Common Fractures in Young Athletes February 10, 2012

1. 40th Annual Meeting Southeast Chapter of the American College of Sports Medicine (SEACSM) Common Fractures in Young AthletesFebruary 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 • NO commercial relationships • Research & Educational funding • NIH U54 Institutional Clinical & Translational Science Award • Gregory • No conflict of interest

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. Bowing without fracture Often requiring reduction Plastic Deformation

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

10. Greenstick Fracture • Cortex Broken on Only One Side • Incomplete

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

12. Salter-Harris Classification I II III IV V

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 Nursemaids Other causes of limp Legg-Calve-Perthes Transient synovitis Septic arthritis Osteomyelitis Bone pain + Fever • Salter-Harris I • Buckle • Avulsions • Occult

15. 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. 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 of the Elbow (CRITOE)

17. Ossification Centers Appearance

18. 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. Elbow Fat Pads

20. Posterior Fat Pad Anterior Fat Pad

21. Occult Fracture

22. Posterior Fat Pad Non-Displaced Supracondylar Fracture

25. 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

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 • 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. • 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

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

38. SCFE

39. 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. 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

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