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Vanderbilt Sports Medicine Common Fractures in Young Athletes February 10, 2012 Alex B. Diamond, D.O., M.P.H. Assistant Professor of Orthopaedics and Rehabilitation.

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Presentation on theme: "Vanderbilt Sports Medicine Common Fractures in Young Athletes February 10, 2012 Alex B. Diamond, D.O., M.P.H. Assistant Professor of Orthopaedics and Rehabilitation."— Presentation transcript:

1 Vanderbilt Sports Medicine Common Fractures in Young Athletes February 10, 2012 Alex B. Diamond, D.O., M.P.H. Assistant Professor of Orthopaedics and Rehabilitation Assistant Professor of Pediatrics Vanderbilt University Medical Center Co-Chair, Youth Sports Safety Taskforce Team Physician Vanderbilt & Belmont Universities Nashville Sounds & Nashville Predators 40th Annual Meeting Southeast Chapter of the American College of Sports Medicine (SEACSM)

2 Vanderbilt Sports Medicine Andrew Gregory, MD, FAAP, FACSM Assistant Professor of Orthopedics & Pediatrics Program Director, Sports Medicine Fellowship Vanderbilt University Medical Center Team Physician Vanderbilt & Belmont Universities Nashville Sounds USA Volleyball Common Fractures in Young Athletes

3 Vanderbilt Sports Medicine Disclosures Diamond – NO commercial relationships – Research & Educational funding NIH U54 Institutional Clinical & Translational Science Award Gregory – No conflict of interest

4 Vanderbilt Sports Medicine Objectives Review briefly the differences of pediatric bone Review pediatric fracture classification Discuss subtle fractures in kids Discuss a few other pediatric only conditions

5 Vanderbilt Sports Medicine Pediatric Skeleton Bone is relatively elastic and rubbery Periosteum is quite thick & active Ligaments are strong relative to the bone Presence of the physis - “weak link” Ligament injuries & dislocations are rare – “kids don’t sprain stuff” Fractures heal quickly and have the capacity to remodel

6 Vanderbilt Sports Medicine Anatomy of Pediatric Bone Epiphysis Physis Metaphysis Diaphysis Apophysis

7 Vanderbilt Sports Medicine Pediatric Fracture Classification Plastic Deformation – bowing – Fibula or ulna common Buckle/Torus – compression, stable Greenstick – unicortical tension Complete – Spiral, Oblique, Transverse Physeal = Salter-Harris Apophyseal avulsion

8 Vanderbilt Sports Medicine Plastic Deformation Bowing without fracture Often requiring reduction

9 Vanderbilt Sports Medicine Buckle (Torus) Fracture Buckled Periosteum – Metaphyseal/ diaphyseal junction

10 Vanderbilt Sports Medicine Greenstick Fracture Cortex Broken on Only One Side – Incomplete

11 Vanderbilt Sports Medicine Complete Fractures Transverse – Perpendicular to the bone Oblique – Across the bone at 45-60 o – Unstable Spiral – Rotational force

12 Vanderbilt Sports Medicine Salter-Harris Classification I II III IVV

13 Vanderbilt Sports Medicine Clues Kids usually poor historians Mechanism  Any Fall – Trampolines, Monkey Bars, Skating May not be swelling, bruising or deformity Limp Non-weight bearing Not using the arm

14 Vanderbilt Sports Medicine Keep In Mind Subtle Fractures Salter-Harris I Buckle Avulsions Occult Mimickers Nursemaids Other causes of limp – Legg-Calve-Perthes – Transient synovitis – Septic arthritis Osteomyelitis – Bone pain + Fever

15 Vanderbilt Sports Medicine Elbow Fractures Multiple physes Look for swelling – Effusion Loss of flexion/ extension No loss of supination/ pronation Typical pattern – Supracondylar in the very young – Radial head in the older child

16 Vanderbilt Sports Medicine Ossification Centers of the Elbow (CRITOE) C = Capitellum R = Radial Head I = Internal (Medial) T = Trochlea O = Olecranon E = External (Lateral ) 2 Years 4 Years 6 Years 8 Years 10 Years 12 Years

