Rockwood & Wilkins'

Fractures In Children
[5th Edition]

James H. Beaty
James R. Kasser
CLICK HERE FOR TABLE OF CONTENTS
 Contributing Authors XI Role of the Pediatric Trauma Center 76
Preface xiii Initial Resuscitation and Evaluation 76
Acknowledgments xv Evaluation and Assessment 77
Nonorthopaedic Conditions of the Multiply Injured
Child 80
Orthopaedic Management of the Multiply Injured
SECTION I: GENERAL PRINCIPLES 1 Child 82
Stabilization of Fractures 85
1 The Present Status of Children's Fractures 3 5 Physeal Injuries and Growth Arrest 91
Kaye E. Wil/?ins and Alaric j. Aroojis Hamlet A. Peterson
The Informational Changes 3 Pbyseal Fractures 91
Changes in the Philosophy of Treating Fractures in Complications 104
Children 4 Other Physeal Fractures 105
The Present Status of the Incidence of Fractures in Physeal Arrest 114
Children 5 Complications 128
Etiology of Fractures 12 Results 128
Preventive Programs 17 6 Pathologic Fractures Associated with Tumors
and Unique Conditions of the
2 The Biologic Aspects of Children's
Musculoskeletal System 139
Fractures 21
John P. Dormans and John M. F6mn
Edward W Johnstone and Bruce K Foster
Fractures Associated with Cysts, Tumors, or
The Immature Skeleton 21
Tumor-like Processes 142
Anatomic Regions of the Child's Bones 21 Bone and Fibrous Tissue Diseases 169
The Molecular Bone 29 Congenital Insensitiviry ro Pain 180
Mechanisms of Bone Growth 35 Marrow Disease of Bone 182
Fracture Repair 37 Osteomyelitis 193
The Future of Fracture Repair 42 Pathologic Fractures After Limb Lengthening 197
3 Pain Relief and Related Concerns in Fractures in Conditions that Weaken Bone 197
Children's Fractures 49 Fractures in Neuromuscular Disease 219
Joseph R. Furman 7 Child Abuse 241
Guidelines and Principles of Sedation in Robert M. Camp be!!, Jr.
Children 49 Epidemiology 241
Sedative Medications 54 Historical Overview 241
Regional Anesthesia in the Child with a The Homes at Risk 242
Musculoskeletal Injury 61 The Children at Risk 242
Posroperative Analgesia in the Child with a Sexual Abuse 243
Musculoskeletal Injury 67 Obtaining the History 243
Treatment of Postoperative Nausea 70 Physical Examination 245
Fractures in Child Abuse 249
4 Management of the Multiply Injured Additional Imaging Studies 253
Child 75 Interpreting Imaging Studies in Child Abuse 254
Vernon T Tolo Dating Fractures 256
Incidence of Injuries 75 Laboratory Studies and Consultations 258
Common Mechanisms of Injury 76 The Differential Diagnosis 258

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viii Contents

Osteogenesis Imperfecta 259 Incidence and General Considerations 577

Treatment and Legal Reporting Requirements 260 Extension-Type Supracondylar Fractures 578
The Courtroom 261 Flexion-Type Supracondylar Fracture 616
Prevention of Child Abuse 263 15 The Elbow: Physeal Fractures, Apophyseal
Injuries of the Distal Humerus, Avascular
Necrosis of the Trochlea, and T-Condylar
SECTION II: UPPER EXTREMITY 267 Fractures 625
James H. Beaty and James R. Kassfr
8 Fractures and Dislocations of the Hand and Physeal Fractures 625
Carpus in Children 269 Apophyseal Injuries of the Distal Humerus 663
Thomas J Graham and Peter !V!. Watm Avascular Necrosis of the Trochlea 681
Overview of Pediatric Hand Injuries 269 T-Condylar Fractures 687
Specific Fractures of the Pediatric Hand 278 16 Dislocations of the Elbow 705
Carpal Injuries in Children 341 George H. Thompson
Dislocations of the Hand and Carpus 360
Classification 705
9 Distal Radius and Ulna Fractures 381 Posterior Elbow Dislocations 705
Peter M. Waters Anterior Elbow Dislocations 722
Classification 382 Medial and Lateral Elbow Dislocations 724
Anatomy 382 Divergent Elbow Dislocation 725
Physeal Injuries 385 Proximal Radioulnar Translocation 726
Radial Physeal Stress Fractures 404 Radial Head Dislocation 727
Ulnar Physeal Fractures 405 Isolated Dislocations of the Ulna 732
Ulnar Styloid Fractures 407 Subluxation of the Radial Head (Pulled Elbow
Metaphyseal Fractures 408 Syndrome) 732
Complete Fractures 416 17 Proximal Humerus, Scapula, and
Pediatric Galeazzi Fractures 432 Clavicle 741
10 Injuries to the Shafts of the Radius and Young Kwon and John F. Sarwark
Ulna 443 Fractures of the Proximal Humerus 741
Charles T Price and Gregory A. Mencio Fractures of the Scapula 751
Fractures of the Shafts of the Radius and Ulna 443 Fractures of the Clavicle 757
Plastic Deformation of the Radius and Ulna 475 Fractures of the Humeral Shaft 765
Distal Humeral Diaphyseal Fractures 776
11 Fractures of the Proximal Radius and Supracondylar Process Fractures 783
Ulna 483 Glenohumeral Subluxation and Dislocation 783
Hemy G. Chambers
Fractures of the Proximal Radius 483
Fractures of the Proximal Ulna (Olecranon) 506 SECTION III: SPINE 807
12 Monteggia Fracture-Dislocation in
Children 529 18 Cervical Spine Injuries in Children 809
Earl A. Stanley and Jose F. de la Garza W C. Warner, Jr.
Historical Background 529 Anatomy 810
Anatomy and Biomechanics 532 History 813
Characteristics and Management of Monteggia Symptoms 813
Injuries 535 Evaluation 813
Summary 560 Radiographic Evaluation 814
13 The Elbow Region: General Concepts in the Initial Management of Cervical Spine Injuries 818
Pediatric Patient 563 Spinal Cord Injury without Radiographic
Abnormalities 822
James H. Beaty and James R. Kassfr
Spinal Cord Injury in Children 822
Incidence 563 Neonatal Injury 823
Anatomy 564
Occipital Condylar Fracture 823
Radiographic Findings 570
Atlantooccipital Instability 824
14 Supracondylar Fractures of the Distal Fractures of the Atlas 830
Humerus 577 Atlantoaxial Injuries 831
James R. Kasser and James H. Beaty SubaxiaJ Injuries 839
 Contents ix

