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Fractures and Dislocations

Ovid: Pediatrics

Editors: Tornetta, Paul; Einhorn, Thomas A.; Cramer, Kathryn E.; Scherl, Susan A.
Title: Pediatrics, 1st Edition
> Table of Contents > Section II: – Emergency Department > 12 – Fractures and Dislocations

Fractures and Dislocations
The views expressed in this chapter are those of the
authors and do not reflect the official policy or position of the
Department of the Navy, Department of Defense, or the United States
12.1 SPINE
Bruce L. Gillingham
Eloy Ochoa
Pediatric spine fractures are relatively rare. Only 5%
of all spinal cord and vertebral column injuries affect those 16 years
and under. Although uncommon, spine fractures in children can lead to
chronic instability, deformity, neurologic sequelae, and posttraumatic
stenosis. Injuries to the spinal column can often be subtle and absent
on initial radiographs. Successful treatment is based on knowledge of
the radiographic, anatomic, and developmental differences between the
pediatric and adult spine.
The location, pattern, and etiology of a child’s spine
fracture are primarily dependent on the age at the time of injury.
Birth trauma is the major cause of spinal trauma in children under age
2. In patients between the ages of 3 and 8 the most frequent mechanisms
of injury are falls from height, motor vehicle accidents, and child
abuse. Children older than 8 years of age are more commonly injured in
motor vehicle accidents, by gunshot wounds, or from sporting activities
such as swimming, diving, and surfing.
Less than 5% of all spinal injuries involve children.
The majority of spinal column fractures in childhood occur in the
thoracolumbar spine. Cervical spine fractures in patients 8 years old
or younger involve the upper cervical spine above C4. These most often
include the occiput, C1, C2 complex and carry an increased risk of
fatality. Patients older than 8 more typically sustain injures below C4
with a much lower fatality rate. Up to 30% of traumatic spine injuries
in children present as a traumatic myelopathy known as spinal cord
injury without radiographic abnormality (SCIWORA).
The patterns and types of spine injuries seen in children reflect features unique to the developing spine (Box 12.1-1).
An appreciation of radiographic features unique to the
immature spine is necessary to accurately diagnose spinal trauma.
Several developmental features can be misconstrued as evidence of
injury to the spine (Table 12.1-1).
After age 8 the spine begins to mature. The ligaments
and facet capsules strengthen, the facets become more vertically
oriented and the vertebral bodies become more rectangular-shaped. By
late childhood the patterns of spinal injuries and healing become
similar to the adult.
In addition to knowledge of normal developmental
anatomy, it is important to be aware of congenital and genetic
conditions manifested in the spine (Table 12.1-2).


Radiographic Finding



Absent cervical lordosis

Muscle spasm from C-spine injury

Seen in up to 14% of patients less than 8 yr of age

Dentocentral synchondrosis

Odontoid fracture

Usually not fused by age 6; lucency below level of body dens interface

Wedge-shaped vertebrae

Compression fracture

Usually present up to age 8; adjacent bodies similar

Incomplete ossification of ring apophysis (secondary ossification)

Avulsion fracture

Appear at age 5, fuse between age 18 and 25

Notching of anterior and posterior vertebral body in infancy

Vertebral body fracture

Vascular channels. Anterior disappears at age 1. Posterior remains throughout life




Radiographic Significance

Os odontoideum

Rounded hypoplasitic apical segment of dens

Can be confused with dens fracture

Remnant of axis at base

May represent nonunion

May require fusion

Klippel-Feil syndrome

Congenital fusion of two or more vertebrae

Longer lever arm may lead to higher incidence of fractures

Down syndrome

Ligamentous laxity leads to decreased SAC/ADI

Atlanto-axial instability, myelopathy

ADI, atlanto-dens interval; SAC, space available for the cord.

Figure 12.1-1 Diagrams of young children on modified spine boards with either an occipital recess (top figure) or a mattress pad (bottom figure)
to raise the chest. (©1998 American Academy of Orthopaedic Surgeons.
Adapted from the Journal of the American Academy of Orthopaedic
Surgeons, 1988;6[4]:204-214, with permission.)
Trauma Evaluation
As with all patients evaluated following a traumatic
event, potentially life-threatening conditions must be identified and
treated. Once airway, breathing, and circulation are secure, a brief
secondary survey can be accomplished. Early proper immobilization in
all patients with suspected C-spine injury is essential in order to
avoid creating or propagating further spinal cord injury, by increased
neck flexion. In a young child with a proportionally large head, this
can be done using a spine board with an occipital recess or by placing
a mattress or blankets beneath the shoulders and trunk of the child (Fig. 12.1-1).
A screening cross-table lateral x-ray of the spine, in addition to
anteroposterior (AP) pelvis and chest x-rays, should be standard in the
evaluation of all trauma patients.
In addition to proper spine board immobilization, a
rigid cervical orthosis, properly designed for infants or children,
should be applied. Sandbags on each side of the head will prevent
motion. Until the cervical spine is cleared (Box 12.1-2), movement of the patient should only be performed with in-line traction using a log-roll technique.
History and Physical Examination
A brief history in the awake, cooperative child is
helpful. A spinal cord injury should be suspected in a patient with a
history of numbness, tingling, or brief paralysis. Physical examination
should begin with inspection of skin for any visible evidence of spinal
trauma to include abrasions, edema, or ecchymosis. Pain or step-off
along the spinous processes should also raise suspicion. Range of
motion should only be attempted when the child is conscious and
cooperative and an unstable injury is not suspected.
Cervical Spine
As in adult victims of trauma, an essential part of the trauma evaluation is clearance of the cervical spine (Algorithm 12.1-1 and Box 12.1-3).
The cervical orthosis and spine board precautions should be removed
only if the patient has no neck pain or tenderness to palpation and a
full painless range of motion.
Algorithm 12.1-1 Clearing the cervical spine.

The cervical spine is evaluated as follows:
  • Lateral C-spine radiograph
    • □ Must see top of T1
  • Assess alignment (Fig. 12.1-2)
    • □ Anterior vertebral line
    • □ Posterior vertebral line
    • □ Spinolaminar line
    • □ Spinous process line
  • Check radiographic relationships (Table 12.1-3)
    • □ Atlanto-dens interval
    • □ Retropharyngeal and retrotracheal spaces
    • □ Space available for the cord
  • AP and open mouth odontoid views
    • □ Alignment of lateral masses
    • □ Odontoid fracture
    • □ Interpedicular distance
  • Flexion-extension views
    • □ Assess ligamentous stability
    • □ Active range of motion only
    • □ Physician-supervised
    • □ Fully cooperative patient
    • □ May need to wait until first follow-up visit
Figure 12.1-2 Normal alignment of the lateral cervical spine. 1, spinous process line; 2, spinolaminar line; 3, posterior vertebral bodyline; 4,
anterior vertebral bodyline. Space available for the cord is the
distance between 2 and 3 at the level of C1. (©1998 American Academy of
Orthopaedic Surgeons. Adapted from the Journal of the American Academy
of Orthopaedic Surgeons, 1998;6:204-214, with permission.)


Normal Value

C-1 facet-occipital condyle distance

≤5 mm

Atlanto-dens interval

≤4 mm

Pseudosubluxation of C2 on C3

≤4 mm

Pseudosubluxation of C3 on C4

≤3 mm

Retropharyngeal space

≤8 mm (at C-2)

Retrotracheal space

≤14 mm (at C-6, under age 15 yr)

Torg ratio (canal to vertebral body)


Space available for cord

≥14 mm

Adapted from Black BE. Spine trauma. In: Sponseller PD, ed.

Orthopaedic knowledge update pediatrics 2. Rosemont, IL: American

Academy of Orthopaedic Surgery; 2002:134.

There are specific differences in the pediatric patient that one must be aware of when reviewing the cervical spine radiograph (Box 12.1-4).
Thoracic and Lumbar Spine
Mechanisms of injury in thoracolumbar spine fractures include:
  • Compression
  • Lumbar apophyseal injury

  • Flexion with compression
  • Distraction
  • Shear
The region is evaluated as follows:
  • Center plain films over injured area.
  • Obtain “cone down” views of suspicious findings.
  • Always obtain two views 90 degrees apart.
  • Oblique views helpful for spondylolysis in lumbosacral spine.
Indications for Special Studies
  • Computed tomography (CT) scan best for evaluating bone “architecture”
    • □ Especially lumbar apophyseal fractures
  • Three-dimensional CT often useful in preoperative planning
  • Bone scan useful to detect occult tumors/spondylolysis
  • Magnetic resonance imaging (MRI) very useful in SCIWORA
  • MRI useful in neurocompression by fracture fragments and disc
Clinical and radiographic findings in spine fractures and other conditions are listed in Tables 12.1-4, 12.1-5 and 12.1-6
Atlanto-Occipital Dislocation
  • Very unstable
  • Require halo immobilization if neurologically intact (Box. 12.1-5)
  • Fusion if instability remains or neurologic deficit
  • Occiput-C1 fusion if neurologically intact
  • Occiput-C2 fusion if neurologically impaired
Atlas Fractures
  • Halo immobilization or Minerva brace
  • Up to 6 months of immobilization may be necessary
  • Surgical intervention rarely indicated
Atlantoaxial (C1-C2) Disruptions
  • Rotatory subluxation can be treated with temporary immobilization
  • Rarely will require traction for reduction (older than 1 week)
  • Dislocation or ligamentous instability less predictable
  • Initial treatment with Halo immobilization for 8 to 12 weeks
  • C1-C2 fusion if instability persistent
Dens Injuries
  • Most heal with closed reduction
  • Halo vest or Minerva cast for 4 months
  • Posterior C1-C2 fusion if persistent motion or suspected os odontoideum
Hangman Fracture (Pedicle Fracture C2)
  • Most respond to closed reduction and halo vest for 8 weeks
  • Posterior C1-C3 fusion indicated for non-union or significant disc disruption
C2-C3 Subluxation and Dislocation
  • Younger than 8 years, closed reduction and halo vest immobilization
  • Older than 8 years, usually require posterior fusion
Middle to Lower Cervical Injuries
  • Younger than 8 years, closed reduction and halo vest immobilization
  • Initial trial of Halo immobilization for 3 months for ligamentous instability
  • Posterior fusion if instability persists beyond 3 months
  • Early surgical stabilization for unstable fractures or spinal cord injury
Child Abuse
  • Contact child protective services
  • Obtain skeletal survey
  • Rule out associated injuries
    • □ Retinal hemorrhages
    • □ Intracranial or intraocular hemorrhages
    • □ Visceral injury
  • Treat spine injury as indicated
Spinal Cord Injury
  • Efficacy of steroids in enhancing recovery not established in children
  • Rarely, decompression of spinal cord impingement required
    • □ Retropulsed disc, bone fragments
  • Monitor for late spinal deformity
    • □ Nearly universal if children are 10 years of age or younger at time of injury
  • Recognize late neurologic deterioration
    • □ Ascending spinal level
    • □ Assess for posttraumatic syrinx with MRI
      • □ Drainage usually required
  • Immobilization in a rigid cervical collar or Thoracolumbar spinal orthosis (TLSO)
  • Physical activity restriction for 3 months
  • Decompression for progressive deficit, discrete lesion
  • Prognosis for neurologic recovery
    • □ Good in mild cases
    • □ Poor in severe cases
    • □ Usually affects children less than 8 years



Clinical Features

Radiologic Features

Atlanto-occipital dislocation

Rare, often results in death

Survivors often ventilator-dependent

Multiple trauma

Massive retropharyngeal/prevertebral swelling

Frank atlanto-occipital dislocation

Atlas fractures

Not common

Neurologic compromise uncommon

Usually results from direct axial load

Open mouth odontoid view is appropriate

May be difficult to evaluate or r/o on plain radiograph

CT offer most precise imaging

Atlantoaxial (C1-C2) disruptions

Include ligamentous instability, rotatory subluxation and odontoid epiphyseal separation

Atlanto-dens interval ≥4 mm

Torticollis or cervical muscle spasm

Lateral view space available for cord (SAC) ≤14 mm in flexion

Continued pain with motion despite normal static films

Open mouth odontoid shows asymmetry of lateral masses

Dynamic and axial CT imaging helpful with evaluation of rotatory subluxation or dislocation

Dens injuries

Usually significant trauma

Most common pediatric C-spine injuries

Patients complain of instability

Often hold their head with two hands to prevent motion

Most can be diagnosed with plain three-view trauma series

Typically at the base but not extending into body

Fractured odontoid moves with C1 on flexion/extension views

Can be confused with os odontoideum

CT if warranted

Flexion-extension MRI/CT may be helpful to evaluate os odonoideum

Hangman fracture (pedicle fracture C2)

Usually results from flexion or extension injuries


Can be confused with primary spondylolysis

Can be confused with synchondrosis of posterior arch

CT helpful

C2-C3 subluxation and dislocation

Must be differentiated from pseudosubluxation

Typically have associated trauma to head, face, and chest

Typically complain of pain

Spinolaminar line (Swischuk line) not disrupted in pseudosubluxation (Fig. 12.1-2)

Pseudosubluxation reduces in extension

MRI helpful to rule out ligamentous injury/instability

Middle to lower cervical injuries

Typical in children older than 8 yr

Average age 13 yr

Typically flexion or extension injuries

Widened interspinous spaces on lateral

Loss of parallelism of articular facets

Kyphosis of the disc space

Calcification in the interspinous ligament seen late

Child abuse

Infants and toddlers

May see SCIWORA in shaken baby syndrome

▪ Relatively weak cervical musculature

▪ Disproportionately large head

Often not recognized

Thoracolumbar and lumbar spine injuries most common

Multiple compression fractures

Fracture-dislocations with or without spinal cord injury

Fractures at different stages of healing

Spinal cord injury

Serial examinations necessary to rule out progressive deficit

Birth trauma

▪ Floppy infant with nonprogressive neurologic lesion

Toddlers and young children

▪ Cervicothoracic junction injury

▪ Most severe deficit but best potential for recovery


▪ Thoracolumbar fractures

▪ Incomplete neurologic deficits

Spinal canal stenosis a risk factor for neurologic impairment

▪ 35% at T11-T12

▪ 45% at L1

▪ 55% at L2

MRI demonstrates characteristic findings (Table 12.1-5)


Spinal column 4 times more elastic than spinal cord

Proposed mechanisms:

▪ Longitudinal distraction

▪ Hyperextension

▪ Flexion

▪ Spinal cord ischemia

May have delayed onset of neurologic loss

Relatively high rate at thoracolumbar junction

Findings absent on plain radiographs MRI findings:

▪ Hemorrhage and edema from occult end-plate fracture

▪ Widening of disc space following spontaneous reduction

Compression fracture (lumbar apophyseal injury)

Injury to posterior lumbar end plate in adolescents

Portion of disc, apophysis, ± body retropulsed into canal

Usually L4-5, L5-S1

Acute onset of low back pain with strenuous activities, athletics

Shoveling, gymnastics, weight lifting

Positive straight leg raise

Variable motor, sensory loss

Often not seen on plain films

CT scan diagnostic study of choice

▪ Fragment size, extent of canal compromise

Four types described (Table 12.1-6)

Flexion injuries

Hyperflexion injuries with compression are common

Intact discs more resistant than vertebral body to axial load

▪ Body collapses before disc fails

Older children more susceptible to adult-type burst fracture

Usually less than 20% compression

Multiple contiguous level injury common

Posterior column involvement rare

Flexion-distraction (pediatric Chance fracture equivalents)

Lap belt injury (check for seat belt sign)

High likelihood of associated neurologic, spinal, and visceral injuries

Flexion-distraction mechanism

▪ Anterior compression, posterior column distraction

Four types (Fig. 12.1-3)

Distraction and shear injuries

High-energy injuries

▪ Pedestrian vs. auto

▪ Crush by falling objects

Fracture through end-plate apophyses

computed tomography; MRI, magnetic resonance imaging; SAC, space
available for the cord; SCIWORA, spinal cord injury without
radiographic abnormality.





Decreased signal due to intraspinal hemorrhage


Bright signal due to spinal cord edema


Mixed signal: central hypointensity and peripheral hyperintensity due to contusion

from Bondurant FJ, Cotler HB, Kulkarni MV, et al. Acute spinal cord
injury: a study using physical examination and magnetic resonance
imaging. Spine 1990;15:161-168.



Age Group (yr)

Radiographic Findings



Separation of the posterior vertebral rim. Arcuate fragment without osseous defect



Avulsion fracture of vertebral body, annular rim, and cartilage



Localized fracture posterior to end-plate irregularity



Defect spans entire length and breadth of posterior vertebral margin between end plates

from Epstein N, Epstein J, Mauri T. Treatment of fractures of the
vertebral limbus and spinal stenosis in five adolescents and five
adults. Neurosurgery 1989;24:595-604 and Takata K, Inoue S-I, Takahashi
K, et al. Fracture of the posterior margin of a lumbar vertebral body.
J Bone Joint Surg 1988;70:589-594.

Pediatric Chance Fracture Equivalents (Fig. 12.1-3)
  • Closed reduction, hyperextension casting for pure bony injuries
    • □ Restore lordosis
  • Open reduction, posterior fusion for ligamentous injury
    • □ Spinous process wiring with casting for small children
    • □ Compression instrumentation in adolescents
Vertebral End-Plate Fractures
  • Surgical excision of retropulsed disc, end-plate and bone fragments
    • □ Prevents healing of lesion to posterior vertebral body
    • □ Avoids subsequent spinal stenosis
Surgical Indications and Contraindications
Spine fractures heal better in children than in adults. Significant potential for remodeling exists. The majority of


pediatric spinal trauma can be treated nonoperatively; however, three
primary factors need to be considered in determining if operative
intervention is required.

Figure 12.1-3
Pediatric Chance fractures. Type A: Bony disruption of the posterior
column with minimal extension into the middle column. Type B: Avulsion
of posterior elements with facet joint disruption or fracture and
extension into vertebral body apophysis. Type C: Posterior ligamentous
disruption with fracture entering vertebra close to pars
interarticularis and extending into middle column. Type D: Posterior
ligamentous disruption with fracture traversing lamina and extending
into apophysis of adjacent vertebral body. (Adapted from Rumball K,
Jarvis J. Seat-belt injuries of the spine in young children. J Bone
Joint Surg [Br] 1992;74:571-574.)


Instability Pattern




First degree


Severe compression fracture

Progressive kyphosis

Brace in extension

Second degree

Neurologic instability

Ligamentously stable burst fracture susceptible to collapse from axial load

Neurologic injury

Operative stabilization

Third degree

Mechanical and neurologic

Unstable burst fracture, fracture-dislocation

Progressive displacement and neurologic injury

Operative stabilization, decompression

Adapted from
Denis F. Spinal instability as defined by the three-column spine
concept in acute spinal trauma. Clin Orthop 1984;189:65-76.

  • Fundamental considerations
    • □ Alignment
    • □ Stability
    • □ Canal compromise
  • Alignment
    • □ Cervical spine
      • □ Radiographic criteria (see Table 12.1-3)
    • □ Thoracolumbar spine
      • □ Initial kyphosis less than 20 degrees
  • Stability of the fracture pattern
    • □ Majority of spine fractures in children are stable
    • □ Cervical spine
      • □ Depends on specific injury
    • □ Thoracolumbar spine
      • □ Denis classification (Table 12.1-7)
  • Canal Compromise
    • □ Insufficient space available for cord
    • □ Encroachment by retropulsed disc, bone fragments
  • General surgical indications:
    • □ Unstable, purely ligamentous injuries
    • □ Unstable fractures that cannot be safely braced
    • □ Fracture with neurologic injury
  • Incomplete neurologic loss with canal compromise
  • Progressive neurologic deficit
Aufdermaur M. Spinal injuries in juveniles: necropsy findings in 12 cases. J Bone Joint Surg 1974;56:513-519.
Bondurant FJ, Cotler HB, Kulkarni MV, et al. Acute spinal imaging. Spine 1990;15:161-168.
MJ, Byrne TP, Abrams RA, et al. Halo skeletal fixation: techniques of
application and prevention of complications. J (Am) Acad Orthop Surg
HS, Filtzer DL. Pseudosubluxation and other normal variations in the
cervical spine in children. J Bone Joint Surg (Am) 1965;47:1295-1309.
Copley LA, Dormans JP. Cervical spine disorders in infants and children. J Am Acad Orthop Surg 1998;6:204-214.
Denis F. Spinal instability as defined by the three-column spine concept in acute spinal trauma. Clin Orthop 1984;189:65-76.
N, Epstein J, Mauri T. Treatment of fractures of the vertebral limbus
and spinal stenosis in five adolescents and five adults. Neurosurgery
M, Zabramski JM, Browner C, et al. Pediatric spinal trauma: review of
122 cases of spinal cord and vertebral column injuries. J Neurosurg
J, Hensinger R, Dedrick D, et al. Emergency transport and positioning
of young children who have an injury of the cervical spine: the
standard backboard may be hazardous. J Bone Joint Surg (Am)
Pang D, Wilberger JJ. Spinal cord injury without radiographic abnormalities in children. J Neurosurg 1982;57:114-129.
Rumball K, Jarvis J. Seat-belt injuries of the spine in young children. J Bone Joint Surg (Br) 1992;74:571-574.
Swischuk LE. Anterior displacement of C2 in children: physiologic or pathologic? Radiology 1977;122:759-763.
K, Inoue S-I, Takahashi K, et al. Fracture of the posterior margin of a
lumbar vertebral body. J Bone Joint Surg (Am) 1988;70:589-594.

Jeffrey R. Warman
Fractures of the humeral shaft may occur secondary to a
direct blow to the arm or, more commonly in children, though indirect
twisting injuries. In neonates they may be associated with breech
deliveries or child abuse.
  • Most common in children under 3 and over 12 years of age
  • Represent about 2% of all children’s fractures
There is no classification specific to humeral shaft
fractures in children. The fracture may be described by separation into
proximal, middle, or distal thirds of the shaft, or more commonly by
the fracture pattern (e.g., transverse, spiral, oblique).
Figure 12.2-1 (A) Anteroposterior radiograph of a humerus fracture sustained at delivery in a 4-week-old girl. (B) Complete remodeling seen at 10 months of age.
History and Physical Examination
  • A newborn child will present with inability to move the arm and localized swelling, crepitance, or deformity of the arm.
    • □ A septic shoulder or brachial plexus palsy must also be considered.
  • In older children, the history of injury is important, especially to rule out child abuse.
    • □ On physical exam, the extremity will usually be held against the body by the opposite hand.
    • □ Localized swelling, tenderness, and deformity may be noted.
    • □ A good neurologic exam is essential.
Plain radiographs are diagnostic in all age groups. Look for evidence of bone cysts or other pathologic fractures.

Figure 12.2-2 (A) Anteroposterior radiograph of a humeral diaphyseal fracture in a 15-year-old girl. (B) Postoperative radiograph after retrograde flexible intramedullary nailing.
Figure 12.3-3 (A) Anteroposterior radiograph of a fracture at the distal diaphyseal/metaphyseal junction in a 9-year-old boy. (B) The fracture was treated with cross pins, using 0.062-inch K-wires.
Nonoperative Treatment
  • Most humeral shaft fractures can be treated nonoperatively.
  • Neonates with humeral shaft fractures can
    be treated by pinning the cuff of the sleeve to the shirt or by
    splinting the arm in extension.
    • □ Angulation of up to 45 degrees can remodel in infants (Fig. 12.2-1).
  • In older children, minimally displaced fractures can be treated in a shoulder immobilizer or Velpeau dressing.
    • □ Displaced or unstable fractures can be
      immobilized with a coaptation splint or hanging arm cast, using
      sedation if necessary for fracture reduction.
    • □ After early callus forms, a functional fracture brace offers protection and early mobilization for the patient.
Operative Treatment
  • Operative treatment is rarely necessary
    in children but should be considered for open fractures, in patients
    with multiple injuries, and in older patients with unacceptable
  • The method of choice for fixation of humeral shaft fractures in children is retrograde flexible intramedullary nailing (Fig. 12.2-2).
  • For very distal shaft fractures, a
    crossed pinning technique may be performed, as with supracondylar
    humerus fractures (Fig. 12.2-3).
  • P.106
  • Plating a humeral shaft fracture is
    acceptable, but stress risers will be present at the ends of the plate,
    and empty screw holes after hardware removal can increase risk of
  • External fixation is useful with comminuted or open fractures.
  • Humeral shaft fractures in children usually do very well; the vast majority may be treated nonoperatively.
  • Malunion is unusual and nonunion is rare.
  • Nerve palsies should be observed for 2 to
    3 months for signs of recovery prior to further investigation or
    exploration, as most recover.
  • Occur in all age groups.
  • In neonates, usually secondary to shoulder dystocia or birth trauma.
  • In older children, the mechanism may be direct or indirect trauma.
  • Pathologic fractures are also common in the proximal humerus secondary to unicameral bone cysts or other benign lesions.
  • Proximal humeral fractures are most common at 11 to 15 years of age.
  • Boys are injured up to three times as frequently as girls.
  • The forces generated by the shoulder girdle musculature displace fracture fragments in a characteristic fashion.
    • □ The rotator cuff flexes, abducts, and externally rotates the proximal fragment.
    • □ The distal fragment is adducted and anteriorly translated by the pull of the pectoralis muscles and latissimus dorsi.
The Salter-Harris classification is used to describe those fractures that involve the proximal humeral growth plate (Table 12.2-1). The Neer and Horowitz classification is based on the amount of fracture displacement (Table 12.2-2).
Fractures of the greater and lesser tuberosities are rare in children.


