AAOS Comprehensive Orthopaedic Review

Section 3 - Pediatrics

Chapter 26. Pediatric Pelvic and Lower Extremity Fractures and Child Abuse

I. Pelvic Fractures

A. Evaluation—Approximately half of all pelvic fractures identified on CT scan are not identified on plain AP pelvis radiographs.

 

B. Classification

 

1. The most common classification systems used for pelvic fractures are the Tile classification system and the Torode and Zieg classification system.

 

a. Tile classification

 

i. Type A—stable

 

ii. Type B—rotationally unstable but vertically stable

 

iii. Type C—rotationally and vertically unstable

 

b. Torode and Zieg classification

 

i. Type I—avulsions

 

ii. Type II—iliac wing fractures

 

iii. Type III—simple ring fractures without segmental instability

 

iv. Type IV—ring disruptions with segmental instability

 

2. Regardless of the classification system used, it is essential to determine whether the pelvic fracture is stable.

 

C. Treatment

 

1. Nonsurgical—Good results can be expected from nonsurgical treatment of almost all pediatric pelvic fractures with bed rest and bed-to-chair transfers for 3 to 4 weeks, followed by progressive weight bearing.

 

2. Surgical indications

 

a. Rapid application of an external fixator is occasionally indicated to close down the volume of the pelvis in open book injuries.

 

b. Surgery is most commonly indicated in adolescents with vertically unstable injuries or significantly displaced acetabular fractures.

 

D. Complications—Malunion and nonunion are extremely rare, though limb-length discrepancy may occur in vertically unstable fractures.



II. Avulsion Fractures of the Pelvis

A. Epidemiology—These fractures typically occur in adolescent athletes involved in explosive-type activities (such as sprinting, jumping, and/or kicking). The most common avulsion sites (and the causative muscles) are the ischium (because of the hamstring/adductor muscles), the anterior superior iliac spine (sartorius), the anterior inferior iliac spine (rectus femoris), the iliac crest (abdominals), and the lesser trochanter (iliopsoas).

 

B. Treatment

 

1. Nonsurgical—Treatment is with local measures, including rest, ice, and anti-inflammatory medication for 2 to 3 weeks. Activities are then resumed gradually.

 

2. Surgical—Surgery is almost never indicated for these injuries, although it may be considered for symptomatic nonunions.

 

C. Complications—There are few, if any, long-term sequelae of these injuries.



III. Hip Fractures

A. Classification—The Delbet classification is used most commonly for these fractures (

Figure 1).

 

1. Type I—transphyseal

 

2. Type II—transcervical

 

[Figure 1. The Delbet classification of pediatric hip fractures. Type I fractures are physeal fractures; type II, transcervical; type III, cervicotrochanteric; and type IV, intertrochanteric.]

3. Type III—cervicotrochanteric

 

4. Type IV—intertrochanteric

 

B. Treatment

 

1. Nonsurgical—Nonsurgical treatment is rarely indicated because of the increased risks of coxa vara and nonunion with closed treatment.

 

2. Surgical procedures

 

a. When feasible, closed treatment and internal fixation is preferred.

 

b. Decompression of the intracapsular hematoma by aspiration or arthrotomy has been advocated by some to decrease the risk of osteonecrosis (ON); however, the supporting data are equivocal.

 

c. Fixation

 

i. When possible, fixation should not cross the physis.

 

ii. Fixation is with Kirschner wires (K-wires) or cannulated screws for Delbet type I fractures, cannulated screws for type II and III fractures, and a pediatric hip screw or dynamic hip screw for type IV fractures.

 

C. Complications

 

1. Osteonecrosis is the most common, and most devastating, complication and is directly related to fracture level. The risk of ON is 90% to 100% for type I fractures, 50% for type II fractures, 25% for type III fractures, and 10% for type IV fractures.

 

2. Coxa vara and nonunion are much more common after nonsurgically treated fractures, particularly for Delbet II and III fractures.

 

3. Limb-length discrepancy is common after hip fractures in young children because the proximal femoral physis accounts for approximately 15% of total leg length.



