37

Pediatric Trauma: Getting Through the Night

Susan A. Scherl, MD
Andrew H. Schmidt, MD

children (for example, compartment

Abstract syndrome, pelvic fractures with he-
As is the case in adults, the timing and type of emergent treatment of fractures in children
modynamic instability, and trau-
can be controversial. Some emergent conditions, such as compartment syndrome, pelvic
matic amputations and open frac-
fractures with hemodynamic instability, and open fractures, are managed similarly in
tures). Instead, it focuses on entities
adults and children. However, other types of fractures are unique to children or are man-
that are either unique to children or
aged differently in children and adults. To prevent complications, it is important to un-
are managed differently in children
derstand the appropriate treatment and timing of treatment of supracondylar humeral
and adults. Specifically, supracondy-
fractures and other specific elbow fractures, hip fractures and dislocations, and physeal
lar humeral fractures and other spe-
fractures about the knee in pediatric patients.
cific elbow fractures, hip fractures
Instr Course Lect 2010;59:455-463.
and dislocations, and physeal frac-
tures about the knee are discussed.
Although most orthopaedic sur- should have an understanding of
geons do not specialize in pediatrics, which pediatric fractures are emer- Supracondylar Humeral
almost all practicing orthopaedic gencies and why, how to treat these Fractures
surgeons, and certainly anyone on fractures or at least temporize before Supracondylar humeral fractures are
emergency trauma call, will be definitive treatment, and how and relatively common. They account
called on at some point to treat a why the treatment of children’s for 30% of extremity fractures in
child with a fracture. It is therefore fractures sometimes differs from children younger than 7 years and
imperative for practitioners to have that of adult fractures. 60% of elbow fractures in that age
some working knowledge of current This chapter does not address group. They are most common in
pediatric fracture care. At a mini- emergent problems that present and the first decade of life. Extension-
mum, all orthopaedic surgeons are managed similarly in adults and type injuries account for 96% of su-
pracondylar humeral fractures and
result from a fall on an outstretched
Dr. Scherl or an immediate family member is a board member, owner, officer, or committee member of the Ortho- arm that forces the elbow into hy-
paedic Trauma Association and the Pediatric Orthopaedic Society of North America; has received research or insti-
tutional support from Arthrex, the National Institutes of Health, Tornier, and ESKA; and has received nonincome perextension. The much less com-
support (such as equipment or services), commercially derived honoraria, or other non–research-related funding mon flexion-type injuries occur
(such as paid travel) from Lippincott Williams & Wilkins and UpTODATE. Dr. Schmidt or an immediate
family member is a board member, owner, officer, or committee member of the Orthopaedic Trauma Association; from a fall onto the point of the
has received royalties from Smith & Nephew; is a member of a speakers’ bureau or has made paid presentations on olecranon with the elbow flexed.
behalf of Synthes; serves as a paid consultant for or is an employee of Smith & Nephew, Twin Star Medical,
Medtronic, DigiMed, and AGA; serves as an unpaid consultant for Conventus Orthopedics and Anthem Ortho-
According to the commonly used
pedics; has received research or institutional support from Synthes, Smith & Nephew, Twin Star Medical, and Gartland classification,1 type I inju-
Medtronic; owns stock or stock options in Twin Star Medical, Conventus Orthopedics, and the International ries are nondisplaced; type II inju-
Spine and Orthopedic Institute; and has received nonincome support (such as equipment or services), commer-
cially derived honoraria, or other non–research-related funding (such as paid travel) from Thieme. ries are angulated posteriorly, but

