Common Fractures in Young Athletes February 10, 2012

Vanderbilt Sports Medicine

Common Fractures in Young AthletesFebruary 10, 2012

Alex B. Diamond, D.O., M.P.H.Assistant Professor of Orthopaedics and Rehabilitation

Assistant Professor of PediatricsVanderbilt University Medical Center

Co-Chair, Youth Sports Safety TaskforceTeam Physician

Vanderbilt & Belmont UniversitiesNashville Sounds & Nashville Predators

40th Annual MeetingSoutheast Chapter of the American College of Sports Medicine (SEACSM)

Andrew Gregory, MD, FAAP, FACSMAssistant Professor of Orthopedics & PediatricsProgram Director, Sports Medicine Fellowship

Vanderbilt University Medical CenterTeam Physician

Vanderbilt & Belmont UniversitiesNashville Sounds

USA Volleyball

Common Fractures in Young Athletes

Disclosures• Diamond

– NO commercial relationships– Research & Educational funding

• NIH U54 Institutional Clinical & Translational Science Award

• Gregory– No conflict of interest

Objectives• Review briefly the differences of pediatric

bone• Review pediatric fracture classification• Discuss subtle fractures in kids• Discuss a few other pediatric only conditions

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

Anatomy of Pediatric Bone

• Epiphysis• Physis• Metaphysis• Diaphysis• Apophysis

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

Plastic Deformation• Bowing without

fracture• Often requiring

reduction

Buckle (Torus) Fracture• Buckled Periosteum

– Metaphyseal/ diaphyseal junction

Greenstick Fracture• Cortex Broken on Only One Side

– Incomplete

Complete Fractures• Transverse

– Perpendicular to the bone

• Oblique– Across the bone at 45-60o

– Unstable

• Spiral – Rotational force

Salter-Harris Classification

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

Keep In MindSubtle Fractures

• Salter-Harris I• Buckle• Avulsions• Occult

Mimickers• Nursemaids• Other causes of limp

– Legg-Calve-Perthes– Transient synovitis– Septic arthritis

• Osteomyelitis– Bone pain + Fever

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

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

Ossification Centers Appearance

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

Elbow Fat Pads

Posterior Fat Pad

Anterior Fat Pad

Occult Fracture

Non-Displaced Supracondylar Fracture

Posterior Fat Pad

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

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

Vanderbilt Sports Medicine1

Reduction Maneuver: Full supination and flexion

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

Volar Bruise

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.

Navicular Fractures can happen in Skeletally Immature

Avulsion Fx common in the Fingers

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

Toddler’s Fracture• Suspect

– Any toddler with a mechanism who refuses to bear weight

– Regardless of exam or xray

• SLWC x 2-3 weeks

Distal Metaphyseal/Supracondylar

• Slipped while running• Tender above the physis• Minimal swelling• Refusal to bear weight• No effusion• A form of Toddler’s fracture

SHII Proximal Tibia - Periosteal Recoil

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

Distal Fibula Salter-Harris I

8 y/o male soccer player

Salter-Harris II

Distal Tibia

12 yo football player

SH III

SH IV Tibia

Calcaneal Fractures• Jump from height• Jump into shallow

water• Xrays sometimes

negative, subtle• Occasionally bilateral

Metatarsals• Physis proximal on the

1st and distal on the others

• 1st MT epiphysis often bipartite

5th Metatarsal Apophysis

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Common Fractures in Young Athletes February 10, 2012

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