Fractures in osteopetrosis and

osteogenesis imperfecta are common. Displacement is
usually slight, and there is much to be said for simple
splinting. Air splints have also been tried for osteogenesis
imperfecta (Figs. 19-19, 19-20). The wide-spread use of
bisphosphonates has greatly reduced fracture frequency in
osteogenesis imperfecta.
 Figure 19-22 This fracture was uncontrollable owing to a severe
head injury. Plating avoids the risk of producing avascular necrosis of
the femoral head from damage of the epiphyseal arteries. Antibiotic
cover is wise because poor nutrition and multiple tubes increase the
risk of infection.

FRACTURES IN SPECIAL GROUPS OF PATIENTS

Head Injuries with Long Bone Fractures

When a child is hit by a car, Waddell’s triad of injuries is
commonly produced. A child’s femur is at the level of the
bumper; his trunk is at the level of the hood; he may
receive a blow to the head on landing on the road (Fig. 19-
21).

Fractures of the femur and the shaft of the humerus can be

difficult to manage in restless, recumbent children. If the
head injury is minor and expected to clear in a day or two,
the fracture should be immobilized by simple splinting until
routine methods can be employed. Fat embolism may be
blamed for prolonged unconsciousness if this is not done.
When decerebration is likely to be prolonged beyond a few
days, internal traction is advised (Fig. 19-22).

Fractures in the Newborn

The literature is full of birth injuries of every type. We still
see a fair number (clavicle, humerus) in especially large
babies (Fig. 19-23). Long bone fractures are easily
recognized, but separations of unossified epiphysis present
a challenge to diagnosis.

Figure 19-23 This type of humeral fracture is common in the

newborn. Large babies seen to be at greater risk.

There may be difficulty distinguishing between a birth

fracture and child abuse. Callus appears within 7-10 days
around a birth fracture. Truesdall, in 1917, analyzed 33,000
deliveries for skeletal injury and found 85 injured children.
These were no greenstick fractures, and only 10% were
epiphyseal separations. The humerus and clavicle were
most commonly fractured, and a Velpeau bandage
controlled these well. Fractures of the midshaft of the
femur accounted for 12% of patients. An infantile femur
fracture can be treated with a Pavlik harness or by
splinting.

Hemophilia
A well-controlled hemophiliac today is free of crippling
deformities and can lead quite an adventurous life.
Fractures present no special problem if cryoprecipitate is
administered. Fractures heal at the normal rate. The child
should either be admitted or monitored by a well-run
hematology service, who can monitor the factor levels, and
carefully watched for a few days.

A greater risk than fractures, which provoke immediate

attention, is a slow bleed into a closed compartment, which
can produce a Volkmann contracture. This obviously
demands urgent decompression.

Renal Dystrophy and Rickets

Children waiting for a kidney transplant may develop
profound osteodystrophy. A slow slip of the upper femoral
epiphysis should be pinned as soon as it is noted. Dialysis is
not a contraindication to general anesthesia (Fig. 19-24).
 Figure 19-24 1. Vitamin D-resistant rickets. This child was receiving
insufficient vitamin D. 2. A slight fall produced a pathologic
epiphyseal separation. The dosage of vitamin D was increased. 3. At 2
months, the separation has healed.

STRESS FRACTURES
The most common sites of stress fracture in children are
the upper third of the tibia, the lower half of the fibula,
followed by metatarsal, rib, pelvis, femur, and humerus.
They are particularly common in the spring, when children
become active after a winter of inactivity. The radiographic
appearance may be confused with a neoplasm or an
infection, but the distinction is usually clear. If the
diagnosis is in doubt, serial radiographs should be obtained
over a short period of time. An MRI will demonstrate a
stress fracture earlier than a radiograph. Also, the MRI can
help differentiate the common subtle, healing stress
fracture from the very rare Ewing sarcoma.

Stress fractures of the femoral neck can occur in the

modern “hyper-trained” juvenile athlete. All stress
fractures of the femoral neck should be immobilized in a
spica or fixed with threaded pins.

SUMMARY
After mastering the treatment of standard children’s
fractures, one soon finds that Osler was right in stating,
“often knowing who has the disease is as important, or
even more important, than the disease that the patient
has.” Phase two of becoming a wise treating doctor for
children’s fractures is the recognition of this concept,
allowing correct diagnosis and treatment in “special
circumstances.”

SUGGESTED READINGS
Caffey J. Multiple fractures in long bones of infants suffering from chronic
subdural hematoma. AJR Am J Roentgonol. 1946;56:163–173.

Engh CA, Robinson RA, Milgram J. Stress fracture in children. J Trauma.

1970;10:532.

Flynn JM, Bashyal RK, Yeger-McKeever M, et al. Acute traumatic compartment

syndrome of the leg in children: diagnosis and outcome. J Bone Joint Surg Am.
2011;93(10):937–941.

Hargens AR, Mubara SJ. Current concepts in pathophysiology, evaluation, and

diagnosis of compartment syndrome. Hand Clin. 1998;14(3):371–383.

Hennrikus WL, Shaw BA. Injuries where children repeatedly fall from a bed or
couch. Clin Orthop. 2003;407:148–151.

Holden CEA. The pathology and prevention of Volkmann’s ischemic

contracture. J Bone Joint Surg Br. 1979;61B:296.

Marlowe A, Pepin MG, Byers PH. Testing for osteogenesis imperfecta in cases
of suspected nonaccidental injury. J Med Genet. 2002;39(6):382–386.

Matsen FA, Mayo KA, Krugmire RB, et al. A model compartmental syndrome in
man with particular reference to the quantification of nerve function. J Bone
Joint Surg Am. 1977;59A:684.
Mubarak SJ, Owen CA, Hargens AR, et al. Acute compartment syndromes.
Diagnosis and treatment with the aid of the wick catheter. J Bone Joint Surg
Am. 1978;60A:1091.

Muzykewicz DA, Goldin A, Lopreiato N, et al. Nonossifying fibromas of the

distal tibia: possible etiologic relationship to the interosseous membrane. J
Child Orthop. 2016;10(4):365–368.

Scaglietti O, Marchetti PG, Bartolozzi P. The effects of methylprednisolone

acetate in the treatment of bone cysts. J Bone Joint Surg Br. 1979;61B:200.
Silas SI, Herzenberg JE, Myerson MS, et al. Compartment syndrome of the foot
in children. J Bone Joint Surg Am. 1995;77(3):356–361.

Sillence DO. Osteogenesis imperfecta; an expanding panorama of variance. Clin

Orthop. 1981;159:11–25.

Stirling J Jr. Beyond munchausen syndrome by proxy: identification and

treatment of child abuse in a medical setting. Pediatrics. 2007;119(5):1026–
1030.

Sullivan CM. Child abuse and the legal system: the orthopaedic surgeon’s role
in diagnosis. Clin Orthop Relat Res. 2011;469(3):768–775.

Walters MM, Forbes PW, Buonomo C, et al. Healing patterns of clavicular birth
injuries as a guide to fracture dating in cases of possible infant abuse. Pediatr
Radiol. 2010;40:537–593.

Wenger DR, Jeffcoat BT, Herring JA. The guarded prognosis of physeal injury in
paraplegic children. J Bone Joint Surg Am. 1980;62A:241.