AAOS Instructional Course Lectures, Volume 59, 2010 455

Trauma
the posterior cortex is intact; and
type III injuries are completely dis-
placed, usually with the distal part of
the humerus and the elbow dis-
placed posteromedially.
A patient with a supracondylar
humeral fracture presents after a
specific injury; has pain, swelling,
and a decreased range of motion of
the elbow; and usually has pain
when motion of the arm is at-
tempted. There is tenderness over
the distal part of the humerus and,
typically, an obvious deformity.
There may be ecchymosis or but-
tonholing of the skin at the fracture
site. The child holds the arm in ex-
tension and pronated at the forearm.
A careful neurovascular examination
is imperative. On initial presenta-
tion, the radial pulse may be absent
secondary to draping of the artery
over the spike of the proximal frac-
ture fragment. Often, the pulse re-
turns after fracture reduction. The
function of the median, ulnar, radial,
and anterior interosseous nerves
must be documented and the fore-
arm assessed for signs of ischemia or
compartment syndrome.
AP and lateral radiographs of the
elbow should be obtained. Compar-
ison radiographs of the contralateral
elbow can aid in interpreting the im-
ages. On the lateral radiograph, a
line drawn along the anterior border
of the humerus should pass through
the center of the capitellum if there
is no displacement. A posterior fat
pad sign (a radiolucent area seen
posterior to the distal part of the hu-
merus, adjacent to the olecranon
fossa, on a plain lateral radiograph)
indicates a hemarthrosis and sug-
gests an occult elbow fracture.2
Vascular injury occurs in approxi-
mately 1% of patients. Indications
for vascular exploration are clinically
obvious ischemia or loss of a pulse
that had been previously palpable or
456
apparent on Doppler examination
after fracture reduction, because this
may indicate that the vascular bun-
dle has become entrapped in the
fracture site. The use of arteriogra-
phy in children is controversial, as is
the management of the “pink, pulse-
less hand;” the usual recommenda-
tion is observation without vascular
exploration in such situations.3
Neurologic injury occurs in
about 7% of patients. Most nerve in-
juries are neurapraxias that resolve
with time. The radial nerve is at the
most risk of transection, which usu-
ally occurs with open fractures. The
anterior interosseous nerve is the
most frequently injured.4 This
nerve is injured when the postero-
lateral part of the distal fracture frag-
ment compresses the nerve against
the anterior structures in the fore-
arm. Injury to the anterior in-
terosseous nerve results in weak
flexion of the interphalangeal joint
of the thumb and the distal inter-
phalangeal joint of the index finger.
The radial nerve is more commonly
injured in patients with a postero-
medial fracture. The median nerve
is more commonly injured in those
with a posterolateral fracture, often
in association with a brachial artery
injury. A median nerve injury can
mask a compartment syndrome be-
cause of the associated sensory loss
in the forearm. Ulnar nerve injury
is often iatrogenic, secondary to
medial pin placement, but it also oc-
curs in conjunction with a flexion-
type supracondylar humeral frac-
ture.
The treatment of supracondylar
humeral fractures depends on the
direction and degree of displace-
ment. Gartland type I injuries may
be treated, without reduction, in a
long arm cast with the elbow flexed
90° to 110° for 3 to 4 weeks. Dis-
placed Gartland type II and III inju-
AAOS Instructional Course Lectures, Volume 59, 2010
ries are treated with closed reduc-
tion and percutaneous pinning, with
either two or three lateral pins or
crossed medial and lateral pins.
There is no substantial difference in
the stability provided by the lateral
and crossed-pin methods if proper
technique and pin placement are
used. The two lateral pins should
be divergent, with one running up
the lateral column and one crossing
over to the medial column. The two
pins should not cross at the fracture
site; a third pin should be added
when there is medial comminution
or persistent instability with
motion5-8 (Figure 1 and Table 1).
The timing of surgery for a dis-
placed supracondylar humeral frac-
ture is controversial. A supracondylar
humeral fracture is one of the classic
pediatric orthopaedic emergencies,
but the need to perform surgery in
the middle of the night for these
injuries has recently been challenged.
Four retrospective studies showed
no increase in complications in chil-
dren for whom surgery had been
delayed more than 12 hours.9-12
Another study showed a possible
increase in the prevalence of com-
partment syndrome in children
with a delay of more than 22 hours
before surgery.13 In the opinion
of the chapter’s authors, if a delay
of 12 to 24 hours is necessary or
inevitable, the outcome should not
be adversely affected. However,
waiting is not a better option. Sur-
gery should not be delayed unless
the child has normal neurovascular
function. Furthermore, surgery
should not be delayed if there is ex-
cessive swelling or soft-tissue dam-
age; the case must still be considered
urgent, with the surgery being done
at the earliest possible opportunity
the following morning and not after
the next day’s elective surgery
schedule, for example.
Pediatric Trauma: Getting Through the Night Chapter 37

