S

Pediatric FracturesJoshua L. Moore DPM FACFAS

Clinical Assistant Professor – Department of Surgery

Assistant Dean of Educational Affairs - TUSPM

Objectives

S Background

S Incidence

S Anatomy

S Classification

S Diagnosis

S Treatment

S Summary

S References

Background

S Management requires awareness of unique anatomy of

pediatric patient.

S Physis is the weakest area of the skeletally immature bone.

S Higher water content in pediatric bone, so more likely to

bend rather than fail.

S Pediatric ankle fractures often missed.

S Children cannot always accurately convey their symptoms.

Incidence

S Tibial and fibular epiphyseal injuries make up 15 - 38% of

all epiphyseal injuries.

S Ankle fractures account for approximately 5% of all

pediatric fractures.

S Most prevalent between ages 8-15.

S Premature physeal closure only about 2%.

Anatomy

S Epiphyses S secondary ossification center

S PhysisS growth plate

S MetaphysisS Location of active bone growth and vascular

elements

S DiaphysisS primary growth center

S Zone of RanvierS Circumferential groove surrounding periphery of

the physisS Supports physis

Anatomy

S Pediatric bone is more porous than adult bone.

S Increased water content makes bone more malleable.

S Pediatric bone:

S More likely to bend than fail

S Unique fracture patterns

S Greenstick fractures

S Torus fractures

Anatomy

S Damage to the germinal cells of the physis

can lead to growth arrest- partial or complete.

S After trauma, growth at the physis

temporarily stops.

S When growth resumes, radiopaque line can

be seen denoting growth recovery (Harris

Growth Lines)

S May see 6 weeks following trauma

Classification

S Salter Harris – growth plate injury anatomic classification

scheme.

S Dias and Tachdjian – merged Lauge-Hansen and Salter

Harris classifications.

S Transitional Fractures

S Triplane fracture

S Juvenile Tillaux fracture

Salter - Harris

S Type I

S Complete separation of the epiphysis from

the metaphysis

S Line of fracture passes through physis

S 6 – 8.5% of physeal injuries

S Minimal displacement due to strong

periosteal adhesions

S Minimal risk for premature physeal closure.

Salter - Harris

S Type II

S 73 – 75% of all physeal injuries

S Fracture through the physis and

exiting through metaphysis

S Metaphyseal avulsion – Thurston-

Holland Sign

Salter - Harris

S Type III

S Begins at the joint surface and exits through

physis

S Occur in older children where physis is

nearing closure

S May have ischemic necrosis due to

epiphyseal blood vessel damage.

Salter - Harris

S Type IV

S Fracture begins at the joint and extends through epiphysis, physis and exits through metaphysis.

S More likely to displace

S Higher likelihood of growth arrest and post traumatic arthritis.

S Goal of treatment:

S Prevent physeal bridging/growth arrest

S Preservation of joint surface

Salter - Harris

S Type V

S Crush injury to physis

S Destroys structural integrity of physis

S Often times diagnosed retrospectively

Juvenile Tillaux Fracture

S 3-5% of all pediatric ankle fractures

S Salter - Harris III fracture of the lateral aspect of the tibial physis

S Anterolateral aspect of the physis still open while the remaining plate is closed

S External rotation of the fibula causes the anterior tibiofibular ligament to avulse the anterolateral epiphysis through the growth plate

S CT to fully evaluate injury

Triplane Fractures

S First described by Marmor in 1970

S 5-7% of all pediatric fractures

S Children reaching skeletal maturity

S May consist of 2, 3 or 4 fragments

S Number of fragments related to age of child and maturity of physis

S 3 planes

S Sagittal fracture extending from the joint, through the epiphysis of the tibia to the level of the physis

S Transverse fracture through the physis

S Coronal fracture of the posterior tibial metaphysis

Triplane Fractures

Diagnosis

S Clinical exam

S Pain

S Limping/refusal to walk

S Decrease in activity/regression of developmental landmark

S Guarding

S Edema

S Ecchymosis

S Deformity

Diagnosis

S X-ray

S Clinical correlation

S May require imaging of contralateral limb

S Physis may appear wider

S CT

S Better able to evaluate physis, ankle articular surface

S Surgical planning

S Bone Scan

S MRI

S If suspect tendon or ligament injury

S New literature suggests SHI of fibula more likely ligamentous injury

Treatment

S Reduce displaced physeal fractures with gentle traction and manipulation.