17 Vanderbilt Sports Medicine Ossification Centers Appearance

18 Vanderbilt Sports Medicine Elbow Fat Pads Indicates hemarthrosis – In the setting of appropriate mechanism = a fracture of the distal humerus, proximal radius or ulna Anterior – Normal if laying flat against the humerus – Abnormal if elevated = “sail sign” Posterior – Always abnormal

19 Vanderbilt Sports Medicine Elbow Fat Pads

20 Vanderbilt Sports Medicine Posterior Fat Pad Anterior Fat Pad

21 Vanderbilt Sports Medicine Occult Fracture

22 Vanderbilt Sports Medicine Non-Displaced Supracondylar Fracture Posterior Fat Pad

23 Vanderbilt Sports Medicine


25 Nursemaid’s Elbow Traction injury usually when it is “time to go” FOOSH Child cries and will not use the arm No swelling or deformity Does not improve with time

26 Vanderbilt Sports Medicine Nursemaid’s Elbow Subluxation of the radial head Small tear in the annular ligament which slides off the radial head and into the joint Average age 2-4 yr but up to 8 yr Radial head goes from being shaped like a pencil eraser to that of a hammer head by about age 5-6 yr

27 Vanderbilt Sports Medicine 1 2 3

28 Reduction Maneuver: Full supination and flexion

29 Vanderbilt Sports Medicine Forearm Fractures Most common fracture in pediatrics – Becoming more common FOOSH May not have swelling, bruising or deformity Tender 1” proximal to the RC joint FROM or loss of supination

30 Vanderbilt Sports Medicine Volar Bruise

31 Vanderbilt Sports Medicine



34 Splint vs. Cast for Buckle Fractures of the Distal Radius LOE 1 – Splint as good as a cast for prevention of re-fracture or loss of alignment – No difference in pain – Easier to bathe, better function – No need for return for cast removal or re-xray Plint AC et al. Pediatrics, 2006.

35 Vanderbilt Sports Medicine Navicular Fractures can happen in Skeletally Immature

36 Vanderbilt Sports Medicine Avulsion Fx common in the Fingers

37 Vanderbilt Sports Medicine Slipped Capital Femoral Epiphysis (SCFE) SH Fracture through proximal femoral physis High index suspicion – Consider in any child with limp or hip/knee pain Xray: AP/Frogleg pelvis Catch before the slip Can be bilateral ORIF

38 Vanderbilt Sports Medicine SCFE

39 Vanderbilt Sports Medicine Toddler’s Fracture Suspect – Any toddler with a mechanism who refuses to bear weight – Regardless of exam or xray SLWC x 2-3 weeks

40 Vanderbilt Sports Medicine Distal Metaphyseal/Supracondylar Slipped while running Tender above the physis Minimal swelling Refusal to bear weight No effusion A form of Toddler’s fracture

41 Vanderbilt Sports Medicine SHII Proximal Tibia - Periosteal Recoil

42 Vanderbilt Sports Medicine Ankle Fractures Physis located 1” above distal maleolar tip SH I of the fibula common with inversion injury ER stress test useful in distinguishing fracture from sprain Tibia closes medial to lateral before the fibula

43 Vanderbilt Sports Medicine Distal Fibula Salter-Harris I

44 Vanderbilt Sports Medicine 8 y/o male soccer player

45 Vanderbilt Sports Medicine

46 Salter-Harris II Distal Tibia

47 Vanderbilt Sports Medicine 12 yo football player SH III

48 Vanderbilt Sports Medicine SH IV Tibia

49 Vanderbilt Sports Medicine Calcaneal Fractures Jump from height Jump into shallow water Xrays sometimes negative, subtle Occasionally bilateral

50 Vanderbilt Sports Medicine Metatarsals Physis proximal on the 1 st and distal on the others 1 st MT epiphysis often bipartite

51 Vanderbilt Sports Medicine 5 th Metatarsal Apophysis

52 Vanderbilt Sports Medicine Please Visit

53 Vanderbilt Sports Medicine Thank You

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