Vascular injury or interposition of Fortunately, complications are beneficial. Cubitus varus is caused
the neurovascular bundle are the infrequent after supracondylar by varus positioning of the fracture
two most definitive indications for humeral fractures, and most are fragment as well as residual rota-
open reduction.14 The antecubital avoided by attention to detail during tional deformity. Although cubitus
approach is useful in both cases. treatment.15,16 Ulnar nerve injury— varus is generally a cosmetic prob-
Although vascular compromise usu- usually a neurapraxia that resolves in lem, ulnar nerve palsy can occur
ally can be managed without the 3 to 6 months—is often the result of later; a distal humeral osteotomy is
need to operate on the artery, arterial medial pin placement. Occupational occasionally necessary. Loss of
repair may be needed and should be therapy during resolution may be reduction is usually a result of
planned for. An inability to achieve
an acceptable closed reduction be-
cause of lateral or medial soft-tissue
or periosteal interposition is another
indication for open reduction. An
approach from the affected side al-
lows removal of the offending soft
tissue.
The pins are removed in the phy-
sician’s office after periosteal new
bone is visible radiographically,
generally at 3 to 4 weeks. Additional
protective immobilization is usually
not necessary. Children generally
regain range of motion within about
3 to 4 weeks without physical thera-
py, although the last few degrees of
flexion may lag. Follow-up with ra-
Figure 1 AP (A) and lateral (B) radiographs showing fixation of a Gartland type III
diographs and physical examination
supracondylar humeral fracture with a three-lateral-pin construct. Note the diver-
is recommended at 3, 6, and 12 gence of the pins, with one going up the lateral column and two traversing the olec-
months after injury. ranon fossa to the medial column.

Table 1
Pearls and Pitfalls for Closed Reduction and Percutaneous Pinning of Supracondylar Humeral Fractures
Place the patient supine.
Flip the C-arm, bring it perpendicular to the operating room bed, and use it as a table.
Reduction maneuver: straight traction, adjustment of the distal fragment medially or laterally, flexion of the elbow while pushing the distal
fragment anteriorly, forearm pronation to “lock” the fragment in place
If no assistance is available, secure the arm in the reduced, flexed position with a roll of gauze.
Use 4-inch (10.2-cm) long, 0.062-inch (1.57-mm) diameter Kirschner wires.
Insert two pins from the lateral side.
If the fracture remains unstable, insert an additional pin: either a third lateral pin or a medial pin.
The medial pin can be inserted through a mini-open incision to ensure that the starting point is directly on the medial epicondyle and the
ulnar nerve is out of the way.
Extend the arm to insert a medial pin; this drops the ulnar nerve posteriorly, further out of the way.
If the patient wakes up with an ulnar nerve palsy, first simply pull the medial pin.
Pay careful attention to rotational alignment; malrotation causes cubitus varus.
Splint with the elbow in 70° to 90° of flexion, in a posterior mold with side slabs.
Do not change the splint until it is time to pull the pin; doing so causes the child unnecessary discomfort and anxiety.
Leave the ends of the pins long enough to grab and pull out with your fingers; children do not like to be approached with pliers.

