Journal Reading

“The Emergency Evaluation and

Management of Pediatric Extremity
Fractures”
dr. Angga Andriyanto
PPDS Bedah Universitas Sriwijaya
2023
Pediatric Bone Anatomy
• Physis
• Area of growth cartilage and may
occur at one or both ends of a long
bone.
• Epiphysis
• Area of bone between the physis and
the adjacent joint.
• Diaphysis
• The midshaft of a long bone.
• Metaphysis
• Area between the diaphysis and the
physis.
Periosteum
Periosteum of the diaphysis and the metaphysis  thick in children.
Continuous from the metaphysis to the epiphysis  surrounding and
protecting the mechanically weaker physis.

Physis

Sensitive to alterations in the blood supply.

Physeal injuries can result in a bony bridge  growth arrest.

Ligament

Ligaments of children are stronger and more compliant than in adults

Tolerate mechanical forces better than the weaker physis.
 Physeal Fractures
The Salter and Harris classification system  prognosis for growth disturbance.
Salter-Harris Type I fractures Salter-Harris Type II fractures Salter-Harris Type III fractures
Cleavage through the hypertrophic Fracture line extends along the physis Fracture line that extends into the
cell zone of the physis, with the reproductive and then out through a part of the intraarticular area from the epiphysis,
cells of the physis remaining with the metaphyseal bone. through the physis  the cleavage plane
epiphysis.
continuing to the periphery.
Separation from the metaphysis (temporary)
or can result in a displaced epiphysis  no
associated fragments of bone.

Radiography : soft tissue swelling. Radiography : Triangular-shaped metaphyseal Radiography : CT / MRI  evaluate the extent
fragment (Thurstan Holland fragment) of the fracture and articular surface
involvement.
Manifestation : Tenderness and swelling
maximal over the physis.

Very low incidence of growth disturbances. Growth is often preserved because the The prognosis for subsequent bone growth
reproductive layers of the physis maintain relates to the preservation of circulation to the
their position with the epiphysis and the epiphyseal bone fragment.
epiphyseal circulation.
 Salter-Harris Type IV fractures Salter-Harris Type V fractures
Fracture line that originates at the articular surface and Rare and typically are the result of a profound
extends through the epiphysis, the entire thickness of compressive force transmitted to the physis.
the physis, and continues through the metaphysis.
Mechanism of injury : fall from a great height.
Radiography : Identification of epiphyseal and Radiography : Normal or may demonstrate focal
metaphyseal fragments narrowing of the physeal plate.
Do comparison views of the uninjured side.
Risk of growth disturbance can be significant.
Radiography
 Torus & Greenstick Fracture

Torus / Buckle fracture Greenstick

• Bulging or buckling of the • cortical disruption on the
periosteum because of convex side of the bone, with
compressive forces. a buckling or intact cortex on
• Radiography : Asymmetry, the concave side of the bone.
bulging, or deviation of the • Radiography : Metaphyseal-
cortical margin. diaphyseal junction of a long
bone.
Radiography
 Plastic Deformities /
Bowing Fracture
• After a fall on the outstretched
hand (FOOSH).
• Clinical finding : Pain out of
proportion to the physical
examination findings.
• Forearm bowing fracture  pain is
maximal on protonation/supination .
• Plastic deformities  Moderate –
severe (obvious clinically).
• Radiography :
• Mild bowing fracture  comparison
films of the uninvolved extremity
 Upper Extremity Injuries
Clavicle Humerus Elbow Forearm
• Middle third of clavicle • Proximal humerus • Supracondylar • Radius and ulna
• Medial clavicle • Humeral diaphysis fractures diaphyseal fractures
• Lateral clavicle • Lateral condylar • Bowing deformities
fractures • Isolated ulnar fractures
• Medial epicondyle • Radius/ulna
fractures metaphyseal
• Monteggia fracture greenstick or complete
dislocation fractures
• Olecranon fractures • Radius and ulnar
• Radial head and neck metaphyseal torus
fractures fractures
• Elbow dislocation • Distal radius physical
• Subluxation of the fractures
radial head • Carpal bone injuries
• Phalangeal fractures
 Clavicle Fractures
• Infant  birth trauma.
• Children  FOOSH / lateral side of the shoulder.