Yuan PS, Pring ME, Gaynor TP, et al. Compartment syndrome folowing
intramedullary fixation of pediatric forearm fractures. J Pediatr Orthop.
2004;24(4):370–375.
 20
Accident Prevention, Risk,
and the Evolving
Epidemiology of Fractures

Dennis Wenger
James Bomar
Accident Frequency and the Need for Prevention
Accident or Cultural Consequence?
Cultural Patterns and Fracture Risk
Risk Homeostasis
Childhood Obesity and Fracture Risk

“It takes as much energy to wish as it

does to plan”
— Eleanor Roosevelt

INTRODUCTION
The late Mercer Rang was a leader in promoting the
concept of safer playgrounds, better sports equipment, and
auto safety issues (for both passengers and pedestrians).
Over time many orthopedic organizations (AAOS, POSNA,
others) have joined this effort in promoting accident
prevention to minimize musculoskeletal injury. Also, these
organizations have expanded their efforts into areas such
as the need for exercise in childhood development,
avoidance of obesity, and efforts to promote bone density
(avoid osteopenia/osteoporosis).

Figure 20-1 Helmet wear is fortunately becoming the standard for

many sports. Efforts to prevent head injury have been a huge
success. (Photo courtesy of R. Knudson.)

ACCIDENT FREQUENCY AND THE NEED FOR

PREVENTION
Vitale and colleagues at Columbia University, through the
International Center for Health Outcomes and Innovation
Research, provide data on children’s musculoskeletal
injuries. A paper from their center clarifies pediatric
trauma as the leading cause of death and disability in
children, accounting for 11 million hospitalizations,
100,000 permanent disabilities, and 15,000 childhood
deaths each year in the United States. Clearly this calls for
a focus on preventing childhood injuries.

Tremendous progress has been made in accident

prevention. Automobiles are now much safer (better design
[structural “cage”], airbags [front, side, head protection],
better brakes [ABS], and better seat belts—plus laws that
mandate their use). The routine (and usually legally
mandated) requirement for helmet use in bicycling and
other sports (Fig. 20-1) has been important in reducing
head injuries. In many neighborhoods, playgrounds are
safer, because of better design with soft surfaces replacing
asphalt or compacted dirt to minimize injury related to a
fall (such as from monkey bars).

Furthermore, in developed countries, the establishment of

effective trauma systems including, in many cases,
pediatric trauma centers has helped reduce the morbidity
and mortality associated with severe musculoskeletal
injury. Also, the rapid growth of pediatric orthopedics as a
subspecialty has reduced fracture morbidity because of
research produced by the major pediatric orthopedic
centers that has led to better treatment methods (as have
been presented in this 4th edition).
 Figure 20-2 Children love the thrill of riding motorized vehicles.
(Photo courtesy of R. Knudson.)

A concentration of experience in treating severe fractures

has greatly improved the quality of children’s fracture care
in North America. The methods learned by pediatric
orthopedic fellows, who have trained in major centers, are
now available in hundreds of communities, not only in large
centers but also in medium-sized cities (e.g., Fargo, North
Dakota; Wichita, Kansas; Jackson, Mississippi, others).
Despite this progress, not all the news is good regarding
risks to children and fracture incidence/prevalence.

ACCIDENT OR CULTURAL CONSEQUENCE?

We continue to marvel at how the North American culture
uses the term “accident” in reference to children’s
fractures (Fig. 20-2). Parents will bring in their 6-year-old
boy who was driving a mini-racing motorcycle in the desert
with a large number of family members (with some family
members enjoying “a few beers” while riding their off-road
vehicles). The child has multiple fractures (one open) with
the parents distraught over the “accident.” In some cases,
the term “accident” has become a euphemism for failure to
provide appropriate guidance and supervision for children.
When small children and powerful machines are involved,
this failure may border on neglect.

Vitale and colleagues suggest that the incidence of

fractures is increasing in North America (rather than
decreasing) because of cultural patterns that will be
discussed later in this chapter (Galano et al.—see
Suggested Readings).

As sports become safer (helmets, pads, etc.), children are

more likely to push themselves to attempt more difficult
maneuvers. The constant progression of aggressive sports
increases the risk for injury. As an example of this
progression, in 2005 (when the previous edition of this text
was released), the X Games (Extreme Games) were largely
unknown. Since then, X Game alumni such as Tony Hawk
and Shaun White have become mainstream athletes and
traditional X Game sports (such as the snowboard half pipe
competition) have become Olympic events.
 “As sports become safer (helmets, pads,
etc.), children are more likely to push
themselves to attempt more difficult
maneuvers”

The unbelievable “musculoskeletal genius” required to

perform their most difficult maneuvers does not safely
transfer to an awkward 8-year-old who just received a
skateboard for his or her birthday. The concept of “risk
homeostasis,” in which those who wear protective
equipment or use vehicles with advanced “safety features,”
then attempt more extreme stunts or drive faster, will be
discussed later.

Brent and Weitzman presented a comprehensive analysis of

the environmental risks of childhood in North America.
They noted that accidents are the leading cause of death in
children under age 15 years, and that many are
preventable with safety education. Although leaders in
pediatric orthopedics have made a concerted effort to work
on developing methods that might prevent fracture, the
prevalence of fractures appears to be increasing in our
culture.

Brent and Weitzman grouped environmental risks to

children with many of the listed subgroups leading to
musculoskeletal injury.

Trauma from falls

Vehicular accidents
Burns
Choking, strangulation
Drowning
Bicycling
Pedestrian injuries
Guns
 Sports injuries
Power tools/farm tools
Obesity
Alcohol, smoking, drug use

In this chapter, we will focus on the conditions with risk for

musculoskeletal injury in children, that is, falls, vehicular
accidents, sports injuries, and power tools. A growing, but
less easily categorized group (not clearly demarcated in the
review by Brent and Weitzman), includes wheeled devices
that are not formally considered vehicles (skateboards,
rollerblades, “razor” scooters, hoverboards, etc.) (Fig. 20-
3) that can be used in very dynamic (even aggressive)
ways. Also, the use of gasoline powered mini-bikes and
battery-powered scooters has increased “childhood speed.”

Figure 20-3 The razor scooter has proven to be a great source of

new fractures. The tiny wheels and large sidewalk cracks are not a
good mix.

Falls
Infants can incur head injuries when falling down stairs, off
of beds, or against sharp, pointed furniture. Toddlers and
older children often fall from windows, stairs, trees, garage
roofs, and ladders. Trampoline injuries produce many
fractures (as well as head and neck injuries). Each year
thousands of children have emergency room visits for
trampoline injuries. When multiple children jump at once,
injury is more likely and younger children are at the
greatest risk for fracture. However, children really enjoy
trampolines (Fig. 20-4). One of our pediatric orthopedic
staff recently purchased one for his children (with side
netting and flexible rods instead of springs). Clearly
children’s orthopedists need a balanced view regarding
what play is “too risky” for children.

Figure 20-4 Trampolines provide enjoyment for millions of children.

This photo shows a “safer model.”
 “Clearly children’s orthopedists need a
balanced view regarding what play is
‘too risky’ for children”

Vehicular Accidents
Passenger injuries are extremely common in young
children, and they should not ride in the front seat of a car.
Education and regulations regarding properly installed car
and booster seats have improved this circumstance.
Government mandated latch systems, which allow a
nationally standardized method for attaching child seats to
the automobile frame, have made auto travel safer.
Legislation-mandated child car seat use also helps. In most
states, a parent who fails to properly restrain a child is
penalized.

“Government mandated latch systems,

that allow a nationally standardized
method for attaching child seats to the
automobile frame, have made auto
travel safer”

Also, children under age 10 years are at great risk for

death from pedestrian accidents including being run over
by the family car in their own driveway (lack of vision from
the height of the new, taller SUVs have added to the
problem). The addition of so-called rear view cameras,
mounted on the back of a vehicle, has reduced this risk.
 Figure 20-5 Preparing for competitive supercross motorcycle racing.
(Photo courtesy of R. Knudson.)

For teenage drivers, impulsive behavior, speeding, and

inattentive driving as well as driving after alcohol intake
make auto accidents a leading cause of death in this age
group. The Europeans may have a better strategy (drink
mildly and while with family, drive late—age 18 years).