AAOS Instructional Course Lectures, Volume 59, 2010 457

Trauma
technical problems with pin place-
ment.16 Pin site infections are rare.
Transphyseal Elbow Fractures
The prevalence of transphyseal frac-
tures of the distal part of the hu-
merus is unknown, as these injuries
are sometimes missed or misdiag-
nosed. They occur primarily in chil-
dren younger than 4 years. They oc-
cur as a result of a fall on an
outstretched arm but may be the re-
sult of abuse if the child is not yet
walking; a high index of suspicion
should be maintained in such cases.
The fractures usually have a Salter-
Harris type I or II pattern.17 The di-
agnosis of transphyseal elbow frac-
ture should be considered when a
very young child presents with pain,
swelling, and decreased use of the
upper extremity. These injuries are
frequently mistaken for elbow dislo-
cations.
Because these fractures occur
in very young children in whom
much of the distal part of the hu-
merus (often including the capitel-
lum) is not yet ossified, radiographs
may be difficult to interpret. When
the elbow is dislocated, the normal
radiocapitellar relationship is dis-
rupted, but it is preserved with a
transphyseal fracture. An arthro-
gram, a MRI scan, or a sonogram,
all of which allow visualization of
the nonossified capitellum, may aid
in the diagnosis. A closed reduction,
with or without percutaneous pin-
ning, is needed. Often, these inju-
ries present late, when there is al-
ready a periosteal reaction indicating
healing. Reduction is not indicated
in these cases.
The most common complication
is malunion as a result of a late diag-
nosis. Luckily, there is substantial
remodeling potential in young chil-
dren. Rarely, osteonecrosis of the
trochlea occurs.
458
Fractures of the
Lateral Condyle
Seventeen percent of elbow frac-
tures in children are fractures of the
lateral condyle. The peak incidence
is between 5 and 10 years of age.
These injuries are caused by varus
stress to an extended elbow with the
forearm in supination. Children
with a fracture of the lateral condyle
present with lateral swelling and
pain in the elbow. These fractures
are much less likely to be associated
with neurovascular injury than are
supracondylar humeral fractures.
AP and lateral radiographs of the el-
bow are essential. Sometimes, ob-
lique radiographs help to visualize
the fracture. Fractures of the lateral
condyle are often mistaken for
“chip” or “avulsion” fractures in
very young children because most of
the distal fracture fragment, includ-
ing its articular surface, is not ossi-
fied. Although fractures of the lat-
eral condyle may be classified with
the Salter-Harris classification or the
anatomically based Milch classifica-
tion, many pediatric orthopaedic
surgeons classify them simply on
the basis of whether they are dis-
placed because displacement dic-
tates treatment.17,18
Nondisplaced fractures of the lat-
eral condyle may be treated in a long
arm cast with the elbow in 90° of
flexion. Frequent follow-up and re-
peat imaging are necessary to watch
for late displacement and the subse-
quent need for surgical treatment.
Displaced fractures are best treated
with an open reduction and pinning
with two or three lateral pins. Direct
visualization before pinning is nec-
essary to ensure an anatomic re-
duction of the articular surface. An
arthrogram can be made for mini-
mally displaced fractures, and, if the
articular surface of the humerus is
congruent, the pins may be placed
AAOS Instructional Course Lectures, Volume 59, 2010
without opening the fracture. Be-
cause fractures of the lateral condyle
are not likely to be associated with
neurovascular injury, they are con-
sidered urgent but not in need of
emergent surgical treatment.
Fractures of the lateral condyle
are prone to late complications, in-
cluding late displacement; malunion
and nonunion, even after appropri-
ate fixation; growth disturbance; late
deformity; and loss of motion. Par-
ents should be warned of these pos-
sibilities at the time of injury.
Monteggia
Fracture-Dislocations
Monteggia fractures involve the
proximal part of the ulna and are as-
sociated with a dislocation of the ra-
dial head. They are rare in children,
accounting for about 0.4% of all
forearm fractures. The peak inci-
dence is between 4 and 10 years of
age. The Bado classification is used
to describe these injuries in children
as well as in adults.19 Bado type I in-
juries, which involve anterior angu-
lation of the ulna and anterior dislo-
cation of the radial head, are the
most common variant in children,
accounting for 70% of the fractures.
Monteggia fractures in children are
easy to miss. On all radiographic
views, a line drawn through the cen-
ter of the radial head should pass
through the center of the capitel-
lum. Any deviation from this is not
normal and requires further evalua-
tion. “Pure” radial head dislocations
may not exist in children; therefore,
it is advisable to look for plastic de-
formation of the ulna in children
with a dislocated radial head.
Monteggia fractures can usually
be treated with closed reduction
(probably best performed with the