19 Fractures of the Thoracic and Lumbar Osgood-Schlatter Lesion 1026

Spine 847 Fractures of the Patella 1029
Randall T Loder and Robert N. Heminger Part II: Intraarticular and Ligamentous Injuries
Anatomy 847 About the Knee 1035
Classification and Mechanism of Injury 848 Osteochondral Fractures 1035
Signs and Symptoms 852 Fracture of the Tibial Spine
Radiographic Findings 853 (Intercondylar Eminence) 1038
Treatment 859 Ligament Injuries 1044
Prognosis and Complications 863 Knee Dislocations 1057
Patellar Dislocations 1059
Meniscal Injuries 1062
Discoid Meniscus 1067
SECTION IV: LOWER EXTREMITY 881 Tibiofibular Dislocations 1068
24 Fractures of the Shaft of the Tibia and
20 Fractures of the Pelvis 883 Fibula 1077
S. Terrance Canale and James H. Beaty Stephen D. Heinrich
Diagnosis 883 Epidemiology 1077
Classification 885 Classification 1079
Applied Anatomy 886 Diaphyseal Fractures of the Tibia and Fibula 1083
Avulsion Fractures 886 Postfracture Immobilization 1099
Fractures of the Pubis or Ishcium 890 Postfracture Rehabilitation 1099
Fractures of the Sacrum 893 Fractures of the Distal Tibial Metaphysis 1099
Fractures of the Coccyx 893 Complications Associated with Diaphyseal
Fractures of the Ipsilateral Rami 895 Tibia/Fibula Fractures 11 0 1
Fractures Near or Subluxation of the Symphysis Special Fractures 1108
Pubis 895 25 Distal Tibial and Fibular Fractures 1121
Fractures Near or Subluxation of the Sacroiliac
R. Jay Cummings
Joint 897
Diagnosis 1122
Unstable Fracture Patterns 897
Mechanism of Injury and Classification 1125
Acetabular Fractures 904
Anatomy 1131
Complications 909
Treatment 1134
21 Fractures and Traumatic Dislocations of the Rehabilitation 1159
Hip in Children 913 Prognosis and Complications 1160
R. Dale Blasier and Laurie 0. Hughes 26 Fractures and Dislocations of the Foot 1169
Fractures of the Hip 913 Thomas P. San Giovanni and Richard H. Gross
Hip Dislocations in Children 929
Anatomy 1170
22 Femoral Shaft Fractures 941 Fractures of the Talus 1172
James R. Kasser and James H. Beaty Osteochondral Fractures of the Talus 1185
Anatomy 941 Subtalar Dislocation 1187
Mechanism of Injtiry 941 Calcaneus 1187
Diagnosis 942 Fractures of the Lesser Tarsal Bones 1195
Radiographic Findings 942 Tarsometatarsal Injuries 1195
Classification 943 Metatarsals 1199
Treatment 943 Fractures of the Base of the Fifth Metatarsal 1202
Complications of Femoral Shaft Fractures 968 Operative Treatment 1206
Special Fractures of the Femoral Shaft 973 Stress Fractures 1206
Fractures of the Phalanges 1208
23 Fractures and Dislocations about the Open Fractures of the Foot 1209
Knee 981 Lawn Mower Injuries and Other Crush
Paul D. Sponsetler and Car! L. Stanitski Injuries 1209
Part I: Extraarticular Fractures 982 Lacerations of the Foot 1214
Distal Femoral Epiphyseal Fractures 982 Puncture Wounds 1215
Fracture of the Proximal Tibial Epiphysis 1011 Lesions that May Resemble Fracture 1215
Avulsion of the Tibial Tubercle 1019 Subject Index J223
 THE PRESENT STATUS OF
CHILDREN'S FRACTURES
KAYE E. WILKINS
ALARIC J. AROOJIS

THE I FORMATIO AL HA GE THE PRES ,NT STATUS Or THE I CIDENCE OF

Single-Authored Texts FRACT RES I CHILDRE
Mulriauthored Texts Incidence Fracrures
Exclusive Children's Fractures Texts Defining the Incidence of Fractures
Multiauthored Children's Fracture Texts Difficulties in Comparing Fracture Srudies
Emergence of Pediacric Orthopaedics Frequency of Childhood Fractures
Specific F racrure Incidences
CHA GES IN TI E PHILOSOPHY OF TREATING
FRACTURES I CHT DREN ETll LOGY OF FRACTURES
Bloum's Nonoperative Axioms Broad Causes
Complications with Operative Intervenrion Fractures Resulting from Accidemal Trauma
Trend Toward Minimal Invasion Summary
Facwrs Creating a Trend Toward Operative Intervention Less Common Etiologies
Changes from Previous Editions
Phases in Developmem of Operative Techniques PREVENTIVE PROGRAMS
Specific Problems with Operative Techniques National Campaigns
Nonoperative Techniques Need w be Maintained Local Community Parricipation

Tn the past generation there have been many changes in how THE INFORMATIONAL CHANGES
fracrutes in children are handled. This has been the result of
many factors. First, there has been a drastic change in the dissem-
Single-Authored Texts
ination of information regarding the management of children's At the turn of the century the major fracture texts were authored
fractures. Second, there has been a change in the philosophy by single individuals who used their own personal experience as
of how fractures are created, with more emphasis on operative their major reference source. In rhe more popular single-auth-
management. Third, there has been a change in the incidence ored texts by Stimson (0), Scudder (9), and Cotton (3), the
offractures in the United States and Europe. Fourth, and finally, trend was to discuss both adult and children's fractures in the
in a modern North American environment, there have been same sections on a geographical basis; for example, fractures
changes in the etiology of fractures in children. Each of these about the elbow. This single-authored text concept continued
factors will be discussed as a separate section in this chapter. into the late I 950s and early I%Os, with the most popular texts
The first twO factors will be discussed briefly. The third and of that period being those by Bohler (2), Key and Conwell (4),
fourth factors will be discussed in more detail. and Watson-Jones (l1).
The whole goal in studying the incidence of children's frac-
tures is to develop preventative strategies. The experience of
others in rhis aspect will be discussed in the [lfth section of this
Mllltiauthored Texts
chapter. With the explosion of orthopaedic knowledge and the develop-
ment of regional anatomic orthopaedic specialization, it became
impossible for one author to produce a fracture text that was
all-encompassing. Thus began rhe trend toward multiauthored
fracrure texts with twO to three editors. The first to stan this
Kaye E. Wilkins: Children's Hospiral, Sanea Rosa Medical Center, San
trend in fracture texts in North America were Charles Rockwood
Anronio, Texas.
Alaric]. Aroojis: Deparrment ofOrrhopaedics, King Edward V11 Memorial and David Green, who produced the first edition of their multi-
Hospital, Bombay, India. authored textbook Fractures in 1975 (7). A year later, Wilson
4 General Principles

had revised Warson-Jones' text with some multiple authors (12). CHANGES IN THE PHILOSOPHY OF
In chis text, Chapter 17, authored by Anthony Carrerall, focused TREATING FRACTURES IN CHILDREN
on children's fractures. The brst edition of Fractures by Rock-
Blount's Nonoperative Axioms
wood and Green did nor include children's fracrures.
Dr. Walrer Blount, in his textbook Fractures in Children, empha-
sized thar because of growth, children's fractures have a grear
Exclusive Children's Fracture Texts
porential to remodel (1). In fact, he outlined the rules of remod-
In Nonh America, one of the pioneers in fracture treatmenr in eling as to what amount of angulation would be accepted in
children was Walter P. Bloum, who in 1955 was the first to children's fracrures. However, he was very opposed to operarive
author a rextbook devoted exclusively to children (1). His philos- intervention. This was especially true in his opinion ofinrramed-
ophy of nonoperative managemenr set the standard for (L'eating ullary fixation of femoral shaft fractures in children:
children's fractures for more than a generation. Almost 20 years 'The operation is unnecessary, however and as such must be
latet, Mercer Rang authored another textbook devoted exclu- condemned. It inrroduces the hazard of an unnecessary anes-
sively to children's fraceures (6). His book has served as a stan- thetic, unnecessary exposure of bone ends, and trauma to the
dard reference for the rreatment of children's fractures to this entire marrow caviry of the femur. There is no reason for doing
day. it" (1).