Also, cell-phone use and texting while driving has become a

recent risk for severe auto accidents. Teenagers, who
believe that only they have the mental agility to both text
and drive, have been a major cause of traffic deaths in the
United States. Just a few seconds of one’s eyes “off the
road” can be fatal. Many states have developed teen driver
education programs to illustrate this risk. Also laws have
been developed to severely penalize those who text and
drive. A teenager in California, who while texting and
driving, causes an accident that kills a pedestrian (or other
driver) will time years in detention.

We see many young patients whose parents have

aspirations for their children to become professionals in
motorcycle racing and/or daredevil motorcycle jumping
activities. If children are adequately skilled, they can “get a
sponsor” (equipment, etc.), at a very young age (Fig. 20-5).
Accidents are very common in these high-risk sports, but
parents are willing to accept these risks because those who
“rise to the top” in competitive events can earn handsome
incomes as “professionals.”
 Figure 20-6 Playground safety is important. This boy was enjoying a
day at the park when the weathered plywood at the top of a slide
finally failed. He had fractures in three limbs.

Children riding a bicycle, tricycle, scooter, or skateboard or

using a razor scooter should use a well-fitted helmet to
reduce the risk for head injury. Bicycling can be risky for
children and ideally would be restricted to daylight use, in
safe areas, with helmet use.

“Organized Sports”
The prevalence of sports injuries in our culture is “sky-
rocketing” as greater numbers of children/adolescents
participate in “organized sports.” The growth of year-round
focus on one sport including the development of “travel
teams” (who spend each weekend in fiercely competitive
tournaments in distant cities) has led to “overuse injuries”
in many children.

Children who play football, baseball, soccer, hockey, and

lacrosse are advised to always wear proper protective
equipment and be properly supervised. Safety
recommendations represent the ideal and are a bit like
recommending a balanced diet for all children. Often
children who play sports do them in an unsupervised
manner and do not wear protective equipment, either
because they are not properly educated or, in many cases,
because they cannot afford the equipment.

Playgrounds
Recently there has been an increased focus in North
America on the dangers of poorly designed playgrounds
that increase the risk for childhood fracture (Fig. 20-6).
Poor landing surfaces, such as hard-packed dirt or asphalt,
can be changed to surfaces such as rubber mats, wood
shavings, or soft sand. Slowly, we are beginning to see
playgrounds becoming safer (perhaps plaintiff attorneys
can be given a bit of credit—once the issue of poor
playground design and fracture risk became apparent,
successful lawsuits against schools and parks ensued).
Although playgrounds are now generally safer, the
pendulum may have swung too far with some
organizations/cities unwilling to provide play facilities
because of insurance costs (due to legal risk).

Figure 20-7 More complex, high-off-the-ground playground

equipment helps to develop balance and judgment (in a slightly
Darwinian way). In the modern era, such playgrounds are being
reined in because of the risk for injury. Lawyers have helped to guide
this trend.

Negative Effects—“Overly Safe Playgrounds”

A less well understood consequence of the move toward
low-height, low-risk playgrounds is the denial of athletic
freedom and risk that many believe are needed to develop
balance and physical dexterity in childhood. The philosophy
of childhood development that became popular in
organizations such as the early “Boy Scouts” and “Outward
Bound” programs included outdoor activities such as
adventuresome swinging ropes, relatively high slides, and
swings with long ropes or chains allowing a large swinging
arc. Complex climbing devices, such as monkey bars, were
common (Fig. 20-7).

The idea behind such equipment is that the activity

develops a child’s dexterity, physical stamina, and ability to
encounter adversity. It is accepted that an unwary child
might be injured but the risk-benefit ratio favors
adventurous design.

In summary, modern super safe, “low rise” playground

equipment may decrease the injury rate but at the same
time prevent children from achieving their full physical
potential by limiting play experiences that demand
judgments regarding distance, height, timing, etc. Experts
have suggested that later life acrophobia (fear of heights)
is more common in individuals who have not had a
challenging childhood play experience. The advent of well-
designed “climbing walls” (for both children and adults)
seems a step in the right direction (Fig. 20-8).

In our culture, the need for adventuresome play that

involves risk has to a great degree moved from the
playground to other venues such as small-wheeled
scooters, rollerblades, skateboards, racing bicycles,
motorized scooters, and small motorcycles that have
proven to be a prolific new cause for fractures.
 Figure 20-8 Climbing walls have gained popularity since the last
edition of this text.

Lawn Mowers—Power Tools

Brent and Weitzman noted that nearly 10,000 children, age
15 and younger, are injured by lawn mowers each year
(Fig. 20-9). Young children should not be nearby when a
power mower is used, and these experts suggest that
children under 12 years should not be allowed to operate a
walking rotary mower and children under 14 should not
operate a riding mower.
Physicians with agricultural roots in America,
understanding the benefit of responsibility learned at an
early age, might quarrel with this advice. Learning to use
power drills, saws, etc. is an important childhood
learning/parental bonding experience (Fig. 20-10) and may
even prepare them for a later orthopedic residency
position!

Injury Frequency—Male versus Female Issues

A study utilizing the population base of Olmstead County,
Minnesota, and surrounding communities, suggested that
the incidence of childhood forearm fracture was increasing:
263 per 100,000 population—1969; 372 per 100,000
population—1999 (30 years later). Although uncertain of
the cause, they suggested a changing pattern of physical
activity or decreased bone acquisition due to poor calcium
intake, or perhaps both.

Figure 20-9 Young children should not use dangerous rotary lawn
mowers. The risk for soft tissue injury and scalping type fractures is
great, especially if the grass is wet. (Photo courtesy of C. Farnsworth.)
 Figure 20-10 Learning to use power drills, saws, etc. can be an
important childhood learning/parental bonding experience.

They also noted a greater rate of fracture increase in girls

(52%) as compared to boys (32%) with the largest
increases in pubertal age children. This female over male
increase led to speculation regarding calcium intake. On
the other hand, another report estimated that in 1971, only
31,000 girls participated in organized high school sports
whereas three million girls participated in 2003. Although
increased numbers wouldn’t necessarily increase the risk
for forearm fractures, increased numbers also means that
more girls are competing at high levels (premier leagues),
which may increase the speed and ferocity of sport
collision.

The Vitamin D “Pandemic”

In our center, we sometimes observe repeat fractures in
the same bones (Fig. 20-11). We attribute this to
aggressive lifestyle with early return to sport/play, rather
than “soft bones.” Since about the year 2000, our national
meetings and journals have been bombarded with reports
and papers emphasizing a previously unrecognized
“epidemic” of vitamin D intake deficiency in childhood
(even in sunny climates).

A recent report in the New England Journal of Medicine

has cast substantial doubt on the validity of the recent
surge of childhood vitamin D deficiency reports. This paper
suggests a misuse/misinterpretation of laboratory
standards/norms as the cause of the vitamin D “Pandemic.”
Wise physicians/surgeons will need to follow this
discussion closely.
 Figure 20-11 Refractures are common, but likely due to an
aggressive lifestyle rather than soft bones.

CULTURAL PATTERNS AND FRACTURE RISK

Throughout history, children likely suffered injuries while
working with their parents, while hunting, and in
adventuresome play. With the evolution of advanced
economies, children now have more leisure time allowing
play in formal playgrounds, vigorous sport, as well as
exposure to both wheeled and motorized wheeled vehicles.
As already noted, we are experiencing an increasing
prevalence of fractures in children.

Our profession’s reaction to this changing childhood risk

has been laudable with many organizations and
government entities devoting resources and research
toward accident and injury prevention. The goal has been
to decrease the incidence and severity of fractures by
methods including playground design, seat belt use,
mandated car seat use, helmet use, the wearing of proper
protective devices for sports, and age and location advice
for all-terrain vehicle (ATV) use.