patient under general anesthesia)
and immobilization with the elbow
in 90° to 110° of flexion and the
Pediatric Trauma: Getting Through the Night
forearm in full supination. Reduc-
tion is achieved by first correcting
the ulnar deformity, then reducing
the radial head, and finally relieving
the deforming forces by positioning
the elbow in flexion and the forearm
in supination. Plastic deformation of
the ulna is sometimes particularly
difficult to reduce.
Associated neurovascular injuries
are rare. A late diagnosis can be asso-
ciated with so much fracture healing
that an osteotomy of the ulna, open
reduction of the radial head, and an-
nular ligament reconstruction are
necessary.
Hip Fractures
Femoral neck and intertrochanteric
femoral fractures are rare in chil-
dren, accounting for less than 1% of
all childhood fractures.20 They are
usually caused by high-energy
trauma, and associated injuries, in-
cluding other fractures, head inju-
ries, and abdominal injuries, are
common. Proximal femoral frac-
tures in children are classified ac-
cording to the scheme first reported
in the French literature by Delbet in
1907 and popularized by Colonna in
1929.21 In this classification, type I
consists of transphyseal separation.
This is an uncommon variant, ac-
counting for 7% of these fractures.
Fifty percent of type I fractures oc-
cur with a femoral head dislocation,
there is an extremely high rate of os-
teonecrosis (up to 100%), and there
is a high rate of growth arrest.
Type II fractures are transcervical,
and they are the most common, ac-
counting for 50% of these fractures.
Up to 80% of type II fractures are
displaced, and there is a high rate of
osteonecrosis (40% to 50%). Type III
fractures are cervicotrochanteric,
and account for 31% of these frac-
tures. Fifty percent are displaced,
and, although the risk of osteone-
AAOS Instructional Course Lectures, Volume 59, 2010
Chapter 37
Table 2
Pearls and Pitfalls for Pediatric Hip Fractures
The goal of treatment is anatomic reduction of the proximal part of the femur.
An anterolateral (Watson-Jones) surgical approach is used for open reduction.
Consider internal fixation for nondisplaced fractures to avoid late displacement and the
subsequent development of coxa vara.
Advise parents before treatment about the potential for serious late complications.
Do not compromise fracture stability/fixation to protect the physis; cross it with fixation
pins if necessary.
The proximal femoral physis grows only 1/8 inch (3 mm) per year. If a limb-length
discrepancy occurs, it can be readily managed.
Internal fixation options:
0 to 3 years of age: smooth pins (5/64 inch [2 mm] or 3/32 inch [2.4 mm]) or
cannulated screws (3.5 or 4.0 mm)
4 to 8 years of age: cannulated screws (4.0 or 4.5 mm) or a pediatric hip-compression
screw
Older than 8 years: cannulated screws (6.5 or 7.3 mm) or a hip-compression screw
Pediatric bone is often denser than adult bone; consider predrilling and tapping.
Consider using a supplemental hip spica cast in children younger than 8 years.
Remove hardware in approximately 1 year.
Pathologic fractures may require additional treatment.
Osteonecrosis is probably predetermined by the fracture “personality.” However, these
fractures are still considered emergent; treatment should not be delayed unless
medically necessary.
Consider hip joint aspiration when a fracture is treated closed.
crosis is lower than the risk with tions are evident within 6 to
type I and II fractures, it is still real. 9 months after the injury. Necrosis
Type IV fractures are intertrochan- of the femoral head is the most seri-
teric. This is an uncommon variant, ous complication and is in large part
is associated with the fewest compli- a function of the initial fracture pat-
cations, and healing is rapid. tern. Coxa vara and coxa valga result
Transphyseal separations (type I) from malunion, as does limb-length
are treated with either closed or discrepancy. Nonunion is rare but
open reduction and transphyseal can occur. Late arthritis can develop
pinning22-24 (Table 2). Femoral secondary to osteonecrosis and
neck fractures (type II) are also malunion.
treated with closed or open reduc-
tion and pin fixation of the femoral Hip Dislocations
neck. Cervicotrochanteric fractures Hip dislocations are uncommon in
(type III) are treated similarly but children, but they are more com-
also can be managed with a spica cast mon than hip fractures. They
if the fracture is not displaced. Inter- can occur with relatively minor
trochanteric fractures (type IV) can trauma. Most (90%) are posterior,
be treated with either a spica cast or and 15% to 20% are associated with
internal fixation with a pediatric hip a hip fracture. Hip dislocations are
screw, depending on the size of the usually easy to diagnose on the basis
child and the degree of displace- of the history, physical examination,
ment. an AP radiograph of the pelvis, and a
Hip fractures in children are as- cross-table lateral radiograph of
sociated with an overall complica- the hip. Typically, with a posterior
tion rate of 60%. Most complica- dislocation, the hip is flexed,
459
Trauma