Middle third of clavicle

The most common fracture. Medial clavicle
Treatment :
• Analgesics, board arm sling (3-4 Usually epiphyseal
Lateral clavicle
weeks), & follow-up with the disruptions.
primary care physician. Minimally displaced distal
• Urgent orthopedic consultation Need urgent orthopedic
clavicle fractures 
 child is > 12 years, fracture is consultation.
≥100% displaced or shortened
immobilization with a sling or
≥2 cm, skin tenting, equivalent.
neurovascular compromise, or Urgent orthopedic
fracture through a pathologic
lesion.
consultation  fractures
with 100% displacement, ≥2
cm shortening or associated
acromioclavicular dislocation.
 Fraktur Humerus
• Midshaft humeral fractures  FOOSH / direct blow to the upper arm.

• Occur at the physis or the proximal humeral metaphysis  extraordinary ability to repair.
• Proximal humeral physeal fractures  adolescence.
Fractures of the proximal humeral metaphysis  preadolescence.
• Treatment  age of the child and degree of displacement or angulation.
Proksimal Humerus
• Children ≤ 10 to 12 years with a proximal humeral fracture that is displaced ≤ 50% and <60⸰
angulated  Broad arm sling (4 weeks) & follow-up in an orthopedics clinic within a week.
• Urgent referral to an orthopedic surgeon  Child i>10 to 12 years with > 50% displacement/ >
30⸰ angulation, pathologic fracture, or neurovascular compromise.

• Transverse fracture  Direct trauma to the humerus.

Spiral/oblique fractures  (infants & toddlers) child abuse / violent rotation.
• Fracture fragment may injure the radial nerve as it runs in the radial groove (rarely)  assess
radial nerve function (eg, wrist extensors and supinators, sensation of dorsoradial hand,
Humeral Diaphysis
thumb, and second digits) on initial examination and following any splinting.
• Treatment : Immobilization in a long-arm plaster splint with orthopedic follow-up (for midshaft
humeral fractures that present clinical deformity / angulation > 20 ⸰ (children) & 10⸰
(adolescents).
 Elbow Fracture
• Acute pediatric elbow injuries 
related to fall.
• Radiography interpretation difficult
 The large cartilaginous
component of the elbow  elbow
fractures in children are commonly
missed in the emergency department.
• Radiography : Lateral and
anteroposterior elbow.
Comparison of the uninjured side.
 Supracondylar Fractures
• Occur in children from 3 to 10 years with the peak incidence between ages 5 and 7 years.
• An extension-type (90-98%) caused by a FOOSH with the elbow hyperextended.
A flexion-type (rare) results from falling on a flexed elbow.
• Complication : Transient neurapraxia to Volkmann ischemic contracture, being an injury to the
anterior interosseous nerve resulting in the “pointing finger sign.”
Type I Type II Type III
• Displaced ≤ 2 mm, inherently • Angulated to varying degrees, but • Completely displaced with no
stable. the posterior cortex of the cortical contact.
• Radiography “fat pad sign”. humerus is intact. • Distal fragment may be
• Treatment : Pain control and • Type II and III fractures need urgent posteromedially (Type IIIa) rotated
immobilization with a long-arm orthopedic consultation (within 4 and can impinge against the radial
posterior splint with the elbow at hours) in the ED for definitive nerve or be posterolaterally (Type
90⸰ and the forearm in protonation management. IIIb) rotated.
or neutral rotation (3 weeks). • Consult orthopedic surgery
Orthopedic follow-up within 2 to 7 emergently (within 1 hour) if there
days. is a suspicion of compartment
syndrome, if there is loss of radial
pulses, or a cool, white hand.
 Forearm Fractures
• The most common pediatric fractures after a FOOSH.
• Clinical appearance : Localized pain, swelling, or limited movement.