IV. Femoral Shaft Fractures

A. Epidemiology

 

1. Child abuse is the cause of the vast majority of femur fractures before walking age.

 

2. Although abuse must be considered in children up to 5 years of age, it is a less common cause of femur fractures after walking age.

 

B. Treatment

 

1. Nonsurgical

 

a. Spica casting is routinely performed in children younger than 6 years. This may be either immediate spica casting or traction followed by delayed spica casting.

 

b. When skeletal traction is used, it should be inserted into the distal femur rather than into the proximal tibia. (Proximal tibial traction pins risk damage to the tibial tubercle apophysis with resultant genu recurvatum.)

 

c. Shortening exceeding 2.5 to 3.0 cm is a relative contraindication and multiple trauma is an absolute contraindication to immediate spica casting.

 

2. Surgical treatment

 

a. Indications—Most children older than 6 years are treated surgically, as are many younger multiple trauma patients.

 

b. Procedures

 

i. Flexible intramedullary (IM) rodding is the treatment of choice for the vast majority of pediatric femoral shaft fractures. Comminuted or very distal or proximal fractures are harder to control with IM rods. Complication rates are higher in children > 10 years of age.

 

ii. External fixation has become less popular over the past 10 years. External fixation may be used for comminuted or segmental fractures. It has higher rates of delayed union and refracture than other forms of fixation.

 

iii. Open plating of femoral shaft fractures is rarely used in most centers because of the increased dissection required, the increased blood loss, the desire to avoid load-bearing implants, and the presence of multiple stress risers following hardware removal.

 

iv. Submuscular bridge plating is becoming increasingly popular, especially for comminuted femoral shaft fractures. Insufficient data are currently available to assess outcomes accurately. Drawbacks for these devices are that they are load-bearing, there are many stress risers in the femoral shaft following hardware removal, and there is a significant learning curve.

 

v. Antegrade, rigid femoral nails are indicated in children with closed proximal femoral physes. In children with open physes, the risk of ON is up to 1% to 2%.

 

vi. Trochanteric entry nails are gaining in popularity for larger children (most commonly those older than 10 years and those with extensive comminution). These nails appear to cause abnormalities of proximal femoral growth (resulting in a narrow femoral neck), and the risk of ON is unknown.

 

C. Complications

 

1. Limb-length discrepancy

 

a. Typically 7 to 10 mm of ipsilateral overgrowth occurs in children who sustain a femur fracture between the ages of 2 and 10 years.

 

b. Limb-length discrepancy may occur as a result of either excessive overgrowth or excessive shortening at the time of fracture healing following cast treatment.

 

2. Malunion

 

a. Angular malunion is typically due to varus and/or procurvatum deformity, is unusual following surgical treatment, and can be minimized following spica treatment by careful technique.

 

b. Torsional malunion is common but rarely of clinical consequence.

 

3. Refracture is most common following external fixation and typically occurs following fixator removal. Refracture is most common following transverse or short oblique fractures.

 

4. Delayed union and nonunion are typically seen only after surgical treatment and are much more common when load-bearing devices (external fixators or plates) are used.

 

5. ON of the femoral head has been reported following rigid antegrade nailing of femoral fractures in skeletally immature individuals with both piriformis fossa and trochanteric nail entry points.



V. Distal Femur Fractures

A. Distal femoral metaphyseal fractures

 

1. Nonsurgical treatment—Casting suffices for the vast majority of low-energy insufficiency fractures in children with neuromuscular disease.

 

2. Surgical treatment—For displaced fractures, surgical treatment (with closed reduction and pinning) is almost always indicated. The physis should be avoided, if possible.

 

3. Complications—Malunion is the most common complication following displaced fractures because accurate assessment of coronal plane alignment is difficult following casting.

 

B. Distal femoral physeal fractures

 

1. Classification—The Salter-Harris classification is used to describe these fractures.

 

2. Nonsurgical treatment is indicated for nondisplaced Salter-Harris I and II fractures.

 

3. Surgical treatment

 

a. Indications—Surgical care is indicated for displaced fractures of the distal femoral physis.