Multiauthored Children's Fracture Texts Complications with Operative Intervention

Again, it soon became impossible for one person to author a It was his experience that non unions often followed open reduc-
textbook on children's fracrures that covered each fraceure type tions in children. He wenr on to delineate the serious other
and its treatment in suHlcienr detail to satisfy the demands of complications thar he had seen with open reduction, including
the present-day onhopaedic surgeon. Thus evolved the multi- dearh from sepsis. His comment was, "One postoperative osteo-
authored text on children's fractures. The first edition of a rext- myelitis in a lifetime is enough to cure a surgeon of a casual
book of this rype was added as volume ]J] to the twO volumes arrirude roward open reduction."
of Fractures in Adults, edited by Rockwood and Green in 1984 This aversion to operative management of children's fractures
(8). This multiauthored concept of textbooks on cl1i Idren's frac- set the tone for a generation of orthopaedic surgeons.
tures has been followed by many other excellent texts. These
multiauthored textbooks have been well received; they are now
in subsequent editions. These present-day textbooks now serve Trend Toward Minimal Invasion
as a single encompassing reference source for the physician who
Certainly, prior to the mid-1950s, when Bloum published his
treats children's fractures.
textbook (1), operative procedures usually required large inci-
sions and extensive dissection. In the 45 years since rhe publica-
Emergence of Pediatric Orthopaedics tion of his book, there has been a trend toward more operative
i mervention with good results. However, the surgery performed
Consolidation of Information
is minimally invasive, and fixation is often only temporary.
Pediatric Orthopaedic Journals
In the past, information regarding the management of children's Factors Creating a Trend Toward Operative
fractures was interspersed in journals and meetings dealing with Intervention
general onhopaedics. In 1981, TheJournal ofPediatric Orthoped-
ics was established by Lynn Staheli and Roben Hensinger, and it This trend toward more operative intervention has been rhe
contained articles devoted exclusively to onhopaedic conditions result of four factors: (a) improvement in technology; (b) rapid
seen in pediatric patients. It is interesting to note that the first healing allowing minimal and temporary fixation; (c) the finan-
article in cheir first volume was related to trauma, "The Surgical cial and social pressures to limit the hospitalization of children;
Treatment of Partial Closure of the Growth Plate" by Anders and (d) the expectation by rhe public for a perfeCt outcome in
Langenskiold (5). Pa.n B of The Journal ofPediatric Orthopedics every case.
was esrablished in 1992 [Q allow rhe expansion of the number
of articles from non-North American authors.
Improvement in Technology
The use of the image intensifier has greatly improved the ease
Pediatric Fracture Courses
wirh which fractures can be reduced and stabilized internally
The recognition of the uniqueness of children's fractures has with percutaneous methods. Other technical advances such as
stimulated the production of a number of courses organized computed tomography (CT), magnetic resonance imaging
world-wide devoted exclusively to the management of children's (MRI) , and sonographic imaging have expanded the ability to
trauma (see Appendix A). Thus, there has been a concentration better define the fracture patterns. The lise of powered inSTru-
of both spoken and written information regarding children's ments and cannulated screws has improved the accuracy of ap-
fractures in the modern orrhopaedic communiry. plying fixation devices via percutaneous rechniques.
 Chaptel' l: The Prf.fent StiltuS 0/ Children's Fracturl'S 5

Rapid Healing problems become more apparent and thus there often are modi-
ficarions of rhe original rechnique. Thus, it takes a period of
Because children heal and remodel rapidly, in many cases the
rime before the technique becomes relarively complication free.
fixation devices need to be utilized for only a shon period of
time. Children rolerare all rypes of casrs well for short periods
of rime, which allows a minimally stabilized fracture ro be immo- Specific Problems with Operative
bilized until rhere is sufficiem imernal callous ro supplement Techniques
the limited imernal fixarion.
Some of the specific problems rhat have occurred over rhe years
are Iisted as follows:
Minimal Hospitalization
1. Ulnar nerve injulY with mecLolateraJ pin fixarion of supra-
The rising cosrs of hospiralizarion have creared a rrend ro mobi- condylar fracrures (16)
lize children to an ourpariem serring as soon as possible. This 2. High reFracrure rate with external fixation of femoraJ shaFt
has been reinforced by rhe facr rhar in [\vo rhirds of rhe families Fracrures (18)
in rhe U nired Srares both parems are wage earners. 3. Avascular necrosis of rhe femoral head following use of imer-
Cox and Clarke, in evaluaring rhe Fracrure managemem in locking inrramedulialY nails (13,17)
rheir hospiral in Sourhampron, England, found a high incidence
As will be memioned in the following chapters of rhis texr-
of secondary hospiral trearmem for fracrures inirially managed
book dealing with the specific fracrures, rhere have been recent
nonoperarively (J 5). There was a 12% read mission rare ro cor-
changes in the operative technique or posroperative management
recr lare displacemem of fracrures of the radius and disral hume-
ro minimize the developmem of rhese problems.
rus. In addition, 24% of their internal fixation procedures were
to saJvage unacceptable results of nonoperative management. It
was their conclusion thar more selecrive inirial operative imer- Nonoperative Techniques Need To Be
venti on in radial and disral humeral fractures could decrease rhe Maintained
incidence of costly readmissions to the hospital.
UnFonunare!y, with this emphasis on operarive management,
There are borh social and financial pressures ro mobilize the
rhe Facr rhar most children's Fractures can be managed by nonop-
child early. The trend now is ro temporarily surgically srabilize
erarive rechniques becomes obscured. As a resulr, many of the
these fracrures so rhar the patient can be discharged early.
recem orrhopaedic rrainees are not developing good nonopera-
tive rechnical skills.
The Perfect Result Two recem arricles have demonsnated improved resulrs of
rrearing children's fractures by focusing on improvemems of
Modern parents have become very sophisticared and now expecr prior nonoperative methods. Chess and co-workers (J 4) have
a perfecr ourcome For rheir child. They inspect the x-rays, ques- shown that when properly applied, a well-molded shon arm cast
rion the alignment, and expecr rhe alignmem ro be perfect or provides JUSt as good a resulr as a long arm casr in trearing
anatomic. displaced fractures of rhe distal radial metaphysis. The key ro
A common starement made by rhe patient's father is, "He success in using a shorr arm cast is in a careful molding of rhe
has rremendous poremial ro be a great athlete." These pressures casr at rhe Fractures site so rhere is a proper casr index of 0.7 or
often direct rhe rrearing physician roward operarive intervemion Jess. Walker and Rang (21) recently revised the concepr of rreat-
ro obrain a perfecr alignment. ing unsrable fractures of rhe shafts of the radius and ulna wirh
a long arm cast with rhe elbow in extension. This has resulted
Changes from Previous Editions in a lower remanipulation rate.
Conrinued Focus on developing and maintaining nonopera-
The trend roward rhe establishment of surgical intervention can rive skills such as appropriare casr applicarion and proper
be seen in rhe changes in the previous editions of rhis textbook. moulding techniques needs ro be consranrly reemphasized as rhe
In the £1rsr edition (19), velY lirde menrion was made t'egarding mainsray of nearing children's fracrures.
inrramedullary fixation of either Femoral or radial and ulnar shah
fracrures. There was an exrensive discussion of methods of rrac-
rion for femoral shah fracrures and supracondylar fracrures. In THE PRES NT STATUS OF THE
rhe foutth edition (20), the reverse was [[ue. There was consider- INCIDENCE OF FRACTURES IN
able discussion ofinrramedullary flxarion and very liule menrion CHILDR N
regarding naction rechniques.
The incidence of children's Fractmes is exrremely variable. It can
vaty with the child's age, rhe season of the year, cui rural and
Phases in Development of Operative
environmentaJ climates, and the hour of the day, ro name jusr
Techniques
a Few facrors. As a culrure changes from a primarily rural ro
Often, a new procedure is proposed and becomes widely used. an urban seuing, rhe injury parrerns may change as well. Ie is
Inirially, rhere is a wave of enthusiasm for rhe benefirs of [he imporrant ro develop a general picrure of how, when, and why
procedure. However, with more widespread use of a procedure, fractures occur in children.
6 General Principle;

