Most Common Pediatric Fractures and How to Prevent Them

GlobalCast MD, along with Ann and Robert H. Lurie Children's Hospital of Chicago. At the forefront of a healthier future for every child. In today's video, we are going to learn about the most common pediatric fractures and how to prevent them with Dr. Jill Larson, an orthopedic surgeon at Ann and Robert H. Lurie Children's Hospital in Chicago, Illinois. By the end of today's grand rounds, you'll be familiar with the most common pediatric fractures and their management, as well as guidelines and public health safety initiatives to prevent pediatric fractures. The ramp up to fracture season is in the spring and summer months. Once the snow has melted, we see an increase in fracture rates, starting in March until the peak, which usually happens in August. Interestingly, we have a spike here at Lurie Children's in October, likely due to return to school with less supervision on the playground and an increase in school athletic participation. So, what are the most common pediatric fractures? The most common location for a pediatric fracture is the distal radius or wrist fracture. Other common locations include ankle, forearm, elbow, and finger fractures. Let's dive a little deeper into the distal radius or wrist fractures and the importance of identifying growth plates when reviewing X-rays. This is the distal radius, which together with the ulna and the carpal bones make up the wrist joint. In general, there are two types of fractures. The first is an extra-ficile that means outside of the growth plate in a region called the metaphasis. Extra-ficile fractures have a low risk of fecile growth plate arrest or damage to the longitudinal growth of the arm. The closer the fracture is to the fecis, the increased potential for remodeling of any residual deformity. When a fracture extends through the growth plate, it is intervisual. These fractures need to be closely monitored as there can be early closure or growth plate arrest during the healing process. Multiple orthogonal radiographic views help to see the nature of the fracture in its entirety to ensure the fracture displacement isn't missed. A fracture can be described based on the amount of displacement or movement of the bony fragments. This is a non-displaced buckle fracture, also referred to as a torus fracture. The torus means bending of the bone. As you can see, it has buckled under a force. A buckle fracture can be treated with removable forearm slint, waterproof cast, or traditional fiberglass cast. In the pediatric population, a buckle fracture that is non-displaced heals very reliably, depending on age and approximately three to four weeks. Recent studies have demonstrated that fracture healing rates are similar in a removable slint versus a cast. Therefore, removable slint can be applied in an urgent care setting and follow up with a pediatric orthopedic surgeon may not be needed. Waterproof casting has revolutionized a child's ability to tolerate casting for a fracture. What important things to know is that it must get wet daily to prevent skin excoration, and we still recommend avoiding sticking anything into the cast that could cause damage to the skin. Displaced fractures are treated differently than non-displaced fractures. Displaced fractures need to have a closed reduction which often requires sedation. Depending on the age of the child, this can be done with or without anatomic reduction. Here, you can see a near anatomic reduction of the fracture. It's now out to length with appropriate restoration of radial height as well as bolar and dorsal angulation. In children greater than age 10, this is imperative because of the remodeling potential left in the distal forearm. Even with appropriate immobilization, children greater than 10 years of age can still have a curinth of displacement. These fractures are followed closely by orthopedic surgeons and should be seen within three to five days of casting as they sometimes need repeat reduction and interoperative stabilization. For example, this 13 year old has a displaced and angulated fracture and therefore was indicated for a closed reduction and pinning with casting in the operating room to maintain the overall alignment of the fracture for four weeks of healing. The pin is removed and clinic to allow for appropriate range of motion after healing. Physiofractures that propagate through the growth plate need to be treated with caution. While the initial fisiol injury occurs at the time of fracture, a second fisiol injury can occur with reduction. If anatomic reduction is not successfully achieved on the first attempt, then we recommend a patient be treated in the OR for closed reduction to minimize any additional trauma and fisiol growth arrest. Additionally, due to the fisiol injury, we recommend a six month follow up with an x-ray to assess for fisiol