 

b. Procedures

 

i. Closed reduction and internal fixation is appropriate for most of these fractures, although open reduction and internal fixation (ORIF) may be needed for irreducible fractures.

 

ii. Fixation avoids the physis when possible. When fixation must cross the physis, smooth K-wires are used and should be removed by 3 to 4 weeks after surgery.

 

4. Complications

 

a. Popliteal artery injury and compartment syndrome are rare but are more likely when the epiphysis displaces anteriorly.

 

b. Growth arrest occurs in ~30% to 50% of distal femoral physeal injuries.

 

[

Figure 2. Lateral view of a patellar sleeve fracture. The only sign on plain radiographs may be patella alta.]

i. Sequelae of distal femoral physeal fractures include limb-length discrepancy and angular deformity.

 

ii. These sequelae are often severe because of the rapid growth of the distal femur.



VI. Patellar Fractures

A. Evaluation—Bipartite patella is a normal variant that occurs in up to 5% of knees. It differs from a patellar fracture in two ways.

 

1. Typically a bipartite patella has rounded borders.

 

2. It is located superolaterally.

 

B. Classification

 

1. Fractures are generally categorized based on location, fracture configuration, and the amount of displacement (if any).

 

2. Patellar sleeve fractures are a relatively common type of pediatric patellar fracture in which a chondral "sleeve" of the patella separates from the main portion of the patella and ossific nucleus. The only finding on plain radiographs may be apparent patella alta for distal fractures (Figure 2) or patella baja for proximal fractures, so these fractures are often missed on initial presentation.

 

C. Treatment

 

1. Nonsurgical—Nonsurgical treatment is indicated for nondisplaced and minimally displaced fractures in children without a knee extensor lag.

 

2. Surgical

 

a. Indications

 

i. Surgical fixation is generally performed for fractures displaced >2 mm at the articular surface. The indication for surgery is confirmed by an extensor lag or the inability to actively extend the knee.

 

ii. Patellar sleeve fractures require surgery.

 

b. Procedures

 

i. For osseous fractures, fixation (as in adults) with tension banding is indicated. A cerclage wire may be needed for extensively comminuted fractures.

 

ii. For patellar sleeve fractures, repair of the torn medial and lateral retinaculum along with the use of sutures through the cartilaginous and osseous portions of the patella generally suffice.



VII. Tibia and Fibula Fractures

A. Tibial spine fractures

 

1. Evaluation—Children with fractures of the tibial spine present with a mechanism consistent with an anterior cruciate ligament (ACL) tear and an acutely unstable knee. Although it is the result of avulsion of the ACL insertion (rather than a tear in the ACL itself), the presentation and physical examination are comparable to those following a ligamentous ACL tear.

 

2. Classification—The Meyers and McKeever classification (

Figure 3) is used to categorize these fractures: type I, minimally displaced; type II, hinged with displacement of the anterior portion; and type III, completely displaced.

 

3. Nonsurgical treatment—Closed reduction and casting suffices for type I and some type II fractures. For type II fractures, the reduction must be within a few millimeters of anatomic to accept closed treatment. The optimal amount of knee flexion for reduction is controversial, though generally

 

[Figure 3. Meyers and McKeever classification of tibial spine fractures.]

   recommended to be 0° to 20°. Arthrocentesis may be needed before casting if there is a large hemarthrosis.

 

4. Surgical treatment

 

a. Indications—Type II fractures that do not reduce with casting and type III fractures are treated surgically.

 

b. Procedures—ORIF and arthroscopic reduction and internal fixation are both effective, and fixation with sutures and/or screws should avoid the physis. The meniscus is often entrapped and must be moved to allow for reduction.

 

5. Complications

 

a. ACL laxity is common, but it is generally not clinically significant.

 

b. Malunion with persistent elevation of the fracture fragment may result in impingement in the notch.