Incidence of Fractures In shorr, che goals for scudying children's fraccures have
changed over che pasc 60 years. Originally, the goal was to iden-
Healing Processes
tifY the most common bones fractured and how chey heal. The
Early reviews primarily developed a knowledge base of fracrure goals of presem scudies are co gather data in an attempt co de-
healing in children. WalkJing's 1934 review demonscraced thac crease the incidence of fractures by establishing preventive pro-
children's fractures heal differently and included such concepts grams.
as me overgrowth of long bones afcer fraccure and the ability of
children's fracrures to remodel significant angular deformicies Defining the Incidence of Fractures
(56). In 1941, Beekman and Sullivan published an excensive
review of me incidence of children's fracrures (24). Their pi- Variations
oneering work-still quoted coday-included a srudy of 2,094 Cultural Differences
long bone fraccures seen over a 1O-year period ac Bellevue Hospi-
cal in New York City. The major purpose of their srudy was co When on.e looks at the incidence of specific fractures within
develop basic principles for creacing children's fraccures. a well-defined group of children, the data are usually concise.
In 1954, two major reports, one by Hanlon and Estes (36) However, when trying to obtain the global or general incidence
and che other by Lichtenberg (47), confirmed the findings of the of injury or fracture patterns for all types of children, there may
previous studies with regard to the general incidence of children's be problems. For instance, Cheng and Shen studied children in
long bone fraccures and cheir ability to heal and readily remodel. Hong Kong who lived in confined high-rise apartments (28).
These initial reviews were mainly stacistical analyses and did noc Their risk of exposure to injury differed from the study by Reed
delve deeply into the crue epidemiology of children's fractures. of children living in the rural environment ofWinnipeg, Canada
In 1965, Wong explored che effect of cultural factors on the (50). Two separate reviews by Laffoy (39) and Westfelt (57)
incidence offractures by comparing Indian, Malay, and Swedish have found that children in a poor sociaJ environment (as defined
children (58). In che 1970s, two other scudies, one by Iqbal (34) by a lower social class or by dependence on public assistance)
and anocher by Reed (50), added more stacistics regarding the had an increased incidence of accidents. In England, children
incidence of the various long bone fracrures. from single-parent families have been found to have higher acci-
dent and infection rates (31).
Preventive Programs Thus, in domestic settings where many people are on. public
assistance or where there is a higher incidence of disruption of
Landin's 1983 report on 8,682 fractures established a trend in
family scructure, social racher chan physical factors may be more
reviewing the incidence of children's fractures (41). He reviewed
of an influence on the incidence of injuries.
the data on all fractures in children that occurred in Malmo,
Sweden, over 30 years, and examined the factors affecting che
incidence of children's fraccures. His study remains a landmark Climatic Differences
on this subject. By studying twO populacions, 30 years apan, he The c1imace may be a strong factor as well. Children in colder
evaluaced whether fraccure patterns were changing, and if so, climaces, with ice and snow, are exposed to risks different from
che reasons for such changes. His initial goal was to escablish those of children living in warmer climates. The exposure time
data for preventive programs, so he focused on fracrures char to oucdoor activities may be grearer for children who live in
produced clean, concise, concrete data. warmer c1imares. For example, me incidence of chronic overuse
In 1997 Landin updaced his work, reemphasizing che stacis- elbow injuries in young baseball players (lictle league elbow) is
tics from his previous publication (40). He felc chat che twofold far greater in the souchern United States rhan in more northern
increase in fraccure race during the 30 years from 1950 co 1979 communities. This is simply because rhere is greater playing or
in Malmo was due mainly co an increased parricipation in spores. exposure time.
In 1999, in cooperation with Tiderius and Duppe, Landin (55)
scudied the incidence in che same age group again in Malmo
Difficulties 1n Comparing Fracture Studies
and found chat the incident race had accually declined by 9%
in che years 1993 co 1994. The only exception was an increase Defining Age Groups
of discal forearm fractures in girls, which he amibuced co cheir
Another problem with comparing srudies is the definition of
increased participacion in sporring evencs.
pediatric age groups. Some use 12 years as a cutoff age; others
Cheng and Shen, in cheir 1993 scudy from Hong Kong, also
extend ir to 16 or 20.
set oue co define che problems of children's fracrures by separat-
ing the incidences into age groups (28). They tried to gacher
epidemiologic daca on which to build prevemive programs. In Inpatient Versus Outpatient Studies
1999 chis study was expanded to include almost 6,500 fraccures Some studies report only fracture victims admitted to a hospital,
in children 16 and younger over a 10-year period (27). The which loads rhem toward the more serious injuries.
fraccure paccerns changed lictle over those 10 years. What did
change was che increased incidence of closed reduccion and per-
Anatomic Location
cutaneous pin flxacion of fractures, with a corresponding de-
crease in open reductions. There was also a marked decrease in Reports vary in the precision of their defined types of fracture
the hospital stay of their patiencs. patterns. I n the older series, reportS were only of the long bone
 CIJaprer 1: Tbe Present Status oj Children's Fractllre)' 7

involved, such as the radius. More recent series have em phasized

a more specific location, separating the radius, for example, inro Annuallncidence/10,000
physeal, distal, shaft, and proximal fracture types.
Thus, in (lying to define rhe exact incidence of fractures, it *------k Boys
500
is difficult to compare series because of culrural, environmental, 1c·· ..* Gi~s
and age differences. In this section, rhese differences were consid-
ered in grouping the results and producing average figures. These
data are presented in an anempt to provide a reasonable and
400 /'*
accurare reflection of the overall incidence of injuries and frac-
rures in all children. 300 I
1*
~:
Frequency of Childhood Fractures
200
In Landin's series from Malmo, Sweden, the chance of a child *
sustaining a fraCture during childhood (birth to age 16) was
100 /. *
42% for boys and 27% for girls (41). When considered on an *.*
annual basis, 2.1 % of all the children (2.6% for boys, 1.7% for
girls) sustained at least one fracture each year. These figures were
*
for all fracrure types and included those treated on an inpatient
0 5 10 15 AGE

basis and an outpatient basis. The overall chance of fracture per FIGURE 1-1. Incidence of fractures by age. Boys peak at 15 years. Girls
peak earlier, at 12 years and then decline. [Reprinted from Landin LA.
year was 1.6% for both girls and boys in a srudy from England Fracture patterns in children. Acta Orthop Scand 1983;54(suppl 202):
of both outpatients and inpatientS by Worlock and StoweI' (59). 13, with permission.]
The chance of a child sustaining a fracture severe enough to
require inpatient treatment during the first 16 years of life is
6.8% (28). Thus, on an annual basis, 0.43% of the children in
an average community will be admined for a fraCture-related Age Groups
problem during the year. Correlation With Incidence of Injuries
In a series of23,915 patients seen at four major hospitals for S[arring with birth and extending [Q age 12, all the major series
injury-related complaints, 4,265 (17.8%) had ftactures (26,32, [hat segregated patients by age group have demonstrated a linear
33,57). Thus, close to 20% of the patients who presem to hospi- increase in the annual incidence of fractures with age (Fig. I-I)
tals with injuries have a fracture. (27,28,34,41,59). There seems co be a peak at 12 years, with
It is intcl'csting to note that in a follow-up study by Tiderius, some decrease unri I age 16, probably relared ro a significant
Landin, and Duppe (55) in the yeaL'S 1993 and 1994, 13 years decrease in the incidence of fracrures in girls over age 12. The
after the tet'mination of the original 30-year study by Landin percentage of injured boys as compared wi[h girls conrinues to
(41), there was almost a 10% decrease in the incidence of frac- increase in the older age groups.
tures in the 0- ro 16-year age group. They attributed this ro less These fracrure sta[istics differ slightly from the incidence of
physical activity on the part of modern-day children coupled overall injuries: the incidence of injuries peaks early, at ages I
with bener prorective SPOrtS equipment and increased traffic ro 2 years (Fig. 1-2) (39). Although there is a high incidence of
safety (e.g., Stronger cars and use of auro restraint systems). The
overall incidence of children's fractures is summarized in Table
1-1.
Thousands
12
"'
..
~
M N
0 "!
0 0

10 '"g
~ ",' M
N

~
M
TABLE 1-1. OVERALL FREQUENCY OF «i
FRACTURES 8
""
g ,
Percentage of children sustaining at least one fracture from a
M
.....
to 16 years of age: boys, 42%; girls, 27%
Percentage of children sustaining a fracture in 1 year:
6

."'
M 0
"'to-
..
.~ ""--
'"