Location of Fracture Line


Entirely through the physis


Traverses the physis and metaphysis


Traverses the physis and proximal epiphysis


Extends across the proximal epiphysis, through the growth plate, and into the metaphysis

History and Physical Examination
  • A neonate with a proximal humerus fracture will present with the arm held at the side.
    • □ Decreased or no active motion of the extremity will be noted and swelling of the proximal arm may be present.
    • □ Without further diagnostic studies,
      this injury will be difficult to differentiate from clavicle fractures,
      brachial plexus injuries, septic arthritis, or the rare shoulder
  • In an older child, making the diagnosis is easier.
    • □ The patient will usually recount a history of trauma and describe pain in the proximal arm.
    • □ The affected extremity will be held against the body, with swelling and tenderness noted in the proximal arm.
Radiographic Features
  • In neonates, the proximal humeral
    epiphysis does not ossify until 6 months of age and an ultrasound or
    arthrogram will easily demonstrate the fracture.
  • In older children, plain radiographs should be diagnostic.
Nonoperative Treatment
The neonate with a proximal humerus fracture may be
treated by pinning the cuff of the sleeve to the shirt. The fracture
should be clinically healed in about 2 weeks.




≤5 mm


5 mm to 1/3 of shaft width


1/3 to 2/3 shaft width


>2/3 shaft width (includes complete displacement)

Sling, Shoulder Immobilizer (Velpeau)
In any age group, Neer grade I and II fractures may be
treated by simple immobilization in a sling or shoulder immobilizer,
whichever is more comfortable for the patient. In children less than 8
years of age, even significant displaced grade III and IV fractures
should remodel, allowing for most all fractures in this age group to be
treated with simple immobilization.
Closed Reduction and Casting
Unstable, displaced fractures of the proximal humerus,
in need of reduction, are difficult to maintain by simple
immobilization. Casting in a salute or Statue of Liberty position is
mentioned for historical reasons only. These casts are difficult to
apply and are associated with shoulder stiffness, nerve palsies, and
cast sores. If fracture reduction is necessary, percutaneous pin
fixation may be a better alternative.
Operative Treatment
Closed Reduction and Percutaneous Pinning
The need for reduction and fixation of displaced
proximal humerus fractures is debated as similar functional outcomes
have been documented in both operative and nonoperative treatment
regardless of displacement. The remodeling capacity of the proximal
humeral physis is significant and symptomatic malunion is unusual.
Consideration for closed reduction and percutaneous pinning should be
given for those children with Neer and Horowitz Grade III and IV
fractures who are within two years of skeletal maturity. In this group,
full remodeling of physeal fractures may not occur, which can result in
limited range of motion at the shoulder.
Open Reduction and Internal Fixation
Proximal humerus fractures rarely require open
reduction. Indications include open fractures, displaced intraarticular
fractures, displaced tuberosity fractures, or fractures irreducible by
closed methods. Failure of closed reduction is often due to entrapment
of the periosteum or biceps tendon at the fracture site, which is
easily removed surgically.
As a general rule, fractures of the proximal humerus do quite well due to their excellent remodeling potential.
  • Occur through both direct and indirect trauma
  • Only bony constraint between the upper extremity and axial skeleton
  • In the newborn, pressure exerted on the shoulder during delivery can lead to fracture
  • In older children, fractures may occur after a fall on an outstretched arm
  • Direct trauma resulting in fractures is commonly due to the prominent and subcutaneous position of the clavicle
  • Occur in about 5 per 1,000 births
  • Associated with high birth weight and shoulder dystocia
  • Represent up to 15% of all children’s fractures in older children
  • Medial fragment is pulled proximally by the sternoclei-domastoid.
  • Distal fragment is pulled inferiorly by the pectoralis minor.
  • Shortening occurs due to the pull of the subclavius and pectoralis muscles.
  • Fractures of the medial or distal end of the clavicle usually occur through the physis.
  • Lateral physis does not close until 19 years of age; medial physis does not close until 22 to 25 years of age.
  • These fractures differ from those of
    adults, where there is associated ligament disruption of either the
    sternoclavicular or acromioclavicular joints.
  • In children, disruption of the thick
    periosteal sleeve allows for displacement of the clavicle. The
    periosteum remains in its bed with its associated ligaments still
    intact. As remodeling occurs through this periosteum, the healed
    clavicle reforms in its anatomic bed and is stable. Often the displaced
    portion of the clavicle will resorb.
  • Children over 13 years of age are more at risk for ligament disruption and may need to be treated as adults.
  • Fractures of the clavicle are classified as involving the shaft, medial end, or distal end of the clavicle.
  • True dislocations of the sternoclavicular
    joint or acromioclavicular joint are rare in children, as the physis
    will fail prior to joint dislocation.
  • Fractures of the medial end of the
    clavicle may be classified by the direction of displacement, anterior
    or posterior, or by the Salter-Harris classification of physeal
  • Fractures of the lateral end of the clavicle may be classified as shown in Table 12.2-3.
History and Physical Examination
  • A newborn presents with the affected extremity held to the side.
  • Swelling or crepitance may be present over the clavicle.
  • Callus formation at the fracture site is palpable about 1 week postinjury.
  • An older child with a clavicle fracture
    presents with pain, swelling, tenderness, and often a palpable step off
    at the fracture site.
  • P.108
  • No active motion is noted.
  • Anteriorly displaced medial clavicular injuries are more obvious than those with posterior displacement.
  • Posteriorly displaced fractures may cause airway compromise or other mediastinal injuries.




Mild sprain of the acromioclavicular ligaments with no disruption of the periosteal sleeve


Partial disruption of the periosteal sleeve with mild widening of the acromioclavicular joint


disruption of the periosteal sleeve with superior displacement of the
clavicle; coracoclavicular interval 25%-100% normal


Complete disruption of the periosteal sleeve with posterior displacement of the clavicle through the trapezius


disruption of the periosteal sleeve with superior displacement of the
clavicle; >100% widening of the coracoclavicular interval

Radiographic Features
  • Fractures of the medial end of the clavicle may not be obvious radiographically.
    • □ A cephalically directed tangential radiograph can show subtle asymmetry between the sternoclavicular joints.
    • □ Computed tomography (CT) scan is the study of choice to visualize the fracture and diagnose mediastinal impingement.
  • Displaced fractures of the midshaft of the clavicle are easily demonstrated radiographically.
  • Incomplete or nondisplaced fractures in
    infants and young children may not be visualized until callus formation
    is radiographically evident, about 7 to 10 days after injury.
  • Displaced fractures of the lateral clavicle are usually well-visualized radiographically.
  • Imaging of both acromioclavicular joints
    on the same radiograph can demonstrate subtle differences, but stress
    views, with weights suspended from both wrists, are needed to reveal
    suspected injuries not otherwise evident.
Nonoperative Treatment
  • In the newborn, clavicle fractures may be treated by pinning the cuff off the sleeve to the shirt for about 10 days.
  • Midshaft clavicle fractures in older
    children can be treated conservatively by a sling or figure-of-eight
    dressing with excellent functional results.
  • Medial clavicle fractures in children do well with nonoperative care.
  • Fractures with anterior displacement can be treated symptomatically as the reduction frequently is unstable.
  • Moderate residual deformity in younger
    children will remodel and despite any residual deformity, older
    children will do well functionally.
  • Mild posterior displacement of the medial clavicle without mediastinal impingement may be treated conservatively.
  • Displacement causing mediastinal
    impingement needs to be urgently or emergently reduced by placing the
    patient supine with a bolster between the scapulae and applying
    longitudinal traction to the arm.
    • □ If traction alone does not affect the
      reduction, a towel clip may be used, under sterile conditions, to grasp
      the clavicle and manually pull it forward.
    • □ A vascular or thoracic surgeon should
      be on hand, even for closed reductions, as manipulation could start
      mediastinal bleeding.
    • □ Operative reduction may be needed if this is also unsuccessful.
  • Lateral clavicular fractures in children less than 14 years should do well with simple sling immobilization.
    • □ Full functional recovery can be expected.
Operative Treatment
  • Open fractures and fractures with
    impingement of underlying structures are indications for operative
    treatment of clavicle fractures.
  • Closed fractures with displaced bone
    fragments endangering the integrity of the overlying skin, may also
    need to be treated operatively.
  • Midshaft fractures of the clavicle requiring open reduction can be treated with a plate and screws or intramedullary fixation.
  • When operative treatment is indicated for
    medial or lateral clavicle fractures, suture repair of the thick
    periosteal tube may provide sufficient stabilization.
    • □ For medial fractures, this avoids the
      potential of hardware migration into the mediastinum, which increases
      with transfixation of the sternoclavicular joint.
  • P.109
  • Internal fixation of these injuries should be avoided if possible.
Functional results of clavicle fractures in children are usually excellent, irrespective of the treatment selected.
Fractures of the scapula in children are rare and
usually secondary to high-energy injuries, such as motor vehicle
accidents. The more superficial and prominent parts of the scapula
however, such as the acromion, may sustain a fracture during sports
activities or falls. If a plausible history for a scapula fracture is
not given, consider the possibility of child abuse.
  • Scapula fractures can be classified by the anatomic location of the fracture:
  • Body of the scapula
  • Spine of the scapula
  • Glenoid fossa or neck
  • Acromion and the coracoid processes.
History and Physical Examination
On examination, there will be localized swelling and
tenderness. Look for injury to structures in proximity to the scapula,
including the ribs, lungs, and brachial plexus. This is especially true
for high-energy injuries.
Radiographic Features
Three views of the scapula, a true anteroposterior (AP)
view, a lateral scapula view, and an axillary view are needed for a
complete radiographic examination of scapula injuries. A CT scan is
often necessary for the evaluation and treatment of glenoid fractures.
Nonoperative Treatment
Most scapula fractures can be treated nonoperatively,
using a sling for comfort. Fractures of the scapula body are usually
only minimally displaced because of the overlying muscular envelope.
Operative Treatment
Displaced fractures of the glenoid body or rim in older
children may require operative intervention. These are intraarticular
fractures and reduction is necessary for stability and function of the
shoulder joint. Displaced fractures of the glenoid neck may require
operative treatment, especially when associated with ipsilateral
clavicle fractures. Operative intervention for acromion or coracoid
fractures is rare in children.
  • Shoulder dislocations in children are uncommon.
  • Usually secondary to indirect forces transmitted to the shoulder through a twisting of the arm.
  • Direct trauma to the proximal humerus and shoulder area can also result in glenohumeral dislocation.
  • Most occur during sports activity.
  • Neonatal shoulder dislocations are rare.
  • To accommodate its wide range of motion, the shoulder joint has minimal bony constraint.
  • Ligamentous thickenings of the joint
    capsule are the primary stabilizers of the shoulder joint and the
    rotator cuff acts as a secondary stabilizer.
  • Disruption of these capsular ligaments or
    their labral attachment (a Bankart lesion) is the mechanism of failure
    leading to dislocation.
  • Shoulder dislocations are uncommon in
    young children, as the proximal humeral physis will often fail prior to
    failure of these thick ligaments.
  • Shoulder dislocations can be classified
    by the direction of dislocation, including anterior, posterior,
    inferior (luxatio erecta), and superior dislocations.
  • In children, anterior or anteroinferior
    dislocations are by far the most common and occur secondary to
    abduction and external rotation of the arm.
  • Multidirectional instability is also possible.
  • Dislocations can also be classified as traumatic or atraumatic.
    • □ Atraumatic dislocations are often seen
      in habitual dislocators, or in those with conditions associated with
      joint laxity (e.g., Larsen syndrome or Ehlers-Danlos syndrome).
    • □ Also found in patients with neuromuscular disease, such as cerebral palsy or brachial plexus injuries, due


      to long-standing chronic muscular imbalance about the shoulder.

  • Shoulder dislocations can also be classified as acute, recurrent, or chronic.
History and Physical Examination
  • The patient with a traumatic shoulder dislocation presents with a painful deformity to the shoulder.
  • If anteriorly dislocated, the arm is usually slightly abducted and externally rotated.
  • The acromion will be prominent, and hollowness will be noted beneath it.
  • The humeral head may be palpable anterior to the glenoid.
  • The less common posterior dislocation
    will cause the arm to be held in adduction and internal rotation, with
    a posterior shoulder prominence.
  • The axillary nerve is at risk of injury
    after shoulder dislocations and should be examined as part of a full
    neurovascular exam prior to initiating treatment.
Radiographic Features
  • A shoulder dislocation can be visualized
    with plain radiographs which include an AP view of the shoulder, a
    lateral scapula view, and an axillary view.
  • Note any associated proximal humeral fracture that could displace during reduction.
  • After reduction, a compression fracture
    of the humeral head, called a Hill-Sachs lesion, can be visualized on
    an AP view with internal rotation of the arm.
Nonoperative Treatment
The reduction of a glenohumeral dislocation may be
accomplished under sedation. For both anterior and posterior
dislocations, a traction/countertraction maneuver is effective for the
reduction, using a sheet placed under the axilla. Postreduction
radiographs are compulsory. Once a patient is comfortable, aggressive
physical therapy should be instituted to strengthen the rotator cuff
and shoulder girdle musculature. The family and patient should be made
aware that there is a high risk of recurrence in children necessitating
operative intervention.
Operative Treatment
Most patients will have a recurrence, and surgical
stabilization is then recommended. The surgical procedure will depend
upon the type of dislocation, whether there is a Bankart lesion, and
the preference of the surgeon. Surgical intervention may not be
recommended for habitual dislocators due to the high postoperative
recurrence rate.
The results of treating shoulder dislocations in children should be similar to the treatment results in adults.
D, Weiner DS, Noble JS, et al. Severely displaced proximal humeral
epiphyseal fracture: a follow up study. J Pediatr Orthop 1998;18:31-37.
De Jong KP, Sukul DMKS. Anterior sternoclavicular dislocation: a long-term follow-up study. J Orthop Trauma 1990;4:420-423.
Eidman DK, Siff SJ, Tullos HS. Acromioclavicular lesions in children. Am J Sports Med 1981;9:150-154.
CF, Kiaer T, Lindequist S. Fractures of the proximal humerus in
children: nine year follow-up of 64 unoperated cases. Acta Orthop Scand
K, Bassett GS. Complete posterior sternoclavicular epiphyseal
separation: a case report and review of the literature. Clin Orthop
HJ, Angel KR, Schemitsch EH, et al. The fate of traumatic anterior
dislocation of the shoulder in children. J Bone Joint Surg (Am)
Neer CS, Horowitz BS. Fractures of the proximal humeral epiphyseal plate. Clin Orthop 1965;41:24-31.
Oppenheim WL, Davis A, Growdon WA, et al. Clavicle fractures in the newborn. Clin Orthop 1990;250:176-180.
Rockwood CA. Dislocations of the sternoclavicular joint. AAOS Instr Course Lect 1975;24:144-159.
K, Sarwark JF. Proximal humerus, scapula, and clavicle. In: Beaty JH,
Kassar JR, eds. Rockwood and Wilkins’ fractures in children, 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2001: 741-806.
12.3 ELBOW
Edward Abraham
The elbow region includes the distal humeral metaphysis,
epiphysis, radial head and neck, and ulnar olecranon process. The
proximity of the radial, median, and ulnar nerves and the brachial
artery to the elbow trauma can be a major source of apprehension and
urgency for the physician.
There are two well-known mnemonics used to remember the
sequential appearance of the ossification centers: “CRITOE” and “Come
rub my tree of life”—capitellum, radius, internal (medial) epicondyle, trochlea, olecranon,


and external (lateral) epicondyle (Fig. 12.3-1).
On a lateral radiograph, the capitellar center is located anteriorly
and tilts downward. Its posterior unossified epiphysis is wider
posteriorly than it is anteriorly. A line drawn down the anterior
surface of the humeral cortex passes through the middle to posterior
half of the capitellum on a lateral roentgenogram (Fig. 12.3-2).

  • Usually caused from a fall on an outstretched extremity with the elbow in full extension.
  • Child abuse must be suspected if child is less than 2 years of age.
Figure 12.3-1 Chronologic appearance of the centers of ossification as seen on radiographs.
  • The rate of occurrence between boys and girls is 3 to 2.
  • Average age is 7 years.
  • Nerve injury occurs in about 10% of cases (median and radial nerves).
  • Distal radius fracture is the most common associated skeletal injury.
Physical Examination and History
Clinical Features
  • Elbow swelling, tenderness, and diminished active movement of extremity.

    Figure 12.3-2 (A) The normal anterior humeral cortical line transecting the center of the capitellum as seen on a lateral radiograph. (B) Anterior radial head dislocation.
  • Anterior Pucker sign occurs when the proximal bone spike penetrates into the subcutaneous tissue.
  • Evaluate humerus, forearm, wrist and hand for associated injuries.
  • Sensory loss is more difficult to assess in young children.
  • Vascular examination: check for pulses, capillary refilling, skin temperature, and forearm compartment tenseness.
  • Painful passive finger extension and flexion may indicate increased forearm compartment pressures.
Radiologic Features
  • Get good quality x-rays of entire extremity.
  • Contralateral radiographs are controversial and should only be obtained if the diagnosis is unclear.
Reduction Technique (Fig. 12.3-3 and Table 12.3-1)
  • Definitive reduction of the fracture is carried out under general anesthesia with C-arm fluoroscopic control.
  • Apply longitudinal traction to reduce the proximal displacement and any varus or valgus angulation (see Fig. 12.3-3A).
  • Reduce medial or lateral displacement (see Fig. 12.3-3B).
  • Internally rotate the forearm if needed to correct external rotation of distal fragment (see Fig. 12.3-3C).
  • Reduce the posterior displacement by applying pressure on the olecranon process while maintaining traction (see Fig. 12.3-3D).
  • Flex elbow acutely with forearm in pronation for both medial and lateral displacement of distal fragment (see Fig. 12.3-3E).
Adolescent T-Condylar Fractures
  • Open reduction and internal fixation for the unstable displaced fractures.
  • Use the same treatment principles that apply to adult fractures.
  • Open reduction indicated if vascular compromise exists or soft tissue interposition prevents adequate fracture reduction.
  • Openly reduced fracture can be fixed with percutaneously placed pins.
Brachial Artery Injury
  • Immediate fracture reduction is the treatment of choice for a distal pulseless extremity.
  • An absent pulse with the following conditions warrants brachial artery exploration:
    • □ Abnormally high forearm compartment pressures and clinical findings of a development of compartment syndrome
    • □ Loss of pulse after closed reduction
Compartment Syndrome
  • Early clinical findings are worsening forearm pain at rest or with passive finger movement.

    Figure 12.3-3 Reduction of supracondylar fractures. (A) Traction. (B) Correction of displacement. (C) Rotation correction. (D) Reduction. (E) Pronation.
  • Compartment syndrome can exist in the presence of a palpable pulse.
  • Forearm compartment pressures greater than 30 mm Hg and the presence of clinical findings warrant fasciotomy.
  • Median nerve injury can mask the pain associated with Compartment syndrome.
Nerve Injury
  • Occurs in about 15% of cases.
  • The anterior interosseous branch of the median nerve is commonly involved.
  • Nerve recovery usually occurs within 3 months
  • Cubitus varus is most common.
  • Lateral downward tilt of the medial side of the fracture is the main cause of cubitus varus
Myositis Ossificans
  • This rare condition is known to resolve within 2 years.
  • Surgery is rarely indicated.
Avascular Necrosis of Trochlea
  • An asymptomatic fishtail deformity may develop.
  • Best treated conservatively.
Elbow Stiffness
  • Loss of elbow flexion and increased hyperextension is associated with residual posterior tilt of the distal fragment.
  • Anterior impingement by a medially rotated distal fragment can restrict elbow flexion.
  • The combination of some bone remodeling with growth and therapy usually restores functional range of motion.






Hyperextension of distal fragment up to 30 degrees of angulation

No displacement

Detached but intact anterior periosteum

Stable transverse fracture line through medial and lateral epicondylar columns and olecranon fossa

Reduction not needed

Long arm splint for 1 week

Convert to long arm cast, elbow flexed to 90 degrees with forearm in neutral rotation

X-rays, then remove immobilization at 3-4 wk

Rehabilitation: home program adequate


Hyperextension of distal fragment beyond 30 degrees of angulation

No displacement

Potentially unstable

Anterior periosteum detached and partially torn

Closed reduction in ER under i.v. sedation.

Long arm splint or cast with the elbow in 100-110 degrees of flexion and the forearm pronated

Or closed reduction in OR under general anesthesia and
immobilization as above or two lateral parallel or cross-fixing
Kirschner pins (0.062 inch or 1.6 mm)

Long arm splint for 1 week with the elbow in 70 degrees of flexion and the forearm in neutral rotation

Convert to long arm cast for a total of 3-4 wk

Pin removal in office

Start exercise program at home


Distal fragment posterior and proximal displacement


Anterior periosteum completely torn

Circumferential detachment of posterior periosteum

No lateral or medial periosteal hinges exist

Distal anterior periosteal hem and retracted anterior proximal periosteum are characteristic findings

Closed reduction under general anesthesiaa

Two lateral parallel or cross-fixing Kirschner wires

Long arm splint for 1 week with the elbow in 70 degrees of flexion and the forearm in neutral rotation

Long arm cast for 2-3 more wk

Pin removal in office

Physical therapy consultation for supervised home rehabilitation


Vertical extension fracture line that is usually medial but can be lateral

Usually completely displaced

Unstable if displaced

There are three sub types:

▪ Type I early childhood—distal extension

▪ Type II preadolescent-distal and proximal extension

▪ Type III adolescent—T-condylar fracture

Closed reduction under general anesthesia

Stabilize main fragment first

Two to four cross-fixing Kirschner wires

Long arm splint for 1 wk with the elbow in 70 degrees of flexion and the forearm in neutral rotation

Replace splint with long arm cast for up to 4 wk. The elbow is in 70 degrees of flexion and the forearm in neutral rotation

Pin removal in office

Physical therapy consultation

Treat T-condylar type as adult fracture

a Caution:
Check both for arterial circulation and ulnar nerve function before and
immediately after fracture reduction and fixation.

ER, emergency room; OR, operating room.

Etiology and Pathophysiology
  • Accounts for less than 2% of all supracondylar fractures.
  • The mechanism of injury in a direct blow on a flexed elbow.
  • The periosteum is torn posteriorly so that the reduced fracture is unstable in flexion.
  • The ulnar nerve is prone to injury.
  • Similar to extension-type fractures
    • □ Type I: nondisplaced
    • □ Type II: mild angulation
    • □ Type III: displaced
  • Swelling and tenderness about elbow.
  • Radiographically, the distal humerus fragment is anteriorly angulated or displaced.