 

B. Proximal tibial physeal fractures

 

1. Classification—The Salter-Harris classification is used to categorize these fractures (

Figure 4).

 

2. Nonsurgical treatment

 

a. Nondisplaced fractures account for 30% to 50% of Salter-Harris I and II fractures.

 

b. Nondisplaced fractures may be treated with cast immobilization.

 

3. Surgical treatment

 

a. Indications—Closed (or open) reduction and internal fixation should be performed for displaced fractures.

 

b. Procedures

 

[Figure 4. Salter-Harris fractures of the proximal tibial physis.]

[

Figure 5. Lateral view of the knee depicting the potential for popliteal artery injury due to proximal tibial physeal fracture.]

i. For most Salter-Harris I and II fractures, fixation is with crossed smooth K-wires, which are removed by 3 to 4 weeks after surgery.

 

ii. For Salter-Harris III and IV fractures (and Salter-Harris II fractures with large metaphyseal fragments), cannulated screws parallel to the physis are indicated.

 

4. Complications

 

a. Popliteal artery injuries (~5%), compartment syndrome (~3% to 4%), and peroneal nerve injury (5%) are relatively common. Vascular complications are particularly common with hyperextension injuries (Figure 5).

 

b. Redisplacement of the fracture is common for displaced fractures treated without internal fixation.

 

c. Growth arrest occurs in 25% of patients and can result in limb-length discrepancy and/or angular deformity.

 

C. Proximal tibial metaphyseal fractures

 

1. Classification—No specific classification is used for these fractures.

 

[

Figure 6. Classification of tibial tubercle injuries. Types I through IV are true fractures, while type V is actually a soft-tissue injury with detachment of the periosteal sleeve.]

2. Nonsurgical treatment—Nonsurgical treatment (with a long-leg cast) is the mainstay of treatment of low-energy injuries in children younger than 10 years.

 

3. Surgical treatment—Surgery is generally necessary for high-energy proximal tibia fractures in older children because these fractures are often significantly displaced and unstable.

 

4. Complications

 

a. For low-energy injuries (so-called Cozen fractures), the most common complication is genu valgum in the first 6 to 12 months after fracture that is due to medial proximal tibial overgrowth. No treatment is needed for this acutely because most of these deformities improve spontaneously.

 

b. For high-energy fractures in older children, neurovascular damage, compartment syndrome, and malunion may occur.

 

D. Tibial tubercle fractures

 

1. Classification—The classification has evolved since Watson-Jones first described three types of fractures. The current classification is shown in Figure 6.

 

2. Nonsurgical treatment is rarely indicated, but it may be used in children with minimally displaced fractures (<2 mm) and no extensor lag.

 

3. Surgical treatment

 

a. Indications—Most children with these fractures require surgery. The only exceptions are those with minimally displaced fractures and no extensor lag.

 

b. Procedures—Surgery is via ORIF with screws for fracture types I through IV. For type III fractures, the joint must be visualized to accurately reduce the joint surface and to assess for meniscal injury. For type V fractures, the periosteal sleeve is reattached with suture, and this may be supplemented with small screws.

 

4. Complications—Compartment syndrome and genu recurvatum are both rare.

 

E. Tibial shaft fractures

 

1. Nonsurgical treatment

 

a. Most tibia fractures in children can be treated with reduction and casting.

 

b. Healing takes 3 to 4 weeks for toddler fractures and 6 to 8 weeks for other tibial fractures.

 

2. Surgical treatment

 

a. Indications include open fractures, marked soft-tissue injury, unstable fractures, multiple trauma, >1 cm of shortening, and unacceptable closed reduction (>10° of angulation).

 

b. Fixation options include external fixation, intramedullary rod fixation, percutaneous pins or plates.

 

3. Complications

 

a. When closed reduction is lost, it is typically due to a drift into varus for isolated tibial fractures and into valgus for combined tibia and fibula fractures.

 

b. Delayed union and nonunion are almost never seen in closed fractures but are more common following external fixation.

 

c. Compartment syndrome, although relatively uncommon, can occur with open or closed fractures.



