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Common Fractures in Young Athletes February 10, 2012

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1 Common Fractures in Young Athletes February 10, 2012
40th Annual Meeting Southeast Chapter of the American College of Sports Medicine (SEACSM) 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

2 Common Fractures in Young Athletes
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

3 Disclosures Diamond Gregory NO commercial relationships
Research & Educational funding NIH U54 Institutional Clinical & Translational Science Award Gregory No conflict of interest 0:30 + 0:10

4 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 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 Anatomy of Pediatric Bone
Epiphysis Physis Metaphysis Diaphysis Apophysis

7 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 Plastic Deformation Bowing without fracture Often requiring reduction

9 Buckle (Torus) Fracture
Buckled Periosteum Metaphyseal/ diaphyseal junction

10 Greenstick Fracture Cortex Broken on Only One Side Incomplete

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

12 Salter-Harris Classification

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

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

16 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 Ossification Centers Appearance

18 Elbow Fat Pads Indicates hemarthrosis Anterior Posterior
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 Elbow Fat Pads

20 Posterior Fat Pad Anterior Fat Pad
A small anterior fat pad is normal = coronoid fossa A posterior fat pad is always abnormal = Olecranon fossa What type of fracture do you have to worry about? Supracondylar/ Radial Head Mechanism of injury? Direct blow to the elbow or a fall on an outstreched hand with elbow extended What type of Splint ? Double Sugar Tong or Posterior Splint with A-Frame Follow-up for rex-ray

21 Occult Fracture

22 Non-Displaced Supracondylar Fracture
Posterior Fat Pad Non-Displaced Supracondylar Fracture Posterior Splint and Follow-up



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 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 2 3 1

28 Reduction Maneuver: Full supination and flexion
2. 1.

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

30 Volar Bruise




34 Splint vs. Cast for Buckle Fractures of the Distal Radius
Plint AC et al. Pediatrics, 2006. 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 Several other LOE 1 studies & systematic review support same findings.

35 Navicular Fractures can happen in Skeletally Immature

36 Avulsion Fx common in the Fingers

37 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


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

40 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 SHII Proximal Tibia - Periosteal Recoil

42 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 Distal Fibula Salter-Harris I

44 8 y/o male soccer player


46 Salter-Harris II Distal Tibia
Fibula fractures through the growth plate = posterior splint

47 12 yo football player SH III

48 SH IV Tibia

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

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

51 5th Metatarsal Apophysis

52 Please Visit

53 Thank You

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