S Closed reduction should not be attempted >7 days after injury unless intra-articular step-off >2mm.

S Compressive fixation parallel to the physis.

S If must cross physis use smooth pins, remove after healing.

S Most physeal fractures have significant healing within 3 weeks.

S Monitor for growth disturbances at least 6 months or until skeletal maturity.

Treatment

S Type I and II Salter Harris fractures

S Closed reduction

S 7-10 days post injury, callus well

established, better left alone

S Remodeling of minor displacement will

take place

S Advocates for removable splint and

return to activity as tolerated for SHI

lateral malleoli injuries

Treatment

S Type III and IV Salter Harris fractures

S Require adequate reduction

S Restore physis and preserve articular surface

S Open reduction: periosteum handled with

care

S Fine, smooth K-wires can transverse the

growth plate for a few weeks without

interruption

S Percutaneous cannulated screw fixation

parallel to the physis

Pearls

S Minimally displaced fractures with anatomic alignment -percutaneous fixation with k-wires and cannulated screws.

S Larger fracture fragments and those with greater displacement may benefit most from ORIF.

S Closed reduction and percutaneous fixation best achieved within 24 hours of injury.

S Closure with absorbable sutures

S Early ROM and return to weight bearing achieves best results

Complications

S Premature or asymmetric growth arrest

S 2-5%

S Reported in upwards of 14-40% in Salter III and IV

S Rotational deformities

S Infection

S Wound healing

S CRPS

S Post traumatic arthritis

Premature Physeal Closure

S If less than 40 - 50%:

S Resect osseous bridge

S Interpose adipose tissue or methyl methacrylate

S If greater than 40 - 50%:

S Supramalleolar osteotomy (opening wedge) > 10˚

S Epiphysiodesis - 2-5 cm anticipated growth

S Limb lengthening via Illizarov technique > 5cm difference

Summary

S SH I and II injuries do well with closed reduction and modified immobilization.

S SH III and IV anatomic reduction necessary > 2mm displacement.

S Transitional fractures have less likely chance of growth disturbances.

S No compression across the physis.

S CT scan for best evaluation and surgical planning.

References

S Banks, AS. Downey, MS. Martin, DE. Miller, SJ. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery.

Vol 2, Ed 3. Lippincott Williams & Wilkins. Philadelphia, PA. 2001.

S Cicekli O et al. Percutaneous cannulated screw fixation for pediatric epiphyseal ankle fractures. SingerPLus 5:1925,

2016.

S Barmada, A. Gaynor, T. Scoot, J. Premature Physeal Closure Following Distal Tibia Physeal Fractures: A New

Radiographic Predictor. Journal of Pediatric Orthopaedics Vol 23(6), November/December 2003, 733-739.

S Berquist, TH. Radiology of the Foot and Ankle. Ed.2. Lippincott Williams & Wilkins. 2000.

S Boutis K et al. Radiograph-negative lateral ankle injuries in children occult growth plate fracture or sprain? JAMA

Pediatr 170(1), January 2016.

S Denning JR. Complication of pediatric foot and ankle fractures. Orthop Clin N Am. 48, 2017 59-70.

S Flynn, JM. Skaggs, D. Sponseller, PD. Ganley, TJ. Kay, RM. Leitch, KK. The operative management of pediatric

fractures of the lower extremity. J Bone Joint Surg Am 84-A:2288- 2300, 2002.

S Gumann, G. Fractures of the Foot And Ankle. Elsevier Saunders. Philadelphia, PA. 2004.

S Luedtke, L. Templeman, D. Pediatric ankle injuries. American Academy of Othopaedic Surgeons Online E

Newsletter, Minneapolis, MN, August 2006.

S Peterson, HA. Metallic implant removal in children. Journal of Pediatric Orthopaedics. Vol 25:1, 2005.

S Salter RB. Harris, WR. Injuries involving the epiphyseal plate. J Bone Joint Surg Am 45-A:587-622, 1963.

S Su AW, Larson AN. Pediatric ankle fractures: Concepts and treatment principles. Foot Ankle Clin.20(4) December 2015,

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