Unfortunately, the exponential growth of automobile use in

large cities throughout the world has made progress in
accident prevention problematic. The number of vehicles
on the streets each day in cities such as Shanghai, Jakarta,
and São Paulo has sky-rocketed over the last 30 years, and
the design and construction of safe, well-designed streets,
highways, and freeways has not kept pace. The prevalence
of auto and auto/pedestrian injuries in “developing
continents” such as Africa has been immense. The result is
a radical increase in musculoskeletal injuries, for both
drivers and pedestrians. Thus industrialization, the growth
of cities, and the use of gasoline powered vehicles of all
types (automobiles to “pocket” scooters) have made life
more risky for children.

“Industrialization, the growth of cities,

and the use of gasoline powered
vehicles of all types have made life
more risky for children”

Human Need for Risk—Traditional Hunter-Gatherer

Activities versus Sport?
The historic male role required dangerous activities on a
daily basis (hunting large animals for food, defending one’s
cave or hut against invasion—animal or human). Modern
existence in the cocoon of a prosperous suburb likely leaves
our evolutionary “aggressive nature” unchallenged.
Females have also joined this need for the “challenge” of
sports, especially demanding ones (such as downhill ski
racing). It would appear that the adolescent brain has an
innate need to experience risk and that the traditional risks
(warfare, hunting wild game with a spear) have been
replaced with modern sporting experiences.
 Figure 20-12 Adventuresome skateboarding is very popular
throughout North America.

New Sports and Risk

Advanced cultures have tried to make sports safer with
helmet wear for bicycling, well-padded surfaces on ideally
designed playgrounds, and strict rules regarding protective
gear for organized sport, yet fracture prevalence is
increasing. It appears that risk seekers have found a need
for new outlets, as evidenced by the rapid growth of
“extreme” sports throughout the world.

Large numbers of the North American population enjoy

participating in extreme sports with a focus on speed and
risk (Fig. 20-12). This began with small numbers of people
in Southern California riding skateboards in empty
swimming pools in the 1970s. The development of the X
Games and events sponsored by Red Bull and others led to
mainstream acceptance of various high-risk sports in the
2000s. The advent of YouTube has further democratized
extreme sports, essentially allowing every child (regardless
of skill level) to have its own daily version of the X Games.
A child and its friend can use their cell phone camera to
record themselves attempting (and often failing) various
stunts and that evening they post the video on YouTube.
Many of the posts are of crashes and if the crash is bad
enough, the video may “go viral” and easily be viewed more
times in a weekend than the entire actual annual
attendance of the X Games.
Each year we see hundreds of children who have suffered
fractures while participating in extreme sports. Commonly
a child arrives in our clinic with a fracture and a video of
them getting it (in rare cases this helps us learn more
about the biomechanics of fractures).

Figure 20-13 Motocross athletes are not risk averse! (Image by Bob
Haarmans https://www.flickr.com/photos/rhaarmans/7670930572.)

Even in well-structured sports (BMX bicycle racing), the

development of new helmets, pads, etc. has been
superseded by the demands of the extreme stunts that
children attempt. Supercross, a popular dirt bike
(motorized bike) racing competition, held in stadiums
throughout North America, has produced an offshoot called
freestyle motocross in which the athletes perform back flips
and other tricks on their dirt bike while 20 feet in the air
(Fig. 20-13).

“We commonly see children and

adolescents, with serious fractures, who
have been emulating their professional
idols”
We commonly see children and adolescents, with serious
fractures, who have been emulating their professional
idols. Some would suggest “outlawing” such activites in
childhood; however the extreme sport stars of the future
require this early, intensive training if they are to have any
hope of becoming a professional. Not every family can
realistically expect their child to become a traditional
“professional” (doctor, lawyer, etc.) For many, the
income/prestige of becoming a car/motorcycle racing
“professional” seems more plausible. Orthopedic surgeons,
placed in the midst of this cultural turmoil, should avoid
being “overly judgmental.”

RISK HOMEOSTASIS
The increase in childhood fracture incidence, despite the
best intended advice of organizations regarding safety
rules, helmet wear, protective equipment wear, and rules
for organized sports, may represent a variation of what the
Dutch (now Canadian) psychologist Gerald Wild has coined
“risk homeostasis.” As vehicles are made safer (air bags,
ABS brakes, etc.) drivers drive more rapidly and have more
accidents. A study of taxi drivers, who were rotated
between “safety performance vehicles” (air bags, ABS,
better suspension) and standard vehicles, experienced a
higher accident rate in the “safety” vehicles. The drivers
simply drove faster and took more risks.
 Figure 20-14 Go-kart racing provides a thrilling activity that children
can safely enjoy.

The same phenomenon is seen in both official (and

particularly unofficial) childhood “sport” (Fig. 20-14). As
helmets, protective splints, and rules evolve, the
participants simply evolve to a higher level of performance,
speed, and risk. The helmets remain up to the task, but the
limbs serve as “crumple zones” (to protect the central, vital
organs). Thus human reflexes and protective limb extension
(with a fall) serve much like the hood and engine mount
design of a safe Volvo automobile (hood collapses—central
“cage” remains intact). The “risk homeostasis” concept in
no way negates the value of protective helmets, protective
splints, and sport rules.
 Figure 20-15 Obesity plays a role in childhood injury.

CHILDHOOD OBESITY AND FRACTURE RISK

Childhood inactivity and obesity are likely related to
television watching, video game use, and parents driving
their children everywhere (including to school), combined
with too much of the wrong type of food (fat, sugar, “fast
food”). The sudden forcing of obese, out-of-shape children
into vigorous sports appears to be increasing the chance
for injury to children in our center (Fig. 20-15).

Obesity increases the risk for musculoskeletal injury,

especially knee injuries and ankle fractures. The state of
Arkansas has mandated that all schoolchildren have their
weight (plus adjusted body mass index [BMI]) measured at
school annually with the parents given a report (see
Suggested Readings—Wall St. Journal). This rather
controversial move may be a positive step towards public
awareness of the devastating effect that obesity has on a
child (limits social and sport opportunity—increased risk
for musculoskeletal problems, diabetes, hypertension).

Aerobic exercise and athletic training are wonderful but

should be started early in life and continued at a regular
pace. Often the opposite is true for obese children whose
parents are often unable to provide good
nutritional/athletic advice. When such children encounter
demanding physical education teachers, their lack of
conditioning increases their risk for injury. The risk for the
ankle, knee, and hip injury in a 100-kg adolescent with
increased femoral torsion, increased genu valgum,
lateralization of the patella, and “weak ankles” is profound.

Orthopedic surgeons should take the lead in educating

parents regarding the importance of conditioning and
preparation for physical education training and sports. For
example, there is little lay knowledge of the increased risk
for the development of femoral retroversion and then
slipped capital femoral epiphysis (a potentially life-
changing event—possible AVN of the hip) in an obese child
(Fig. 20-16). Publicly sponsored advertising spots on
television regarding obesity, slipped epiphyses, as well as
the global musculoskeletal consequences of obesity would
be a great advance. In March 2017, the AAOS began a
series of public service television “spots” that focus on how
obesity can harm a child—and provides hints on how
parents can help their child avoid the problem.
 Figure 20-16 This obese child sustained an unstable slipped capital
femoral epiphysis and then developed severe avascular necrosis
(AVN). A total hip replacement was required at age 16 years.

Value of Sport—Later Life Benefits

The contemporary child (particularly in sunny California—
which allows year-round activity) (Fig. 20-17), may develop
a sense of balance and body control that may better
resemble the more healthy activity patterns of our
forefathers. Establishing good dietary habits and exercise
patterns will benefit them in many ways in later life,
allowing sport participation and an active lifestyle into the
middle and upper years.