growth arrest. X-rays help assess the patency of the growth plate to rule out fisiol bar and visualize uninterrupted Harris-Groath arrest line, which are a reassuring sign of continued longitudinal growth. This also helps us make sure that the fisiol open with appropriate Harris-Groath arrest lines and no evidence of a fisiol bar or growth arrest. Fisiol involvement in pediatric ankle fractures is also a differentiating characteristic in the treatment of ankles fractures when comparing adults and kids. The most common ankle fracture in kids is a distal-fibular fisiol fracture. The fysis in children is often the weakest part of the bone, even weaker than the ligaments or tendons themselves, so we often see fisiol injuries of the distal fibula. These fractures can be treated with a walking type boot or short leg cast. They should be non-weight bearing to prevent further injury to the fysis. Children under the age of 10 may need a walker for stabilization. However, children over the age of 10 can typically mobilize with crutches or a knee-scooter. Fractures at the ankle can also involve the tibia. This is a sulter Harris-2 distal-tibia fracture. The fracture line propagates through the fysis here and then out the metathesisial region of the tibia. The interarticular portion of the tibia is maintained without fracture. This injury also has an associated extra-fisial distal-fibular fracture at the same level as the distal-tibia fracture. A good neurovascular exam is important to assess in any injury, but in a very displaced fracture it is even more critical to evaluate in a timely fashion. The clinician should assess sensory and motor function of the foot, as well as the vascular status. The drosalus pedus and posterior to the alis pulses are the best spots to check for vascular compromise as well as capillary refill of the toes. Once this has been confirmed, it's important to do a reduction maneuver to take off the pressure on the skin as the bony spike can cause soft tissue or skin necrosis and ultimately lead to an open fracture. Another common pediatric ankle fracture type is called a triplane fracture. This fracture propagates through three different planes. So here on the AP image, you can see that there is a fracture through the epiphasis and enters the joint making it intratuticular. The fracture exits through the feces in the second plane and then in the third plane here on the sagittal, you can see it propagates through the metaphasis. This can also be classified as a salt or hairis-four fracture due to the involvement of the metaphasis, the feces, and the epiphasis. Triplane fractures occur most often in the older teenage population and require advanced imaging such as CT scan to better identify the exact displacement of the fracture and the involvement of the joint surface. If the displacement of the joint surface is more than 2 millimeters, an open reduction and internal fixation of the articular surface with a positional screw is required to maintain alignment of the metaphasial fragments. This fracture went on to healing without difficulty, as you can see here. The articular surface is closed down, well maintained, and healed. If this were a younger patient, it's recommended that limb alignment and length are monitored closely due to the possible physical growth arrest. Another common lower extremity injury in younger children are tibial shaft fractures. A toddler's fracture or non-displaced spiral fracture of the tibia shaft is very common in children ages nine months to three years old. At this age, children have a robust periosteal sleeve around their bones, so it is not disrupted. The fracture remains very stable and heals very reliably. However, we still recommend immobilization for comfort. In children with limited verbal skills, there is a high risk of heal ulceration when the leg is placed in temporary splints. Thus, it's imperative that we get close follow-up with a pediatric orthopedic surgeon to make sure that the skin is appropriately decompressed, especially over the heal. We see these children back in clinic three to five days after initial injury. This injury heals very reliably in a short leg cast and toddlers, or sometimes even a walking boot if necessary. In older children, tibial shaft fractures are typically caused by blunt trauma or abending twisting mechanisms such as in tackle football. These can often be treated with a non-operative, closed reduction and a long leg cast above the knee for rotational civility. They are non-weight bearing for six to eight weeks, and then can be transitioned to a short walking cast. Occasionally, however, the fracture displacement or angulation is outside of acceptable functional limits, and therefore, it is recommended that they undergo intramedulary flexible kneeling to maintain the alignment of the fracture during healing. These flexible nails are usually