1.6%-2.1% 4 ,.; . "'

.N
,.;

Percentage of children who are hospitalized because of a frac-

ture: during entire childhood (0-16 years), 6.8%; each year, 2
0.43%
Percentage of patients with injuries (all types) who have frac- a
tures: 17.8% <1 yr 1-2 yrs 3-6 yrs 7-12 yts 13-18 yrs
FIGURE 1-2. Injuries per 100,000 children per year. Estimated U.S. in-
Data from references 26, 28, 32, 33, 42, 57, and 59. jury rates in children by age and sex, 1978. (Reprinted from .Ri~ara FP,
Bergman AB, LoGerfo JP, et al. Epidemiology of childhood II1Junes. Am
J Dis Child 1982; 136: 503; with permission.)
8 General Principles

injuries in children ages 1 (0 2, [he incidence of fractures is low. left (0 right overall averages 1.3: 1. In some fractures, however,
Most injuries in children or this age are nononhopaedic enrities especially those of supracondylar bones, lateral condyles, and the
such as head injuries, lacerations, and abrasions. In facr, the distal radius, the incidence is far gteater, increasing ro as much
incidence of lacerations in both sexes peaks at this age (51). as 2.3: 1 for the lateral condyle. In the lower extremity, the
incidence of injuty on the right side is slightly increased (32,
Trauma 41).
The reasons for the predominance of the Jeft upper extremity
In 1962, Kempe and associates (37) called auenrion (0 the high
have been studied, but no definite answers have been found.
incidence of fracrures and other injuries in young children that
Rohl (52) speculated that the right upper extremity is often
were due ro nonaccidenral rrauma. They termed these injuries
being used actively during the injury, so the left assumes the
pan of the barrered child syndrome. Akbarnia and colleagues
role of protection. In a study examining the left-sided predomi-
later defined the specific fracture patterns seen in victims of
nance in the upper extremity, Monensson and Thonell (49)
child abuse (22). Not all fractures in the first year of life can be
questioned patienrs and their parents on atrival ro the emergency
arrributed to abuse, however. In a review of fractures occurring
department about which arm was used for protection and the
in the first year or life, McClelland and Heiple found that fully
position of the fractured extremity at the time of the accident.
44% were from documenred accidental and nonabusive etiolo-
They found two trends: regardless of handedness, the left arm
gies (47). They also nored that 23% of these patients had a
was used more often (0 break the fall, and when exposed ro
generalized condition that predisposed them (0 fractures. Thus,
trauma, the left arm was more likely ro be fractured. The cause
although nonaccidenral trauma remains the leading cause of frac-
tures during the first year of life, other constitutional conditions for this larrer increased incidence in the left side was thought
may predispose children ro fractures from accidenral causes. The ro be due ro either rile increased fragility or immature neuromus-
high incidence or fracrures from nonaccidenral rrauma extends cular coordination of the nondominanr extremity.
(0 age 3 (38).

Frequency by Season and Time of Day

Gender
Fractures are more common during the summer, when children
The male predominance of injUlY and fracture vierims has been
are out of school and exposed to more vigorous physical activi-
discussed (Figs. 1-1 and 1-2, Table 1-1). For all age groups, the
ties. Four studies from the northern hemisphere have confirmed
overall ratio or boys ro girls who sustain a single fracrure is 2.7: 1
this summertime increase (Fig. 1-3) (27,28,52,59).
(28). In girls, fracture incidence peaks just before adolescence
The mOSt consistent climatic facror appears to be the number
and then decreases during adolescence (28,41,50). In Cheng
of hours of sunshine. Masterson and co-workers (46), in an
and co-workers' 10-year study from Hong Kong (27), the male
eloquent study from Ireland, found a strong positive correlation
incidence in the 12- (0 16-year age group was 83%. The inci-
between monthly sunshine hours and monrhly fracture admis-
dence of fractures in girls steadily declined from their peak in
sions. There was also a weak negative correlation with monrhly
the 0- (0 3-year age group.
rainfall. Overall, the average number of fractures in the summer
In some areas there is little difference in the incidence of
was 2.5 times that in the winter. In days with more sunshine
fractures between boys and girls. For example, during the first
hours than average, the average fracture admission rate was 2.31
2 years of life, the overall incidence of injuries and rractures in
per day; on days with fewer sunshine hours than average, the
both genders is nearly equal. During these first 2 years, the injury
admission rate was 1.07 per day.
rates for foreign body ingestion, poisons, and burns have no
significanr gender differences. With activities in which there is
a male difference in participation, such as with sports equipment
and bicycles, there is a marked increase in the incidence or inju-
ries in boys (27,51). 50
The injury incidence may not be due ro the rate of exposure
alone; behavior may be a major fac(Or. For example, one study
40
found that the incidence of au(O/pedestrian childhood injuries w
peaks in both sexes at ages 5 ro 8 (53). When the total numbet U
z
of street crossings per day was studied, both sexes did so equally, w 30
Cl
but despite this equal exposure, boys had a higher number of (3
injuries. Thus, the difference in the rate between the sexes begins ~
20
(0 develop a male predominance when behaviors change. The

difference in the injury rate between the genders may change in

the ruture as more girls panicipate in activities with increased 10
physical risk (27,51).
J F M A M J J A 5 0 N D
Right Versus Left Frequency FIGURE 1-3. Distribution of children's fractures on a monthly basis.
Note the general increase from May to October. (Reprinted from Reed
In most series, the left upper extremity demonstrates a slight MH. Fractures and dislocations of the extremities in children. J Trauma
bur significant predominance (27,28,32,34,41,51). The ratio of 1977; 17: 353; with permission.)
 Chapter 1: The Present Status of ChiLd/'en 's Fractures 9

In Sweden, the incidence of fractures in the summer had a Long- Term Trends
bimodal pattern that seemed to be influenced by cultural tradi-
Increase in Minor Trauma
tions. In twO large series of both accidents and fractutes in Swe-
Landin's srudy is the only one that has compared the changes
den by Westfelt (57) and Landin (41), the researchers noticed
over a significant time span: his data were collected over 30 years
increases in May and September and significant decreases in
(41). He classified the degree of trauma as slight, moderate, or
June, July, and August. Both writers attributed this to the fact severe. The incidence of all trauma in both boys and girls in-
that children in their region left the cities to spend the summer creased significantly over the 30-year study period, but the inci-
in the countryside. Thus, the decrease in the overall ftacture rate dence of severe trauma increased only slightly. The greatest in-
probably was due to a dectease in the number of children at risk crease was seen in the "slight" categoty. Landin attributed the
remaining in the city. increase in this category to the introduction of subsidized medi-
Masterson and co-workers (46) speculated that because the cal care. Because expense was not a factor, parents were more
rate of growth increases during the summer, the number of phy- inclined in the later years of the study to seek medical attention
seal fractures should also increase, because the physes would be for relatively minor complaints. Physicians, likewise, were more
weaker during this time. For example, the incidence of a slipped inclined to order x-rays. Thus, many of the minor injuries, such
capital femoral epiphysis, which is related to physeal weakness, as torus fractures, which were often ignored in the earlier years,
increases during the summer (23). However, Landin, in his study were seen more often at medical facilities during the later years.
of more than 8,000 fractures of all types, found the overall sea- Likewise, the overall incidence of fractures in Malmo, Swe-
sonal incidence of physeal injuries to be exactly the same as den, (the same city as Landin's original srudy) (41) significantly
nonphyseal injuries (41). decreased (10%) in the more recent years (55).
Age may affect the seasonal variation of fractures. In children The one fracture type that exhibited a true increase over this
ages 0 to 3, no seasonal variations are seen. The number of period was that of the femoral shaft. This increase was thought
fractures in this age group was consistent throughout the year to be influenced by new types of play activities and increased
(38). participation in spons.
Thus, it appears that climate, especially in areas where there
are definite seasonal variacions, influences the incidence of frac- Increase in Child Abuse
tures in all children, especially in the older children. However, The number of fractures due to nonaccidental causes (child
in small children and infanrs, whose acrivities are not seasonally abuse) has risen consistently in the past decades. In Kowal-Vern
dependent, there appears to be no significant seasonal influence. and associates' study of fractures in children ages 0 to 3 (38),
The time of day in which children are most active seems to the number of fractures due to abuse increased almost 150 times
correlate with the peak time for fracture occurrence. In Sweden, from 1984 to 1989. This increase was attributed to a combina-
the incidence peal<ed between 2 and 3 P.M. (57). In a well- tion of improved recognition, better social resources, and an
documented study from Texas by Shank and co-workers (54), increase in the number of cases of child abuse.
the hourly incidence offractures formed a well-defined bell curve
peal<ing at about 6 P.M. (Fig. 1-4). Specific Fracture Incidences
Age Factors
The anatomic areas most often fractured seem to be the same
in the major series, but these rates change with age. For example,
30 / 26
the supracondylar fracture of the humerus is most common in
25 the first decade, with a peak at age 7. Fractures of the femur are
most common in children ages 0 to 3. Fractures of the physis
25
..- -- are more common just before skeletal maturity. This variation
19 19 is best illustrated in Cheng and Shen's data (Fig. 1-5) (28).
20 17
16
.. _._--
Landin found a similar age variability and divided it into
13 six distinct patterns (Fig. 1-6) (41). When he compared these
15 12
11 .. - _. •.. 1-.. _.. ·10 - _ .... -
variability patterns wirh the common etiologies, he found some
correlation. For example, late-peak fractures (distal forearm,
10 7 phalanges, proximal humerus) were closely correlated with sports
6 -_. - _.
'-- ~.
·····5·~--
4 and equipment etiologies. Bimodal pattern fractures (clavicle,
5

