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

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

I II

III

IV V


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

time


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

2

3


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


SCFE


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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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