Type I
  • Long arm cast with elbow flex for comfort, neutral forearm rotation
  • Home therapy program
Type II
  • Closed reduction under general anesthesia by extending elbow
  • Unstable fracture requires percutaneous Kirschner pin fixation
  • Apply a long arm cast with elbow extended and forearm in neutral rotation
Type III
  • Closed reduction under general anesthesia
  • Percutaneous pin fixation with elbow in extension or 30-degree flexion
  • Immobilize in a splint or cast with elbow in flexion or extension
  • Remove Kirschner wires (K-wires) in 3 to 4 weeks
Physeal injuries about the elbow rank third in frequency
for all physeal fractures after phalanx and wrist. The physis fracture
type depends mainly on skeletal age and injury mechanism (Table 12.3-2).
Figure 12.3-4 Classification of lateral condyle fractures. (A) Milch type I, lateral view (Salter-Harris type IV). (B) Milch type II, lateral view (Salter-Harris type II).

Fracture Type

Age (yr)

Total separation of physis (Salter-Harris type I)


Lateral condylar physis fractures (Salter-Harris type IV)


Medial epicondylar apophysis


Lateral Condylar Physeal Fractures
  • Account for 20% of distal humerus fractures.
  • Likely mechanism of injury is elbow extension, forearm adduction, and supination.
  • The commonest fracture line travels from
    the posterior lateral metaphysis, along the physis, and into the
    trochlea (Milch type II) (Fig.12.3-4).
  • The rare fracture line type starts from
    the posterolateral metaphysis, through the physis and body of the
    capitellum (Milch type I) (see Fig. 12.3-4).
  • Elbow arthrogram under general anesthesia
    and magnetic resonance imaging (MRI) are good for accessing lateral
    displacement of elbow if not obvious on radiographs.
History and Physical Examination
  • History of mechanism is variable.
  • Outer elbow swelling and tenderness with pain on elbow motion.
  • P.116
  • Plain radiographs of elbow must include anteroposterior, lateral, and oblique views.
  • MRI or arthrogram recommended if diagnosis unclear.
Lateral condylar physeal fractures are classified by, and treatment is based on, stage (Table 12.3-3 and Fig. 12.3-5).
Delayed Union
  • Seen more frequently in patients treated with cast immobilization.
  • For minimally displaced fractures (≈2 mm) keep immobilization for 2 months if necessary.
  • Delayed in situ pinning is an option.
  • Open reduction after 3 weeks of injury is controversial.
  • Results from inadequate treatment.
  • Untreated nonunion may lead to cubitus valgus and ulnar nerve dysfunction.
  • Specific treatment is controversial—the best goal is prevention.
  • Lateral spur formation most common deformity associated with this fracture.
  • Cubitus varus may result secondary to condylar physeal overgrowth or inadequate fracture reduction.
Fishtail Deformity
  • The sharp angle wedge type is caused by a
    bony bar from inadequate fracture reduction between the lateral condyle
    ossification center and that of the trochlea.
  • The smooth curved wedge type is associated with osteonecrosis of the lateral part of the medial crista of the trochlea.
  • Not associated with any significant elbow function deficiency.
  • May be caused by extensive dissection needed for late reduction of fracture.
  • Regeneration of the condyle is likely to occur if union occurs.
  • Loss of joint motion may result.
Myositis Ossificans
  • Rare complication with resulting loss of elbow motion.
Physeal Arrest
  • Premature closure of the physis can occur
    in conjunction with premature fusion of the secondary centers of
    ossification in the epiphysis.
  • Limited growth potential of the distal
    humeral physis and the non-weightbearing status of the humerus
    decreases the adverse effects of a physeal arrest.





Condylar changes

▪ ≤2 mm of downward displacement

▪ Articular surface intact

▪ No lateral shift


▪ Long arm splint with elbow in 90-degree flexion and forearm in neutral rotation


▪ Long arm cast in above position for 4 wk

▪ Weekly radiographs for first 2 wk

▪ Home physical therapy


Nondisplaced articular surface

▪ 2-5 mm of downward displacement

▪ Articular surface broken

▪ Lateral shift possible

Displaced articular surface


▪ Same as stage I


▪ Closed or open reduction with two Kirschner wire (1.6 mm) fixation

▪ Long arm cast at stage I with wire removal in 3-4 wk


▪ Open reduction and wire fixation, rest same as for nondisplaced


Total displacement

▪ Lateral displacement with break of capitellar line

▪ Rotated (long axis of ossification center is vertical instead of horizontal)

▪ Olecranon and radial translation possible with Milch I fractures


▪ Same as stage I


▪ Open reduction and Kirschner wire fixation

Figure 12.3-5 Rutherford classification of lateral condyle. (A) Type I. (B) Type II. (C) Type III.
Fractures of the capitellum are intraarticular
epiphyseal fractures of the lateral condyle and occasionally the
lateral crista of the trochlea.
  • Usually caused by the impaction of the radial head on the capitellum
  • Rare injury, seen mainly in children older than 12 years
  • Difficult to diagnose in the younger child
  • Radial head fractures seen in one-third of patients
  • Hahn-Steinthal type: includes the capitellum and cancellous bone from the lateral condyle and lateral crista of the trochlea.
  • Kocher-Lorenz type: articular fracture seen mainly in adults.
  • The Rutherford classification.
Clinical Features
  • Elbow flexion is restricted.
  • Swelling is limited in isolated injuries.
Radiologic Features
  • Routine radiographs with oblique views to detect small bone fragments.
  • Computed tomography (CT), arthrogram, and MRI are useful diagnostic tools.
  • Look for associated radial head fractures.
  • Surgery is indicated in most cases because of intraarticular involvement.
  • Excision of the fragment is recommended for comminuted or neglected fractures.
  • Reattachment of large bone fragments with compression screw fixation gives better results than K-wire fixation.
  • Avascular necrosis of the fragment is a potential complication.

  • Isolated medial condylar fractures are
    rare, accounting for less than 1% of all elbow fractures in children
    between 8 and 14 years.
  • Occasionally seen in association with
    supracondylar fractures of the humerus, olecranon process fractures,
    and posterolateral elbow dislocations.
  • The most likely mechanism is a fall on an outstretched arm with a valgus strain or a direct fall on the flexed elbow.
  • Swelling and pain on inner side of elbow.
  • Joint instability on valgus stress.
  • Diagnosis is based on radiograph findings.
  • Before the age of 8 years extraarticular
    medial epicondylar apophyseal fractures may be confused with medial
    condylar fractures. An MRI or arthrogram may be helpful.
  • A posterior fat pad sign is suggestive of intraarticular involvement.
The Kilfoyle classification and recommended treatment are given in Table 12.3-4.
  • Cubitus varus: associated with failure to reduce a displaced fracture, nonunion, or avascular necrosis of the medial condyle.
  • Avascular necrosis of the medial crista of the trochlea may follow open reduction of the fracture.
  • Cubitus valgus can occur secondary to overgrowth.





Starts in the medial epicondylar column and ends between the capitellum and trochlea

Long arm splint or cast with elbow flexed to 90 degrees and forearm in neutral rotation


Fracture line extends into joint; potentially unstable

Same as type I if nondisplaced or same as type III if displaced


Medial condyle and epicondyle displaces and rotates

Open reduction and Kirschner pin or screw fixation

  • Primarily cartilaginous epiphysis makes diagnosis difficult.
  • Fracture separation of entire physis usually occurs before 6 years of age.
  • The medial epicondyle apophysis shares a
    common physeal line with the distal epiphysis until about 6 years of
    age in girls and 8 years of age in boys.
  • It is believed that the horizontal line
    of the physis and its close proximity to the olecranon fossa are
    responsible for this fracture pattern.
Delee and colleagues’ classification is given in Table 12.3-5.
  • High index of suspicion is key.
  • Often the result of abuse in non-ambulatory children.
Clinical Features
  • Swelling may be minimal in the newborn
  • Swollen elbow in an infant or toddler
  • Crepitus with elbow motion
Radiologic Features
  • Relationship between the radial head and lateral condylar center of ossification is maintained.
  • Intact proximal radius and ulna displaces posterior and medial; with elbow dislocations the displacement is posterolateral.
  • Arthrography, ultrasound, and MRI are helpful in differentiating the fractures.
  • Closed reduction is attempted in all
    cases under sedation. Medial displacement corrected in extension and
    elbow, then flexed and pronated.





    Group A (Salter-Harris type I)

    Newborn-12 mo

    Epiphysis is mainly cartilaginous tissue

    Group B (Salter-Harris type I)

    12 mos-3 yr

    Possible metaphyseal bony flakes with epiphysis

    Group C

    3-7 yr

    Large metaphyseal fragment, usually from the lateral side

    • □ Two percutaneous K-wires can be used to fix the fracture in older children.
    • □ For neglected fractures (more than 5 days) immobilize and expect sufficient remodeling with time.
  • Malunion:
    • □ Most frequent complication
    • □ Seen mainly in untreated patients
  • Rare: traumatic osteonecrosis of the trochlea, nonunion
  • Male-to-female ratio of 4:1
  • Associated with elbow dislocation in 50% of cases
  • Peak age of incidence is 9 to 12 years.
  • A traction apophysis that does not contribute to longitudinal humeral growth
  • Common origin for forearm flexion muscle mass and medial capsular attachment
  • Becomes an extraarticular structure at age 8 years
Mechanism of Injury
  • Indirect:
    • □ Acute hyperextension of elbow with
      forced elbow valgus stress. Associated with anterior and distal
      displacement of apophysis greater than 5 mm.
    • □ Chronic repetitive or dominant overuse of extremity (e.g., Little League pitchers)
  • Direct:
    • □ Direct posterior blow to the epicondyle
Clinical Features
  • Pain, tenderness, and swelling localized medially.
  • Increased pain with resistive wrist flexion or valgus stress to elbow.
  • Loss of elbow motion.
  • Other injuries may complicate the clinical findings (i.e., elbow dislocation, olecranon, or coronoid fractures).
Radiographic Features
  • Standard anteroposterior, lateral, and oblique views of the elbow joint are required.
  • In children younger than 5 years, MRI or arthrograms are useful.
  • Look for widening of the physis, distal and anterior migration of apophysis.
Types of medial epicondylar apophyseal fractures, and their characteristics and treatment are shown in Table 12.3-6 and Figure 12.3-6.
Nonunion or Fibrous Union
  • Seen in 60% of cases treated conservatively
  • Elbow function rarely compromised
  • Treatment necessary if pain or tenderness persists
Ulnar Nerve Dysfunction
  • Associated with severe displacement or incarceration of the epicondyle in the elbow joint
  • Necessitates exploration of the ulnar nerve and reduction of fracture
Elbow Stiffness
  • Seen in 10% of cases
Myositis Ossification
  • Rare
  • Conservative measures recommended since lesions may spontaneously resolve






Less than 10 mm of displacement

Conservative measures only

Long arm splint with elbow flexed at 90 degrees and wrist in neutral rotation for up to 2 wk

Replace with splint Ace wrap and sling until patient is asymptomatic

Start elbow motion exercises


Greater than 10 mm

Conservative treatment as minimally displaced fracture

ORIF controversial

Gross elbow instability

Ulnar nerve dysfunction


Incarcerated fragment in elbow

Requires ORIF

Figure 12.3-6 Degrees of medial epicondylar apophyseal fractures.
Lateral apophyseal epicondylar fractures are rare and
the natural appearance of this center is frequently confused for a
  • Ossification center appears at about 10 years of age.
  • The early bony sliver is normally separated from the metaphysis and epiphysis by 2 to 3 mm.
  • The ossifying epicondylar epiphysis fuses first with the capitellum then the humeral metaphysis.
  • Violent contraction of the common extension muscles of the forearm causes isolated avulsion fractures.
Clinical Features
  • Local pain and swelling over outer elbow
  • Elbow joint stiffness
Radiologic Features
  • Lateral separation of the ossification center from the metaphysis and capitellum is a normal finding.
  • An avulsion fracture is diagnosed when the ossification center lies distal to the osteochondral epiphysis.
  • Immobilization of extremity in a sling or splint for comfort
  • An incarcerated fragment in the elbow requires open reduction and wire fixation.
  • Nonunion: usually asymptomatic

  • Usually caused by an indirect hyperextension and valgus force to elbow with supination of forearm.
  • Uncommon anterior elbow dislocation is caused by a direct force on the flexed joint.
  • Accounts for 3% of all joint dislocations
  • Usually occur at age 13 to 14 years
  • Associated elbow fractures in about 50% of cases
  • Boy-to-girl ratio is 3:1
  • Left-to-right-side ratio is 3:2
  • Elbow hyperextension is the cause in over 90% of cases.
  • Based on the position of the proximal radioulnar joint with regard to the distal humerus:
    • □ Proximal radius and ulna usually displace as a unit.
    • □ Disassociation of the proximal radioulnar joint rarely occurs.
    • □ Divergence of radius and ulna is rare.
Radiographic Features
  • Routine anteroposterior and lateral radiographs are not always possible and multiple views and
  • Comparison radiographs of the contralateral elbow may be helpful.
  • Prompt reduction is necessary to relieve pain, and prevent or minimize neurovascular complications.
  • Check neurovascular status before and after reduction.
  • Radiographs are necessary before and after reduction.
  • Sedation and analgesia are recommended.
Posterolateral Dislocation
Closed Reduction Technique
  • Hypersupinate forearm and apply traction
  • Apply downward force along the distal arm and proximal forearm while using counter traction
  • Loss of elbow motion:
    • □ Most common complication
    • □ Terminal extension loss of 15 degrees is commonplace
  • Neurologic injuries:
    • □ Usually transient
    • □ Ulna nerve most commonly affected
  • Arterial insufficiency:
    • □ Can be caused by thrombosis, rupture, or entrapment
    • □ Collateral arterial flow may be
      sufficient to permit a weak Doppler radial pulse or a good nailbed
      capillary flow in the finger in the presence of an obstructed proximal
      radial or brachial artery
  • Myositis ossificans and heterotopic ossifications
  • Recurrent posterior dislocation rare, but occurs more commonly in children than adults
  • Anterior elbow dislocation:
    • □ Incidence 1%
    • □ Elbow held in extension and a fullness in the articubital fossa is felt
    • □ Treated by closed reduction: elbow is partially flexed with traction and a downward force on the distal arm
  • Medial and lateral elbow dislocations:
    • □ Only lateral elbow dislocations are reported in children
    • □ Lateral subluxation may not be obvious as a complete dislocation on radiographs
  • Divergent elbow dislocations:
    • □ Rare injury associated with excessive compressive forces of the elbow
    • □ Usually associated with radial head, neck, and proximal ulnar fractures
    • □ Proximal radius displaced posteriorly and radially
Closed reduction with general anesthesia is usually successful and prognosis for elbow function is very good.
  • Isolated traumatic dislocations of the radial head are considered a variant of Monteggia fracture, type I.
  • Partial or complete anterior displacement
    of the radial head and subtle anterior bowing of the ulnar shaft on
    lateral radiographs (ulna bow sign) are diagnostic.
  • Other possible causes of anterior radial
    head dislocations: cubitus varus after supracondylar fractures,
    osteochondritis dissecans of the capitellum, and birth trauma.
  • The mechanism of injury is the same as that for Monteggia injuries but without obvious ulna fracture.
  • P.122
  • Unlike acute traumatic dislocations, long-standing traumatic dislocation may mimic congenital dislocations on radiographs.
  • Acute anterior dislocation: closed reduction with flexion and supination
  • Chronic (more than 3 weeks) anterior
    dislocation: open reduction is controversial but may be recommended up
    to 3 years after injury.
  • Annular ligament slips proximally because of weak distal attachments of the annular ligament to the radial head.
  • Common injury under age 5 years (mean age, 2.5 years)
  • Girls: 65% of the time
  • Left elbow: 70% of the time
  • Mechanism of injury: longitudinal pull on a straight elbow with forearm in pronation
  • In forearm pronation, the lateral head surface is narrower and rounder, but it is wider and squarer in supination.
  • History may not be readily obtainable.
  • Child stops using the extremity.
  • Forearm supination is more painful than pronation.
  • Radiography is often normal.
  • Look for other occult fractures (i.e., supracondylar, lateral condyle, or radial head and neck fractures)
  • Closed reduction by flexion and supination.
  • Spontaneous reductions may occur before patient is seen by physician.
  • Acute injury:
    • □ Usually a combination of forces, compression, angulation, and rotation on a hyperextended valgus elbow
    • □ May be isolated to the radius or in
      association with elbow dislocation, where the radius fracture may be
      caused as the elbow dislocates or when the joint reduces
  • Chronic injury:
    • □ Seen in athletes who stress the elbow in a repetitive fashion (i.e., Little League pitcher)
  • 7% of elbow fractures
  • Fractures seen at all ages (median age 9.5 years)
  • Equal incidence between sexes
  • Most common fracture pattern is through the less dense neck and physis.
  • Radial head fracture likely to occur in older child.
Physical Examination and History
Clinical Features
  • Isolated injury: outer elbow pain,
    swelling, and tenderness associated with loss of forearm rotation and
    elbow flexion and extension
  • Associated with other injuries: elbow
    dislocation, olecranon process and ulnar shaft fractures (Monteggia),
    medial epicondyle injury, or distal radioulnar joint
  • Elbow pain, swelling, and tenderness are more severe.
  • Joint mobility severely restricted due to greater involvement of other elbow structures and hemarthrosis.
  • Wrist and forearm pain may be present.
  • Weak wrist extension with radial deviation occurs if posterior interosseous nerve function is compromised.
The following treatment plan applies to the majority of
fractures, where the articular surface of the radial head is intact and
the fracture line is through the neck. The two important factors
dictating treatment outcomes are radial head angulation and




Sedation or general anesthesia required


Elbow extended

Flex elbow 90 degrees

Rotate forearm to bring head radially (use thumb palpation or fluoroscopy)

Place thumb anteriorly and over radial head, apply steady pressure

Apply distal traction and apply a varus force to increase radiocapitellar space

Pronate forearm fully

Check radiographs for quality of reduction


Apply long arm cast with elbow at 90 degrees and forearm in pronation


  • Radial head—angulation ≤30 degrees and displacement ≤3 mm:
    • □ Stable fracture pattern
    • □ No reduction necessary
    • □ Immobilization with long arm splint or cast with elbow flexed at 90 degrees and forearm in neutral rotation
    • □ Discontinue immobilization in 2 to 3 weeks
    • □ Protected physical therapy in tally
    • □ Note: a minimally displaced articular
      fracture of the radial head usually seen in older child with closed
      physis is treated in a similar fashion
    • □ Fracture reduction required to guarantee acceptable elbow function
  • Radial head angulation ≥30 degrees and displacement ≥3 mm
    • □ Closed reduction only
    • □ Patterson or Kaufman manipulation (Table 12.3-7)
    • □ Long arm cast with elbow at 90 degrees and forearm pronated
    • □ Remove cast at 3 weeks
  • Percutaneous pin reduction or intramedullary pin reduction may be indicated if closed methods fail
  • Open reduction indicated for a residual
    angulation ≥40 and displacement ≥3 mm or when there is failure to
    regain forearm supination 50% and pronation
  • Elbow stiffness: associated with severe trauma or open reduction
  • Hypertrophic changes of radial head:
    • □ Seen in about 30% of cases
    • □ Associated with a clicking sound with forearm rotation
    • □ No treatment needed
  • Avascular necrosis of radial head:
    • □ Seen in about 15% of cases
    • □ Associated with surgical reduction
    • □ Expect unsatisfactory functional results
  • Premature physeal closure:
    • □ Can potentially produce cubitus valgus
    • □ Elbow function not significantly affected
  • Nonunion of radial neck: rare; treat conservatively
  • Radioulnar synostosis: associated with severe trauma; open reduction and delay fracture treatment
  • Malunion: predisposes the radiocapitellar joint to arthritis
  • Nerve injury: posterior interosseous nerve injury is usually iatrogenic
  • Myositis ossificans:
    • □ Common (30% of cases in one series)
    • □ Supinator muscle usually involved
The proximal ulna’s secondary center of ossification appears after 10 years of age and fuses at 14 years of age.
  • Olecranon fracture accounts for 5% of elbow injuries and results from an avulsion force acting across a flexed elbow
  • Triceps muscle insertion extends into the metaphysis, offering some protection to the epiphysis and physis
Classification of apophyseal fractures is given in Table 12.3-8.
Clinical Features
  • Palpable defect can be felt between the apophysis and metaphysis with displaced fractures
  • Tenderness and local soft tissue swelling present







Abnormal development of the secondary ossification center with or without widening of the apophyseal line incompletely


Shen fracture

Occurs along the apophyseal line

Usually associated with the overuse of the elbow (i.e., baseball pitcher)


Complete fractures

Two types:

▪ Pure apophyseal avulsion

▪ Apophyseal-metaphyseal fracture (Salter-Harris type II physeal injury)

Radiographic Features
  • Obvious in the older child after the appearance of ossification centers
  • Elbow arthrogram or MRI useful in the younger child
  • Open reduction and internal fixation with axial pins and figure-of-eight tension—band wiring for displaced fractures
  • Rest for most stress fractures and avoidance of the offending elbow motion
  • Nonunion requires compression screw fixation with bone graft
  • Apophyseal arrest may occur but is not associated with functional loss
  • Indirect traction forces with the elbow flexed
  • Valgus or varus forces with elbow extended
  • A direct blow to the olecranon
  • Seen at all ages, with peak incidence at age 5 to 10 years
  • 20% associated with other elbow injuries
  • By Chambers:
    • □ Group A: flexion injuries
    • □ Group B: extension injuries
      • □ Valgus pattern
      • □ Varus pattern
    • □ Group C: shear injuries
  • By Papavasilouetted:
    • □ Group A: extraarticular
    • □ Group B: intraarticular
Clinical Features
  • Local swelling over the olecranon
  • Skin abrasions
  • Palpable defect
  • Weakness in elbow extension
Radiographic Features
  • Get routine radiographs of entire elbow
  • Look for perpendicular fracture lines
  • Residual physeal line is oblique and runs proximal and anterior
  • Look for associated injuries involving medial epicondyle, radial head and neck, and lateral condyle
  • Extension type, minimally displaced:
    • □ Long arm cast or splint immobilization for 3 weeks
    • □ Elbow may be flexed at 80 degrees or 10 degrees
    • □ Supervised rehabilitation
  • Extension type, displaced more than 2 mm: open reduction
  • Shear type:
    • □ Closed reduction if angulated more than 10 degrees with immobilization in a long arm cast for 3 weeks
    • P.125
    • □ Screw or pin fixation for unstable fractures
    • □ Long arm cast or splint with elbow flexed to 90 degrees for nondisplaced or minimally displaced fracture
  • Uncommon
  • Loss of elbow function associated with failure to correct alignment or loss of reduction
  • Other uncommon complications include
    elongation of olecranon process, ulnar nerve transient neuropraxia,
    compartment syndrome, delayed unions, and nonunions
Abraham E, Powers T, Wit P, et al. Experimental hyperextension supracondylar fractures in monkeys. Clin Orthop 1982;171:309-318.
JH, Kasser JA. Rockwood and Wilkins’ fractures in children, 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2001: 483-739.
Brodeur AE, Silberstein MJ, Graviss ER. Radiology of the pediatric elbow. MA: GK Hall Medical Publishers, 1981.
Delee J, Wilkins K, Rogers L, et al. Fracture separation of the distal numeral epiphysis. J Bone Joint Surg (Am) 1980;62:46-51.
S. On osteochondrosis deformans juvenilis capituli humeri including
investigation of intra-osseous vasculature in distal humerus. Acta
Orthop Scand [Suppl] 1959;38:81-93.
R, Fowels, JV, Rang M, et al. Observations concerning fractures of the
lateral humeral condyle in children. J Bone Joint Surg Br
Lincoln TL, Mubarak SH. “Isolated traumatic radial-head dislocation.” J Pediatr Orthop 1994;14:455.
Perry CR, Elstrom JA. Handbook of fractures, 2nd ed. New York: McGraw-Hill, 2000:98-130.
Silberstein MJ, Brodeur AE Craviss ER. Some vagaries of the lateral epicondyle. J Bone Joint Surg (Am) 1982;64:444-448.
JA, Graham HK. Angulated radial neck fractures in children: a
prospective study of percutaneous reduction. J Bone Joint Surg (Br)
Twee Do
Radius and ulna fractures account for nearly half of all
skeletal injuries in the pediatric population. The mechanism is usually
an axial load, such as a FOOSH (fall onto an outstretched hand), with
varying degrees of rotation. Depending on the amount of force at the
time of impact, the fracture can occur at any location within the
forearm. The distal one-third radius is usually the most common site of
injury. Although most metaphyseal forearm fractures can be
conservatively treated without sequelae in skeletally immature patients
due to remodeling, some fractures at the midshaft and proximal
one-third forearm may need operative intervention to avoid the
occasional poor results. A thorough understanding of forearm fractures
and an awareness of the potential pitfalls that may occur in some of
these can ward off potential complications and assure a more clinically
satisfactory result at the completion of fracture healing.
Forearm fractures usually occur as a part of normal
child’s play. Tripping while running or a resisted fall during sports
are probably the more common causes of fracture, followed closely by a
fall from short heights, such as the monkey bars or trees. Higher
energy trauma, such as from auto-pedestrian or motor vehicle accidents
result in more dissipation of energy and more comminution, as well as
fractures that are located more at the distal metaphysis or epiphysis.
  • Forearm fractures tend to occur during seasons of active play, such as spring and summer, or with changes in the temperature.
  • Boys are affected more often than girls, in a 2.9:1 ratio.
  • Both sexes tend to fracture the nondominant arm most frequently, as it is the free arm available to break a fall.
  • The average age for forearm fractures
    tends to be 10.5 years for girls and 12.8 years for boys, although boys
    can tend to follow a bimodal peak.
  • The first peak occurs around 9 years,
    with the second peak happening around 13 to 14 years. The distal third
    of the forearm is the most common location for fractures overall, as
    well as the most common site in the older child.
  • The midshaft region is more commonly
    fractured in younger children. This is a reflection of their inherent
    anatomy, which includes more cancellous bone extending beyond the
    metaphysis into the diaphysis.
  • Distal metaphyseal and epiphyseal
    fractures occur in the older child (most commonly in boys between 13
    and 15 years, and girls between 12 and 13 years). This difference
    reflects the difference in the average age of skeletal maturation
    between the two genders. Near skeletal maturity, the amount of cortical
    bone at the diaphysis


    increases and the metaphyseal area decreases, making the distal radius the weaker portion of forearm bone.