Figure 2 A, AP radiograph of the pelvis, showing a dislocation of the left hip sustained by a 13-year-old boy while playing foot-
ball. B, AP radiograph of the left hip, made after an attempt at closed reduction in the emergency department with the patient un-
der sedation. Note the resultant displaced transphyseal fracture of the femoral head. C, Lateral radiograph of the left hip, made
immediately following open reduction and internal fixation of the fracture-dislocation.

adducted, and internally rotated.
With an anterior dislocation, the hip
is extended, abducted, and exter-
nally rotated.
A closed reduction should be per-
formed with the patient under gen-
eral anesthesia and with the use of
muscle relaxation to minimize the
risk of creating a transphyseal fracture
when the femoral head contacts the
acetabular rim (Figure 2). Preferably,
the reduction should be performed
within 6 hours after the injury, to re-
duce the chance of subsequent fem-
oral head necrosis. The reduction
maneuver for a posterior dislocation
involves anterior traction with the
hip and knee flexed. Longitudinal
traction with the hip extended and
the knee slightly flexed is used for an
anterior dislocation. If it is irreduc-
ible, proceed to open reduction
from the direction of the disloca-
tion. After reduction, the stability
and congruency of the joint should
be assessed. If there is any doubt
about the quality of the reduction, a
CT scan should be performed to
identify interposed soft tissue or
intra-articular loose fragments. A
spica cast or hip abduction brace is
used for 6 weeks.
Femoral head necrosis develops
after 10% to 16% of hip dislocations.
Some patients experience a transient
sciatic neurapraxia. Recurrent dislo-
cation is rare in children.
Physeal Fractures
About the Knee
Physeal fractures about the knee are
relatively rare; they account for 1%
to 6% of physeal injuries in children.
The Salter-Harris system is used to
classify these injuries.17 Fractures
through the growth plate should be
anatomically reduced if the child has
more than 2 years of growth re-
maining; restoration of the articular
surface is critical to achieve a good
outcome. Salter-Harris type I and II
fractures can be treated with closed
reduction and cast immobilization
or with closed reduction and percu-
taneous pin or screw fixation. Salter-
Harris type III and IV fractures are
best treated with an open reduction
and percutaneous or internal fixa-
tion, usually with screws that do not
cross the physis.
Distal Femoral
Physeal Fractures
These fractures are usually hyperex-
tension injuries, but they can be
caused by a hyperflexion force.
They are a childhood analog of a
knee dislocation, and injury to the
neurovascular structures is a risk.
Motor and sensory function and
vascular supply to the distal part of
the lower limb should be carefully
examined. As is the case for a patient
with a neurovascular injury after
a supracondylar fracture, insuffi-
ciency of the vascular supply to the
distal part of the lower limb requires
emergent care.
Treatment of the fracture de-
pends on the fracture pattern, the
amount of displacement, and the
nature of the physeal injury, as de-
scribed according to the Salter-
Harris classification17 (Table 3).
Salter-Harris type I fractures that are
not displaced can be treated in a long
leg cast, with or without a pelvic
band, for 4 to 6 weeks. The preva-
lence of growth arrest is low after
such injuries. Displaced Salter-
Harris type I fractures should be re-