Radius and ulna diaphyseal fractures

Proximal third shaft fractures are relatively Bowing Deformities
uncommon.
Injury of the shaft  closed reduction and These injuries can be difficult to diagnose Isolated ulnar fractures
occasionally require open fixation. and often missed  Failure to correct
In skeletally immature children younger bowing may lead to permanent deformity
than 10 years, angulation less than 10⸰  and disability. Rare and caused by a direct blow.
does not require anatomic reduction. If caused by indirect force  there is an
Treatment : associated fracture or dislocation of the
Minimally angulated  a splint/cast and radius.
follow-up with an orthopedic surgeon.
Urgent orthopedic consultation  “plastic Fraktur Monteggia : the combination of an
deformities”. ulnar fracture with a dislocation of the
radial head.
Reduction : Angulation ≥20⸰ in children <
10 years / ≥15⸰ children > 10 years. Fraktur Galeazzi : Radial shaft fracture with
an associated dislocation of the distal
radioulnar joint.
Do immediate orthopedic consultation.
Treatment : Minimally angulated  splint
and follow-up in an orthopedic clinic.
 Lower Extremity Injuries
Pelvic
• Femoral shaft
Femur • Slipped capital femoral epiphysis

• Fractures through the distal femoral physis

• Patellar dislocations
Knee • Patellar fractures
• Fractures of the tibial spine
• Tibial tuberosity fractures

• Proximal tibial physis and metaphysis fractures

Tibia & Fibula • Fractures of the tibia and fibula diaphyses

• Distal fibula ankle fractures

Ankle • Distal tibia ankle fractures

Foot & Toe

 Pelvic Fractures
Non avulsive
Etiology : Result from significant force
(most common mechanism is pedestrian versus motor vehicle collisions).
Child with a pelvic fracture  assumed to have multisystem trauma  transferred to a level 1 pediatric trauma
center.

Avulsive
Seen in the adolescent and are unusual before 8 years of age.
Etology : Sudden contraction of musculature attached to the pelvis / athletic activities.
Clinical appearance : Sudden pain and have point tenderness over the fracture site.
Treatment : Conservatively with rest, limitation of activity until symptoms resolve, and orthopedic follow-up.
 Femur
• Trauma can result in an epiphyseal disruption or a fracture of the head, neck, trochanteric, or subtrochanteric region of the femur.
• Proximal fractures involving the femoral head or neck  high risk of complications (eg, avascular necrosis, growth arrest).
• Traumatic dislocations of the hip are rare in the pediatric population and tend to occur only in older children/adolescents  urgent closed
reduction.

• Mechanisms of injury  falls, pedestrian versus automobile incidents, motor vehicle

collisions, and sports-related injuries, consider child abuse in a child with a femur fracture
who is not yet walking.
Femoral Shaft • Clinical findings : tenderness and swelling over the fracture site, child may hold the leg
externally rotated and will likely refuse to bear weight, Leg may be shortened.
• Do evaluation for multisystem trauma.
• Treatment : Immediate orthopedic consultation.

• The most common cause of hip disability in adolescents.

• Etiology : Multifactorial  most affected children are obese adolescents whose hips are
exposed to repetitive minimal trauma.
• Type : Chronic, acute, or acute-on-chronic.
• Acute  The child cannot bear weight  Surgery for reduction and fixation.
Slipped capital femoral
• Chronic  Minimal trauma / without trauma. Clinically : Hip (groin) pain, or referred to
epiphysis
the thigh or, much more commonly, the knee. Radiography : bilateral hip
(anteroposterior & lateral  Lowenstein) to evaluate for SCFE because delay in diagnosis
can lead to significant disability.
• Immediate orthopedic consultation  Definitive operation.
• Complications : necrosis of the hip and premature closure of the physis.
 Knee
• Radiography : Anteroposterior dan lateral knee.
• Uncommon  high risk of developing significant complications..
• Salter-Harris type I.
Fractures through the distal femoral physis • The popliteal artery are injured along with the peroneal nerve.
• Growth arrest may also occur secondary to permanent physeal damage.
• Need immediate orthopedic evaluation for reduction.

• Mechanism of this injury : one of pivoting the knee on a fixed lower leg.
• Clinical findings : History of the “knee popping out of place.”  Displaced patella
usually sits laterally, and the knee is held in flexion.
Patellar dislocations • Radiography after the reduction to assess for fractures  seen at either the lateral
femoral condyle or the medial margin of the patella.
• Treatment : Knee immobilizer and arrange follow-up with orthopedics within 1 to 2
weeks.