Anatomy and Pathophysiology
The radius is a gently bowed bone with a semilunar
proximal end that articulates with a relatively straight ulna during
forearm rotation. Muscles that attach to the forearm and act as
potential deforming forces in fractures include, proximally, the biceps
and supinator and, more distally, the pronators teres and quadratus.
Fracture at the level of the supinator leads to a
supinated proximal fragment and the position of reduction should place
the distal fragment into supination. Fracture at the midshaft should be
reduced and stabilized in neutral. Fractures of the distal third of the
radius need to be stabilized in neutral to slight pronation due to the
activity of the pronators on the proximal fragment (Fig. 12.4-1)
Figure 12.4-1 Musculature of the forearm.
Classification of forearm fractures includes the location of the fractures and the type of fractures (Boxes 12.4-1 and 12.4-2).
History, Physical Examination, and Diagnostic Workup
A history of a fall onto an outstretched hand with pain
and ecchymosis at the forearm is fairly diagnostic. Gross displacement
and angulation will enhance the deformity further and make the fracture
more obvious on clinical examination. Swelling, crepitus, and gross
motion can usually be elicited at the site of the fracture, which is
associated with pain. Check for any lacerations or areas of fatty blood
to rule out an open fracture (which may necessitate an operative
irrigation and débridement).
  • Examination of the wrist, elbow, and
    shoulder on the ipsilateral side should also be performed to rule out
    other associated fractures or dislocations [e.g., the radial head in
    Monteggia fractures, or distal radioulnar joint (DRUJ) disruption in
    Galeazzi fractures]. Supracondylar humeral fractures can occur in up to
    5% of forearm fractures. Although rare, the most common ipsilateral
    carpal injury is the scaphoid fracture.

Figure 12.4-2 Anterior radial head dislocation with apex anterior ulna fracture.
Figure 12.4-3 Torus, or buckle, fracture.
  • The fingers should be checked for color and capillary refill.
  • The hand should be checked for warmth of the distal limb and the presence of a good radial pulse.
  • Neurovascular exam should include motor
    and sensory testing in the radial, ulnar, and median nerves (RUM)
    distribution (i.e., radial [motor—thumbs up/sensation—first web space
    dorsally], ulnar (motor—spread fingers against
    resistance/sensation—little finger), and median distributions
    [motor—cross index and middle finger/sensation—tips of index and middle
    finger]), including the anterior interosseous branch of the median
    nerves (primarily a motor branch to the Hexor indicisproprius (FIP),
    Hexor pollicis longus (FPL), and pronator quadratus/okay sign).
  • Radiographs should include orthogonal
    visews of the entire forearm to include the wrist and elbow in order to
    determine rotational alignment and to rule out involvement of the
    joints above and below the fracture.

Figure 12.4-4 Greenstick fracture.
Rotational alignment is gauged by evaluation of the
cortical thickness and contour of the fractured ends. This can
sometimes be difficult in comminuted fractures. Other means of checking
for fracture alignment include evaluation of the radial tuberosity
relationship to the radial styloid in the coronal plane. They are
usually 180 degrees apart. Other anatomic landmarks include the
coronoid process and styloid on the ulna, which are not visible on the
anteroposterior radiograph, but could be seen on the lateral x-ray. In
this view, the coronoid process faces anteriorly and the styloid points
posteriorly. The fracture is reduced by appropriately rotating the
distal fragment to reestablish these normal anatomic landmarks.
Figure 12.4-5 Complete fracture.
Because of the unique potential of remodeling that can
occur in skeletally immature individuals, most fractures tend to heal
without sequelae. The goals of treatment are to initially obtain an
acceptable alignment and maintain this alignment until the completion
of healing.
  • Initial immobilization with a sugar tong
    splint (Ushaped splint around the wrist and elbow) in the emergency
    room (or cast if minimally swollen) is sufficient for buckle or
    minimally angulated greenstick fractures of the distal metaphysis.
  • In badly angulated greenstick fractures,
    complete and displaced fractures or comminuted fractures, a provisional
    reduction is attempted under fentanyl/midazolem, or nitrous oxide
    conscious sedation in the emergency department, followed by application
    of a sugar tong splint.
  • The reduction is achieved by first
    obtaining gentle traction through the fingers (manually or in finger
    traps), followed by exaggeration of the deforming force under traction
    to clear any intervening periosteum and reestablish length.
  • The arm is then forcefully manipulated to achieve reduction.
  • P.129
  • A three-point mold is placed into the
    splint with a good anteroposterior interosseous squeeze. Postreduction
    radiographs are always obtained to check the position of the reduction
    and to document the institution of treatment.
Occasionally, it is necessary to complete a greenstick
fracture in order to obtain the reduction. Another benefit of
completing a greenstick fracture is to avoid the stress of refracture.
In metaphyseal fractures of the forearm of children
under 10 years of age, angulations up to 20 degrees, rotation up to 45
degrees, and shortening up to 1 cm will heal without clinical or
functional sequelae (Table 12.4-1). This is
because of the significant amount of longitudinal growth of the distal
forearm, which varies between 75% to 81%. This allows overgrowth to
occur at a rate of almost 6 mm on average in length and 0.8 degrees of
angulation per month of remaining growth. Beyond these limits, and in
more mature individuals, the amount of correction is limited and
malalignment may not completely remodel. This may eventually lead to
limitations of motion. Thus, in children over age 10 or those with less
than 2 years of growth remaining, the acceptable range of angulation is
less than 10 degrees and that of malrotation is less than 30 degrees.
Proximal fractures of the forearm tend to be more
unstable, partially because of deforming muscular forces, and partially
because of the muscle bulk that limits direct molding of the fracture
fragments. Fractures associated with dislocations of the radial head
need complete reduction and immobilization in supination. Closer
monitoring of these fractures is necessary since less angulation, less
rotation, and no joint dislocation can be accepted without clinical
sequelae. As in the older child with more distal fractures, the limits
of acceptability of proximal forearm fractures include 10 degrees of
angulation, 30 degrees of rotation, and complete joint reduction.
Plastic deformation deformities do not demonstrate
obvious fracturing, but there is an increase in the natural bow of the
forearm. These “fractures” need to be manipulated in the operating room
under pressure to restore the natural alignment as plastic deformation
will not remodel over time.
Results and Outcome
Most fractures of the forearm in children heal well.
This is due to their thicker periosteum, which may help contain
fractures and limit their displacement as well as enhance the speed of
healing and remodeling. The remodeling potential of the younger child
allows acceptance of a greater degree of displacement, but not all
perfectly aligned fractures will result in normal functioning limbs.
Although Fuller and colleagues demonstrated a direct correlation with
malrotation and the resulting range of motion, others have noted minor
to moderate losses of rotation even in perfectly aligned limbs. In
these cases, it is hypothesized that contractures of the soft tissue or
interosseous membranes occurred, either from the injury or the
subsequent immobilization (especially in pronation where the fibers are
As a general rule, it is advisable to obtain as near
anatomic alignment as possible, with acceptance of only what has been
previously outlined as these are well supported by the literature. As
soon as fractures are radiographically healed, gentle range of motion
should be initiated. Refracture at the site of previous injury may


up to 30% of patients within the first 6 months of healing. This is
most likely due to weakened bone structure from incomplete
corticalization of a diaphyseal fracture. Patients and parents need to
be forewarned at the time of cast removal that this potential
complication may occur and early protective mobilization, such as a
forearm splint, may be beneficial.


Acceptable Range Age <10 (Age >10)




Position of Shortening


Time in a Cast

Potential Problems



20 (15)

45 (30)

1 cm


3-4 wk


30 (15)

45 (30)

1 cm

4-6 wk



30 (15)

45 (30)

1 cm

6-8 wk



30 (15)


6 wk

Ulnar prominence



15 (10)

45 (30)

1 cm


6-8 wk


Between supinator and pronator

15 (10)

45 (30)

1 cm


6-8 wk


Distal pronator

15 (10)

45 (30)

1 cm

Slight pronation

6-8 wk




15 (0)

45 (30)

1 cm

(0) Neutral to slight supination

6 wk


0 (0)

10 (0)


(0) Supination

6 wk

Posterior interosseus nerve injury stiffness





Pins and plaster

Maintains traction

Pin tract infection

Loosening as swelling decreases

Closed reduction with Nancy nail

Closed reduction with PCP

Minimizes scarring

Minimizes soft tissue violation

Minimizes scarring

Minimizes soft tissue violation

Need for hardware removal

Prominent insertion site


Difficult to place (useful only in distal 1/3)

Hardware removal

Open reduction and internal fixation

Stable fixation

Early ROM

No cast


Nerve injury (PIN)

Hardware removal



PCP, percutanesus pinning; PIN, posterior interosseous nerve; ROM, range of motion.

Surgical Indications
  • Open fractures
  • Neurovascularly compromised fractures
  • Compartment syndrome of the forearm
  • Displaced fractures in patients nearing skeletal maturity
  • Floating elbow (ipsilateral supracondylar elbow fracture)
  • Unstable fracture losing alignment on follow-up
Operative options are given in Table 12.4-2.
Postoperative Management
  • Follow-up closely.
  • Pins are removed when the bone appears healed on radiographs.
  • After surgery, the arm is usually in a
    long cast for 4 to 6 weeks, followed by initiation of range-of-motion,
    depending on the type of fracture.
Blount W. Forearm fracture in children. Clin Orthop Rel Res 1967; 51:93-107.
C, Zaleske D, Erhlich M. Analyzing forearm fractures in children. The
more subtle signs of impending problems. CORR 1984;188:40-53.
Davis D, Green D. Forearm fractures in children: pitfalls and complications. Clin Orthop Rel Res 1976;120: 172-184.
T, Strub W, Foad S, Mehlman C, Crawford A. Reduction vs. remodeling in
pediatric distal forearm fractures: a preliminary cost analysis. J
Pediatr Orthop B 2003;12(2):109-15.
KS. Remodeling after distal forearm fractures in children. The effects
of residual angulation on spatial orientation of the epiphyseal plates.
Acta Orthop Scand 1979;50:527-546.
Fuller D, McCullough C. Md united fractures of the forearm in children. JBJS (Br) 1982:64(3):364-7.
H, Nilsson B, Willner S. Correction with growth following diaphyseal
forearm fractures. Acta Orthop Scand 1976;47: 299-303.
Jones K, Weiner D. The management of forearm fractures in children: a plea for conservatism. J Pediatr Orthop 1999;19:811-815.
W, Clegg J. Intraoperative wedging of casts: correction of residual
angulation after manipulation. J Pediatr Orthop 1995;15: 826-829.
Noonan K, Price C. Forearm and distal radius fracture in children. JAAOS 1998;6:146-156.
A, Tredwell S, Mackenzie W. Factors affecting fracture position at cast
removal after pediatric forearm fracture. J Pediatr Orthop
A, Tredwell S, Mackenzie W, et al. Accurate prediction of outcome after
pediatric forearm fracture. J Pediatr Orthop 1994;14: 200-206.

12.5 HAND
Lawrence L. Haber
Fractures involving the hand are common injuries in
children. They account for 25% of all pediatric fractures, and many go
unrecognized. Hand fractures have a bimodal distribution. The major
peak occurs in adolescents due to sports injuries. There is a smaller
peak in toddlers due to crush injuries of the distal phalanx. Anytime a
child or adolescent “jams” a finger; this usually results in a
fracture. This is evident by swelling, ecchymoses, and tenderness over
the bone that lasts for 2 to 3 weeks. Fortunately, most of these
fractures have a benign course and heal uneventfully. Most will be
nondisplaced fractures. However, there are specific fractures that
without proper treatment can lead to certain morbidity. This chapter
discusses how to treat simple fractures, as well as how to identify
more serious injuries and understand their treatments.
  • Carpal fractures occur in children less commonly than in adults and may be difficult to diagnose due to a lack of ossification.
  • Many of these fractures result from axial loading with the wrist dorsiflexed or from direct impact.
  • The scaphoid is the most commonly fractured carpal bone, with a peak incidence around 15 years of age.
  • A direct impact mechanism usually causes a distal pole fracture.
    • □ More common in younger children
    • □ Rarely displaced; usually heal without complications
  • In adolescents, hyperdorsiflexion
    injuries cause the more adultlike waist fracture, carrying an increased
    risk for nonunion and avascular necrosis.
  • Scaphoid fractures are frequently occult injuries with normal initial radiographs.
  • Radiographs should include anteroposterior, lateral, scaphoid, and pronated oblique views.
  • Mid-body or “waist” fractures can usually be seen on all views.
  • Pronated oblique radiograph is valuable for distal fractures.
  • When an occult fracture is suspected, magnetic resonance imaging or computed tomography may be useful.
  • Tenderness over the scaphoid and normal radiographs indicate treatment with a short arm-thumb spica cast.
    • □ At 3 weeks, anteroposterior, lateral, and scaphoid views of the wrist are repeated.
    • □ In children with normal clinical and radiographic exams, casting is discontinued.
  • If a fracture exists, the child will still be tender and radiographs may be positive.
    • □ These children are treated for 3 more weeks in a cast.
  • Nondisplaced fractures, obvious on radiographs, are treated in a short arm-thumb spica cast for 6 weeks and then reassessed.
  • Displaced fractures are treated operatively, as they are in adults.
  • Any child with a scaphoid fracture should
    have a final radiographic exam 3 to 6 months after the injury is healed
    to avoid undetected late displacement.
  • Other carpal fractures occur, but are rare and are usually a result of direct impact.
  • The most common is the hook of the hamate fracture, which is treated with immobilization in a short arm cast.
  • Rare painful nonunions may be treated with excision.
  • Ligamentous carpal injuries are unusual in young children and occur rarely in adolescents via a dorsiflexion loading mechanism.
  • The most common injury is a scapholunate ligament sprain, diagnosed by tenderness in this region.
  • Without displacement, these patients are treated in a short arm-thumb spica cast for 4 to 6 weeks.
  • Injuries with carpal displacement or instability are rare and should be treated as in adults.
  • Metacarpal fractures are common in
    children and most occur through the metacarpal neck proximal to the
    physis. Fractures through the shaft and base also occur.
Metacarpals II Through IV
  • Fractures at the metaphyseal base of the second through fourth metacarpals occur as the result of a direct blow


    or axial load. Due to the ligament stability of the carpometacarpal (CMC) joint, significant displacement is rare.

  • These fractures can be treated in a gutter splint or short arm cast for 3 to 4 weeks.
  • If displaced, closed reduction with longitudinal traction and downward pressure is performed.
  • Many of these will be unstable and
    require pin fixation across the base of the adjacent metacarpals or
    down the shaft of the involved metacarpal.
  • Open reduction is rarely needed.
Metacarpal I
  • Classified as A through D (Fig. 12.5-1).
    • □ Type A fractures are usually treated with closed reduction and immobilization in a thumb spica cast or splint.
    • □ Type B and C fractures are
      Salter-Harris type II fractures and are treated with closed reduction
      and immobilization. Unstable reductions may require pin fixation.
    • □ Open reduction is sometimes needed, especially in type C fractures, as the medial fragment may buttonhole the periosteum.
    • □ Type D fractures are more of an adult injury and when displaced require open reduction and internal fixation.
Metacarpal Shaft Fractures
  • Occur mostly in older children.
  • A twist, bend, or crush can result in an oblique or spiral fracture pattern.
  • Careful clinical examination of alignment is important; special attention should be paid to rotational malalignment.
  • In the absence of rotational
    malalignment, most of these can be handled by closed reduction and
    splinting with pressure on the apex and a three-point mold.
  • If the reduction is unstable, pinning will hold the reduction.
    Figure 12.5-1
    Classification of thumb metacarpal fractures. Type A is a metaphyseal
    fracture. Types B and C are Salter-Harris type II physeal fractures
    with lateral (type B) or medial (type C) angulation. Type D is a
    Salter-Harris type II fracture (pediatric Bennett fracture). (Adapted
    from Graham TJ, Waters PM. Fractures and dislocations of the hand and
    carpus in children. In: Beaty JH, Kasser JR, eds. Rockwood and Wilkins’
    fractures in children, 5th ed. Philadelphia: Lippincott Williams &
    Wilkins, 2001:269-379.)
  • Any significant angulation will leave a bump on the back of the hand, but is of little functional significance.
  • After adequate reduction, most metacarpal shaft fractures require 3 to 4 weeks of immobilization followed by only motion.
Metacarpal Neck Fractures
  • Common in children and usually result from a direct blow or punch.
  • Frequently volarly angulated.
  • Closed reduction with flexion of the
    metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints to
    90 degrees is usually successful.
  • A gutter splint with 60 to 90 degrees of MCP joint flexion and the PIP joint in extension is applied.
  • Angulation of less than 40 degrees is well tolerated in the fourth and fifth digits
    • □ No more than 20 degrees of angulation should be accepted in the second or third digits.
  • Occasionally an unstable fracture will require pin fixation.
  • Intraarticular head fractures are rare but require open reduction and pin fixation when displaced.
  • Some remodeling will occur in younger children with open physes.
  • Common in children, can involve any area.
  • Salter-Harris I and II fractures and metaphyseal fractures at the bases of the proximal and middle phalanges are common.
  • Fractures of the proximal phalanx are most common and result from axial loading, hyperextension, or a twisting mechanism.
  • Nondisplaced fractures are splinted in a position of comfort for 2 to 3 weeks.
  • Fractures with more than 10 degrees of
    angulation in the coronal plane usually appear deviated clinically and
    reduction is recommended.
  • Angulation of up to 25 degrees in the plane of motion in a digit with open physes is well tolerated and will usually remodel.
  • Digital block with longitudinal traction and a reversal of the mechanism will reduce displaced fractures.
  • Coronal malalignment may require a
    fulcrum or bolster in the web space of the finger and is incorporated
    into the splint for 2 to 3 weeks.
  • In the event of an unstable fracture, pinning with smooth Kirschner wires (K-wires) will achieve stability.
  • Need for open reduction is rare.
  • Can occur from bending, hyperextension, rotation, or crush injuries.

    Figure 12.5-2 (A) Irreducible proximal phalangeal shaft fracture. (B) After open reduction and internal fixation through a dorsal approach.
  • Fractures with more than 10 degrees of
    coronal deformity, 20 degrees of sagittal deformity, or any significant
    rotational deformity should be reduced.
    • □ Remember to check for rotational deformity. Clinically, it will not be visible on x-ray.
  • Flexion at the PIP joint is sometimes
    needed for proximal phalanx fractures and extension is usually used for
    middle phalanx fractures.
    • □ The fracture force is reversed. If the reduction is unstable, percutaneous pinning is required.
  • If closed reduction is not possible, open reduction is performed.
  • This occurs in spiral fractures with rotational displacement and oblique fractures with shortening.
    • □ The dorsal approach is preferred, though some use a midlateral approach.
    • □ Fixation can be with smooth pins;
      however, mini-fragment screws afford earlier mobilization and improved
      stability in older children (Fig. 12.5-2).
    • □ Fractures undergoing reduction should be splinted for 3 weeks.
    • □ As soon as callus is seen, the pins are removed and motion is begun.
  • Occur at the proximal, middle, and distal phalanx.
  • In the proximal phalanx, they are the result of a bending motion.
    • □ The collateral ligament is avulsed with a fragment of bone.
    • □ This results in a Salter-Harris III or IV fracture.
    • □ May involve a significant part of the articular surface.
    • □ If the fracture is nondisplaced, treatment is conservative with splinting for 3 to 4 weeks.
    • □ If more than 25% of the joint is involved and there is more than 2.0 mm of displacement, open reduction is recommended.
    • □ Any widely displaced fracture should be reduced.
    • □ Fixation is with smooth pins in younger children.
    • □ In older children, mini-fragment screws may be used.
  • Fractures in the middle and distal
    phalanges are usually a result of an avulsion of the central slip of
    the extensor at the base of the middle phalanx and the terminal
    extensor over the distal phalanx.
    • □ Rarely these avulsions will present as a Salter-Harris I or II fracture.
  • There are four mallet finger equivalent fractures (Fig. 12.5-3).
    • □ These occur from forced flexion, usually during a ball sport.
    • □ A terminal extensor avulsion leads to a mallet finger.
    • □ Closed reduction is attempted with longitudinal traction and pressure over the displaced fragment.
      • □ If successful the finger can be splinted in extension for 3 weeks.
      • □ If significant displacement persists, greater than 2 mm, open reduction should be performed.
  • Displaced fragments of greater than 25% of the joint surface area may lead to instability in addition to incongruity.
  • In the distal phalanx, the fracture is approached dorsally.

    Figure 12.5-3
    Mallet equivalent fractures. (Adapted from Graham TJ, Waters PM.
    Fractures and dislocations of the hand and carpus in children. In:
    Beaty JH, Kasser JR, eds. Rockwood and Wilkins’ fractures in children,
    5th ed. Philadelphia: Lippincott Williams & Wilkins, 2001:269-379.)
    • □ A transverse incision within the distal creases with a proximal and distal limb is useful.
    • □ Avoiding the germinal matrix of the nailbed is important.
    • □ This incision leaves a minimal scar.
    • □ The extensor apparatus will be retracted with the avulsed fragment.
    • □ The fracture is reduced and fixed with K-wires or a pull out suture.
    • □ The distal interphalangeal (DIP) joint is splinted in extension for 3 weeks.
    • □ A smooth pin across the joint can be used to protect the repair.
    • □ At 3 to 4 weeks, the splint is removed to begin motion, but should be left on for all other activities for 6 weeks.
    • □ Prolonged splinting, without motion, will lead to a stiff DIP joint.
  • Left displaced and untreated, a central slip avulsion may lead to a boutonniere deformity or incongruity of the joint surface.
    • □ Open reduction of middle phalanx fractures consists of a dorsal approach, incising between the central slip and lateral band.
    • □ If small, the fragment is excised and the tendon is reattached.
    • □ When significant, it is repaired with pins or a mini-fragment screw.
  • A flexor digitorum profundus (FDP) avulsion may cause a volar Salter-Harris type III, IV, or simple avulsion fracture.
    • □ These are rare in comparison to the dorsal injuries.
    • □ This is known as a reverse mallet or a jersey finger.
    • □ It is analogous to the adult type 2 or 3 FDP avulsion.
    • □ Repair is with open reduction and a pullout suture or other fixation.
    • □ Treated with open reduction when displaced.
  • Fractures through the phalangeal necks of the proximal and middle phalanx are particularly bad actors.
    • □ When nondisplaced, treatment consists of splinting and careful follow-up.
      • □ These heal slowly and may require 4 weeks of immobilization.
    • □ When displaced, they are highly unstable.
      • □ Their juxtaposition to the joint and tendency to malrotate cause severe deformity (Fig. 12.5-4).
      • □ Closed reduction and cross-pinning can
        be attempted in minimally displaced fractures, but most will require
        open reduction and pinning.
      • □ It is almost impossible to judge rotation without a direct reduction.
      • □ A dorsal approach used, incising between the central slip and lateral band. Cross-pinning of the fragment with 0.45 K-wires (Fig.12.5-5).
        Figure 12.5-4 Angulated middle phalanx condylar neck fracture.