Figure 20-17 Childhood play helps to develop a sense of balance

and body control.

SUMMARY
Children’s fracture epidemiology is changing in advanced
cultures. It appears that the incidence/prevalence of
children’s fractures is increasing rather than decreasing,
because of cultural trends including crowded cities,
motorized vehicles, participation in dynamic sports, and the
eager adoption of “extreme” athletic activities.

The concept of “risk homeostasis” may be partially

responsible, with the safety benefits of better equipment,
rules, and regulations being outpaced by increased speed
and risk (that satisfies a human need). Along with
developing better methods for treating such injuries,
orthopedic surgeons should continue to be active in
educating and advising parents, schools, and government
agencies regarding measures that will minimize the burden
of musculoskeletal injuries.

SUGGESTED READINGS
Brent R, Weitzman M. The pediatricians role and responsibility in educating
parents about environmental risks. Pediatrics. 2004;113(4):1167–1172.

Busko A, Hubbard Z, Zakrison T. Motorcycle- helmet laws and public health. N

Engl J Med. 2017;376(13):1208–1209.

Cheng J, et al. A 10 year study of the changes in the pattern and treatment of
6,493 fractures. J Pediatr Orthop. 1999;19:344–350.

Galano G, et al. The most frequent traumatic orthopedic injuries from a

national pediatric inpatient population. J Pediatr Orthop. 2005;25(1):39–44.

Johnsen MB, et al. Sports participation and the risk of anterior cruciate
ligament reconstruction in adolescents: a population-based prospective cohort
study (The Young-HUNT Study). Am J Sports Med. 2016;44(11):2917–2924.

Kessler J, et al. Childhood obesity is associated with increased risk of most

lower extremity fractures. Clin Orthop Relat Res. 2013;471(4):1199–1207.

Khosla S, et al. Incidence of childhood distal forearm fractures over 30 years—a

population based study. JAMA. 2003;290(11):1479–1485.

Landin LA. Fracture patterns in children. Analysis of 8,682 fractures with

special reference to incidence, etiology and secular changes in a Swedish
urban population 1950–1979. Acta Orthop Scand Suppl. 1983;202:1–109.

Loftis CM, et al. The impact of child safety restraint status and age in motor
vehicle collisions in predicting type and severity of bone fractures and
traumatic injuries. J Pediatr Orthop. 2016 Jan 11. [ePub ahead of print].

Lovejoy S, et al. Preventable childhood injuries. J Pediatr Orthop.

2012;32(7):741–747.

Manson JE, et al. Vitamin D deficiency—is there really a pandemic? N Engl J

Med. 2016;375:1817–1820.

McKay B. “Weigh-In” of Arkansas children sparks more fears over obesity. Wall
St J. Sep 8, 2004, New York.
Szalay EA, et al. Pediatric vitamin D deficiency in a southwestern luminous
climate. J Pediatr Orthop. 2011;31(4):469–473.
 Coda
OTHER TEXTS
Ours is a basic text that covers common problems. To see
the future, we have stood on the shoulders of giants. These
“giants” are the comprehensive children’s fracture texts
from around the world, which have helped us understand
the nuances of fracture care. We present a short list.

Benson MKD, Fixsen JA, Macnicol MF, et al., eds. Children’s

Orthopaedics and Fractures. London: Springer; 2009.
Blount WL. Fractures in Children. Baltimore, MD: Williams
and Wilkins; 1955.
Green NE, Swiontkowski MF, eds. Skeletal Trauma in
Children. 4th ed. Philadelphia, PA: Saunders; 2009.
Hefti F. Pediatric Orthopedics in Practice. 2nd ed. Berlin,
Germany: Springer; 2015.
Weinstein S, Flynn J, eds. Lovell and Winter’s Pediatric
Orthopaedics. 7th ed. Philadelphia, PA: Wolters
Kluwer/Lippincott Williams & Wilkins; 2014.
Rang M. The Growth Plate and its Disorders. Baltimore, MD:
Williams and Wilkins; 1969.
Rang M. Children’s Fractures. 2nd ed. Philadelphia, PA:
Lippincott, 1983.
Rang M, Wenger DR, Pring ME. Children’s Fractures. 3rd ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2005.
Flynn JM, Waters PM, Skaggs DL, eds. Rockwood and
Wilkins Fractures in Children. 8th ed. Philadelphia, PA:
Wolters Kluwer; 2015.
Herring JA, ed. Tachdjian’s Pediatric Orthopaedics. 4th ed.
Philadelphia, PA: Saunders; 2008.
Weber BG, Brunner C, Freuler F. Die Frakturenbehandlung
bei Kindern und Jugendlichen. Berlin, Germany: Springer-
Verlag; 1978.
We thank these authors for their immense contributions.
We also apologize for not listing other texts that are also
available.

DW
VU
MP
AP
 Index
A
Accidents
prevention of, 337–344
vehicular
prevention, 341
Waddell’s triad, 333
Acetabular fractures, 216–217
ACL (anterior cruciate ligament) injuries, 242
ACPs (advanced care practitioners), 49
Acromial fracture, 109
Acuity, SCFE, 210
Adduction, 36
Adolescent fibula fractures, 277–278
Advanced care practitioners(ACPs), 49
Analgesia, for reduction, 56
Anatomic planes, 29–34
Anesthesia, for reduction, 56
local, 56–57
regional, 57–58
Aneurysm, posttraumatic, 318
Angiogram, in thrombus, 131
Angulation, distal fragment, 168
Ankle injury, 265–280
adolescent fibula fractures, 277–278
anatomy, 266–267
articular fractures, 273–276
assessment, 267
children vs. adults, 265
classification, 268–269
distal fibula epiphysis, 277
fibula fractures, 276
non-articular fractures, 269–272
 radiography, 267–268
sprains, 279–280
syndesmosis, 278–279
Ankle sprains, 279–280
Anterior cruciate ligament (ACL) injuries, 242
Anterior drawer test, knee injury, 239
Anterior humeral line, elbow x-ray, 118
Apprehension test (Fairbank sign), 239
Arterial injuries. See Vascular complications
Athletic injuries, 342–344
Atlanto-axial fracture/dislocations, 304
Atlanto-axial instability, 304–305
Atlanto-axial rotary subluxation, 305
Automobile accidents
injury prevention, 341
Waddell’s triad, 333
Avulsion injuries
hip, 208–209
pelvis, 216–217
physeal, 14
Axial plane, 30, 31

B
Bankart lesion, 102
Bathing, with cast, 84–85
Baumann’s angle, elbow x-ray, 118
Bicipital tuberosity, for arm, 168–169
Bier block, 57–58
Birth injuries
clavicle, 89–90, 92
shoulder, 102
Bivalve casts, 61, 67, 69–71
Bone
biomechanics, 2
growth plate, 5
 overgrowth, 9
physiology, 8–11
progressive deformity, 9–10
remodeling, 8–9
traumatic bowing, 3
Bone cyst, pathologic fractures and, 329–331
Bony bridging, physeal, 27–28
Boxer’s fracture, 191–193
Brace
figure-of-8, 93, 94
sarmiento, 108
Brachial plexus injury, 89
Buckle fractures, 3, 172
Butterfly fractures, 3