0 1/
, ••
1 I
• /
femur, radioulnar, diaphyses) showed an early increase from
lower energy trauma, then a late peak in incidence due to injury
from high- or moderate-energy trauma. Early peak fractures (su-
7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 pracondylar humeral fractures are a classic example) were due
Time of Day mainly to falls from high levels.
FIGURE 1-4. Incidence of children's fractures per time of day. There is
an almost bell-shaped curve with a peak at around 6 P.M. (Reprinted Locations
from Shank LP, Bagg RJ. Wagnon J. Etiology of pediatric fractures: the
fatigue factors in children's fractures. Presented at the National Confer- Early reports of children's fraerures lumped tOgether the areas
ence on Pediatric Trauma, Indianapolis, 1992; with permission.) fractured, and fractures were reponed only as to the long bone
10 Ceneral Principles

35 -

31.18

30 - 28;94-

27.06

25
23.31

20 18.33
17.13
16.2
15.24
15 - -
12.28
11.45 11.26
10.01
10 9.53

6.26
.,e, FIGURE 1-5. The frequency of occurrence of the most com·
5 --., 1-
man fracture areas in children. The frequency of each frac·
3.12
ture pattern differs with the various age groups. The figures

o 0-3 yrs, ('!oj 4·7 yrs. ('!o) 8·11 yrs. ('!o)

~ express the percentage of total fractures for that age group
and represent boys and girls combined. (Reprinted from
12·16 yrs, ('!o) Cheng JC, Shen WY. Limb fracture pattern in different pedi-
_ Forearm Shall
atric age groups: a study of 3,350 children. J Orthop Trauma
• Dls1Il Rldlus Supracondylar Humerus ffiJITJ Tibial Shall
1993;7:17; with permission.)

involved (e,g., radius, humerus, femur) (24,32,34,43,44,48). elbow (mainly supracondylar fractures) in Cheng and Shen's
More recent reports have split fractures into the more specific series (27,28).
areas of the long bone involved (e.g., the distal radius, the radial
neck, the supracondylar area of the humerus) (28,34,41,50,59).
Physeal Injuries
This change in reporring-from the so-called "Iumpers" to the
"splitters"-has produced a more accurate picture of the true The incidence of physeal injuries overall varied from 14.5% (29)
incidence of each specific fracture rype. ro a high of 27.6% (45). To obtain an overall incidence of
physeal fractures, six repons rotaling 6,479 fractures in children
were combined (25,29,45.48,50,59). In this group, 1,404 in-
Single Bones volved the physis, producing an average overall incidence of
21. 7% for physeal fractures (Table 1-4).
In children, fractures in the upper extremiry are much more
common than those in the lower extremity (32,34). Overall, the
radius is the most commonly fractured long bone, followed by Open Fractures
the humerus. In the lower extremity, the tibia is more commonly
The overaJl incidence of open fractures in children is consislent.
fractured than the femur (Table 1-2).
The data were combined from the four reportS in which the
incidence of open fractures was reporred (28,32,45,59). The
incidence in these reports varied from 1.5% to 2,6%. Combined,
Specific Areas Fractured
these repons represented a total of 8,367 fractures with 246
In recent years, five reportS produced by so-called splitters di- open fraerures, resul ti ng in an average incidence of 2.9% (Table
vided fracture types into many anatomic areas (28,34,41,50,59). 1-5).
In trying to reach a global consensus, the author has identified Regional trauma centers often see patients exposed to more
areas common to all the reports but has taken some liberties to severe trauma, so there may be a higher incidence of open frac-
do so. For example, distal radi:tl metaphyseal and physeal frac- tures in these patients. The incidence of open fracrures was 9%
tures were combined to form the distal radius. Likewise, the in a report of patients admitted 1'0 the trauma center of the
carpals, metacarpals, and phalanges were combined ro form the Children's National Medical Centet·, Washington, D.C. (26).
region of the hand and wrist. AI I the fractures around the elbow,
from rhose of the radial neck ro supracondylar fractures, were
Multiple Fractures
grouped as elbow fractures. This grouping allows comparison
of the regional incidence of specific fracture types in children Multiple fractures in children are uncommon: the incidence
(Table 1-3). ranges in the various series from 1.7% to as much as 9.7%. In
The individual repons agreed that the most common area four major reports totaling 5,262 patients, 192 patients had
fractured was the distal radius. The next most common area, more than one fracture (Table 1-6) (28,32,34,59). The inci-
however, varied from the hand in Landin's series (41) to the dence in this multiple series was 3.6%.
 Chapter 1: The Present Status of Children's Fractures 11

Late Peak
TABLE 1-3. INCIDENCE OF SPECIFIC FRACTURE
DISTAL FOREARM TYPES
PHALANGES (HAND, FOOT)
PROXIMAL END OF THE HUMERUS Fracture %
Distal radius and physis "" 23.3
Hand '(carpals," metacarpals, and 20.1
o 5 10 15 age phalanges)
Elbow area (distal humerus and 12.0
Bimodal
proximal radius and ulna)
CLAVICLE Clavicle 6.4
FEMUR
TARSAL·METATARSAL
Radius shaft 6.4
Tibia shaft 6.2
RADIUS-ULNA, DIAPHYSIS
Foot (metatarsals and phalanges) 5.9
Ankle (distal tibia) 4.4
Femur (neck and shaft) 2.3
o 5 10 15 age Humerus (proximal and shaft) 1.4 .
Other 11.6
Rising
Data from references 28,34,'41,50, and 59.
ANKLE
CARPAL-METACARPAL

o 5 10 15 al!e

Early Peak
TABLE 1-4. INCIDENCE OF PHYSEAL
FRACTURES
SUPRACONDYLAR REGION
OF THE HUMERUS Total fractures = 6,477
Number of physeal injuries = 1,404
Precentage of physeal injuries = 21.7%

0 5 10 15 age
Data from references 25, 29, .30, 45, 48, and 59.