        Figure 12.5-5 Anteroposterior (A) and lateral (B) views of a displaced condylar neck fracture. (C) After open reduction and pin fixation through a dorsal approach.
      • □ The finger is immobilized for 4 weeks, at which time the pins are removed and motion begun.
      • □ Stiffness is common, necessitating early occupational therapy.
    • □ Intraarticular fractures of the distal end of the proximal and middle phalanges are uncommon.
      • □ Except in minimally displaced fractures, open reduction and fixation is required.
      • □ Treatment is similar to condylar neck fractures.
      • □ Fixation is best with mini-fragment screws, which allows for early motion.
    • □ Tuft fractures of the distal phalanx
      represent more of a soft tissue injury involving the distal pulp of the
      finger and the nailbed.
      • □ These are usually from a crush mechanism.
      • □ When the nail is avulsed from the fold, the nailbed must be explored and repaired.
      • □ The nail is then sewn back into the fold.
      • □ Some controversy exists about exploring a nailbed due to the presence of hematoma alone.
      • □ The most recent literature suggests
        these fingers can be treated with trephination of the hematoma by
        placing a hole in the nail.
      • □ Outcomes were equal to children undergoing exploration and repair.
    • □ The nail is then sewn back into the
      eponychial fold. Splinting is of the middle and distal phalanges only
      and is discontinued when pain is gone, usually at 2 weeks.
Al-Quattan M. Phalangeal neck fractures in children: classification and outcome in 66 cases. J Hand Surg (Br) 1999;26112-121.
Beatty E, Light TR, Belsole RJ, et al. Wrist and hand skeletal injuries in children. Hand Clin 1990;6:723-738.
JP. Transcarpal injuries associated with distal radial fractures in
children: a series of three cases. J Hand Surg (Br) 1992; 17:311-314.
Coonrad RW, Pohlman MH. Impacted fractures of the proximal phalanx of the finger. J Bone Joint Surg (Am) 1969;51:129-1296.
D’Arienso M. Scaphoid fractures in children. J Hand Surg (Br) 2002; 27:424-426.
Greene WB, Anderson WJ. Simultaneous fracture of the scaphoid and radius in a child. J Pediatr Orthop 1982;2:191-194.
Hastings H II, Simmons BP. Hand fractures in children. Clin Orthop 1984;188:120-130.
Jahss SA. Fractures of the metacarpals: a new method of reduction and immobilization. J Bone Joint Surg 1938;20:178-186.
Leclerc C, Korn W. Articular fractures of the fingers in children. Hand Clin 2000;16:523-534.
RL, Dobyns JH, Beabout W, et al. Traumatic instability of the wrist:
diagnosis, classification, and pathomechanics. J Bone Joint Surg (Am)
Meek S, White M. Subungual hematomas: is simple trephining enough? Accident Emerg Med 1998;15:269-271.
Nafie SAA. Fractures of the carpal bones in children. Injury 1987;18: 117-119.
Simmons BP, Lovallo JL. Hand and wrist injuries in children. Clin Sports Med 1988;7:495-511.
Wood VE. Fractures of the hand in children. Orthop Clin North Am 1976;7: 527-542.
Worlock PH, Stower MJ. The incidence and pattern of hand fractures in children. J Hand Surg (Br) 1986;11:198-200.

Martin J. Herman
Pediatric pelvic fractures are rare, accounting for only
1% to 2% of all fractures in children. In most cases, these fractures
are the result of high-energy trauma. Identification of a fracture of
the pelvis in a pediatric trauma patient mandates a thorough search for
concomitant, potentially more life-threatening injuries of the brain,
abdominal viscera, and genitourinary system. As opposed to the adult
trauma patient with a pelvic fracture, fatalities rarely occur in
children with pelvic fractures as a direct result of their pelvic
injury, but rather as the result of associated injuries.
Most pediatric pelvic fractures result from pedestrian
or cyclist/motor vehicle accidents, falls from heights, and other
high-energy mechanisms. A subgroup of pelvic injuries—avulsion
fractures—occur during sports activities such as soccer, gymnastics,
and track and field.
Fracture patterns vary depending on the level of skeletal maturity:
Figure 12.6-1
Torode and Zieg classification. Type I, avulsion fractures; type II,
iliac wing fractures; type III, simple ring fractures (stable pelvic
ring); type IV, ring disruption fractures (unstable pelvic ring). (From
Canale ST, Beaty JH. Fractures of the pelvis. In: Beaty JH, Kasser JR,
eds. Rockwood and Wilkins’ fractures in children, 5th ed. Philadelphia,
Lippincott Williams & Wilkins, 2001:883-911.)
  • Children whose triradiate cartilage is
    open most commonly sustain fractures of the pubic rami and iliac wings;
    the triradiate cartilage of the acetabulum closes at approximately 14
    years of age in boys and 12 years of age in girls.
    • □ The elasticity of the ligaments of the
      pubic symphysis and the sacroiliac joints, and the plasticity of the
      bony pelvis, are most likely responsible for the rare occurrence of
      unstable pelvic ring disruptions seen in adults.
  • Adolescents approaching skeletal
    maturity, whose triradiate cartilage is closed, sustain pelvic injuries
    similar to those seen in adults.
  • Older children and adolescents are more
    likely to require surgical treatment, with morbidity and mortality
    related to their pelvic injuries
  • Avulsion injuries of the anterior
    superior and inferior iliac spines, ilium, and ischium most commonly
    occur in adolescent and young adult athletes.
Application of adult classification schemes to
children’s pelvic injuries is not ideal. The Torode and Zieg
classification of pediatric pelvic fractures is the most widely used (Fig. 12.6-1 and Table 12.6-1).
Bucholz and colleagues observed different patterns of physeal
disturbance associated with triradiate cartilage injuries based on the
Salter-Harris classification of these triradiate injuries (Fig. 12.6-2).





Avulsion fractures


Iliac wing fractures


Separation of the iliac apophysis


Fracture of the bony iliac wing


Simple ring fractures (stable pelvic ring)


Fractures of the pubis and separation of the pubic symphysis; the posterior structures remain intact


Fractures involving the acetabulum, without a pelvic ring fracture


Fractures producing an unstable segment (unstable pelvic ring)


“Straddle” fractures (i.e., bilateral inferior and superior pubic rami fractures)


Fractures involving the anterior pubic rami or pubic symphysis and the posterior structures


Fractures that result in an unstable segment between the anterior ring of the pelvis and the acetabulum

Evaluation of the child with a suspected pelvic fracture
begins with a thorough history of the traumatic events, as well as past
medical and surgical history. The best effort must be made to gather
this information from emergency personnel at the scene of an accident,
emergency room staff, and family members. In a polytraumatized child,
often the pelvic injury is a lower priority. The airway, breathing,
circulation (ABC’s) must be assessed and established as a first
priority. Injuries of the head and spine, chest, and abdominal viscera,
as well as the pelvis, must be carefully evaluated as potential sources
of life-threatening injuries.
Figure 12.6-2 Triradiate cartilage injuries. (A) Normal. (B) Salter-Harris type I fracture. (C) Salter-Harris type II fracture. (D)
Salter-Harris type V fracture. Growth disturbance, most commonly seen
after type V injuries (compression), results in acetabular dysplasia.
(From Scuderi G, Bronson MJ. Triradiate cartilage injury: report of two
cases and review of the literature. Clin Orthop 1987;217:179-189.)
Physical Examination
  • Visual inspection of the pelvis and
    perineum for lacerations, ecchymosis, hematoma, blood at the urethral
    meatus, and vaginal or scrotal injury is indicated.
  • The anterior superior iliac spines, iliac crests, sacroiliac joints, and pubic symphysis are palpated.
  • With hands placed on the iliac crests, apply posteriorly directed forces with gentle side-to-side rocking.
  • Pain, crepitus, or excessive mobility is indicative of a potentially serious pelvic injury.
  • Rectal examination is necessary to
    identify bony fragments, or a superiorly displaced prostate secondary
    to a urethral injury in older males.
  • Hip range of motion must be evaluated,
    with pain or limits of mobility suggestive of a joint dislocation or
    associated acetabular fracture.
  • Neurovascular examination of the lower extremities is documented.
    • □ Injuries of the lumbosacral plexus,
      femoral and sciatic nerves, as well as vascular injuries, may occur as
      the result of severe pelvic trauma.
Radiologic Findings
A standard component of the initial assessment of the
polytraumatized patient is an anteroposterior radiograph of the pelvis
in the emergency room. While this information is rarely necessary to
effectively resuscitate and stabilize the child, early recognition of
an unstable pelvic injury may be critical in the survival of the older
child and adolescent. After the child is initially stabilized, rapid
sequence spiral


tomography (CT) scanning of the pelvis is the most effective method to
fully evaluate the extent of pelvic injury. Often more serious
concomitant injuries of the head and abdomen warrant evaluation by CT
scan. Inclusion of the pelvis in the initial series of imaging studies
allows for a more complete and efficient injury assessment.

Inlet, outlet, and oblique radiographic views of the
pelvis may be useful for preoperative planning. Magnetic resonance
imaging and bone scan have no role in acute evaluation of pelvic
injuries. However, these modalities may be helpful in the analysis of
soft tissue injury, cartilaginous injuries, and occult fractures.
Most pelvic fractures in children are treated nonoperatively.
  • Avulsion fractures (type I) are treated
    symptomatically with protected weightbearing for 2 to 4 weeks, followed
    by a stretching and strengthening program.
    • □ Return to sports may be expected within 6 to 8 weeks.
  • Fractures of the iliac wing and iliac apophyseal separations (type II) are treated in a similar fashion.
  • Simple ring fractures (type III) are stable fractures of the pelvis with intact posterior structures.
    • □ Cooperative patients without acetabular
      involvement may be treated with protected weightbearing with
      progression to full weightbearing over a 6-week period.
    • □ Bed rest or bed-to-chair activities are indicated for the noncompliant or very young child.
    • □ Type III fractures with nondisplaced
      fracture of the acetabulum may be treated with non-weightbearing
      ambulation or spica cast immobilization.
    • □ Distal femoral skeletal traction may be
      useful to improve alignment of minimally displaced fractures or to
      prevent premature weightbearing.
    • □ Intraarticular and triradiate cartilage displacement greater than 2 mm warrants open reduction and internal fixation.
  • Type IV pelvic fractures are unstable ring disruptions.
    • □ A pelvic binder may be used as a temporary measure to assist in resuscitating the hemodynamically unstable child.
    • □ Emergent external fixation is indicated to control hemorrhage and to grossly align and stabilize the pelvis.
    • □ Pelvic arteriography and embolization are indicated if blood loss persists despite external fixation.
    • □ In a hemodynamically stable child,
      unstable pelvic disruptions may be treated with bed rest with or
      without skeletal traction, or in a spica cast. Progressive
      weightbearing and rehabilitation may be started within 6 weeks of
    • □ Open reduction with internal fixation
      is indicated for acetabular and triradiate cartilage fractures with
      more than 2 mm of displacement.
    • □ Reduction and fixation of pelvic ring displacement, beyond the use of external fixation, is rarely indicated in children.
    • □ Displacement of up to 2 cm is
      acceptable, since rapid healing and significant remodeling of
      extraarticular fractures of the pelvis can be expected in children with
      more than 2 years of growth remaining.
Most pelvic injuries in children heal without
complications. Nonunion and ligamentous instability of pediatric pelvic
ring injuries do not occur. Malunion of the pelvic ring is
well-tolerated because of the remodeling potential of the pediatric
pelvis; leg length inequality may occur after an unstable fracture if
residual vertical displacement of the hemipelvis exceeds 2 cm.
Fractures involving the triradiate cartilage, especially in children
younger than 10 years of age, may lead to growth disturbance of the
acetabulum secondary to premature physeal closure. Manifestations of
this abnormal growth include acetabular dysplasia, hip subluxation, and
hip joint incongruity. Displaced acetabular fractures, despite anatomic
realignment, may develop premature degenerative joint disease of the
hip. Avascular necrosis of the femoral head may develop after fractures
of the acetabulum associated with hip dislocation.
Other complications of fractures of the pediatric pelvis
include myositis ossificans and permanent neurologic deficits of the
lower extremity secondary to associated lumbosacral plexus, sciatic,
and femoral nerve injuries. Death, as direct result of hemorrhage due
to pelvic fracture, occurs in less than 0.5% of children. Nonskeletal
injuries occurring in association with pelvic fractures in children,
however, result in death of the child 10 times more frequently.
Bryan WJ, Tullos HS. Pediatric pelvic fractures: review of 52 patients. J Trauma 1979;19:799-805.
Bucholz RW, Ezaki M. Ogen JA. Injury to the acetabular triradiate physeal cartilage. J Bone Joint Surg (Am) 1982;64:600-609.
ST, Beaty JH. Fractures of the pelvis. In: Beaty JH, Kasser JR, eds.
Rockwood and Wilkins’ fractures in children, 5th ed. Philadelphia:
Lippincott Williams & Wilkins, 2001:883-911
Ismail N, Bellamare JF, Mollit DL, et al. Death from pelvic fracture: children are different. J Pediatr Surg 1996;31:82-85.
RC Jr, Bensard DD, Moore EE, et al. Pelvic fracture geometry predicts
risk of life-threatening hemorrhage in children. J Trauma
Quinby WC. Fractures of the pelvis and associated injuries in children. J Pediatr Surg 1966;1:353-364.
JS, Flynn, JM. Changing patterns of pediatric pelvic fractures with
skeletal maturation: implications for classification and management. J
Pediatr Orthop 2002;22:22-26.
Torode I, Zeig D. Pelvic fractures in children. J Pediatr Orthop 1985; 5:76-84.

12.7 HIP
Raymond D. Knapp Jr.
Hip fractures in children vary in several important
aspects from those in adults. The bone is generally stronger and
therefore significant trauma is usually required for fracture. The
periosteum is thicker, thus making it possible for a fracture to be
nondisplaced and relatively stable. This, however, does not protect the
tendency for coxa vara if treated without fixation. The presence of the
proximal femoral physis provides a weakened point for potential
fracture. Damage to the physis can cause subsequent deformity of growth
of the proximal femur. This group of fractures, although relatively
rare, provides a significant challenge to the treating orthopedist, due
to the frequency of potential complications including avascular
necrosis, coxa vara, nonunion, premature physeal closure, and
subsequent leg length discrepancy.
Most proximal femur fractures occur as a result of
severe trauma. Causes include motor vehicle accidents, pedestrian or
cyclist/motor vehicle accidents, falls from heights, and child abuse.
Occasionally, fractures may occur through pathologic bone such as a
cyst or fibrous dysplasia.
These fractures are classified by the four-part classification system of Delbet (Table 12.7-1 and Fig. 12.7-1).
The prevalence of pediatric hip fractures is less than 1% of that in adults. They account for 1% of all pediatric fractures.
  • Type II fractures are most common—45% to 50%
  • Type III—approximately 35%
  • Type IV—12%
  • Type I—8%




Transepiphyseal separation, with or without dislocation of the femoral head


Transcervical fracture


Cervicotrochanteric fracture (base of neck)


Intertrochanteric fracture

The pertinent pathophysiology of proximal femoral
fractures involves the blood supply to the capital femoral epiphysis
and the manner in which complications are caused by its disruption. The
blood supply to the femoral head from birth to 2 to 3 years of age
comes from the medial and lateral circumflex vessels. This anastomotic
ring courses along the intertrochanteric notch and is extracapsular.
Transphyseal vessels exist up to 18 months of age.
After age 3 the entire femoral head is supplied by
branches of the medial circumflex artery, and the posterosuperior and
posteroinferior arteries, which course along the femoral neck and are
vulnerable to injury from fracture. The posterosuperior artery supplies
the lateral and anterior head, and the posteroinferior artery supplies
the medial head.
Most of the metaphyseal circulation is supplied by the lateral circumflex artery. This limited vascular supply


accounts for the frequent occurrence of avascular necrosis after fracture of the hip in children.

Figure 12.7-1
Delbet classification for proximal femur fractures. Type I is a
transepiphyseal fracture. Type II is a transcervical fracture. Type III
is a cervicotrochanteric fracture (basicervical). Type IV is an
intertrochanteric fracture. (From Blasier RD, Hughes LO. Fractures and
traumatic dislocations of the hip in children. In: Beaty JH, Kasser JR,
eds. Rockwood and Wilkins’ fractures in children, 5th ed. Philadelphia:
Lippincott Williams & Wilkins, 2001:913-939.)
Physical Examination and History
Since these injuries occur in association with
significant trauma, a thorough physical and radiologic exam is
necessary to rule out other injuries. With displaced fractures, the leg
is usually shortened and externally rotated. A thorough motor, sensory,
and vascular exam of the extremity should be performed.
Nondisplaced fractures may present a diagnostic dilemma.
Comparison radiographs may be helpful. Magnetic resonance imaging (MRI)
has become increasingly useful to confirm the presence of a fracture.
Also, a hip aspiration can be performed with a bloody aspirate being
In infants, a type I fracture may be difficult to
diagnose and often is associated with child abuse. Aspiration,
ultrasound, or MRI also can be useful to confirm the diagnosis.
General Principles
  • Accurate reduction must be obtained. If closed reduction fails, then open reduction should be performed.
  • Stable fixation must be obtained.
    • □ Fracture stability takes precedence over physis sparing.
  • Type I, II, and III fractures should be taken to the operating room emergently, preferably in less than 12 to 24 hours.
  • Hip decompression should be performed with either open arthrotomy or aspiration for all type I, II, and III injuries.
  • Spica cast should be used in younger children or if necessary to supplement internal fixation.
Type I Fractures
  • Less than 2.5 years of age: closed
    reduction and spica cast if a stable reduction is obtained. Insertion
    of smooth pins if unstable
  • Less than 9 years of age: closed or open reduction and smooth pins with hip decompression. Spica cast immediately
  • More than 9 years of age: closed or open reduction and screw fixation with hip decompression
About half of these fractures are associated with a
dislocation of the epiphysis. If the femoral head is dislocated, an
attempt at closed reduction can be performed. If unsuccessful, this
should be followed by immediate open reduction and pinning. The open
reduction is performed on the side of the dislocated head [i.e.,
posterior approach of a posterior dislocation and an anterior
(Watson-Jones) approach for an anterior dislocation].
Between 80% and 100% of those with a dislocation will
develop avascular necrosis and premature physeal closure. Avascular
necrosis is less often a problem in the under 2.5-year-old age group,
since these are usually not associated with a dislocation, and
remodeling of a severe varus malunion will occur if a growth arrest
does not develop.
Type II Fractures
  • Nondisplaced: screw fixation short of the physis if possible. Perform hip decompression.
  • Displaced: closed or open reduction
    (anterior Watson-Jones) and screw fixation short of the physis. Hip
    decompression should also be performed.
Do not compromise fixation. If necessary, place fixation across the physis.
Consideration should be given for smooth pins in children under 9 years of age, if it is necessary to cross the physis
Type III Fractures
  • Nondisplaced: screw fixation short of the physis and hip decompression
  • Displaced: closed or open reduction (anterior Watson-Jones) with screw fixation short of the physis and hip decompression
Type IV Fractures
  • Nondisplaced:
    • □ Children under 8 years of age may be treated with spica casting.
  • Displaced:
    • □ Children under 8 years of age can be
      treated in 90-90 traction for 2 to 3 weeks followed by an abduction
      spica cast. Most are preferably treated with closed or open reduction,
      internal fixation, and spica casting.
    • □ For children older than 8 years of age,
      treatment should be similar to that of an adult, with open reduction
      and internal fixation.
Avascular Necrosis
Avascular necrosis is the most common and devastating
complication of pediatric hip fractures. The incidence of avascular
necrosis is directly related to the amount of fracture displacement and
type of fracture.
  • Type I fractures with associated
    dislocation have an 80% to 100% incidence, whereas without dislocation,
    the incidence is less than 25%.
  • Displaced type II fractures—40% to 50% incidence
  • Displaced type III fractures—approximately 25%
  • Type IV fractures—avascular necrosis occurs rarely
Ratliff divided avascular necrosis into three types (Table 12.7-2 and Fig. 12.7-2). Avascular necrosis can be detected


as early as 6 weeks after injury and usually develops by 1 year after
injury. The risk of avascular necrosis can be markedly decreased in
displaced fractures by immediate reduction in less than 24 hours, along
with stable internal fixation and evacuation of the intracapsular
hematoma. Recent studies show rates of 0% to 8% incidence of avascular
necrosis with displaced fractures using this approach. Once avascular
necrosis occurs there is no proven effective treatment. The internal
fixation should be removed once the fracture heals.






Whole head



Partial head

Slightly better than type I


From the fracture line to the physis


Coxa Vara
Coxa vara resulting from malunion has essentially been
eliminated with the routine use of stable internal fixation and spica
casting. However, it may occur as a result of asymmetric physeal
closure. This can be corrected by subtrochanteric valgus osteotomy.
Premature Physeal Closure
This complication usually occurs secondary to avascular
necrosis or internal fixation crossing the physis. The proximal femoral
physis provides 13% of the length of the leg. Therefore, growth arrest
usually does not create significant (more than 2 cm) shortening except
in very young children.
Historically, the rate of nonunion has been reported to
be as high as 10%. Current recommended treatment has reduced this rate
in most studies to 0% to 4%. If nonunion occurs, it should be treated
as soon as it is recognized and usually by subtrochanteric valgus
osteotomy and bone grafting, with internal fixation and spica casting.
Figure 12.7-2
Three types of avascular necrosis. (Adapted from Ratliff AHC. Fractures
of the neck of the femur in children. J Bone Joint Surg 1962;44B:528.)
This complication has been reported in one series and
was always associated with avascular necrosis. Three of seven had pin
penetration in the joint. All had a poor result.
Stress Fractures
Stress fractures can occur in children and adolescents,
but less commonly than adults. All reported cases have involved the
femoral neck.
Two types exist:
  • Fatigue fracture: usually a result of overuse in children who have rapidly increased their activities.
  • Insufficiency fractures: these occur in deficient bone in children with underlying disease processes.
Most stress fractures appear as compressive injuries
with callus present along the inferior neck. A bone scan may be needed
for diagnosis if there is no apparent radiographic abnormality. These
can be treated with non-weightbearing on crutches or in a cast. If the
fracture site widens or is displaced initially, then internal fixation
is necessary.
Hip dislocations are uncommon in childhood, but do occur
more frequently than hip fractures and with less severe trauma. Prompt
knowledgeable treatment is important to avoid potentially devastating
complications. Specific treatment guidelines should be followed, thus
avoiding the pitfalls of treating this rare injury.
Hip dislocations are more likely to occur in children
under 10 years of age from relatively minor trauma, such as a fall.
This is thought to be due to the increased amount of cartilage in the
joint, and the more generalized ligamentous laxity present in children.
For children older than 10 years of age, a more forceful injury such as
that sustained in a


motor vehicle accident or from contact sports is more likely.