C
Calcaneal fractures, 291–292
Car accidents
injury prevention, 341
Waddell’s triad, 333
Carpal fractures, 191–193
Carpal navicular fractures, 194–196
Carrell, Brandon, 69
Casts, 63–86. See also specific injuries
application, 61, 66–69
bivalve, 61, 67, 69–71
complications, 83–86
dorsiflexion crinkle, 85, 86
duration, 66
equipment, 67, 71, 72
ergonomics, 69
foreign bodies, 85
hanging arm, 108
hip-knee flexion, 83, 225
hip spica. See Hip spica casts
 history, 64–66
immobilization, knee injury, 254–255
lower extremity, 77–81
materials, 64, 65, 66, 84
molding, 69
padding, 67
poorly designed, 85–86
removal, 72
rolling technique, 68
showering/bathing, 84–85
spacers, 61, 70
splitting, 61, 67, 69–71
swimming (Gore-Tex), 85
ulceration, 85
upper extremity, 72–75
vascular complications, 321–324
wedging, 80–81
Cerebral palsy, pathologic fractures in, 332
Cervical collar, 304, 306
Cervical spine injuries, 304–307. See also Spinal injuries
Chance fractures, 308–309
Child abuse, 324–329
management, 328
Munchausen by proxy syndrome, 328–329
by other children, 328
overdiagnosis, 328–329
recognition, 325–327
reporting, 328
spinal injuries, 311
transphyseal distal humeral fractures, 121
Childhood obesity, 347–348
Clavicle fractures, 87–97
anatomic aspects, 88–89
birth injury, 89–90
classification, 91–93
complications, 95
 diagnosis, 90
follow-up, 94
lateral, 95–96
medial, 97
midshaft, 93–95
neonatal, 89–90, 93
radiography, 90–91
treatment, 93–97
Clear view, 101
Communication, family
medical jargon, 37–40
urgent reduction, 45
Compartment syndromes, 321–324. See also Vascular
complications
diagnosis, 322–323
differential diagnosis, 323
lower limb, 324
treatment, 323
upper limb, 323–324
Complete distal fractures, of radius and ulna, 173
Complete fractures, 3–4
Compression test, in pelvic fractures, 200–201
Conscious sedation, 58, 59
Continuous passive motion (CPM), 18
Coracoid fractures, 109
Coronal plane, 29–30, 31, 32
Coronoid fractures, 159–160
Cozen fracture, 252–253
CPM (continuous passive motion), 18
Crush injuries, 196–197
Cubitus valgus, 145, 156
Cubitus varus, 121, 132
Cuboid fractures, 290–291
Cultural aspects, accident, 344–345
Cuneiforms fractures, 290–291
Cysts, pathologic fractures and, 329–331
D
Deformity, of hand, 9–10
DeLee classification, of transphyseal fractures, 120
Diaphyseal fractures
adolescents, 256
cast immobilization, 254–255
in child and adolescent, 254
children with osteopenia, 261
flexible nails, 257–258
floating knee, 260–261
K-wires, 257
open fractures, 259–260
operative treatment, 257
plate fixation, 259
reduction, 255–256
rigid intramedullary nails, 259
stress fractures, 261–262
Toddler’s fracture, 253–254
Dislocations
atlanto-axial fracture, 304
elbow, 102–103, 148–151
foot, 285
hip, 201–204
Monteggia fracture, 160–163
radial head, 160–163
sacroiliac, 201
shoulder, 102–103
subtalar, 292
thumb injuries, 194
Distal femur fractures, 227, 247–248
Distal phalangeal fractures, 186
Distal radius fractures
above physis, 172–175
buckle, 172
complete (both bones), 173
 Galeazzi’s, 174–175
physeal, 170–172
reduction, 173
solitary, 174
Dorsal, 35
Dorsiflexion crinkle, 85, 86

E
Elbow injuries, 111–141, 143–163
anatomic aspects, 112–113, 143–163
compartment syndrome, 323
coronoid fractures, 159–160
dislocations, 148–151
distal humerus, 111–141
initial assessment, 113–115, 145
lateral condyle fractures, 133–137
lateral epicondyle fractures, 141
medial condyle fractures, 137–138
medial epicondyle fractures, 138–141
Monteggia fracture/dislocation, 160–163
olecranon fractures, 156–159
proximal radius and ulna, 143–163
proximal ulna fractures, 156–163
pulled elbow syndrome, 146–148
radial head and neck fractures, 151–156
radiography, 115–119, 145–146
supracondylar fractures, 121–129. See also
Supracondylar fractures
transphyseal distal humerus fractures, 119–121
vascular status, 114, 130
Electronic medical record (EMR), 50
Emergency reduction, in fracture, 47–61
administration, 59, 60
anesthesia, initial, 51
local, 56–57
 regional, 57–58
arrival at ED, 52
assessment, initial, 51
orthopedic, 53
cast application, 61. See also Casts
conscious sedation, 58, 59
current trends, 49
developments, 47–48
in emergency department vs. operating room, 54,
55, 56
family education, 45
follow-up, 61
indications, 41–45
monitoring sequence, 59, 60
nurse triage, 52–53
oral/nasal medication, 56
orthopedic residents in, 49–50
physician assistants in, 53
postreduction events, 61
protocol, 50–56
treatment strategy, 54
EMR (electronic medical record), 50
Epiphysis. See also Physis
blood supply, 16
distal fibula fractures, 277
fractures, 6, 13–14
healing reaction, 16–18
articular surfaces, repair of, 18
cartilaginous, 17
internal fixation, 18
ossified, 17–18
slipped capital femoral, 210–212
with soft-tissue attachments, 16
terminology, 6
Erb’s palsy, 89
Extensor retinaculum syndrome, 272
 External fixation, femoral, 235
Extra-octave fracture, 189–190

F
Falls
child abuse, 325–327
prevention, 340
Family education
medical jargon, 37–40
urgent reduction, 45
Fasciotomy, 323
Fat pad sign, elbow injury, 117, 119
Femoral fractures
distal, 227
head, 205–212. See also Hip injuries
shaft. See Femoral shaft fractures
Femoral shaft fractures, 219–236
classification, 221–222
parkour, 219–220
patient assessment, 220
radiography, 221
treatment, 222–224
cast position, 225
children age 0-2 years, 224–225
children age 2-6 years, 226–228
children age 7-12, 228–231
children age 12 and older, 231–235
distal fractures, 227
duration, 227
elastic intramedullary nailing, 228–229
external fixation, 235
flexible nail, 228–229
midshaft fractures, 227
Pavlik harness, 224–225
proximal fractures, 226–227
 skeletal traction, 223
skin traction, 223
spica cast, 225
standard spica cast with, 228–231
submuscular plating, 233–235
trochanteric-entry intramedullary nailing, 231–
233
walking hip spica cast, 226–228
Fibroma, pathologic fractures and nonossifying, 331
Fibula fractures, 276
Fibula shaft fracture, 249–263
anatomy, 251
assessment, 250
classification, 251
diaphyseal fractures, 253–262
proximal metaphyseal fractures, 252–253
radiography, 251
Figure-of-8 brace, 93, 94
“Fish-tail” deformity, AVN of trochlea treatment, 137
Fixation methods. See specific fractures
Flexible nail
femoral shaft fractures, 228–229
humerus shaft fractures, 177–180
Floating knee, 260–261
Foot injuries, 281–296
anatomy, 282
arches of, 282
assessment, 282
calcaneal fractures, 291–292
cuboid fractures, 290–291
cuneiforms fractures, 290–291
dislocations, 285
fifth metatarsal base fractures, 287–288
first metatarsal fractures, 287
forefoot, 283–289
growth arrest, 284
 hindfoot, 291–292
Jones fracture, 288
metatarsal fractures, 285
midfoot, 289–291
multiple metatarsal fractures, 286–287
navicular fractures, 290–291
phalangeal fractures, 283–284
pseudomonas osteomyelitis, 295
puncture wounds, 295
radiography, 283
shaft and neck fractures, 285–286
stress fractures, 288–289
subtalar dislocations, 292
talar fractures, 293–295
tarsometatarsal, 289–290
terminology, 36, 37
Forearm fractures, 165–182
anatomy, 166
clinical examination, 166–167
distal
above physis, 172–175
buckle, 172
complete (both bones), 173
Galeazzi’s, 174–175
physeal, 170–172
reduction, 173
solitary, 174
malunions, 181
midshaft, 175–180
flexible nailing, 177–180
greenstick, 175
plastic deformation, 176
reduction, 176–180
pathology, 166
radiography, 168–169
refracture, 180–181
 remodeling, 180
treatment, 44–45
Forefoot fractures. See Foot injuries
Foreign bodies, under cast, 85
Fractures. See specific types and sites
Frontal plane, 29–30, 31, 32