Irregular

;vv- TIBIA, DIAPHYSIS

INCIDENCE OF OPEN FRACTURES

TABLE 1-5,
0 5 10 15 age

FIGURE '·6. Patterns of fracture: variations with age. The peak ages Total number of fractures" =8,367
for the various fracture types occur in one of five patterns. [Reprinted Total open fractures = 246
from Landin LA. Fracture patterns in children. Acta Orthop Scand 1983; Percentage = 2.9%
54(suppl 220):80; with permission.]
Data from references 28, 32, 45, and 59.

TABLE '-2. INCIDENCE OF FRACTURES IN

LONG BONES

. BonE! %
TABLE 1-6. INCIDENCE OF MULTIPLE
" Radius 45.1 FRACTURES
Humerus 18.4
Tibia 15.1 Total fractures = 5,262
Clavicle" 13.8 Total number of multiple fractures = 192
Femur 7.6 Percentage = .:1.6%

""Data from references 24, 32, 34, 43, 44, and 48. " Data from references 28, 32, 45, and 58.
12 General PrincipLes

Recurrent Fractures and fracrures resulring from parhologic condirions wil.l be ad-
dressed in larer chaprers of rhis book.
Children with generalized bone dysplasias, such as osteogenesis
imperfecta and other metabolic diseases that produce osteopenia,
are expected to have repeat fractures. In these patients, the etiol- Fractures Resulting from Accidental
ogy of these recurrent fractures is understandable and predict- Trauma
able. However, some children with normal osseous strucwres
are prone to recurrent fractures, for reasons that remain unclear. Accidental trauma can occur in a variery of serrings, some ofren
The incidence of recurrent fractures in children is about 1% overlapping orhers. However, for purposes of simpliciry, frac-
(30). rures can be considered ro occur in rhe following five environ-
Landin and Nilsson (42) found that children who susrained menrs: horne environmenr; school environment; play and recrea-
fractures with relatively little rrauma had a lower mineral coment rional acriviries; moral' vehicle and road accidcnrs; and
in rheir forearms, but they could nor correlare rhis finding I'vjrb uncommon causes such as ice cream cruck, water rubing, and
children who had repear fractures. Thus, in children who seem gunshor and missile injuries.
to be srructurally normal, rhere does nor appear ro be a physical
reason for rheir recurrent fractures. Home Environment

Repeat Fractures Fracrures susrained in rhe home environmenr are defined as

Failure to find a physical cause for repear fracrures shifrs rhe rhose rhar occur in rhe house and surrounding viciniry. These
focus to a psychological or social cause. The one common facror generally occur in a fairly supervised environmenr and are mainly
in accidenr repearers has been a high incidence of dysfuncrional due co falls from furnirure, srairs, fences, and crees.
families (36).]n Sweden, Wesrfelr found rharchildren who were
accident tepearers came from "sociaJly handicapped" families Falls from Heights
(i.e., rhose on public assisrance or rhose wirh a caregiver who Falls call valY in severiry from a simple fall while running, ro a
was an alcoholic) (57). Thus, recmrent fractures are probably fall of grear magnirude, such as from a rhird scory window. In
due more ro behavioral or social causes rhan physical causes. falling from heighrs, adulrs often land on rheir lower exrremiries.
Landin in his follow-up article (40) followed children with repear accounting for rhe high number of lower extremiry fractures.
fracwres (four or more) inro adolescence and adulrhood. He especially rhe calcaneus. Children tend co fall head flrsr, using
found rhese children had a significantly increased incidence of rhe upper exrremiries co break rhe fall. This accounrs for rhe
convicrions for serious criminal offenses when compared wirh larger number of skull and radial fractures in children. Femoral
children wirh only one liferime fracture. fracrures are also more common in children falling from grear
heighrs. In conrrast co adulrs, spinal fracrures are rare in children
who fall from grear heights (61,84,97,100).
ETIOLOGY OF FRACTURES In one srudy, children falling rhree scories or less all survived.
Falls from rhefifrh or sixrh floor resulred in a 50% mortaliry
While studying rhe epidemiology of fracrures, ir is imporranr ro rare (61).
focus on rhe eriology of fractures and rhe serrings in which rhey
occur. ]n rhis age of compurerized gizmos and rhe "need for Injury Rate Increases with Age
speed," children are ofren rhe vicrjms of rhe consumer marker Injuries also can occur from rhe unsupervised use of unsafe play
and unsafe producrs. Fracrures do nor OCCur in a vacuum, and equipmenr, such as trampolines and monkey bars, within rhe
well-researched srudies rhar analyze rhe physical and social envi- home environmenr and will be considered in derail larer. The
ronment in which they occur are exrremely valuable. lr is a overall incidence of franures occurring because of such play
truism rhar children, unforrunarely, learn more from experience acriviry in rhe home environmenr increases wirh age. Only 15%
rhan by educarion, so effons should be made toward nearing a occur in roddlers, but 56% occur during older years (J 10).
safer environmenr for play and recreation. Srudies thar idenrify
risky parrerns of use or unsafe playground behaviol' go a long Social Factors
way in directing specific prevenrive healrh measures. Recom- 1nreresri ngly, a Swedish srudy (I09) showed rhat an increased
mendations can be made to manufacturers regarding modi fica- incidence offracrures in a home environmenr did nor necessarily
rion of a producr, and educarion can be imparted co parenrs, correlate wirh rhe physical amibures or poor safery precaurions
school authorities, healrh-care professionals, physical rrainers, of rhe house. Radler, ir implicared disruprion of rhe family struc-
and children. rure and presence of social handicaps (alcoholism, welfare reeipi-
enrs, ere.) as rhe rrue cause for rhe increase.

Broad Causes
School Environment
Broadly, fracrures can occur due to rhree main causes: accidenral
rrauma, nonaccidenral injury (child abuse), and parhologic con- The supervised environmenrs ar school are generally safe, and
dirions. Because accidental trauma forms the largesr eriologic the overaU annual rare of injury (rocal percenrage of children
group, ir will be addressed in detail here. Nonaccidenral rrauma injured in a single year) in rhe school environmenr ranges from
 Chapter 1: The Present Status of Children's Fractures 13