Hip dislocations can occur at any age with no specific peak incidence. They are more common in males than in females.
The femoral head can dislocate in any direction with 90%
being posterior. These occur bilaterally 1% of the time. An associated
fracture about the hip occurs approximately 15% to 20% of the time and
is less frequent in younger children.
No formal classification of pediatric hip dislocations
has been published. Each hip is described by its direction of
  • Anterior: the femoral head lies medial to the acetabulum.
  • Anteroinferior: the femoral head lies in the region of the obturator foramen.
  • Inferior: the femoral head lies inferior to the acetabulum and lateral to the ischial tuberosity.
  • Posterior: the femoral head lies superior and lateral to the acetabulum.
History and Physical Examination
The history of mechanism of injury may range from a
minor fall to a major high-energy accident. Approximately 65% are due
to lower velocity injuries. Complaints of groin and hip pain will be
Clinical Fractures
A thorough multisystem examination should be performed
to determine associated injuries. An exam of the position of the limb
will usually indicate the direction of dislocation. The leg is flexed,
adducted, and internally rotated with a posterior dislocation, or
extended, abducted, and externally rotated with an anterior
dislocation. With an inferior dislocation, the hip is hyperflexed. A
thorough neurologic examination of the lower extremity is mandatory,
since sciatic nerve injury occasionally occurs. Pulses should be
palpated, since femoral artery injuries have been reported. An
associated femoral fracture may cause the lower extremity to be
externally rotated.
Radiologic Features
A dislocated hip is evident on an anteroposterior (AP)
pelvis x-ray. The entire involved femur should be imaged to exclude
fracture. Careful viewing of the hip x-rays should occur and further
films taken, if necessary, to rule out femoral head, acetabular,
femoral neck, or transphyseal fractures. Judet (45-degree oblique)
views may help to delineate a suspected acetabular fracture.
Prereduction computed tomography (CT) scan may also be useful if
fractures are suspected about the femoral head and acetabulum, as long
as this doesn’t significantly delay reduction.
Prompt reduction of the dislocation should occur within
the first 6 hours following injury to decrease the likelihood of
avascular necrosis. An initial attempt under conscious sedation can be
performed in the emergency department. If this fails, the next attempt
should be performed under general anesthesia in the operating room. A
posterior dislocation is reduced with the hip and knee flexed with
countertraction to the pelvis applied by an assistant. An anterior
dislocation is reduced with the hip extended and the knee flexed. If,
after several attempts, reduction cannot be achieved, an open reduction
should be performed. Failed reduction can occur secondary to interposed
capsule, inverted labrum, and osteocartilagenous fragments. An anterior
dislocation should be opened anteriorly and posterior dislocations
should be opened posteriorly.
If there is an associated hip fracture, stabilization
should be performed prior to reduction. If the femoral neck fracture is
displaced, open reduction is performed.
After reduction, an AP pelvis x-ray should be taken to
assess symmetry of the hip joints. If the joint spaces are not
symmetric following reduction, a CT scan should be performed. If there
is evidence of interposed soft tissue or bony fragments, an open
reduction with removal of the interposed tissue should be performed.
Old Dislocations
Old traumatic dislocations are rare but can be treated
initially by 1 to 2 weeks of skeletal traction. If this fails, open
reduction is indicated.
Recurrent Dislocation
Recurrent traumatic dislocations usually occur in
children under 8 years of age and are rare. The first recurrence should
be treated with closed reduction and spica casting. Further recurrences
should be treated with an open reduction, capsular repair, and spica
Postoperative Management
There is no consensus regarding postoperative care. Most
would recommend a spica cast for 6 weeks after reduction in children
less than 6 to 8 years of age. A 6-week period of protected
weightbearing is recommended in older children.
Most children do well following an appropriately treated hip dislocation with functional outcomes being very good


in 95%. Complications include avascular necrosis, sciatic nerve injury, recurrent dislocations, and osteoarthritis.

Avascular necrosis is associated with delay in reduction
greater than 6 hours. The incidence ranges from 5% to 58% with most
estimates between 8% and 10%. The risk of avascular necrosis is also
related to the severity of the injury and age greater than 5 years.
This can usually be detected by 6 months after injury, but children
should be followed for up to 4 years.
Sciatic nerve injury occurs approximately 5% to 20% of
the time and is usually a transient neuropraxia. Osteoarthritis is
usually associated with the development of avascular necrosis.
Canale ST. Fractures of the hip in children and adolescents. Orthop Clin North Am 1990;21:341-352.
ST, Bourland WL. Fracture of the neck and intertrochanteric region of
the femur in children. J Bone Joint Surg (Br) 1977;59: 431-443.
JM, Wong KL, Yeh GL, et al. Displaced fractures of the hip in children:
management by early operation and immobilisation in a hip spica cast. J
Bone Joint Surg (Br) 2002;84:108-112.
Hughes LO, Beaty JH. Fractures of the head and neck of the femur in children. J Bone Joint Surg (Am) 1994;76:283-292.
CT, Hubbard GW, Crawford AH, et al. Traumatic hip dislocation in
children: long-term follow-up of 42 children. Clin Orthop Rel Res
2000;376: 68-79.
GPK, Cole WG. Effect of early hip decompression on the frequency of
avascular necrosis in children with fractures of the neck of the femur.
Injury 1996;27:419-421.
Ratliff AHC. Fractures of the neck of the femur in children. J Bone Joint Surg (Br) 1962;44:528-542.
Salisbury RD, Eastwood DM. Traumatic dislocation of the hip in children. Clin Orthop Rel Res 2000;377:106-111.
Pierre P, Staheli LT, Smith JB, et al. Femoral neck stress fractures in
children and adolescents. J Pediatr Orthop 1995;15:470-473.
Swiontkowski MF. Complications of hip fractures in children. Complications Orthop 1989;Mar/Apr:58-63.
12.8 FEMUR
Dale R. Blasier
Femoral shaft fractures in children are common and
usually result from moderate to high-energy injury. Fractures after
trivial trauma should prompt a search for weakened bone. Nonoperative
treatment methods are tried and true, but may be best suited for young
children who are unable to walk with crutches. Operative stabilization
is best suited for those who can be taught to ambulate without bearing
weight. The prognosis for healing is excellent. Some overgrowth is to
be expected and should be considered in the treatment plan.
Overtreatment should be avoided.
The femur may fracture as a result of a strong axial
load, twisting force, three-point bend, or a direct blow. Motor vehicle
accidents, recreational vehicle accidents, sports injuries, and falls
are common causes. Rarely stress fractures or pathologic bone lesions
may progress to overt fracture.
Femur fracture is very common in childhood. About 1 in
2,000 children sustains a femur fracture each year. Up to 40% of boys
and 25% of girls sustain a femur fracture in childhood.
The child’s femur can be mildly deformed and will
elastically recoil. Larger amounts of applied energy will cause the
bone to fracture. The more energy applied to the bone, the more
comminution and soft tissue disruption should be expected. Muscles that
span the length of the thigh will tend to shorten the fractured femur.
For this reason, traction—either skeletal or skin—is often applied to
prevent shortening prior to definitive management. These fractures
always heal unless open or operated. Hyperemic overgrowth is to be
expected and should be considered in the treatment plan.
Three types of classification are useful (Box 12.8-1).

Physical Examination and History
  • A history of significant trauma is usual.
  • The diagnosis is usually obvious in displaced fractures.
  • Undisplaced fractures occur. Get an x-ray after a history of significant injury.
  • Look for associated injuries.
Clinical Features
  • Swelling and deformity are immediate findings. Ecchymosis occurs later.
  • Tense swelling or unremitting pain should
    prompt compartment pressure measurement. Thigh compartment syndrome is
    rare, but significant.
  • Check and document pulses. Vascular injury is rare.
  • Check and document distal nerve status.
    Nerve palsy is presumed to be due to treatment unless clearly
    documented before treatment.
  • Look for associated injuries in relation
    to the history of injury. Check the hip after an axial loading injury.
    Check the knee after a direct blow to the limb.
Radiologic Features
  • Make sure the hip and knee joints are visible.
  • Look for undisplaced (ghost) fracture lines which may affect choice of fixation.
    Algorithm 12.8-1 Treatment decision algorithm for femur fractures.
  • If there is considerable comminution or
    bone loss, an x-ray of the uninjured femur will provide an estimate of
    original bone length.
  • If intramedullary fixation is contemplated, the size of the canal and bone length should be estimated.
Algorithm 12.8-1 covers treatment decisions.
  • Patient age is important:
    • □ Patients under 6 years of age should generally be treated with a spica cast as the fractures tend to heal quickly
    • □ Children older than 6 years will benefit from fixation of the femur, which allows ambulation with crutches.
  • The presence of growth plates mitigates against treatment with a standard reamed nail placed through the piriform fossa.
    • □ Damage to the ascending vessels of the
      femoral neck may cause avascular necrosis, for which there is no
      satisfactory treatment.
    • □ Skeletally mature patients can be treated with a standard, reamed locked nail.
  • The fracture pattern is important.
    • □ Fractures prone to shortening due to
      comminution or segmentation should be treated with an external fixator
      or locked nail to maintain length.
  • P.145
  • Short oblique or transverse fractures are excellent candidates for flexible nails.
  • Femur fractures in polytrauma patients
    will benefit from stabilization to facilitate patient care and mobility
    or to permit wound or skin care.
Nonoperative Treatment
Spica Casting
  • Casting is the mainstay of treatment for the young.
  • Reduction and casting are performed under sedation or anesthesia
  • Positive piston test (fracture can be
    overlapped more than 2.5 cm) indicates preoperative traction until
    sticky to prevent shortening in cast.
  • The cast can be wedged up to 1 to 2 weeks after application to correct angulation.
  • Two weeks is long enough to heal in infants. Healing takes up to 6 weeks in older children.
Figure 12.8-1 Lateral approach to the femur for open reduction and internal fixation. 1, rectus femoris; 2, vastus intermedius; 3, vastus lateralis; 4, sciatic nerve; 5, biceps femoris (long head). (A) A direct lateral skin incision is made. The fascia is sharply incised. Vastus lateralis muscle (3) will be elevated off the intramuscular membrane. (B) With the vastus lateralis elevated, a plate can easily be placed along the lateral femoral cortex. (C)
The plate should span the fracture site and screws should engage six to
eight cortices on either side of the fracture to provide adequate
  • Safe and effective
  • Prolonged recumbency is a drawback.
  • Skin traction is useful for young
    children. Larger children will benefit from a distal femoral traction
    pin as the skin will not tolerate large shear forces from skin traction.
  • Periodic x-rays needed to check alignment and length. Make corrections.
  • Traction is maintained until fracture is sticky. Spica cast is then applied and maintained until healing.
Operative Treatment
  • Open reduction and internal fixation with plate and screws (Fig. 12.8-1):
    • □ Relatively safe and effective
    • □ Easily placed by direct lateral approach, elevating the vastus lateralis.

      Figure 12.8-2 (A) Fixator pin placement. Placing pins too close to the fracture (left)
      provides poor control of fracture alignment. Pins in diaphyseal bone
      will act as stress risers. Try to limit the number of diaphyseal pins.
      Keeping the pins spread out (right) will
      provide better mechanical advantage in controlling fracture alignment.
      Try to place the proximal pin as proximal as possible and the distal
      pin as distal as possible without violating the physes. The
      intermediate pins should be close to but not violate the fracture site.
      (B) Cross-section of proximal thigh. 1, tensor fascia lata; 2, vastus lateralis; 3, femoral neck; 4, gluteus maximus; 5, ischium; 6,
      pubis. The most proximal pin should be in the intertrochanteric region,
      which is largely cancellous bone. Cancellous bone is less likely to
      fracture through pin tracts than is cortical bone. Because there is
      considerable motion of the soft tissues over the greater trochanter,
      some irritation is to be expected at this pin tract. (C) Cross-section of midthigh. 1, rectus femoris; 2, vastus intermedius; 3, vastus lateralis; 4, sciatic nerve; 5,
      biceps femoris (long head). The diaphyseal pins will be in cortical
      bone. Here, they have significant stress riser effect. There will
      always be a risk of fracture through a pin tract until the pin has been
      removed and the hole refills with bone. The pins will transfix the
      vastus lateralis muscle. Few children will want to bend the knee as
      long as these pins are in place. (D) Cross-section of distal thigh, just above the distal femoral epiphysis. 1, quadriceps tendon; 2, suprapatellar pouch; 3, vastus lateralis; 4,
      biceps femoris. The most distal fixator pin should be in metaphyseal
      bone. Fracture through a pin tract here is virtually unheard of. The
      pin will transfix the iliotibial band, thereby precluding painless knee
    • P.147
    • □ Requires a large incision and surgical dissection.
    • □ There are stress risers while the hardware is in place and after removal.
    • □ May be a good choice for patients who cannot be placed on a fracture table or subject to vigorous manipulation.
    • □ Requires non-weightbearing until fracture callus is seen.
  • External fixation (Fig. 12.8-2):
    • □ Usually quite effective; there is occasional delayed healing or refracture.
    • □ Pin tracts require daily cleansing and still may drain or become infected.
    • □ Pins should be spread out to allow control of fracture and limit stress risers.
    • □ Pins through the iliotibial band cause pain. Expect limited knee motion until the fixator is removed.
    • □ Weightbearing must be encouraged to strengthen fracture callus.
    • □ The knee can be manipulated under anesthesia when the fixator is removed at about 3 months after implantation.
    • □ May be a good choice in children (a)
      who are too young for a locked nail with fractures prone to shortening,
      (b) who have a deformed canal that will not accommodate flexible nails,
      and (c) who are too sick to tolerate prolonged anesthesia or vigorous
  • Flexible intramedullary nails (Fig. 12.8-3):
    • □ Excellent for fractures in juveniles with short oblique or transverse fracture patterns.
    • □ The fracture must be reducible in order
      to pass the nails. If the fracture is not reducible under anesthesia,
      open reduction or another method of stabilization should be considered.
    • □ Usually placed retrograde from distal femoral metaphyseal portals.
    • □ Must be prebent to provide three-point fixation.
    • □ Must be sized to fit in canal—larger is
      stronger. The two nails should be the same size, and should fill 80% of
      the canal at the isthmus.
    • □ Should be cut just outside femoral cortex to allow later removal. If they protrude, there will be irritation with knee motion.
    • □ Non-weightbearing should be maintained until callus is seen, usually 3 to 4 weeks after implantation.
    • □ Nails should be removed after solid fracture healing.
  • Locked intramedullary nail through the piriformis fossa (Fig. 12.8-4A):
    • □ May damage the ascending cervical
      vessels so this procedure is contraindicated in the skeletally
      immature. There is no satisfactory treatment for avascular necrosis of
      the capital femoral epiphysis.
    • □ Reaming of the isthmus allow placement of a larger diameter nail.
    • □ Should be the standard treatment for femur fracture in the skeletally mature.
  • Locked intramedullary nail through the greater trochanter (see Fig. 12.8-4B):
    • □ Avoids damage to the ascending cervical vessels.
    • □ Passing a small diameter nail prevents obliteration of the greater trochanteric apophysis.
      Figure 12.8-3
      Retrograde placement of flexible nails for femoral shaft fracture.
      Small incisions just proximal to the knee allow creation of entry holes
      into the distal metaphyseal flare. Nails should be prebent with a long,
      gentle C-curve, which will provide three-point fixation of the
      fracture. Two nails are inserted—one from each side. The prebends
      oppose each other. The distal nail tips should be cut just outside the
      distal femoral cortex. They should be left long enough to enable future
      removal and short enough to prevent irritation of the mobile soft
      tissues around the knee—approximately 1 cm outside the bone.
    • □ Allows passage of the nail from the
      greater trochanter into the intramuscular canal, which is not collinear
      with the greater trochanter.
    • □ May not fill the canal, so may not be as strong a construct as a standard reamed nail.
    • □ Requires non-weightbearing until callus is seen.
  • Débridement of open fractures:
    • □ Open fractures always need prompt débridement.
    • □ The traumatic wound should be extended
      to allow visualization and curettage of bone ends. The surgical wound
      should be closed and the traumatic wound left open.
    • □ Open fracture is not a contraindication
      to internal fixation. If there is gross contamination, consider use of
      an external fixator and repeated débridement.
  • Antibiotics should be given.
    • □ A cephalosporin is indicated for clean wounds.
    • □ Add an aminoglycoside for contaminated wounds and penicillin for barnyard wounds.
Surgical Anatomy and Biomechanics
The intramedullary canal is narrowest at its isthmus.
The isthmus must be scrutinized prior to any planned intramedullary
fixation to make sure it is large enough to


passage on the implant. The distal femur gradually expands into a
metaphyseal flare which is much wider from medial to lateral than front
to back. There is a gradual transition from cortical to cancellous bone.

Figure 12.8-4 (A)
Placement of intramedullary through the piriform fossa. This starting
point is ideal for placing a reamed antegrade nail as it is coaxial
with the intramedullary canal. Its use must be avoided in the
skeletally immature patient due to the risk of damage to the ascending
vessels, which supply the capital femoral epiphysis. (B)
Placement of intramedullary through the greater trochanteric apophysis.
This starting point is not ideal for placing an antegrade nail as it is
not coaxial with the intramedullary canal. A smaller diameter nail will
be used than with a standard piriform fossa approach to be able to “get
around the corner” from the trochanter into the femoral canal and to
eliminate the need to ream a very large hole in the trochanteric
Postoperative Management
  • Routine wound surveillance is indicated.
  • Non-weightbearing should be maintained until callus is seen.
  • Crutches should be used until bridging callus is seen on anteroposterior and lateral radiographs.
  • Hardware should be removed after fracture healing and remodeling.
  • Superficial infection (cellulitis) can sometimes be managed with antibiotics.
  • Deep infections need open débridement.
  • Antibiotics should be tailored to the culture organism.
  • Loose hardware should be removed and an external fixator can provide stability.
  • Stable hardware should be maintained in place.
Delayed Union
  • Unusual in children
  • Weightbearing, bone stimulators, and bone grafting can be effective.
  • Extremely rare in the absence of an open fracture or surgical treatment.
  • Fractures tend to heal in children even if the bone ends are not apposed.
  • Treatment is the same as for delayed union.
  • Repeat or more secure fixation may be required.
Leg Length Discrepancy
  • Fractures not reduced out to length can heal shortened.
  • 1 cm of overgrowth can be expected in children between 4 and 10 years.
  • The treatment plan should take this into account.
  • The process of overgrowth should be complete 6 to 12 months after injury.
  • Discrepancies of less than 2 cm can generally be treated with shoe modifications.
  • Discrepancies predicted to be from 2 to 4 cm can be managed by epiphysiodesis.
  • Greater discrepancies may require lengthening procedure.

Angular Deformity
  • Should be prevented.
  • Infants have impressive remodeling potential.
  • Up to 15 degrees of angulation can be accepted in younger children and less angulation can be accepted near skeletal maturity.
  • In general, valgus is better tolerated than varus and procurvatum is better tolerated than recurvatum.
  • Persistently symptomatic angulation, which is not likely to remodel should be treated with osteotomy.
Rotational Deformity
  • Should be prevented.
  • No more than 20 degrees should be accepted.
  • If there is any doubt as to whether
    rotation is correct, simultaneous radiographs should be taken of femurs
    to include hips and knees in an effort to match version prior to
    surgical fixation.
  • Persistently symptomatic rotation, which is not likely to remodel should be treated with osteotomy.
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Berbeek HO, Bender J, Sawidis K. Rotational deformities after fractures of the femoral shaft in childhood. Injury 1976;8:43-48.
Blasier RD, Aronson J, Tursky EA. External fixation of pediatric femur fractures. J Pediatr Orthop 1997;17:342-346.
Buckley SL. Current trends in the treatment of femoral shaft fractures in children and adolescents. Clin Orthop 1997;338:60-73.
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P, Pevny T, Teague D. Early complications with external fixation of
pediatric femoral shaft fractures. J Orthop Trauma 1996; 10:191-198.
SD, Drvaric DM, Darr K, et al. The operative stabilization of pediatric
diaphyseal femur fractures with flexible intramedullary nails: a
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PJ, Song KM, Routt ML, et al. Plate fixation of femoral shaft fractures
in multiply injured children. J Bone Joint Surg (Am)1993;75:1774-1780.
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DL, Leet AI, Money MD, et al. Secondary fractures associated with
external fixation in pediatric femur fractures. J Pediatr Orthop
JD, Buehler KC, Sponseller PD, et al. Shortening in femoral shaft
fractures in children treated with spica cast. Clin Orthop
DR, Hoffinger S. Intramedullary nailing of femoral shaft fractures in
children via the trochanter tip. Clin Orthop 2000;376: 113-118.
12.9 KNEE
Julia E. Lou
Jevere Howell
John M. Flynn
Theodore J. Ganley
Most knee injuries in children occur as a result of
sportsrelated injuries, motor vehicles accidents, or falls. Fractures
may disrupt the extensor mechanism, create knee instability, or injure
the physes. Therefore, diagnosis and treatment measures are critical to
the future function and development of the child with a knee fracture.
Direct trauma, sudden forceful contraction of the
quadriceps, or a combination of the two may result in patella fracture.
Linear or comminuted fractures are characteristic patterns that result
from direct impact to the knee and patella subluxation or dislocation
may result in an osteochondral fracture. Patella fractures can be
classified according to location (Table 12.9-1).
Patella fractures may be difficult to diagnosis due to
existing knee joint anomalies such as bipartite patella,
Osgood-Schlatter disease, or Sinding-Larsen-Johansson (SLJ) disease.
Additionally, small fracture fragments associated with patella
fractures are easily missed on radiographs.






Mechanism of Injury


Proximal patellar pole

Least common

Sleeve (inferior)

Distal patellar pole

Small fragment

Large cartilaginous component

8-12 yrs of age

Acute, sudden forceful contraction of quadriceps following extension of knee


Superolateral margin

Vertically oriented, traverse entire patella, crescent-shaped line

Bipartite patella 0.2%-6% incidence

Male > female

Fragment edges are sclerotic in chronic conditions


Medial margin

Fragment edges are sclerotic in chronic conditions

Acute lateral patellar dislocation

Osteochondral fracture

Patellar margin

May be difficult to see radiographically

Associated with large amount of cartilage

Lateral patellar dislocation (occurs in 5%)

Physical Examination and History
Clinical Features
  • Effusion, hemarthrosis
  • Refusal to bear weight
  • Point tenderness
  • Patella alta
  • Inability to fully extend knee
  • Palpable defect (sleeve fracture)
In patients with distal pole avulsions, the patella
moves proximally with voluntary contraction of the quadriceps while the
patellar ligament remains relaxed. Patients with stable, nondisplaced
fractures will be able to perform straight leg raises. Osteochondral
fractures may result from patellar dislocations which have
spontaneously reduced prior to presentation. A patient who has had a
dislocated patella will resist passive manipulation by contracting the
quadriceps or by physically grabbing the examiner to prevent further
manipulation (positive apprehension test).
Radiologic Features
  • Fragmentation
  • Fracture lines
  • Patella alta
  • Knee effusion

Fracture Type

Radiographic Studies


Lateral x-ray with knee flexed 30 degrees

Marginal (longitudinal)

Anteroposterior, axial, or merchant x-ray

Some fracture patterns are best seen on a specific radiographic view (Table 12.9-2).
In patients with large knee effusions who have sustained significant
injury, magnetic resonance imaging (MRI) scans may be valuable to
visualize cartilage damage or fracture fragments.
Surgical Indications
Fractures with more than 3 mm of displacement or
articular step-off require open reduction and fixation, followed by 4
to 6 weeks of immobilization in a cylinder cast. A torn retinaculum and
other functionally debilitating cartilage or ligament injuries should
be surgically treated.
Nondisplaced fractures are treated conservatively with 4
to 6 weeks of immobilization with the knee held in extension in a
cylinder cast.
Results and Outcome
Adequate surgical repair of patella fractures generally
achieves acceptable results. Overall, patients with nondisplaced
fractures have good results while patients with comminuted, displaced
fractures experience more complications.
  • Decreased range of motion
  • Patella deformity
  • Patella alta
  • Osteochondral defects
  • P.151
  • Quadriceps weakness
  • Posttraumatic osteoarthritis
  • Extensor lag
  • Osteonecrosis
Postoperative Management
Following cast removal, patients should be assigned a
physical therapy program for range of motion and continued muscle
Although rare, patella sleeve fractures are the most
commonly reported patella fracture in children. A small fragment of
bone attached to a sleeve of cartilage avulses from the lower pole of
the patella.
Physical Examination and History
Clinical Features
  • Severe knee pain
  • Inability to fully extend the knee
  • Point tenderness
  • Palpable gap
  • Inability to bear weight
  • High-riding patella
  • Effusion
  • No history of direct blow to knee
It is important to differentiate patella sleeve
fractures from SLJ disease. Unlike SLJ disease, patella sleeve
fractures are an acute injury with intense pain. The palpable gap at
the distal pole of the patella is an important clinical sign
characteristic of patella sleeve fractures.
Radiologic Features
  • Effusion
  • Small fragment avulsed from distal patellar pole
  • Patella alta
The fragment may be so small that it is difficult to see
radiographically. Sagittal MRI views along the axis of the patellar
tendon are helpful in diagnosis.
This injury must be accurately reduced to ensure proper healing and return to function.
Surgical Indications
The majority of patellar sleeve fractures should be
treated with open reduction and fixation in order to realign the
articular surfaces. Patients treated by cast immobilization have a
higher rate of complications than those treated surgically.
Results and Outcome
Normal range of motion and return to normal function generally occurs following successful surgery.
  • Loss of full knee extension
  • Subchondral articular defect
  • Patellar deformity
  • Loss of reduction
  • Loss of motion
  • Ossification of patellar tendon
Postoperative Management
After surgery, the knee should be immobilized for 4 to 6
weeks in a cylinder cast. Following casting, physical therapy for range
of motion and strengthening is helpful.
Osteochondral fractures in children often occur in
association with lateral patellar dislocations. Dislocation may cause a
fragment of the medial patella or lateral femoral condyle to break away
from the bone. Osteochondral fractures can be classified by location
and mechanism of injury.
Physical Examination and History
Clinical Features
  • Effusion
  • Knee held in slight flexion
  • Knee pain
  • Inability to bear weight
  • Resist movement
  • Point tenderness
Radiologic Features
Osteochondral fractures (Table 12.9-1)
are often difficult to see on plain films, as the fragment size may be
very small or hidden from view. Anteroposterior and lateral as well as


and tunnel views should be obtained. Arthrography, computed tomography
(CT) scan, or MRI can be useful in visualizing the cartilaginous nature
of the injury, which may be extensive.