VIII. Ankle Fractures

A. Classification

 

1. An anatomic classification system is most typically used for ankle fractures. The Salter-Harris classification is commonly used for physeal fractures.

 

2. A mechanistic classification system (typically, the Dias-Tachdjian classification) may be used. The Dias-Tachdjian classification is patterned after the Lauge-Hansen categorization of adult fractures and describes four main mechanisms: supination-inversion, supination-plantar flexion, supination-external rotation, and pronation/eversion-external rotation.

 

B. Distal tibial physeal fractures

 

1. Salter-Harris I and II fractures

 

a. Closed treatment suffices for most of these fractures. To minimize the risk of iatrogenic physeal injury, no more than one or two attempts at reduction should be made in the emergency department. Acceptable reduction is to within 2 to 3 mm of anatomic alignment and <10° of angulation.

 

b. Open treatment may be needed for irreducible fractures (usually the result of interposed periosteum, tendons, or neurovascular structures). Hardware is rarely needed following open reduction.

 

c. Complications—Physeal injury with growth arrest and angular deformity and/or limb-length discrepancy is rare in these fractures.

 

2. Salter-Harris III fractures

 

a. Overview—Medial malleolus and Tillaux fractures are the most common Salter-Harris III ankle fractures.

 

b. Pathoanatomy

 

i. Tillaux fractures (

Figure 7) are Salter-Harris III fractures of the anterolateral tibial epiphysis that occur with supination-external rotation injuries.

 

ii. Tillaux fractures (as well as triplane fractures) occur in this location because the distal tibial physis closes centrally, then medially, and then laterally.

 

c. Closed treatment suffices for most minimally displaced fractures. A postreduction CT is used to confirm that there is less than 2 mm of joint step-off and fracture diastasis.

 

d. Open treatment is indicated when there is >2 mm of displacement based on postreduction CT. Percutaneous manipulation with a K-wire may aid in reduction. Fixation is with one or two cannulated screws. Ideally, the screws are inserted parallel to the physis.

 

e. Complications

 

i. Joint incongruity is a risk, as with any Salter-Harris III physeal fracture.

 

ii. The risk of physeal arrest is less when reduction within 2 mm of anatomic alignment is obtained.

 

[Figure 7. Tillaux fracture as seen from anterior (A) and inferior (B). The anterolateral fragment is avulsed by the anterior inferior tibiofibular ligament.]

3. Salter-Harris IV fractures

 

a. Medial malleolus shear fractures

 

i. Closed treatment—Closed reduction and casting suffices for minimally displaced fractures.

 

ii. Open treatment—Open treatment is indicated for fractures displaced >2 mm following reduction. ORIF (with 2 epiphyseal screws) is required for the vast majority of these fractures to optimize joint and physeal alignment (and minimize the risk of growth arrest).

 

iii. Complications—Medial malleolar Salter-Harris IV fractures have the highest rate of growth disturbance of any ankle fracture.

 

b. Triplane fractures

 

i. Pathoanatomy—Triplane fractures (

Figure 8) are Salter-Harris IV fractures that include an anterolateral fragment of the distal tibial epiphysis (as in a Tillaux fracture) in conjunction with a metaphyseal fracture. These may be 2- or 3-part fractures.

 

ii. Closed treatment—Closed reduction and casting suffices for minimally displaced fractures. Postreduction CT is used to confirm <2 mm of joint step-off and fracture diastasis.

 

iii. Open treatment—Open treatment is indicated for fractures with >2 mm of displacement based on postreduction CT. Fixation is

 

[Figure 8. A two-part lateral triplane fracture as seen from anterior (A) and inferior (B). (Adapted with permission from Jarvis JG: Tibial triplane fractures, in Letts RM (ed): Management of Pediatric Fractures. Philadelphia, PA: Churchill Livingstone, 1994, p 739.) C, A two-part medial triplane fracture. (Adapted with permission from Rockwood CA Jr, Wilkins KE, King RE: Fractures in Children.Philadelphia, PA, JB Lippincott, 1984, p 933.)]

   with one or two cannulated screws (ideally, parallel to the physis); the screws may cross the physis (if necessary) once distal tibial physeal closure has begun. Comminuted and/or high fibula fractures may require concomitant fixation in children with high-energy injuries.