460 AAOS Instructional Course Lectures, Volume 59, 2010

Pediatric Trauma: Getting Through the Night
duced (usually with a closed reduc-
tion), and cross-pins should be
placed to maintain the reduction.
Reduction should be achieved, with
the patient under general anesthesia,
by applying traction in extension
supplemented by slight flexion or
extension of the distal fragment as
needed. Cross-pin fixation is ac-
complished with smooth Steinmann
pins that cross proximal to the frac-
ture site. The pins are typically in-
serted retrograde, from distal to
proximal, starting just posterior to
the midpoint of the condyle and
aiming 10° anteriorly. Alternatively,
they may be inserted antegrade, from
proximal to distal. This method is
technically more demanding, but the
advantage is that pins do not pass
through the joint (Figure 3). The
pins may be buried or be left outside
the skin and can be removed in
4 weeks. The rate of growth arrest in
association with displaced injuries is
high (up to 40%).
Salter-Harris type II fractures are
treated with closed reduction and
percutaneous pin fixation. To treat
these fractures, pins or screws
should be placed in the metaphyseal
Figure 3 A, Lateral radiograph of a displaced Salter-Harris type I fracture of the distal part of the femur in a 12-year-old boy. AP
(B) and lateral (C) radiographs of the knee, made after closed reduction and antegrade percutaneous pin fixation.
AAOS Instructional Course Lectures, Volume 59, 2010
Chapter 37
(Thurston-Holland) fragment, if it to determine if there is a growth
is large enough, and parallel to the disturbance, and the patient and
physis (Figure 4). Placing pins or parents should be advised of this
screws across the physis should be risk at the initial assessment.
avoided whenever possible.
Salter-Harris type III and IV frac- Proximal Tibial Fractures
tures have intra-articular extensions, Fractures through the growth plate
and should be reduced with an open of the proximal part of the tibia are
procedure and internally fixed with uncommon but, like distal femoral
pins or screws placed parallel to the physeal injuries, they are a child-
physis. Crossing the physis with hood analog of a knee dislocation
hardware should be avoided when- and can therefore be associated with
ever possible. All patients with neurovascular injury or compart-
physeal injuries should be followed ment syndrome.
Table 3
Pearls and Pitfalls for Pediatric Distal Femoral Fractures
Salter-Harris fractures are more common than ligamentous injuries in children.
Nondisplaced Salter-Harris type I fractures may present with normal radiographs, and a
high index of suspicion must be maintained if there is clinical evidence of the fracture
(tenderness over the physis).
At a minimum, obtain orthogonal (AP and lateral) radiographs of the knee.
Obtain additional views, and contralateral comparisons, as needed.
The use of stress radiographs is controversial.
Never hesitate to treat a presumed Salter-Harris type I fracture on the basis of clinical
findings.
The findings on physical examination are similar for all of these injuries. There is pain and
knee effusion with or without an inability to bear weight, deformity, and point
tenderness.
Distal femoral physeal fractures in particular are associated with a high rate of postinjury
premature growth arrest.
461
Trauma

Figure 4 A, AP and lateral radiographs of a completely displaced Salter-Harris type II fracture of the distal part of the femur in
an 11-year-old boy. B, Radiographs made immediately after open reduction and internal fixation with the use of two screws
placed across the metaphyseal component of the fracture (the Thurston-Holland fragment).

pulseless pink hand in pediatric su-

Table 4
Pearls and Pitfalls for Pediatric Proximal Tibial Fractures pracondylar fractures of humerus.
J Pediatr Orthop 1997;17:303-310.
Physeal injuries about the knee are relatively uncommon.
4. Lyons ST, Quinn M, Stanitski CL:
Non–intra-articular (Salter-Harris type I and II) fractures can often be treated nonsurgically.
Neurovascular injuries in type III hu-
Most intra-articular (Salter-Harris type III and IV) fractures require surgical treatment. meral supracondylar fractures in chil-
One should not hesitate to open a Salter-Harris type I or II fracture if an adequate closed dren. Clin Orthop Relat Res 2000;376:
reduction cannot be achieved.
62-67.
These fractures have a guarded prognosis. The prevalence of growth arrest is high. Parents
must be informed of this at the time of injury. 5. Davis RT, Gorczyca JT, Pugh K: Su-
Beware of neurovascular injury and compartment syndrome. pracondylar humerus fractures in
children: Comparison of operative
treatment methods. Clin Orthop Relat
Res 2000;376:49-55.
Most Salter-Harris type I and II drome, osteonecrosis, or growth ar-
6. Skaggs DL, Cluck MW, Mostofi A,
injuries can be treated with closed rest, which may be avoided by Flynn JM, Kay RM: Lateral-entry pin
reduction and cast immobilization timely and accurate reduction and fixation in the management of supra-
or percutaneous pinning (Table 4). fixation. condylar fractures in children. J Bone
Salter-Harris type III and IV frac- Joint Surg Am 2004;86-A:702-707.
tures require open reduction and in- 7. Skaggs DL, Hale JM, Bassett J, Ka-
ternal fixation.
References
minsky C, Kay RM, Tolo VT: Opera-
1. Gartland JJ: Management of supra- tive treatment of supracondylar frac-
Summary condylar fractures of the humerus in tures of the humerus in children: The
Pediatric fractures that require con- children. Surg Gynecol Obstet 1959; consequences of pin placement.
109:145-154. J Bone Joint Surg Am 2001;83-A:
sideration for an emergent trip to
2. Skaggs DL, Mirzayan R: The poste- 735-740.
the operating room include supra-
rior fat pad sign in association with 8. Thomson JD, Stricker SJ, Wil-
condylar humeral fractures, Mon-
occult fracture of the elbow in chil- liams MM: Fractures of the distal
teggia fracture-dislocations, hip dren. J Bone Joint Surg Am 1999;81: femoral epiphyseal plate. J Pediatr Or-
fractures and dislocations, and phys- 1429-1433. thop 1995;15:474-478.
eal fractures about the knee. These
3. Sabharwal S, Tredwell SJ, Beau- 9. Gupta N, Kay RM, Leitch K,
fractures are prone to neurovascular champ RD, et al: Management of Femino JD, Tolo VT, Skaggs DL: Ef-
compromise and compartment syn-