Surgical Indications
Acute osteochondral fractures with large fragments (≥2
cm) should be treated surgically with pins or screws. The knee is then
immobilized in flexion for 4 to 6 weeks following surgery. Small
fragments (≤1 cm) may be removed arthroscopically.
Results and Outcome
Smaller fragments in non-weightbearing areas produce better outcomes than large fragments in weightbearing areas.
  • Loss of motion
  • Femoral condyle deformity
  • Patellar deformity
  • Late osteoarthritis changes
  • Blow to the knee with a planted foot
  • Fall on a bent knee
  • A birth injury may occur with a breech presentation
  • Hyperextension of the knee
  • Other factors may also predispose patients to physeal injury:
    • □ Osteomyelitis
    • □ Myelomeningocele
    • □ Leukemia
    • □ Osteosarcoma
    • □ Hemophilia
  • Account for about 1% to 6% of all physeal injuries
  • Occur in adolescents between 12 and 16 years of age
  • Associated pathology: ligament, popliteal artery, and peroneal nerve injury possible
  • Classified according to the Salter-Harris classification
Physical Examination and History
Clinical Features
  • Swelling and effusion
  • Report hearing a pop at the time of injury
  • Tenderness about the physis
  • Inability to bear weight
Because of the potential risk to nerve and vessels, a complete neurovascular assessment is necessary.
Radiologic Features
Anteroposterior, lateral, and oblique views are
valuable. MRI, ultrasound, or arthrography may aid in the diagnosis of
physeal fractures in infants. Arteriography should be performed when
vascular injury is suspected.
Radiographs demonstrate:
  • The patella and femoral condyles in line with the proximal tibia, ruling out knee dislocation
  • Fracture line
  • Degree of displacement
Surgical Indications
Surgery consists of reduction and internal fixation for
all displaced distal femoral physeal fractures. The joint may be
aspirated prior to manipulation and traction should be applied to
minimize cartilage damage. Closed reduction should be performed under
general anesthesia to prevent muscle spasm, which may cause grinding of
the physis.
Closed reduction alone (without internal fixation) risks loss of reduction.
Smooth pins or wires should be used if the physis must
be crossed. Many type II fractures can be fixed with interfragmentary
screw fixation through the Thurston-Holland fragment and type III
fractures can be reduced with pins or screws placed transversely
through the epiphysis. Similarly, pins or screws should be placed
transversely through the epiphysis or metaphysis when reducing type IV
Nondisplaced fractures can be immobilized. After
aspiration of tense effusions, the patient should be placed in a long
leg or hip spica cast with 15 to 20 degrees of knee flexion.
Results and Outcomes
The prognosis for these fractures is generally good with
a greater potential for leg length discrepancy and angular deformity
secondary to physeal arrest in younger children.
  • Popliteal artery impairment
  • Angular deformity
  • Compartment syndrome
  • Partial/complete physeal arrest
  • Peroneal nerve palsy
  • Leg length discrepancy
  • Recurrent displacement
  • Knee stiffness
  • Ligamentous injury
Postoperative Management
After surgery, the patient is placed in a long leg cast with slight flexion and allowed to ambulate on crutches.


Straight leg raises are initiated within 1 week and at 4 weeks; range of motion and muscle strengthening exercises are begun.

Fracture of the proximal tibial physis is extremely rare
in children and its mechanisms are similar to those of distal femoral
fractures. Fractures of the proximal tibial physis account for
approximately 0.8% of all physeal injuries and occur most commonly in
adolescent boys.
Associated injuries include injury to the popliteal artery, damage to the collateral ligaments, and proximal fibular fracture.
The Salter-Harris classification is also used to describe proximal tibial fractures.
Physical Examination and History
Clinical Features
A thorough neurovascular examination should be performed
to assess the status of the peroneal nerve and popliteal artery.
Compartment syndrome must be ruled out:
  • Tense joint with hemarthrosis
  • Tenderness over the physis 1.0 to 1.5 cm below the joint line
  • Fibular tenderness
Radiologic Features
  • Fracture line
  • Effusion
  • Associated injuries
Associated ligamentous or knee injury may be present but
difficult to appreciate on plain radiographs alone. CT scanning or MRI
may provide additional information. Arteriography should be performed
when vascular injury is suspected.
Surgical Indications
Unstable reductions and Salter-Harris type II, III, and
IV fractures are candidates for operative treatment. Unstable
Salter-Harris type I fractures may be fixed with percutaneous pins that
cross distal to the physis. The wires should be removed 4 to 6 weeks
after surgery. Open reduction and internal fixation is indicated for
displaced type III and type IV fractures and pins or screws may be
placed horizontally parallel to the physis. Ligamentous and meniscal
injuries should be repaired.
  • Nondisplaced fractures treated in a long leg cast with 30 degrees of flexion for 4 to 6 weeks.
Results and Outcome
  • Similar to those of patients with distal femur physeal fractures.
  • Popliteal artery impairment
  • Angular deformity
  • Compartment syndrome
  • Partial/complete physeal arrest
  • Peroneal nerve palsy
  • Leg length discrepancy
  • Recurrent displacement
  • Knee stiffness
  • Ligamentous injury
Postoperative Management
Patients placed in a long leg cast with 30 degrees of
flexion should be immobilized for 6 to 8 weeks. After removal of the
cast, range of motion and quadriceps strengthening exercises should be
Tibial spine fractures result when a force causes a bony
fragment of the anterior or posterior aspect of the tibial eminence to
avulse. The more common anterior tibial spine injuries result in a bony
fragment with an attached (anterior cruciate ligament) ligament.
Tibial spine fractures are relatively uncommon, with an
estimated incidence of 3 per 100,000 each year. They are thought to
result from a combination of rotational, hyperextension, and valgus
force. Children often sustain this injury after falling from a bicycle,
during athletic activity, or rarely as a result of trauma. The
classification for this injury is based on fragment displacement (Fig. 12.9-1).

Figure 12.9-1 (A-D) Meyers and McKeever classification of tibial eminence fractures.
Physical Examination and History
Clinical Features
  • Pain
  • Hemarthrosis
  • Inability to bear weight
  • Painful and limited range of motion
The ligaments should be assessed for stability and associated injury using:
  • Lachman test
  • Drawer test
  • Pivot shift test
Radiologic Features
Anteroposterior and lateral radiographs should be
obtained and examined for the presence of a bony fragment. Tunnel or
stress views may also be helpful. The lesion is frequently larger than
it appears radiographically due to cartilaginous involvement not
visible on plain radiographs.
Surgical Indications
Type III and IV fractures are most often treated with
open reduction and internal fixation with sutures, pins, screws, or
Kirschner wires. These injuries have poor outcomes when treated
Type I and II fractures are most often treated with
closed reduction in a splint or a cast for 4 to 6 weeks. The knee
should be immobilized in slight flexion (10 to 20 degrees).
Results and Outcome
Proper treatment generally achieves good results, although complications are associated with inappropriate treatment.
  • Anteroposterior laxity
  • Loss of extension due to bony block
  • Late sequelae meniscal injury as a result of cruciate laxity
  • Extensor lag
  • Quadriceps weakness
Postoperative Management
Whether the patient undergoes surgery followed by
immobilization or closed reduction through cast immobilization for 4 to
6 weeks, all patients should be assigned range of motion therapy and
muscle strengthening training following cast removal.
Tibial tubercle avulsions typically result from jumping
or landing during a sporting event. Associated pathology may include
meniscal tear or patellar fractures. This injury represents 1% to 3% of
all physeal injuries and is seen most commonly in athletic adolescent
males. Predisposing factors include:
  • Patella baja
  • Osgood-Schlatter disease
  • Tight hamstrings
  • Physeal abnormalities
The Watson-Jones classification is used to describe this injury (Fig. 12.9-2).

Figure 12.9-2 (A-C) Watson-Jones classification of tibial tubercle avulsions.
Physical Examination and History
Clinical Features
  • Swelling and tenderness
  • Lack of full extension (type II and III fractures)
  • Palpable fracture fragment
  • Patella alta
  • Effusion
  • Hemarthrosis
Radiologic Features
Lateral plain radiographs with slight internal rotation are optimal imaging studies to view this injury.
  • Patella alta
  • Fracture fragment
  • Effusion
Surgical Indications
Surgery is indicated for type IB and higher grade
fractures. Fixation is achieved by smooth pins or small wires if the
patient is more than 3 years from skeletal maturity or if the fracture
fragment is small. Large fragments or older children can have fracture
fixation with screws, threaded Steinmann pins, or tension holding
Typically, minimally displaced type I fractures are treated by reduction with the knee in extension and casting.
Results and Outcome
Patients with completely reduced fractures of the tibial
tubercle tend to have a favorable outcome and usually return to normal
  • Compartment syndrome
  • Loss of flexion or extension
  • Meniscal tear
  • Patella alta
  • Genu recurvatum
Postoperative Management
Patient should be placed in a long leg cast with the
knee in extension for 4 to 6 weeks. Physical therapy for quadriceps
strengthening and range of motion exercises are instituted at cast
JM, Hresko T, Reynolds RA, et al. Titanium elastic nails for pediatric
femur fractures: a multicenter study of early results with analysis of
complications. J Pediatr Orthop 2001;21:4-8.
JM, Luedtke L, Ganley TJ, et al. Titanium elastic nails for pediatric
femur fractures: lessons from the learning curve. Am J Orthop
Ganley TJ, Pill SG, Flynn FM, et al. Pediatric and adolescent sports medicine. Curr Opin Orthop 2001;12:456-461.
GR, Ackroyd CE. Sleeve fractures of the patella in children: a report
of three cases. J Bone Joint Surg (Br) 1979:61:165-168.
Insall JN, Windsor RE, Scott WN, et al, eds. Surgery of the knee, 2nd ed. New York: Churchill Livingstone, 1993.
LJ, Foster TE. Acute knee injuries in the immature athlete. In Heckman
JD, ed. Instructional Course Lectures 42. Rosemont, IL: American
Academy of Orthopaedic Surgeons, 1993:473-481.
Ogden JA, Tross RB, Murphy MJ. Fracture of the tibial tuberosity in adolescents. J Bone Joint Surg (Am) 1980;62A;205-215.
CB, McGinnis DW. Knee. In: Sullivan JA, Anderson SJ, eds. Care of the
young athlete. Rosemont, IL: American Academy of Orthopaedic Surgeons,
Smith AD, Tao SS. Knee injuries in young athletes. Clin Sports Med 1995;14:629-650.
PD, Stanitski CL. Fractures and dislocations about the knee. In JH
Beaty, JR Kasser, eds. Rockwood and Wilkins’ fractures in children, 5th
ed. Philadelphia: Lippincott Williams & Wilkins, 2001:981-1076.

Michael C. Albert
Gurpal S. Ahluwalia
  • The postnatal development of the tibial tubercle can be divided into four stages (Table 12.10-1).
  • Fractures of the tibial tuberosity can occur during any of the first three stages of development.
  • Most fractures occur while a child or adolescent is involved in athletics, especially in those that involve jumping and landing.
  • Basketball, track and field, and gymnastics are the three sports in which these injuries most commonly occur.
  • The mechanism of these fractures is an
    avulsion most often caused by sudden acceleration or deceleration of
    the knee extensor mechanism.
  • Fractures of the tibial tuberosity only
    occur in children and adolescents in whom the ossification centers are
    still open or incompletely closed.
  • Some studies suggest that acute
    disruptions of the tibial tuberosity occur with increased incidence in
    knees with preexisting Osgood-Schlatter disease.
  • Despite the considerable force exerted
    upon the insertion of the quadriceps muscle when it contracts,
    especially when jumping or landing, fractures of the tibial tuberosity
    are relatively rare.
  • These avulsion-type fractures occur when
    the patellar tendon pulls hard enough to overcome the combined strength
    of the growth plate underlying the tubercle, the surrounding
    perichondrium, and the adjacent periosteum.
  • There are two ways in which this mechanism can occur:
    • □ Violent contraction of the quadriceps muscle against a fixed tibia.
    • □ action occurs when an athlete springs off to jump, as in a basketball game or a track and field event.
  • Acute passive flexion of the knee is strong enough to override the contracted quadriceps.
    • □ This variation of the mechanism can
      occur, for example, when an athlete makes a bad landing at the end of
      the jump or fall, as in a gymnastic event or in the long jump.
Watson-Jones classified the three types of injury to the tibial tuberosity (Table 12.10-2).
In general, the difference between the subtypes is in the degree of
separation from the metaphysis and in comminution of the avulsed




Occurs before
the secondary ossification center appears and persists until
approximately age 11 yr in girls and approximately age 13 yr in boys


The ossification center appears in the tongue of cartilage and occurs in girls between 8-12 yrs and in boys between 9-14 yr


The secondary ossification centers coalesces to form a tongue of bone continuous with the proximal tibial epiphysis.

This stage occurs in girls between ages 10-15 yr and in boys between the ages of 11-17 yr.


Defined as the point at which the epiphyseal line is closed between the fully ossified tuberosity and the tibial metaphysis





Fracture across secondary ossification center


Fracture of junction of primary and secondary ossification centers


Fracture extends into knee joint through proximal tibial epiphysis

Physical Examination and History
Clinical Features
  • Patients with a fracture of the tibial
    tuberosity will present with a history of an acute injury, most often
    during participation in an athletic event involving jumping.
  • They describe immediate marked pain and swelling at the time of injury, and are often unable to stand or walk.
  • These fractures can be distinguished from
    Osgood-Schlatter disease because in the latter, onset of symptoms is
    often insidious rather than acute. In addition, the symptoms in
    Osgood-Schlatter disease are usually mild and intermittent, the
    patients have only partial disability as opposed to the inability to
    stand or walk, and treatment is only symptomatic and supportive.
Radiologic Features
  • The tibial tuberosity lies just laterally to the midline of the tibia.
  • The best radiologic view to evaluate this
    injury is a lateral radiograph with the tibia rotated slightly
    medially. Findings will vary depending upon the type of injury.
Surgical Indications
There are two primary indications for surgery in fractures involving the tibial tuberosity:
  • Anterosuperior displacement of one or more fragments of the tuberosity
  • Extension of the fracture through the proximal tibial ossification center into the joint with disruption of the joint surface
Surgical Contraindications
  • In general, the only type of tibial
    tuberosity fracture that should be managed without surgery is a type I
    fracture that involves small fragments that are either nondisplaced or
    only minimally displaced.
  • Type II and III fractures are treated with open reduction and internal fixation.
  • In cases of displaced fractures, a periosteal flap may be folded under the avulsed fragments.
    • □ The fracture bed should be cleared of
      any debris and any such periosteal flaps should be extracted and spread
      out during reduction of the fragment with the knee extended.
    • □ Fixation of the fragment should be reinforced by repair of the torn periosteum.
Results and Outcome
  • The outcome of properly reduced or surgically treated fractures of the tibial tuberosity is good.
  • Nearly all patients are able to return to full activity, including participation in athletics.
Postoperative Management
  • After reduction or repair, a cylinder or long leg cast should be applied for 4 weeks.
  • Rehabilitation should focus on active range of motion and quadriceps strengthening exercises.
  • The patient can return to full
    participation in athletics after the mass and strength of the
    quadriceps on the affected side is equal to that on the opposite side.
  • Patients should be followed for any loss
    of range of motion of the knee, atrophy of the quadriceps muscles,
    persistent prominence of the tuberosity, the possibility of patella
    alta in an inadequately reduced displaced tuberosity, and the
    possibility of infection following open reduction.
  • Usually occur in younger children between the ages of 3 and 6 years
  • Result from a valgus stress applied to an extended knee.
  • May be nondisplaced and incomplete versus displaced with valgus opening of the medial cortex
  • Present with swelling and tenderness of the proximal tibia
  • Significant displacement requires a
    thorough neurovascular exam to rule out compartment syndrome. Most
    patients will have a nondisplaced buckle fracture or valgus greenstick
    fracture by radiographs.

  • An acute valgus deformity requires a closed reduction under conscious sedation and placement of a long leg cast in extension.
  • If correction cannot be achieved by
    closed techniques, an open reduction with removal of interposed soft
    tissue should be performed.
  • The most common complication of proximal
    metaphyseal tibial fractures, even in anatomically reduced injuries, is
    valgus deformity. Most practitioners believe that asymmetric growth
  • Parents should be informed about the
    possibilities of valgus overgrowth occurring the first year after
    injury; bracing is ineffective and corrective osteotomies should not be
    performed until skeletal maturity. Most patients will correct the
    valgus deformity with continued growth.
  • Common injuries to the lower extremities.
  • Closed injuries heal faster and have fewer complications than similar adult injuries.
  • Indirect means through a rotational twisting force, presenting as a spiral or oblique fracture pattern.
  • A direct force presents as a transverse or butterfly-type fracture pattern.
Tibia Fractures
  • Tibial and fibular fractures can be categorized according to which bone is fractured.
  • The most common type of fracture is an isolated tibia fracture in the distal third of the tibia.
  • The intact fibula prevents shortening but
    varus angulation can occur secondary to deforming force of the toe
    flexors and posterior tibialis tendon.
Tibia and Fibula Fractures
  • The second type of fracture pattern involves both the tibia and fibular shafts.
  • The most common angular problem is valgus malalignment secondary to deforming forces of the anterior extensor muscles.
  • Maintaining length can be a problem.
Fibula Fractures
  • The third type involves an isolated
    fibula fracture, which usually occurs from direct trauma to the lateral
    aspect of the leg. One must rule out an associated distal tibial
    physeal injury.
  • Pain with local swelling and tenderness will be present.
  • Radiographs should include anteroposterior and lateral views to include the knee and ankle joint.
  • Most will have a nondisplaced buckle fracture or valgus greenstick fracture by radiographs.
  • Most closed tibial and fibular shaft fractures can be treated with closed reduction and long leg casting.
  • There is minimal overgrowth of the tibia so shortening of more than 1 cm is unacceptable.
  • In younger children angulation of up to
    10 degrees is acceptable, however angulation of more than 5 degrees in
    adolescents may not remodel.
Surgical Indications
  • Unstable or open tibial fractures that
    cannot be adequately reduced and held in a cast can be treated by a
    variety of techniques including external fixation, pins and plaster,
    lag screws, plating and flexible intramedullary nails, taking care to
    avoid the growth plates at the insertion sites of the nails.
  • All open tibia and fibular fractures are treated with emergent irrigation and débridement and antibiotics.
  • Gustillo and Anderson grade 1 fractures can be treated with long leg casting.
  • Grade 2 and 3 open fractures can be
    treated with various techniques previously mentioned, depending on the
    soft tissue injury and wound contamination.
Results and Outcomes
  • Complications such as angulatory
    deformity, leg length discrepancy, and malrotation can occur. Adherence
    to acceptable amounts of angulation and shortening will prevent these
  • Malrotation will not remodel with growth and should not be accepted.
  • Delayed union and nonunion is unusual in closed tibial shaft fractures.
  • Delayed union and osteomyelitis can occur
    in open fractures; however, current treatment techniques can achieve
    good results in these types of fractures.
  • Compartment syndrome can occur in tibial
    shaft fractures and a high index of suspicion must be present when a
    child has pain out of proportion to the injury and has pain of passive
    stretch of the toes.

  • Stress fractures must be considered in the differential diagnosis of leg pain.
  • Generally tibial stress fractures occur between 10 and 15 years of age without a history of specific injury.
  • Most children have a painful limp and have local bone tenderness usually occurring on the upper tibia.
  • Radiographs may be normal in the first 10 to 14 days, but subsequent radiographs will show periosteal reaction.
    • □ The proximal posterior medial tibia is the most common site.
  • Magnetic resonance imaging or bone scan may aid in diagnosis if early plain radiographs are normal.
  • Differential diagnosis includes Ewing sarcoma and osteomyelitis.
  • The treatment of tibial stress fractures is relative rest.
  • If there is significant pain on
    weightbearing, crutches and a long leg cast may be used for 4 weeks
    followed by gradual increase in activity.
  • Nonunion of tibial stress fractures has been reported but is extremely rare.
  • “Toddler’s fracture” is a spiral fracture of the tibia without a concomitant fibular fracture.
  • Mechanism of injury is usually a
    rotational force through the tibia, namely internal rotation of the
    proximal leg, with the foot and ankle in a fixed position. It most
    often occurs when a toddler stumbles while running or walking.
  • The majority of these fractures occur in children less than 2.5 years of age.
  • The most common site of this fracture is the distal metaphysis of the tibia.
  • Spiral fractures of the midshaft of the
    tibia can also occur, but are more often associated with child abuse
    rather than an accidental twisting or tripping injury.
Toddler’s fractures can simply be classified as either displaced or nondisplaced.
Physical Examination and History
Clinical Features
  • The inability to bear weight and focal
    tenderness are the most common presenting features in a child with a
    toddler fracture. History of an acute twisting or tripping injury may
    be elicited, but more commonly the injury mechanism is not obvious.
Radiologic Features
  • Radiographs of the tibia and fibula should be obtained in both anteroposterior and lateral projections.
  • An internal oblique view can help in
    recognition of nondisplaced toddler’s fractures and sometimes may be
    the only view that identifies this type of fracture.
  • Follow-up films at 10 to 14 days will usually demonstrate callus formation.
  • A long leg cast, bent knee, is applied for about 3 weeks.
Results and Outcome
  • Most patients with these fractures recover full preinjury activity and normal growth following immobilization.
JS, Owen HF, Nogrady MB, et al. Obscure tibial fracture of infants: the
toddler’s fracture. J Can Assoc Radiol 1964;25: 136-144.
MF, Finzel KC, Carrion WV, et al. Toddler’s fracture: presumptive
diagnosis and treatment. J Pediatr Orthop 2001;21: 152-156.
Ogden JA, Tross RB, Murphy MJ. Fractures of the tibial tuberosity in adolescents. J Bone Joint Surg (Am) 1980;62A:205-215.
Tenenbein M, Reed MH, Black GB. The toddler’s fracture revisited. Am J Emerg Med 1990;8:208-211.
HR, Keeler KA, Gabos PG, et al. Posttraumatic tibia valga in children:
a long term follow up note. J Bone Joint Surg (Am) 1999; 81:799-810.
JP, Letts RM. Isolated fractures of the tibia with intact fibula in
children: a review of 95 patients. J Pediatr Orthop 1997;17: 347-351.