removed in the operating room, six to twelve months after surgery, and appropriate fracture healing. Green sick fractures are an incomplete or bending fracture of the radius and ulna heal nicely after immobilization in a long arm cast after four to six weeks. That's in contrast to a displaced, both bone form fracture, which requires closed reduction to maintain appropriate functional alignment for healing. Due to the swelling from the fracture and the associated softitude trauma within the region, both bone form fractures are at a high risk to develop compartment syndrome. Close, neurovascular monitoring is important if the fracture is reduced, and providers should have high suspicion for compartment syndrome if a pediatric patient has increasing agitation, anxiety, and analgesic requirements after closed reduction and casting. Displaced, both bone forearm fractures are also at high risk for pocole injuries of the skin due to the sharp point of the displaced bones causing a penetrating open fracture. A good skin exam to evaluate for compromise is critical to prevent the sequela of untreated exposed bone. As long as the skin integrity is intact, a reduced both bone forearm fracture is treated in a long arm cast and worn for three to four weeks to immobilize the elbow and prevent pronose supination, followed by two to three weeks in a short arm cast before transition to removable forearm brace. I do counsel families on the increased risk of refracture of this type of injury within the first six months. Occasionally, both bone forearm fractures fail closed reduction attempt due to poor cast fit, reduced swelling causing bony migration or difficulty aligning the bones due to soft tissue interposition. Often, there is a failed closed reduction particularly if there is a proximal fracture of the radius with rotational malalignment, and pediatric patients we often treat these with flexible nailing. Again, this flexible nailing is temporary in nature. It allows the bones to maintain alignment for appropriate healing and then the nails are removed at a later date. It also preserves the feces to prevent any early fecesial closure. The nails are typically removed six to twelve months after healing to avoid the high risk of refracturing within the first six months. The most common fracture at the elbow is a supercondular humorous fracture. There are three types of supercondular fractures. Type 1 is a non-displaced fracture and is treated with a long arm cast for three to four weeks. Type 2 are displaced fractures with a cortical hinge posteriorly intact and treated with closed reduction and percutaneous pinning followed by three to four weeks of casting. Type 3 has a complete disruption of the posterior cortex and often widely displaced, which has an increased risk of neurovascular compromise. These are either treated with a closed reduction and percutaneous pinning versus open reduction and percutaneous pinning. Depending on the stability of the fracture or the concern for vascular compromise. Interoperatively, a supercondular fracture is treated with three laterally-based pins to provide stability to the reduced fracture site and then casting of the elbow in less than 90 degrees of flexion for three to four weeks depending on age. The pins are then removed and clinic at the follow-up appointment and range of motion of the elbow is initiated. Fall pro-nactivities are recommended to be avoided for at least eight weeks postoperatively. Now that we've reviewed the most common types of pediatric fractures and how to treat them, it's even more important that we discussed how to prevent them- obesity, vitamin D, insufficiency, and fall prevention are some of the easiest ways to prevent fractures. Let's dive a little deeper into the implications of obesity and fracture prevention. From an obesity perspective, we know that there has been an obesity epidemic here in the United States. And studies have shown that obese or overweight children are at higher risk for fracture, primarily due to the increased stress on their bones and secondarily due to the inactivity or immobility. OVs children have increased complications of fracture management due to implant failures or fracture millionions. Crutches are often more difficult to fit for obese children as well. And cast immobilization may not be sufficient to stabilize broken bones due to increasing adipose tissue. So when considering fracture prevention in your own patient population or your own family, curbing obesity and maintaining a healthy active lifestyle is one of the best things that you can do for your patients or children. Immundi insufficiency is common in pediatrics, especially in children who are malnourished, lack fun exposure due to geographic location, or absorption due to darker skin tones. Why is vitamin D so important? It's a crucial part of calcium absorption which is necessary