 

iv. Complications—Joint incongruity is a risk, as with any Salter-Harris IV physeal fracture. Ankle pain and degenerative changes are both relatively common, especially in those fractures not reduced within 2 mm of anatomic alignment.

 

4. Salter-Harris V fractures appear to be Salter-Harris I fractures on initial presentation and are noted to be type V fractures only retrospectively, when the child presents with a growth arrest and limb-length discrepancy.

 

C. Distal fibula fractures

 

1. Isolated distal fibula fractures

 

a. Epidemiology

 

i. Isolated distal fibula fractures are very common after inversion ankle injuries and are almost exclusively Salter-Harris I and II fractures.

 

ii. These fractures are much more common than ankle sprains following an ankle inversion injury in a child.

 

b. Treatment—Closed treatment with a short-leg walking cast for 3 weeks is typical for Salter-Harris I and II fractures, but for the very rare Salter-Harris III and IV fractures, surgical fixation may be necessary.

 

c. Complications are rare for distal fibula physeal fractures, and growth disturbance occurs in <1%. Complex regional pain syndrome should be considered if the pain does not resolve promptly with appropriate treatment.

 

2. Distal fibula fractures associated with tibia fractures

 

a. These fractures are reduced in conjunction with the tibia fracture.

 

b. ORIF may be needed in cases of high fibula fracture and/or severe comminution in a child approaching skeletal maturity.



IX. Foot Fractures

A. Pathoanatomy—Accessory ossicles in the foot (

Figure 9) are common and must be differentiated from acute injuries.

 

B. Talar fractures and dislocations

 

1. Overview

 

a. Most talar fractures are avulsion fractures.

 

b. Talar neck and body fractures are generally high-energy injuries, with falls from a height and motor vehicle accidents accounting for 70% to 90%.

 

2. Classification

 

a. Talar fractures are categorized as avulsion fractures, talar neck fractures, or talar body fractures. Osteochondral lesions are considered fractures by some authors.

 

b. Talar neck fractures are classified by the Hawkins classification (as are adult fractures) (

Table 1).

 

3. Nonsurgical treatment is indicated for nondisplaced talar neck and body fractures, and closed reduction should be attempted for displaced fractures. Because talar neck fractures are dorsiflexion injuries, these fractures are generally most stable in plantar flexion.

 

4. Surgical treatment—Although surgical indications are not well defined, surgery should be considered for displaced intra-articular talar fractures.

 

5. Complications—Chronic pain and ON are common following talar neck and body fractures. ON risk is highest for Hawkins III and IV injuries and lowest for type I injuries.

 

C. Calcaneus fractures

 

1. Classification—Although a variety of classification schema have been described, the most important distinctions are whether the fracture is intraor extra-articular and whether the fracture is displaced.

 

2. Nonsurgical treatment is the mainstay of treatment of pediatric calcaneal fractures because of relatively favorable results and potential calcaneal remodeling.

 

3. Surgical treatment is often indicated in adolescent children with displaced intra-articular calcaneal fractures.

 

D. Other tarsal fractures

 

1. Avulsion fractures of the navicular, cuneiforms, and cuboid are the most common type of fracture and are generally low-energy injuries. Treatment is with a walking cast for 2 to 3 weeks; the results are excellent.

 

2. Displaced fractures of the navicular, cuneiforms, and cuboid are generally high-energy injuries, with high rates of associated injuries and compartment syndrome. ORIF is generally required.

 

[Figure 9. Accessory ossicles of the foot and their frequency of occurrence (when data are available) as viewed from the plantar (A), medial (B), and lateral (C) aspects of the foot.]

[Table 1. Hawkins Classification of Talar Neck Fractures]

E. Lisfranc injuries

 

1. Treatment

 

a. Closed treatment is indicated for nondisplaced fractures and is attempted for displaced fractures (often with the aid of finger traps).