12.11 ANKLE
Andrew W. Howard
Andrew M. Wainwright
Ankle fractures are fractures of the distal tibia, or
distal fibula, distal to the metaphysis. This may affect the ankle
joint by entering the articular cartilage or disrupting the
tibiofibular syndesmosis, thus widening the space between the tibia and
These injuries are different in children than they are
in adults, although the mechanism may be similar. The differences are
attributed to the presence of the growth plates, which are weaker than
the ligaments and adjacent bones. These physes also close slowly
resulting in a stress riser at the point where the unossified growth
plate meets the ossified growth plate. Many of these fractures may be
treated nonoperatively. However, it is important to identify, assess,
and operate on those fractures that require open reduction and internal
fixation to prevent complications.
Growth Plates
  • Tibial and fibular growth plates are most important features that make these injuries different from adult injuries.
  • Damage to the growth plate may lead to angular or longitudinal growth problems.
  • Tibial growth plate is proximal to the joint line and to the fibular growth plate.
  • Fibular growth plate is level with the ankle joint line.
  • The growth plate is weaker than adjacent ligaments.
  • Distal tibial growth plate closes over a period of 18 months.
  • Order of closure: central, medial, lateral, posterior, anterior.
  • Medial: deltoid ligaments—superficial and deep
  • Lateral:
    • □ Anterior talofibular ligament
    • □ Posterior talofibular ligament
    • □ Calcaneofibular ligament
  • Central—syndesmosis:
    • □ Anterior inferior tibiofibular ligament
    • □ Posterior inferior tibiofibular ligament
    • □ Interosseous membrane
  • Annual incidence:
    • □ 0.1% of children sustain ankle fractures
    • □ Constitute 10% to 25% of all physeal injuries
    • □ Second most common fracture after distal radius
  • Sex ratio: boys more than girls by 2:1
  • Especially common at age 10 to 15 years (during which time physes are closing)
  • The ankle joint transmits the whole body weight to the ground through the foot.
  • Resists torsion in all three planes.
  • Indirect mechanism: with a fixed foot,
    the body is forced into internal rotation/external rotation,
    eversion/inversion, plantarflexion/dorsiflexion
  • Direct mechanism: vehicle crash, falls, sports
Anatomy of Fracture
  • The Salter-Harris classification describes the fracture anatomically relative to the growth plate and joint line (Figs. 12.11-1 and 12.11-2 and Table 12.11-1).
  • Higher grades represent increasing risks of growth complications.
  • Type of fracture can be correlated with patient age.
  • Understanding the injury mechanism
    facilitates planning closed or open reduction maneuvers. In general,
    this is done by reversing the injury mechanism.
  • Dias-Tachdjian system (Fig. 12.11-3):
    • □ Modified Lauge-Hansen classification system of adult ankle fractures.
    • □ Used with descriptors from the Salter-Harris classification system.
Differential Diagnosis
  • Fracture of adjacent bone:
    • □ Distal tibia proximal to metaphysis
    • □ Proximal fibula fracture
    • □ Hindfoot, especially the talus and base of fifth metatarsal
  • Septic arthritis, osteomyelitis
  • Osteochondritis dissecans of talus
  • Tarsal coalition
  • Chronic ankle instability
  • Tendinitis
  • Juvenile chronic arthritis
  • Tumor, osteoid osteoma, osteosarcoma, Ewing sarcoma

Figure 12.11-1
Salter-Harris classification system for growth plate fractures.
(Adapted from Salter RB, Harris WR. Injuries involving the epiphyseal
plate. J Bone Joint Surg 1963;45A:587-622.)





Complete separation of the epiphysis from the metaphysis (without a fracture through bone)


Tibia—less common, seen in younger children


Fracture through the physeal plate and cuts through portion of metaphysis

Triangular piece of metaphyseal bone is called the Thurston-Holland fragment


fracture that extends from the joint surface to the deep zone of the
growth plate and along the plate to the periphery

Special type:
juvenile Tillaux (named after Paul Jules Tillaux)—avulsion fracture of
distal tibia; anterolateral epiphysis is avulsed by anterior
talofibular ligament


fracture that extends from the joint surface across all of the growth
plate and through a portion of the metaphysis

Special type: triplane fracture—fracture of the distal tibia that runs in three perpendicular planes:

▪ Sagital plane from the joint surface to the growth plate

▪ Axial plane along the growth plate

▪ Coronal plane from the growth plate through part of the metaphysis


Crush injury to one area of the physeal plate

Uncommon fracture

Difficult to diagnose at time of injury, but often diagnosed
retrospectively (on review of initial radiographs after growth arrest
has occurred)

Additions to Original Salter-Harris Classification


Injury to the perichondrial ring of LaCroix

Leads to scarring/bridge across the growth plate and angular deformity


Avulsion fractures of the medial malleolus

a Added by Mercer Rang.

b Added by John Ogden.

Figure 12.11-2 Ankle fractures. (A) Sagittal reconstruction of computed tomography (CT) scan of a Salter-Harris type II fracture. (B) Three-dimensional (3D) rendering of CT scan reconstruction of Salter-Harris type III fracture. (C) 3D rendering of CT scan reconstruction of Tillaux fracture. (D) Sagittal reconstruction of CT scan of Salter-Harris type IV fracture. (E) 3D rendering of CT scan reconstruction of triplane fracture. (The fibula has been digitally removed for easier appreciation.)

Physical Examination and History
  • Trauma usually not witnessed and details poorly described
  • Important to exclude from history:
    • □ Nonaccidental injury
    • □ Pathologic fracture
    • □ Differential diagnosis (chronic ankle pain)
Clinical Features
  • Inspection:
    • □ Open/closed
    • □ Impending skin breakdown
    • □ Bruising, swelling, deformity
    • □ Foot perfusion, capillary refill
  • Palpation:
    • □ Local tenderness over fracture (may
      have tenderness anteriorly only with a Tillaux fracture, not along
      medial or lateral malleoli)
    • □ Salter-Harris type I fibula fracture: localized tenderness over bone rather than ligaments distinguishes this from sprain
    • □ Pedal pulses
    • □ Crepitus
  • Movement:
    • □ Range of motion
  • Special tests:
    • □ Neurologic assessment of sensation and foot intrinsic muscle function
    • □ Joint instability (ankle anterior drawer)
Radiologic Features
Imaging is not required (i.e., low risk of significant
fracture being missed) if there is isolated pain and tenderness, edema,
and swelling over distal fibula and adjacent ligament below level of
joint line.
  • Standard views: anteroposterior, lateral, mortise view (15- to 20-degree internal rotation oblique)
  • Special views:
    • □ Oblique view in adolescents to exclude lateral fracture distal tibia (that would otherwise be overshadowed by fibula)
    • □ Stress views: occult joint instability
Computed Tomography
  • To determine displacement in Tillaux, triplane fracture
  • Best to do this after initial closed reduction to assess success
  • Aims:
    • □ To obtain and maintain a satisfactory reduction
    • □ To avoid joint incongruity or instability
    • □ To avoid growth plate incongruity and growth plate arrest
By Type
Salter-Harris Type I Fibula Fracture
  • Below-knee walking cast for 3 weeks
Salter-Harris Type II Tibia Fracture
  • May be more rotated than appears on anteroposterior and lateral view: consider oblique and assess clinically
  • Closed reduction; hold reduction in molded cast for 3 weeks with weekly x-rays
  • Can accept less than full reduction if no
    soft tissue interposition (less than 5 degrees varus, less than 10
    degree valgus acceptable)
  • If full reduction not possible because of periosteal interposition, open procedure required to remove periosteum
Salter-Harris Type III Tibia or Tillaux Fracture
  • Intraarticular fracture requires reduction if displaced 2 mm or more
  • Stabilize with Kirschner wire or screw directed parallel to physis and joint line
  • Avoid crossing physis unless very near complete growth plate closure
Salter-Harris Type IV Tibia Fracture
  • Intraarticular fracture and transphyseal fracture
  • Requires accurate open reduction and internal fixation
  • Thurston-Holland fragment can be used to stabilize fracture if large
Salter-Harris Type IV Triplane Fracture
  • Intraarticular fracture and transphyseal fracture
  • Computed tomography (CT) scan required to plan approach, reduction, and fixation
  • Requires accurate open reduction and internal fixation
  • Operation is difficult because of fragmentation and soft tissue swelling
  • Many anatomic variants
  • Order of reduction: posteromedial fragment → fibula fracture → anterolateral fragment
Salter-Harris Type V Tibia Fracture
  • If recognized at time of injury, patient
    should be maintained non-weightbearing for 3 weeks to avoid further
    damage to the crushed part of the physis, although no intervention is
    known to reduce risk of partial growth arrest.
Ankle Dislocation
  • Requires urgent closed reduction because soft tissues and neurovascular structures at risk.
  • Often associated with open injuries.
  • Should not delay initial manipulation to correct severe deformity to obtain a radiograph.
  • Once reduced, radiographs or special imaging (e.g., CT scans) can be performed.
Summary of Treatment
  • Indications: usually Salter-Harris type I or II fractures of tibia and fibula can be reduced.

Figure 12-11.3 Dias and Tachdjian classification system of pediatric ankle fractures. SH,
Salter-Harris. (Adapted from Dias LS, Tachdjian MO. Physeal injuries of
the ankle in children. Clin Orthop Rel Res 1978;136:230-233.)

  • Indications:
    • □ Inability to obtain and maintain a closed reduction
    • □ Displaced intraarticular fracture (Salter-Harris type III or IV)
    • □ Displaced transphyseal fracture
    • □ Open fractures
  • CT to plan approach
  • Delay definitive open reduction until severe swelling of soft tissue has diminished (this may be up to 7 days)
  • For 2 years; growth arrest may occur at any time from 6 to 18 months
  • Clinical and radiologic assessment for:
    • □ Angular deformity
    • □ Harris lines (nonparallel, closer together on side of growth arrest)
    • □ Leg length discrepancy: distal tibia contributes 2 to 3 mm of growth per year.
  • Inability to obtain reduction
  • Growth plate arrest:
    • □ In general, risk of growth arrest is higher with higher class of fracture in the Salter-Harris fracture classification system.
    • □ Salter-Harris types I and II: central arrest common. Early closure of growth plate compared with opposite ankle
    • □ Salter-Harris types III, IV, V, and VI: peripheral arrest/bone bridge leading to angulation:
      • □ Often varus deformity with supination inversion injury
      • □ Consider completing epiphysiodesis to prevent angulation
  • Postoperative: wound complication, infection
  • Medial malleolar ossicle
  • Malunion, avascular necrosis, and nonunion—rare
  • Talar dome osteochondral lesion: may become symptomatic after associated fracture is healed
  • Depends on:
    • □ Skeletal age: bone, ligament, physis
    • □ Amount of soft tissue injury
    • □ Involvement of physis
    • □ Involvement of articular surface
    • □ Amount of fragmentation
K, Komar L, Jaramillo D, et al. Sensitivity of a clinical examination
to predict need for radiography in children with ankle injuries: a
prospective study. Lancet 2001;358:2118-2121.
A. Fractures and dislocations of the foot and ankle. In: Green NE,
Swiontkowski MF, eds. Skeletal trauma in children, 2nd ed. Vol 3.
Philadelphia: WB Saunders, 1998.
Dias LS, Tachdjian MO. Physeal injuries of the ankle in children. Clin Orthop Rel Res 1978;136:230-233.
Salter RB, Harris WR. Injuries involving the epiphyseal plate. J Bone Joint Surg (Am) 1963;45:587-622.
12.12 FOOT
Juan A. Realyvasquez
The ossification of a child’s foot varies with age and
influences fracture patterns, making recognition of injury more
difficult. The calcaneus is the first bone to ossify, followed by the
talus. The major mechanism of injury is direct force from a fall, being
crushed by a heavy object, or indirect injury from a lawn mower or
forceful rotation. Fortunately, the cartilage anlage gives the foot
more resilience to injury.
  • Fractures of the talus are rare in children, and the pattern varies with age.
  • In the very young child, an incompletely ossified talus is able to absorb more energy before disruption.
  • Magnetic resonance imaging (MRI) and
    computed tomography (CT) scanning may be necessary to appreciate damage
    to the cartilaginous body.
  • The mechanism of injury is usually forced dorsiflexion or dorsiflexion and rotation.
  • The main blood supply is provided by an
    anastomosis between the laterally arising artery of the sinus tarsi and
    medial artery of the tarsal canal.
  • Both enter the talus inferiorly at the junction of the neck with the body.

    Figure 12.12-1 Hawkins sign.
  • Hawkins sign, the presence of subchondral lucency, indicates an intact blood supply, resulting in osteopenia (Fig. 12.12-1).
  • Marti classifies fractures of the talus by their potential to develop avascular necrosis (Table 12.12-1).
Nondisplaced fractures of the talar neck are immobilized
in a long leg cast with the knee bent to prevent weightbearing.
Displaced fractures require open reduction and internal fixation and
weightbearing is not allowed for 6 to 8 weeks.
Fractures of the body, especially if associated with
dislocation, require immediate reduction. The posterior approach does
not disturb the medial blood supply. An anteromedial approach combined
with a medial malleolar osteotomy can be used.
Forceful supination and pronation on a dorsiflexed foot
can lead to fractures of the medial and lateral process of the talus.
These are often confused with ankle sprains and are common in
snowboarders. A high index of suspicion is necessary and oblique views
of the foot and ankle and CT are useful. Treatment for large or
displaced fragments is open reduction.


Fracture Location

Blood Supply to Body



Distal talar neck




Proximal talar neck or body; nondisplaced

Largely intact



Fracture-dislocation of proximal neck or body

Interosseous intact; maxillary disrupted



Proximal neck fracture with body located out of mortise

Interosseus and auxiliary disrupted


Adapted from Marti R. Fractures of the talus and calcaneus. In: Weber BG, Brunner CH, Freuler F, eds.

Treatment of fractures in children and adolescents. New York: Springer-Verlag, 1980.





Trabecular compression that can only be seen by magnetic resonance imaging


An incomplete separation


A subchondral cyst


An unattached and nondisplaced fragment


An unattached displaced fragment

Adapted from Anderson JF, Crichton KJ, Gratten-Smith T, et al.

Osteochondral fractures of the dome of the talus. J Bone Joint Surg (Am) 1989;71:1143-1152.

Osteochondral fractures of the talus (Table 12.2-2 and Fig. 12.12-2)
are the result of torsional impaction. Forceful plantar flexion and
inversion combined with external rotation of the foot produces the
medial lesion. Inversion and dorsiflexion produces an anterolateral
lesion that can be accompanied by injury to the lateral ankle ligaments.
Treatment is directed at preservation of ankle joint
congruity. Removal of a displaced fragment through medial malleolar
osteotomy is reported and arthroscopic treatment may also be considered.
Calcaneal fractures are more common in children than
talar fractures and are usually the result of a fall from a significant
height. Most fractures involve the body and the subtalar joint. In the
younger child, incomplete ossification makes diagnosis more difficult
and an MRI may be indicated.


Wiley’s classification is most applicable to children and CT is helpful for visualization:

Figure 12.12-2
Osteochondral fractures of the talus. (Adapted from Marti R. Fractures
of the talus and calcaneus. In: Weber BG, Brunner CH, Freuler F, eds.
Treatment of fractures in children and adolescents. New York:
Springer-Verlag, 1980.)
  • Type I fractures involve the subtalar joint.
  • Type II fractures do not involve the
    joint. Open reduction and restoration of the articular surface in
    intraarticular fractures is recommended.
These can present as chronic foot pain with peroneal
spasm and may be confused with ankle sprains. Accurate diagnosis
requires an oblique x-ray or CT scan. Cast immobilization is usually
successful in acute injuries, but excision of a loose fragment may be
necessary in chronic problems.
These may be confused with Achilles tendonitis, plantar
fasciitis, or other causes of heel pain. Diagnosis is made by clinical
examination and confirmed by bone scan. A swollen painful heel without
a history of trauma should raise suspicion. Tenderness is localized to
the posterosuperior aspect and the medial and lateral aspect of the
calcaneus. Radiographs are usually negative for up to 3 weeks; however
bone scan or MRI may be useful in establishing an early diagnosis.
Treatment is rest and limited weightbearing and resumption of
activities is not recommended before 4 to 6 weeks.
An occult fracture of the calcaneus has been found in
young children resulting from minor trauma. Pain is elicited by medial
and lateral compression and scintigraphy can confirm the diagnosis.
Treatment is immobilization with follow-up radiographs showing the
fracture and callus.
Fractures of the midfoot are rare and the result of
direct trauma from a falling object or indirect force from a fall
applied on a plantarflexed foot. Fractures of the tarsal navicular are
rare and are classified into three anatomic sites (tuberosity, dorsal
lip, body) plus stress fractures, which are seen in runners.
These are the result of an acute eversion force. The
fragment is usually not displaced. Treatment is cast immobilization
with molding of the medial longitudinal arch. Nonunion can occur and if
associated with recurrent symptoms, excision of the fragment is
recommended. Differentiation from an accessory navicular is made by
smooth contour of the line of separation in the latter.
These are the most common type of navicular fractures.
They are associated with sprains occurring in the inverted,
plantarflexed foot. Treatment is similar to an ankle sprain. If a
significant portion of the joint is involved, open reduction is
necessary to preserve the integrity of the medial longitudinal arch.
These are the least common of all navicular injuries (Table 12.12-3).
A direct force will cause comminuted nondisplaced fractures, whereas
force from a fall on the hyperplantar flexed foot will result in
dislocation and injury to


head of the talus and other tarsal bones. Marked displacements will
disrupt the subtalar and midtarsal joints and lead to degenerative
arthritis. Treatment is restoration of the joint surface by closed or
open methods. Severely comminuted type III fractures may require
primary arthrodesis.





Fracture line in plane of foot resulting in dorsal and plantar fragments


Fracture line passes dorsolateral to plantar medial resulting in medial and lateral fragment


Severe comminution of the body of the navicular

These have been described in children who perform
highimpact sports or activities. They are associated with the tight
heel cords limiting dorsiflexion of the foot, a short first metatarsal
or metatarsus adductus, or limited subtalar motion. The presenting
symptom is pain in the medial longitudinal arch with tenderness on
compression of the tarsal navicular. The fracture is best visualized by
a true anteroposterior radiograph of the foot centered on the
navicular. Treatment is a cast immobilization and non-weightbearing for
at least 6 weeks. Surgery is recommended if there is delay in healing
and the fracture extends through two cortices.
  • Metatarsal fractures are usually nondisplaced. Lisfranc injuries mimic adult patterns.
  • Mechanisms of injury as listed in Box 12.12-1.
  • Multiple fractures occur proximally in the first metatarsal and distally in the lateral four rays.
  • Fracture of the first metatarsal is more common before the age of 5 years and often goes unrecognized at the initial evaluation.
  • Cuneiform fractures can also occur and these usually heal uneventfully unless the fracture involves the physis.
  • Accurate reduction is necessary to prevent growth disturbance from early physeal closure.
  • In children, the apophysis of the fifth metatarsal does not appear until age 8 and is seen as a line parallel to the shaft.
  • Fractures of the tuberosity are avulsion fractures and have a better prognosis.
  • Avulsion fractures are transverse and are treated in a short leg cast.
  • Usually the result of a crash injury.
  • Treated with compression dressing, casting, and elevation.
  • Reduction is necessary if the metatarsal heads are displaced or plantarflexed.
  • Common in ballet dancers, runners, and gymnasts.
  • Second metatarsal is most commonly involved, followed closely by the third.
  • Predisposing factors include overtraining, delayed menarche, and poor nutrition.
  • Treatment is a short leg cast for 6 to 8 weeks.
  • Fracture of the proximal fifth metatarsal is the most common metatarsal fracture and is common in children over the age of 10.
  • It is a transverse fracture at the junction of the metaphysis and diaphysis (Fig. 12.12-3).
    Figure 12.12-3 Jones fracture.

  • Treatment is difficult because of poor blood supply.
  • The presence of previous injury, such as
    sclerosis or preinstall reaction, often leads to delayed union,
    nonunion, and refractors.
  • Acute injury is treated with a short leg cast for 6 weeks or until the fracture is healed radiographically.
  • Surgery is recommended for fracture with evidence of chronic injury.
  • Grafting can be done in delayed unions.
  • Return to full activity before complete healing is often associated with treatment failure.
  • Evaluation for compartment syndrome must be considered in all injuries to the foot.
  • It is most common in crush injuries of the foot with fractures of the metatarsals, phalanges, and Lisfranc dislocation.
  • Surgical decompression is required.
  • Box 12.12-2 outlines clinical features.
  • Most common injury of the forefoot.
  • May result from direct axial injury (striking the toe against an object) or a crush injury.
  • Fractures of the proximal phalanx of the great toe require accurate reduction of displacement and angulations.
  • Salter-Harris type III physeal injuries are common and require open reduction if displaced to restore the joint surface.
  • Fractures of the distal phalanx, even if
    crushed, require alignment of the toe and nail should be preserved as
    it acts as splint.
  • Phalanx fractures of the lesser toes can
    be treated less aggressively, however reduction is necessary for
    displaced plantarflexed fractures of the head as they can cause
    abnormal plantar pressure.
Sever disease or calcaneal apophysitis is a common
finding in the rapidly growing child athlete. The child presents with
heel pain and tenderness is elicited on compression of the metaphysis
and not the apophysis. Treatment is rest, physical therapy, and
The accessory navicular is also often a source of foot
pain. Its opposition and intimate association with the posterior tibial
tendon can result in a tendonitis known as a prehallux syndrome. This
is often associated with a pronated flat foot. Ogden describes three
types of accessory navicular: ossicle in substance of posterior tendon,
synchondrosis, and cornuate navicular. Treatment is rest and
immobilization in a cast followed by orthotic support of the medial
longitudinal arch. Persistent pain is relieved by excision of the
accessory navicular. Advancement of the posterior tibial tendon does
not restore the arch.
Freilberg’s infraction is an avascular necrosis of the
second metatarsal head and is often confused with a fracture. It is
more common in adolescent girls and is associated with repetitive
trauma. It can be symptomatic for up to 6 months before radiographic
changes are visible. Hamilton describes four types (Table 12.2-4).
Treatment of type I is cast immobilization, while surgery is indicated
in types II and III. Each metatarsal is treated individually.
Köhler’s disease is a clinical diagnosis presenting with
a painful limp and tenderness of the tarsal navicular. It is more
common in boys, presenting around the age of 5 years. In girls it
presents at age 4 and is unilateral in the majority of cases. Köhler’s
disease is associated with x-ray changes of density and narrowing of
the navicular.
Treatment of Köhler’s disease is immobilization in a
short leg walking cast for 8 weeks. Casting for a shorter period may
result in recurrence of symptoms and prolonged recovery.




Avascular necrosis of head heals by “creeping substitution”


Head collapses during revascularization but articular surface remains intact


Head collapses and articular surface is disrupted


Multiple heads involved (form of epiphyseal dysplasia)

from Hamilton WG. Foot and ankle injuries in dancers. In: Mann RA,
Coughlin MJ, eds. Surgery of the foot and ankle. St Louis: Mosby, 1993.

JF, Crichton KJ, Gratten-Smith T, et al. Osteochondral fractures of the
dome of the talus. J Bone Joint Surg (Am) 1989;71A: 1143-1152.
Berndt AL, Harty M. Transchondral fractures. J Pediatr Orthop 2001; 10B:68-72.
Bibbo C, Lin S, Cunningham FJ. Acute traumatic compartment syndrome of the foot in children. Pediatr Emerg Care 2000;16:244-248.
WG. Foot and ankle injuries in dancers. In: Mann RA, Coughlin MJ, eds.
Surgery of the foot and ankle. St Louis: Mosby, 1993.
Laliotis N, Pennie BH, Carty H, et al. Toddler’s fracture of the calcaneus. Injury 1993;24:169-170.
R. Fractures of the talus and calcaneus. In: Weber BG, Brunner CH,
Freuler F, eds. Treatment of fractures in children and adolescents. New
York: Springer-Verlag, 1980.
Owen RJ, Hickey FG, Finley DB. A study of metatarsal fractures in children. Injury 1995;26:537-538.
Spitz DJ, Newberg AH. Imaging of stress fractures in the athlete. Radiogr Clin North Am 2002;40:313-331.
Wiley JJ, Prifitt A. Fractures of the os calcis in children. Clin Orthop Rel Res 1984;188:131-138.
Williams GA, Cowell, Henry HR. Köhler’s disease of the tarsal navicular. Clin Orthop Rel Res 1981;158:53-58.

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