for bone growth and stability. Children with vitamin D insufficiency have a fracture risk that is three times greater than a vitamin D sufficient child. Now how do we give vitamin D? It's best to provide a supplementation because we don't get enough vitamin D in our food and rarely enough through the sun. The American Academy of Pediatrics recommends both calcium as well as vitamin D intake daily for those ages four to eight years of age. We recommend 1,000 milligrams of calcium per day and 1,000 international units of vitamin D daily. Let's turn our attention to common mechanisms of injury and what safety guidelines we can follow to help prevent fractures. Each year, 200,000 children injure themselves on playgrounds in the United States of America and another 200,000 get hurt on trampolines alone. Additionally, more than 166,000 children ages five to 14 are treated each year in hospital emergency rooms for injuries related to skateboards, scooters and skates. How can injuries be prevented in the home? Installing window guards. Strapping kids properly into high chairs, infant carriers, swings or strollers. Proper installation of safety gates at the top and bottom of the stairs. Secure TVs and front-served to the wall with mounts, brackets, braces or anchors to prevent them from tipping over. But what about playgrounds? Take your kids to playgrounds with shock-observing surfaces. Most playground injuries are caused by a fall from the monkey bars onto an outstretched hand, which causes a forearm or an elbow fracture. Supervision is the most important factor in preventing or minimizing playground injuries. How do we prevent injuries on scooters, skateboards and roller skates? Remember the pneumonic poo. If there is a wheel, then helmet on. Kids should wear a properly fitted helmet. Risk guards, knee and elbow pads. The American Academy of Pediatrics recommends that children under five years old should not ride a skateboard. It's also important to wear closed-toed shoes that have slip-resistant soles rather than sandals. And goggles or glasses to keep debris out of the eye. The American Academy of Pediatrics recommends that children younger than eight years old should not use a formal two-wheeled scooter. Avoid riding in dangerous settings. Do not ride on slippery or uneven ground or uncrowded sidewalks or streets. Do not do any jumps, tricks or stunts without proper supervision. Did you know that in 2016, more than 4500 children in the United States were treated in emergency departments for injuries related to lawn mowers? There are some recommendations to avoid lawn mower injuries. Use common sense. Keep children out of the yard or at least 20 feet away from a running lawn mower. Children should be at least 12 years of age or older before operating a push lawn mower and 16 years or older to operate a riding lawn mower. Children should never be passengers or ride on lawn mowers. Let's not forget about cell phones. Starting on a phone accounted for 69% of injuries between 2004 and 2010 and texting for 9% of injuries during the same period. So most importantly, just turn off the phone and be aware of your surroundings. Finally, what are Dr. Larson's recommendation for trampolines? The American Academy of Pediatrics guidelines is the safest course of action is to not buy or use a trampoline. However, trampolines are fun, so if you're going to use them, here are the recommendations. Use a net or ground level trampoline to decrease risk of fall from height, only one child at a time on a trampoline. Children and groups should be the same age or size. An adult should directly supervise trampoline use at all times. So here are my key take home points. Do keep your children healthy and active. It's important to have adequate calcium and vitamin D intake daily. They should also be getting 35 to 60 minutes of weight-bearing play per day. Do encourage or enforce appropriate protective wear on a bicycle, scooter, or skateboard, which means always have a helmet and use appropriate guards, especially risk guards for skateboarding. Discourage distracted walking in your teenage patients. Children allow your child to be unsupervised on a trampoline. Thank you for joining us today as Dr. Jill Larson, a pediatric orthopedic surgeon at Lurie Children's, reviewed common pediatric fractures, prevention, and management. She highlighted the top five most common fractures in active children and emphasized their seasonal trends. She also provided essential insight into fracture types, management, growth plate concerns, cognitive measures, including vitamin supplementation, obesity, and safe play guidelines. Thank you Dr. Larson for providing us with a comprehensive understanding of pediatric orthopedic injuries. Global cast MD, along with Annan Robert H. Lurie Children's Hospital of Chicago, at the forefront of a healthier future for every child.