G
Galeazzi’s fracture, 174–175
Gamekeeper’s thumb, 193–194
Gartland classification, of supracondylar humerus
fracture, 121–122
Gillespie fracture, 262
Glenoid fracture, 109–110
Gore-Tex casts, 85
Greater tuberosity fractures, proximal humerus, 107
Greenstick fractures, 3
midshaft, forearm, 175
proximal humerus, 106–107
of ulna, 146
Growth plate. See Physis
Growth remodeling, 8–9
Gunstock deformity, 132

H
Hallux valgus, 36, 37
Hand injuries, 183–198
assessment, 189
carpal, 194–196
crush, 196–197
initial management, 185
intra-articular fractures, 191
metacarpal fractures, 191–193
nerve, 197
 phalangeal fractures, 186–190. See also Phalangeal
fractures
physical evaluation, 184–185
radiography, 185
tendon, 197
terminology, 184–185
thumb, 193–194
Hanging arm casts, 108
Hangman fracture, 306
Hawkins talar neck fracture classification, 293
Head trauma, 333
Healing, speed of, 10
Health Insurance Portability and Accountability Act
(HIPAA), 39–40
Hematoma block, local anesthesia, 56–57
Hemophilia, 334
Hemorrhage, in pelvic fractures, 201
High volume fracture care models, 42–43
Hill Sachs lesion, 102
Hip injuries, 199–218
dislocations, 201–204
fractures, 204–212
anatomy and physiology, 204
cervicotrochanteric (type III), 206–208
displaced, 206–208
greater trochanter, 209
inter-trochanteric (type IV), 208
lesser trochanter, 208
nondisplaced, 206
vs. slipped capital femoral epiphysis, 210
transcervical (type II), 206–208
transphyseal (type I), 205, 210
treatment, 205–210
initial assessment, 200
Hip, snapping, 204
Hip spica casts, 81–83
 application, 225
indications, 81–83
HIPAA (Health Insurance Portability and Accountability
Act), 39–40
Hip-knee flexion casts, 83, 225
Humerus fractures. See also Elbow injuries; Shoulder
injuries
proximal
classification, 104
greater tuberosity, 107
greenstick, 106–107
lesser tuberosity, 107
malunion risk, 106
outcome, 107
reduction, 105, 106
tent-shaped physis, 103
treatment, 104, 106
shaft, 107–109
transphyseal distal, 119–121
Hunter, John, 5
Hyndman, Joe, 74

I
Immobilizer, shoulder, 108
Internal fixation, healing reactions of
physis, 18
Intra-articular phalangeal condyle fracture, 191
Intramedullary fixation. See specific fractures
Intravenous lidocaine block, 57–58

J
Jones fracture, 288
Judet classification, for radial neck fracture, 152
Judet X-rays, of acetabulum, 213
K
K wires. See specific fractures
Ketamine, 58
Kilfoyle classification, of medial condyle fractures, 137–
138
Klippel-Feil syndrome, 300
Knee, anatomic considerations, 1–2
terminology, 29–30
Knee injury, 237–248
anterior cruciate ligament injuries, 242
assessment, 238–240
distal femur fractures, 227, 247–248
patella fractures, 245–247
patellar instability, 241–242
proximal tibia fractures, 243–245
radiography, 241
Kump’s bump, 266

L
Lachman test, knee injury, 239
Lateral condyle fractures, 133–137
Lateral epicondyle fractures, 141
Lateral wall fractures, foot injury, 294
Lesser tuberosity fractures, proximal humerus, 107
Lidocaine, 57
Ligament injuries
ankle, 242
wrist, 196
Lisfranc injury, 289–290
Local anesthesia, for reduction, 56–57
Loser’s view, of elbow, 115
Lower limb
compartment syndromes, 324
terminology, 35–36
 Lucas-Championnere, Just, 19

M
Maisonneuve fracture, 263
Mallet finger, 186–188
Malunions. See also specific fractures
forearm fractures, 181
of supracondylar fracture, 132
Mathijsen, Anthonius, 64
McMurray test, knee injury, 239
Medial condyle fractures, 137–138
Medial epicondyle fractures, 116, 138–141
Medial malleolus fracture, 275–276
Metacarpal fractures, 191–193
Metatarsal fractures
fifth metatarsal base, 287–288
first metatarsal, 287
Jones, 288
multiple, 286–287
stress, 288–289
Midfoot fractures. See Foot injuries
Midshaft femoral fractures, 227
Midshaft greenstick fractures, 175
Milch classification, of lateral condyle fractures, 133
Missed Monteggia fracture, 162
Monteggia fracture/dislocation, 160–163
Moore, John Royal, 41, 52
Moro, Ernst, 89
Mortise X-ray, ankle fractures, 268
Munchausen by proxy syndrome, 328–329
Muscular dystrophy, pathologic fractures in, 332

N
Nail bed injuries, 197
 Nancy nail
femoral shaft fractures, 228–229
humerus shaft fractures, 177–180
Nerve injury, 132–133. See also Compartment
syndromes
brachial plexus, 89
Erb’s palsy, 89
hand, 197
pelvic fractures, 201
radial nerve, 108–109
ulnar nerve, 151
Neuromuscular disorders, pathologic fractures in, 332
Neurovascularly intact (NVI), 115
Newborn, fractures in, 334
clavicular, 89–90, 92
shoulder, 101–102
90-90 casts, 83, 227
Nitrous oxide, 58
Nonossifying fibroma, pathologic fractures and, 331
Nonunion, 10. See also specific fractures
Nursemaid’s elbow, 146–148
NVI (neurovascularly intact), 115

O
Oblique fractures, 3
Odontoid fracture, 306
Olecranon fractures, 156–159
Open fractures, treatment, 43–44
Open tibia fractures, 259–260
Os odontoideum, 299
Os trigonum, of talus fracture, 295
Osteochondral fragments, 14
Osteochondrallesions, of talus, 294
Osteodystrophy, renal, 334
Osteogenesis imperfecta, pathologic fractures in, 333
 Osteopetrosis, pathologic fractures in, 333
Overgrowth, 9

P
PACS (picture archiving and communication systems),
50
Parachute reflex, forearm fractures, 165
Paraplegia, pathologic fractures, 332
Parental anxiety, fracture reduced, 54, 55
Patella fractures, 245–247
Patellar instability, knee injury, 241–242
Pathologic fractures, 329–333
Pedestrian injuries, 333
Pelvic fractures, 213–217
acetabular, 216–217
associated injuries, 200
avulsion, 216–217
blood loss, 201
classification, 214–215
initial assessment, 200
nerve injuries, 201
pelvic ring, 215
radiography, 201
sacroiliac dislocation, 201
treatment, 215–216
Periosteal biomechanics, 8
Phalangeal fractures, 186–190. See also Hand injuries
distal, 186
extra-octave, 189–190
foot, 283–284
mallet finger, 186–188
neck, 188–189
proximal, 189–190
shaft, 189
Physical therapy, in elbow motion 129
 Physiological, changes in bone, 8–11
Physis, 5–8
anatomy, 15
avulsion injury, 14
healing reaction, 16–18
injuries, 14–15
bony bridging, 27–28
cartilage defects, 18
classification, 18–24
internal fixation, 18
reduction, 25–26
stress, 24
Picture archiving and communication systems (PACS),
50
Pin fixation. See specific fractures
Pivot shift, knee injury, 239
Planes of body, 29–34
Plaster, 64, 65
Plastic deformation, for radius and ulna fracture, 176
Playground injuries, 342–343
Posterior drawer test, knee injury, 239
Posterior splints, 80
Power tools, 343
Preventive measures, accident, 337–344
Progressive deformity, of hand, 9–10
Pronation, of hand, 112
Proximal femoral fractures, 226–227
Proximal metaphyseal fractures, 252–253
Proximal phalangeal fractures, 189–190
Proximal tibia fractures, 243–245
Proximal tibia metaphyseal fractures, 253
Pseudomonas osteomyelitis, 295
Pulled elbow syndrome, 146–148