• Occur from a direct blunt force..

Patellar fractures • The “sleeve” fracture of the patella distal patellar “sleeve” is avulsed from the body of the
patella (unique to children).
• Mechanism of an avulsion  Forceful contraction of the quadriceps against afixed lower
leg.
• Do consultation with an orthopedist.
Fractures of the Tibial tuberosity
tibial spine fractures
Mechanism : Avulsion Avulsion fractures and
fracture of the tibial occur most commonly
spine is the from strong
equivalent of an contraction of the
anterior cruciate quadriceps against a
ligament rupture in fixed leg  during
an adult (its insertion sports.
are much stronger Treatment : Reduction
than the epiphyseal and fixation,
bone in children). immediate orthopedic
Treatment : consultation.
• Nondisplaced fractures
 conservatively with
immobilization in
extension and orthopedic
follow-up.
• Displaced fractures 
reduction and immediate
orthopedic consultation.
 Tibia & Fibula
Proximal tibial physis and metaphysis fractures

• Relatively uncommon.
• Complication : Vascular injury to the popliteal artery  assessment and
documentation of intact pulses and an ankle brachial index.
• There is a high risk of drift through healing and growth into a valgus deformity
of the knee (Cozen phenomenon)  Do orthopedic follow-up.

Fractures of the tibia and fibula diaphyses

• Spiral/oblique fracture of the distal tibia displaced minimally (< 2 mm) on child
between 9 months to 2 years  child is limping or refusing to bear weight for
no apparent reason or after seemingly insignificant trauma.
• Mechanism  external rotation of the foot with the knee flexed.
Clinical findings : Pain with palpation and rotation of the distal tibia, although
swelling or tenderness may be minimal or absent.
• Radiography : fracture line may at the distal third of the tibial shaft.
• Initial radiographs are negative  follow-up in one week for repeat
radiographs.
• Treatment : Immobilize in a long leg posterior splint and arrange orthopedic
follow-up. If there is >10⸰ of angulation  orthopedic consultation and
reduction.
 Ankle
• Pediatric ankle injuries  only 12%
result in ankle fractures.
• Low-Risk Ankle Rule  To avoid
unnecessary radiographs (reduce
22%).
• Ottawa Ankle Rule  Validated in
children (reduce 10%).
• Radiography : Anteroposterior,
lateral, oblique.
• CT dan MRI  distal tibia growth
plate fractures.
 The most common lower Salter-Harris I & II (common),
extremity injuries in children III & IV (rare).
older than 5 years. Tillaux Fracture  Type III
Salter-Harris I, II, and fibular fracture of the antero lateral
avulsion fractures. portion of the distal tibia.
Lateral ankle injuries in Triplane Fracture  Type IV,
fractures
Distal fibula ankle

Distal tibia ankle fractures

children  Radiograph- involves fractures in the
negativeare  Diagnosed sagittal, coronal, and
with ligamentous injuries  transverse planes, resulting in
Managed with a removable multiple fracture fragments.
ankle brace and self-regulated Radiography : CT scan (the
return to activities. extent of the joint surface
Salter-Harris Type II and distal injury in type III and IV).
fibular avulsion fractures  Treatment : Surgical reduction
inversion injury  Managed & urgent orthopedic
by immobilization in a weight- Consultation.
bearing cast or commercial
immobilizer.
 Foot & Toe
• Fractures of the mid- and hindfoot (rare)  result from a fall 
Treatment : Splint and orthopedic follow-up.
• Fractures of the metatarsals and phalanges (common)  result from a
direct blow from a falling object  Treatment : Immobilization in a
posterior short-leg splint and orthopedic follow-up.
• Fractures of the base of the fifth metatarsal  result from injuries of the
ankle  Radiographs of the foot when there is tenderness over the fifth
metatarsal  Treatment : Immobilization and orthopedic follow-up.
• Ossification center may be confused with a fracture.
• Crush injury  Cause vascular compromise and compartment syndrome
 urgent orthopedic consultation.
Thankyou