462 AAOS Instructional Course Lectures, Volume 59, 2010

Pediatric Trauma: Getting Through the Night
fect of surgical delay on perioperative
complications and need for open re-
duction in supracondylar humerus
fractures in children. J Pediatr Orthop
2004;24:245-248.
10. Iyengar SR, Hoffinger SA, Town-
send DR: Early versus delayed reduc-
tion and pinning of type III displaced
supracondylar fractures of the hu-
merus in children: A comparative
study. J Orthop Trauma 1999;13:
51-55.
11. Leet AI, Frisancho J, Ebramzadeh E:
Delayed treatment of type 3 supra-
condylar humerus fractures in chil-
dren. J Pediatr Orthop 2002;22:
203-207.
12. Mehlman CT, Strub WM, Roy DR,
Wall EJ, Crawford AH: The effect of
surgical timing on the perioperative
complications of treatment of supra-
condylar humeral fractures in chil-
dren. J Bone Joint Surg Am 2001;83-A:
323-327.
13. Ramachandran M, Skaggs DL, Craw-
ford HA, et al: Delaying treatment of
AAOS Instructional Course Lectures, Volume 59, 2010
supracondylar fractures in children:
Has the pendulum swung too far?
J Bone Joint Surg Br 2008;90:1228-
1233.
14. Reitman RD, Waters P, Millis M:
Open reduction and internal fixation
for supracondylar humerus fractures
in children. J Pediatr Orthop 2001;21:
157-161.
15. Mostafavi HR, Spero C: Crossed pin
fixation of displaced supracondylar
humerus fractures in children. Clin
Orthop Relat Res 2000;376:56-61.
16. Sankar WN, Hebela NM, Skaggs DL,
Flynn JM: Loss of pin fixation in dis-
placed supracondylar humeral frac-
tures in children: Causes and preven-
tion. J Bone Joint Surg Am 2007;89:
713-717.
17. Salter RB, Harris WR: Injuries in-
volving the epiphyseal plate. J Bone
Joint Surg Am 1963;45:587-622.
18. Milch H: Fractures and fracture dis-
locations of the humeral condyles.
J Trauma 1964;4:592-607.
Chapter 37
19. Bado JL: The Monteggia lesion. Clin
Orthop Relat Res 1967;50:71-86.
20. Canale ST: Fractures of the hip in
children and adolescents. Orthop Clin
North Am 1990;21:341-352.
21. Colonna PC: Fracture of the neck of
the femur in children. Am J Surg
1929;6:793-797.
22. Cheng JC, Tang N: Decompression
and stable internal fixation of femoral
neck fractures in children can affect
the outcome. J Pediatr Orthop 1999;19:
338-343.
23. Ng GP, Cole WG: Effect of early hip
decompression on the frequency of
avascular necrosis in children with
fractures of the neck of the femur. In-
jury 1996;27:419-421.
24. Song KS, Kim YS, Sohn SW,
Ogden JA: Arthrotomy and open re-
duction of the displaced fracture of
the femoral neck in children. J Pediatr
Orthop B 2001;10:205-210.
463
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