 

b. Fixation in adolescents is with cannulated screws and in younger children with smooth K-wires.

 

2. Complications—Compartment syndrome and chronic pain are both common and often result in poor outcomes.

 

F. Metatarsal fractures

 

1. Classification—There is no specific classification system for most metatarsal fractures.

 

2. Treatment

 

a. Nonsurgical treatment suffices for most metatarsal fractures. Weight bearing is allowed for almost all such fractures; one exception is a fifth metatarsal base fracture at or distal to the metaphyseal-diaphyseal junction.

 

b. Surgical—The rare indications for surgical intervention include:

 

i. Marked displacement of the metatarsal head in the sagittal plane

 

ii. Fractures of the fifth metatarsal distal to the metaphyseal-diaphyseal junction that fail closed treatment

 

3. Complications—Complications are rare, though delayed union or nonunion are relatively common for fifth metatarsal base fractures distal to the metaphyseal-diaphyseal junction.

 

G. Phalangeal fractures

 

1. Treatment

 

a. Nonsurgical treatment suffices for almost all phalangeal fractures.

 

b. Surgical—The few indications for surgical intervention include:

 

i. Open fractures

 

ii. Significantly displaced intra-articular fractures

 

2. Complications—Complications are rare, although growth arrest may occasionally occur following a physeal fracture of the great toe.

 

H. Occult foot fractures

 

1. General

 

a. Occult foot fractures are a common cause of limp in preschool-age children.

 

b. If a child crawls without difficulty but limps or refuses to weightbear when standing, the pathology is distal to the knee.

 

2. Evaluation

 

a. Radiographs are typically negative.

 

b. Bone scans (although rarely necessary) will show increased uptake in the affected tarsal bones.

 

3. Treatment is with a short-leg walking cast for 2 to 3 weeks. If the child does not feel better within days of cast application, another source of pain should be sought.



X. Child Abuse

A. Evaluation

 

1. Child abuse should be suspected in the following circumstances:

 

a. Any fracture before walking age

 

b. Multiple injuries in a child without a witnessed and reasonable explanation

 

c. Multiple injuries in a child <2 years

 

d. A child with long-bone injury(ies) and a head injury

 

2. Corner fractures (seen at the junction of the metaphysis and physis) and posterior rib fractures are essentially pathognomonic for nonaccidental trauma, but isolated, transverse long-bone fractures are actually more common.

 

3. A skeletal survey must be obtained in all children suspected of child abuse to rule out other fractures of differing ages (including examination for skull and rib fractures).

 

4. Thorough examination of the child by nonorthopaedists is necessary to rule out other evidence of abuse, including skin bruising (especially bruises of different ages) or scarring, retinal hemorrhages, intracranial bleeds, or evidence of sexual abuse.

 

B. Treatment

 

1. Reporting of suspected child abuse is mandatory.

 

a. The orthopaedic surgeon is protected from litigation when reporting cases of suspected abuse.

 

b. Failure to report suspected abuse puts the abused child at a 50% risk of repeat abuse and up to a 10% risk of being killed.

 

2. Many fractures are sufficiently healed at the time of presentation to the orthopaedic surgeon that they do not require treatment.



Bibliography

Flynn JM, Schwend RM: Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg 2004;12:347-359.

Flynn JM, Skaggs DL, Sponseller PD, Ganley TJ, Kay RM, Leitch KK: The surgical management of pediatric fractures of the lower extremity. Instr Course Lect 2003;52:647-659.

Gray DW: Trauma to the hip and femur in children, in Sponseller PD (ed): OKU Pediatrics 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 81-91.

Kay RM, Matthys GA: Pediatric ankle fractures: Evaluation and treatment. J Am Acad Orthop Surg 2001;9:268-278.

Kay RM, Tang CW: Pediatric foot fractures: Evaluation and treatment. J Am Acad Orthop Surg 2001;9:308-319.

