Most Common Pediatric Fractures and How to Prevent Them by Dr. Jill Larson

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 increased 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-physeal, that means outside of the growth plate, in a region called the metaphysis. Extra-physeal fractures have a low risk of physeal growth plate arrest or damage to the longitudinal growth of the arm. The closer the fracture is to the physis, the increased potential for remodeling of any residual deformity. When a fracture extends through the growth plate, it is intra-physeal. 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. 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 splint, waterproof cast, or traditional fiberglass cast. In the pediatric population, a buckle fracture that is non-displaced heals very reliably, depending on age, in approximately three to four weeks. Recent studies have demonstrated that fracture healing rates are similar in a removable splint versus a cast. Therefore, a removable splint 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. But important things to know is that it must get wet daily to prevent skin excoriation, 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. These 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 volar 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 recurrence 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 intraoperative 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 in clinic to allow for appropriate range of motion after healing. Physeal fractures that propagate through the growth plate need to be treated with caution. While the initial physeal injury occurs at the time of fracture, a second physeal 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 physeal growth arrest. Additionally, due to the physeal injury, we recommend a six month follow up with an x-ray to assess for physeal growth arrest. X-rays help assess the patency of the growth plate to rule out physeal bar and visualize uninterrupted Harris growth arrest lines, which are a reassuring sign of continued longitudinal growth. This also helps us make sure that the physis is open with appropriate Harris growth arrest lines and no evidence of a physeal bar or growth arrest. Physeal 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 physeal fracture. The physis in children is often the weakest part of the bone, even weaker than the ligaments or tendons themselves. So, we often see physeal 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 physis. 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 Salter Harris 2 distal tibia fracture. The fracture line propagates through the physis here, and then out the metaphyseal region of the tibia. The intra-articular portion of the tibia is maintained without fracture. This injury also has an associated extra-physeal 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 dorsalis pedis and posterior tibialis 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 epiphysis and enters the joint, making it intra-articular. The fracture exits through the physis in the second plane, and then in the third plane here on the sagittal, you can see it propagates through the metaphysis. This can also be classified as a Salter Harris 4 fracture, due to the involvement of the metaphysis, the physis, and the epiphysis. 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 two millimeters, an open reduction and internal fixation of the articular surface with a positional screw is required to maintain alignment of the metaphyseal fragment. 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 physeal 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 9 months to 3 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 heel 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 heel. We see these children back in clinic three to five days after initial injury. This injury heals very reliably in a short leg cast in toddlers or sometimes even a walking boot if necessary. In older children, tibial shaft fractures are typically caused by blunt trauma or a bending twisting mechanism 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 stability. 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 intramedullary flexible nailing to maintain the alignment of the fracture during healing. These flexible nails are usually removed in the operating room 6 to 12 months after surgery and appropriate fracture healing. Greenstick fractures or 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 forearm fracture, which requires closed reduction to maintain appropriate functional alignment for healing. Due to the swelling from the fracture and the associated soft tissue trauma within the region, both bone forearm fractures are at a high risk to develop compartment syndrome. Close neurovascular monitoring is important after 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 poke hole 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 pronosupination, 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. In 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 physis to prevent any early physeal closure. The nails are typically removed 6 to 12 months after healing to avoid the high risk of refracturing within the first six months. The most common fracture at the elbow is a supracondylar humerus fracture. There are three types of supracondylar fractures. Type one is a non-displaced fracture and is treated with a long arm cast for three to four weeks. Type two 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 three 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. Intraoperatively, a supracondylar 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° of flexion for three to four weeks, depending on age. The pins are then removed in clinic at the follow-up appointment, and range of motion of the elbow is initiated. Fall prone activities 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. Obese children have increased complications of fracture management due to implant failures or fracture malunions. 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. Vitamin D insufficiency is common in pediatrics, especially in children who are malnourished, lack sun 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 get 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 4 to 8 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 176,000 children ages 5 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 furniture 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 absorbing 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 who? If there is a wheel, then helmet on. Kids should wear a properly fitted helmet, wrist guards, knee and elbow pads. The American Academy of Pediatrics recommends that children under 5 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 8 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 4,500 children in the United States were treated in emergency departments for injuries related to lawn mowers? Here 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. Talking 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 heights. Only one child at a time on a trampoline. Children in groups should be the same age or size. And adults 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 wrist guards for skateboarding. Discourage distracted walking in your teenage patients. Don't 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, preventative measures, including vitamin supplementation, obesity, and safe play guidelines. Thank you, Dr. Larson, for providing us with a comprehensive understanding of pediatric orthopedic injuries.