Q
 Quadriceps active test, knee injury, 239

R
Radial head and neck fractures, 151–156
Radial head dislocations, 160–163
Radial malrotation, 168
Radial nerve injury, in humeral shaft fractures, 108–109
Radiographs. See specific injuries
Radius injuries
radial head and neck fractures, 151–156
radial head dislocations, 160–163
shaft, 165–182. See also Forearm fractures
Recurvatum, 35
Reduction. See Emergency reduction, in fracture and
specific fractures
Refracture, 10–11, 344
forearm fractures, 180–181
Regan and Morrey classification, for coronoid fractures,
159
Regional anesthesia, upper extremity fractures, 57–58
Remodeling, 8–9
Renal dystrophy, 334
Rickets, 334
Rigid intramedullary nails, 259
Risk homeostasis, 346–347
Rotational deformity, apex volar fracture, 168

S
Sacroiliac (SI) dislocation, 201
Sagittal plane, 30, 31, 34
Sail sign, elbow injury, 117, 119
Salter-Harris classification, 18–24. See also specific
fractures
Sarmiento brace, 108
Saw, cast, 72
Scaphoid fractures, 194–196. See also Shoulder injuries
Scapular fracture, 109–110. See also Shoulder injuries
SCFE (slipped capital femoral epiphysis), 210–212
Sedation, conscious, 58, 59
Severity, SCFEs, 211
Shaft-condylar angle, elbow x-ray, 118
Shoulder immobilizer, 108
Shoulder injuries, 99–110
anatomy, 100
assessment, 99–100
dislocation, 102–103
humeral shaft, 107–109
newborn, 101–102
proximal humerus
classification, 104
greater tuberosity, 107
greenstick, 106–107
lesser tuberosity, 107
malunion risk, 106
outcome, 107
reduction, 105, 106
tent-shaped physis, 103
treatment, 104, 106
radiography, 100–101
scapular, 109–110
Showering, with cast, 84–85
SI (sacroiliac) dislocation, 201
Skeletal traction, 223
Skin traction, 223
Skin ulcers, under cast, 85
Slings
clavicle fractures, 93–94
proximal humerus fractures, 104
Slipped capital femoral epiphysis (SCFE), 210–212
Snapping hip, 204
Solitary distal radial fractures, foream fracture, 174
Spacers, casts, 61, 70
Spica casts. See Hip spica casts
Spina bifida, pathologic fractures in, 332
Spinal cord injury, 311–313
without radiographic abnormality, 313–314
Spinal injuries, 297–314
anatomy, 298–300
atlanto-axial, 304–305
atlanto-axial rotary subluxation, 305
atlanto-occipital dislocation, 304
atlas fractures, 305
burst fractures, 307–308
cervical spine, 304–307
Chance fractures, 308–309
compression fractures, 307–308
etiology, 297–298
hangman fracture, 306
immobilization, 304
initial evaluation, 300–301
level of, 298
non-accidental, 311
odontoid fracture, 306
radiography, 301–303
ring apophysis fractures, 309
spinal cord injury, 311–313
without radiographic abnormality, 313–314
spondylolysis/spondylolisthesis, 309–311
thoracic/lumbar, 307–311
treatment, 303–304
Spiral fractures, 3
humeral shaft, 107
Splints
lower extremity, 80
suspension tape, for mallet finger, 187
ulnar gutter, 186
 Split casts, 61, 67, 69–71
Spondylolysis/spondylolisthesis, 309–311
Sports injuries, 345–346
Stability, SCFEs, 212
Stress fractures, 335
diaphyseal, 261–262
foot, 288–289
physeal, 24
Subluxation, atlanto-axial rotary, 305
Submuscular plating, of femur fractures, 233–234
Supination, of hand, 112
Supracondylar fractures
classification, 121–122
complications, 129, 132
flexion type, 127
initial management, 122
malunion, 132
mechanics, 121
percutaneous pinning, 123–124, 127–128
post-operativecare, 128–129
pulseless hand, 129–132
reduction, 123
treatment, 44, 122
type I, 124
type II, 124, 126
type III, 126–127
Suspension taping, for mallet finger, 187
Swimming casts, 85
Syndesmosis injury, 278–279

T
Talar neck fractures, 293–294
Taping, suspension, for mallet finger, 187
Tarsometatarsal injuries, 289–290
Tendon injuries, hand, 197
Terminology, 2–5, 29–40
anatomic, 29–34
communication with family, 37–40
hand injuries, 184–185
orthopedic, 30–40
physis/epiphyis, 5, 6
treatment implications, 40–41
TFCC (triangular fibrocartilaginous complex) injuries,
196
Thomas, Hugh Owen, 19
Thrombosis, posttraumatic, 318
Thumb injuries, 193–194
Tibial fractures, 249–263
anatomy, 251
assessment, 250
classification, 251
diaphyseal fractures, 253–262
distal. See Ankle injury
proximal metaphyseal fractures, 252–253
radiography, 251
toddler’s, 253–254
Tillaux fracture, 273–274
Toddler’s fracture, 253–254
Torus fracture, 3
Traction
skeletal, 223
skin, 223
vascular complications, 318
Transphyseal distal humerus fractures, 119–121
Transverse fractures, 3
Transverse plane, 30, 31
Traumatic bowing of bone, 3
Triangular fibrocartilaginous complex (TFCC) injurie, 196
Triplane fracture, 274–275
U
Ulcers, under cast, 85
Ulnar injuries. See also Elbow injuries
olecranon fractures, 156–159
proximal ulna, 156–163
Ulnar nerve injuries, 114, 151
Ultrasound
displacement of fracture, 134
forearm fractures, 169
Univalve casts, 61, 67, 69–71
Upper extremity, quick motor nerve testing for, 114
Urgent reduction. See Emergency reduction, in fracture

V
Valgus stress, knee injury, 239
Value of sport, 348
Varus stress, knee injury, 239
Varus/valgus, 30, 32, 33
Vascular complications, 315–335
arterial injury, 315–316
arterial occlusion, 316
compartment syndromes, 321–324
compensated occlusion, 317
elbow injuries, 114, 130
fracture sites, 317
lesions in discontinuity, 320–321
limb ischemia, 319–320
non-accidental trauma, 324–329
pathophysiology, 316–317
pelvic fractures, 200
physical signs, 316
prevention, 318
pulseless hand, 129–132
supracondylar fractures, 114, 130
 Vehicular accidents
injury prevention, 341
Waddell’s triad, 333
Ventral, 35
Vitamin D, 344

W
Waddell’s triad, 333
Waist fractures, 195
Weber classification, 19
Weiss classification, of lateral condyle fractures, 134
Wire fixation. See specific fractures
Wrist injuries. See also under Forearm; Radius
ligament, 196
scaphoid fractures, 194–196