Kocher MS, Kasser JR: Orthopaedic aspects of child abuse. J Am Acad Orthop Surg 2000;8:10-20.

Zionts LE: Fractures around the knee in children. J Am Acad Orthop Surg 2002;10:345-355.

 

Top Testing Facts

Fractures of the Pelvis, Hip, and Femur

1. Plain AP pelvis radiographs fail to identify about half of all pediatric pelvic fractures found on CT scan.

 

2. Most pediatric pelvic fractures can be treated nonsurgically with good results.

 

3. The rate of ON of the hip is inversely related to the Delbet fracture category (90% to 100% for type I fractures, 50% for type II, 25% for type III, and 10% for type IV).

 

4. Surgical fixation of hip fractures (particularly Delbet II and III fractures) significantly decreases the risks of coxa vara and nonunion.

 

5. Child abuse is by far the most common reason for a femoral shaft fracture in a child younger than 1 year. Child abuse can also be causative in children up to 5 years of age.

 

6. Spica casting for femoral shaft fractures is appropriate for most children younger than 6 years.

 

7. Surgical treatment of femoral shaft fractures is indicated for most children older than 6 years.

 

8. Femoral overgrowth of 7 to 10 mm is typical in children who sustain a femoral shaft fracture between the ages of 2 and 10 years.

 

9. Most displaced distal femoral metaphyseal fractures are treated surgically to prevent malunion.

 

10. Distal femoral physeal fractures have a worse prognosis than other physeal fractures because of the high rate of growth arrest (up to 50%) and the rapid growth of the distal femur.

 

11. Fixation should be used for all displaced fractures of the distal femoral physis to minimize the risk of redisplacement.

 

Fractures of the Knee

1. Bipartite patella is seen in up to 5% of knees. Classically, these appear different from patellar fractures because they have rounded borders and are located superolaterally.

 

2. Patella sleeve fractures are common in children. Radiographs may only only patella alta or baja.

 

3. Because of the fact that ligaments in children are generally stronger than bone, tibial spine fractures, rather than ACL injuries, often occur in children.

 

4. An entrapped meniscus often prevents type II tibial spine fractures from reducing closed.

 

5. Vascular injury and/or compartment syndrome occurs in nearly 10% of patients with fractures of the proximal tibial physis; the risk is highest with hyperextension injury.

 

6. Proximal tibial metaphyseal fractures in children younger than 10 years typically grow into valgus in the first 6 to 12 months after injury. Observation is indicated in these cases because the genu valgum usually resolves spontaneously.

 

7. Tibial tubercle fractures may be treated closed only if there is minimal displacement and no extensor lag.

 

Fractures of the Lower Leg and Foot

1. Isolated tibia fractures tend to drift into varus; combined tibia and fibula fractures tend toward valgus.

 

2. Medial malleolar Salter-Harris IV fractures have the highest rate of growth arrest of any ankle fracture and often result in varus ankle deformity and limb-length discrepancy.

 

3. Tillaux fractures and triplane fractures both occur in the anterolateral distal tibial physis because of the order of distal tibial physeal closure (the central portion closes first, then the medial, and finally the lateral).

 

4. When a child sustains an inversion injury to the ankle, a distal fibula physeal fracture is much more likely than an ankle sprain.

 

5. Osteonecrosis is common following talar neck and body fractures. The risk is highest for Hawkins IV fractures and lowest in type I injuries.

 

6. Calcaneal fractures can remodel in children and generally have favorable long-term outcomes, though ORIF may be indicated in adolescents with significantly displaced intra-articular calcaneal fractures.

 

7. Even in children, long-term outcomes following Lisfranc injuries appear poor.

 

8. If a child crawls without difficulty but limps or refuses to bear weight when standing, the pathology is below the knee.

 

9. If a child who is treated for an occult foot fracture does not feel better almost immediately in the cast, another source of pain should be sought.

 

Child Abuse

1. Reporting of suspected child abuse is mandatory.

 

2. Many of the findings of child abuse are nonorthopaedic, so involvement of a child abuse team or specialists is requisite.