2.8% to 9.2% (63,81,95,109). True rates may be higher because line skates over the past decade, and several studies have high-
of inaccurate reporting, especially of mild injuries. In one series, lighted their risks and dangers.
the official rate was 5.6%, but when the parents were closely
questioned, the incidence of unreported, trivial injuries was as Bicycle Injuries
much as 15% (71). The annual fracture rate of school injuries Bicycle injuries are a significant cause of mortality and morbidity
is low. Of all injuries sustained by children ar school in a year, for children (92). Bicycle mishaps are the most common causes
only 5% to 10% involved fractures (71,81,95). In Warlock and of serious head injury in children (108). Boys in the 5- to 14-year
Stower's series of children's fractures from England (110), only age group are at greatest risk for bicycle injury (80%). Puranik et
20% occurred at school. A large incidence of injuries (53%) al. (92) studied the profile ofpediatric bicycle injuries in a sample
occurring in school are related to athletics and sporting events of 211 children who were treated for bicycle-related injury at
(81). These injuries are highest in the middle-school children. their trauma center over a 4-year period. They found that bicycle
The peak time of day for injuries at school is in rhe morning, injuries accounted for 18% ofall pediatric trauma patients. Bicy-
which differs from the injury patterns of children in general cle/motor vehicle collisions caused 86% of injuries. Sixty-seven
(81). percent had head injuries and 29% sustained fractures. More
than half of the incidents occurred on the weekend. Sixteen
percent were injured by ejection from a bicycle after losing con-
Play and Recreational Activities
trol, hitting a pothole, or colliding with a fixed object or another
Playground bicycle. Fractures mainly involved the lower extremity, upper
Play is an essential element of a child's life. It enhances physical extremity, skull, ribs, and pelvis in decreasing order of incidence.
development and fosters social interaction. Noncompetitive
sports and recreational activities are enjoyed by all children. Un- Helmet Use Low. More importantly, the study detected that
fortunately, unsupervised or careless use ofsome play equipment the use of safety helmets was disturbingly low «2%). Other
can endanger life and limb. When Matt et al. (86) studied the studies confirm the observation that less than 13% to 15% of
incidence and pattern of injuries to children using public play- children wear helmets while riding bicycles (72,93). The Year
grounds, they found that approximately 1% of children using 2000 Health Objectives call for helmet use by 50% of bicyclists
playgrounds sustained injuries. Sixty-five percent of these chil- (102). Research has shown that legislation, combined with edu-
dren were injured by falling from equipment such as climbing cation and helmet subsidies, is the most effective srraregy to
frames, slides, swings, and monkey bars. They found that chang- increase use of safety helmets in child bicyclists (65). As public
ing playground surfaces from concrete to more impact-absorbing awareness of both the severity and preventability of bicycle-re-
surfaces such as bark reduced the incidence and severity of head lated injuries grows, the goal of safer bicycling practices and
injury but increased the tendency to long bone fractures (40%), lower injury rates can be achieved (92).
bruises, and sprains.
In a study of injuries resulting from playground equipment, Injuries from Bicycle Parts. Bicycle spokes and handle bars
Waltzman et al. (06) found rhar most injuries occurred in boys are also responsible for an increasing number of fractures and
(56%) with a peak incidence in the summer months. Fractures soft tissue injuries in children. D'Souza et al. (70) and Segers
accounted for 61 % of these injuries, 90% of which involved the et at. (94) found that bicycle spoke injuries are typically sustained
upper extremity and were sustained due to falls from playground when the child's foot is caught in the spokes of the rotaring
equipment such as monkey bars and climbing frames. Younger wheel. Out of a total of 130 children with bicycle spoke injuries,
children (1-4 years) were more likely to sustain fractures than 29 children sustained fractures of the tibia, fibula, or foot bone.
older children. In their study, the surface below the equipment Several had lacerations and soft tissue defects. D'Souza et al.
apparently did not influence rhe type or severity of fracture; with (70) suggested that a mesh cover to prevent the toes from enter-
30 of the 79 fracrures occurring on "soft surfaces." ing between rhe spokes and a plastic shield to bridge the gap
Similar observations were made in a study by Lillis and Jaffe between the fork and horizontal upright can substantially de-
(83) in which upper extremiry injuries, especially fractures, ac- crease the incidence of these injuries.
counted for the majority of hospitalizations resulting from inju-
ries on playground equipment. Older children sustained more Skateboarding
injuries on climbing apparatus, whereas younger children sus- Skateboarding and in-line skating have experienced a renewed
tained more injuries on slides. surge in popularity over the past two decades. With the increas-
ing number of participants, high-tech equipment development
Newer Play Devices and vigorous advertising, skateboard and skating injuries are
Other recreational activities enjoyed by children, such as bicy- expected to increase. Because the nature of skateboarding en-
cling, skating, skateboarding, and sledding, are an important compasses both high speed and extreme maneuvers, high-energy
cause of fractures and injuries in children. Several studies have trauma fractures and other injuries can occur, as highlighted by
analyzed rhe incidence and pattern of injuries arising from the several studies (73,89,91). Studies have shown that skate-
unsupervised or cateless use of this equipment and have sug- boarding-related injuries are more severe and have more serious
gested safety precautions and equipment modification to de- consequences than roller-skating or in-line skating injuries (89).
crease the risk of injury. A disturbing trend is the rekindled In a study of skateboarding injuries, Fountain et al. (73) found
enthusiasm toward the use of trampolines, skateboards, and in- that fractures of the upper or lower extremity accounted for 50%
14 emeral Principli'j"

of all skateboarding injuries. Interestingly, more tnan one third Skiing Injuries
of those injured sustained injuries within the first week of skate- Skiing injuries are seasonal in nature and occur with outdoor
boarding. Most injuries occurred in preadolescent boys (75%) winter recreational activity. In a study of major skiing injuries
10 to 16 years of age, and despite traffic legislation, 65% sus- in children and adolescents, Shorter et a!. (96) found greater
tained injuries on public roads, footpaths, and parking lots. Sev- than 90% of injured children to be boys 5 to 18 years of age.
eral organizations have recommended safety guidelines and pre- Sixty percent of the accidents occurred due to collisions with
cautions such as use of helmets, knee and elbow pads, and wrist stationary objects such as trees, poles, and stakes. Most injuries
guards, but such regulations are seldom enforced. occurred in the afternoon, among beginners, and in the first
week of skiing season. Fractures accounted for one third of rhe
Roller Skates and In-Line Skates tOral injuries sustained. The twO main factOrs implicared in
In a study of in-line skate and roller skate injuries in childhood, skiing injuries are excessive speed and loss of control; effective
Jerosch et aI. (78) found that in a group of 1,036 skaters, 60% prevention efforrs should target both of rhese factors.
had sustained injuries. Eight percent of these were fractures,
mosrly involving the elbow, forearm, wrist, and fingers (78%).
Less than 20% used protective devices, and most Jacked knowl- Snowboarding Injuries
edge of the basic techniques of skating, braking, and falling. [n Snowboarding runs a similar risk to skiing. Bladin et a!. (62)
a larger study of 60,730 skating injuries in children, Powell and found that approximarely 60% of snowboarding injuries in-
Tanz (91) found that 68% of the children were preadolescent volved the lower limbs and occurred in novices. The mosr com-
boys with a mean age of 11.8 years. Fracrures were the most mon injuries were sprains (53%) and fractures (26%). Com pared
common injury (65%), and [WO thirds of these involved the with skiers, snow boarders had 21:z times as many fractures, par-
distal forearm. Two and a half percent required hospital admis- ticularly to the upper limb, as well as more ankle injuries such
sions; 90% of these admissions were for a fracture. Similarly, as sprains. The absence of ski poles and the fixed position of
Mitts and Hennrikus (85) found that 75% of in-line skating the feet on the snowboard mean that the upper limbs absorb
fractures in children occurred in the distal forearm as a result the fuJI impact of any fall.
oHalls on the outStretched hand. One in eight children sustained
a fracture during the first attempt at the sporr. The orthopaedic
community has an obligation to educate the public on the need Motor Vehicle Accidents
for wearing wrist guards when using in-line skates or roller skates.
This category includes injuries sustained by occupants ofa motOr
vehicle and victims of vehicle-versus-pedestrian accidents.
Trampoline-Related Injuries
The injury parrerns of children involved in motOr vehicle
Trampolines enjoyed increasing popularity in the 1990s and are
a significant cause of morbidity in children. Several studies have accidents differ from those of adults. In all rypes of motor vehicle
noted a dramatic increase in the number of pediatric trampoline accidents for all ages, children constitute a little over 10% of
injuries (PTIs) during the past 10 years, rightfully deeming it the tOtal number of patients injured (79,101). Of all the persons
as a "national epidemic" (75,98). Furnival et al. (75), in a retro- injured as motor vehicle occupants, only abour 17% to 18% are
spective srudy ofPTIs over a 7 -year period, found that the annual children. Of the victims of vehicle-vets us-pedestrian accidents,
number of PTIs tripled between 1990 and 1997. In contrast to about 29% are children. Of the total number of children in-
other recreational activities in which males constirute the popu- volved in motOr vehicle accidents, 56.4% were vehicle-versus-
lation at risk, PTI patients were predominantly female, with a pedestrian accidents, and 19.6% were vehicle-versus-bicycle ac-
median age of 7 years. Nearly a third of the injuries resulted cidents (69).
from falling off the trampoline. Fractures of the upper and lower The fracture rate of children in motor vehicle accidents is
extremi ries occurred in 45% and were more frequen rly associated less than that of adults. Of the total number of vehicle-versus-
with falls off the trampoline. In another excellent study on PTIs, pedestrian accidents, about 22% of the children sustained frac-
Smith (98) found that there was virtually a 100% increase in tures; 40% of the adults sustained fractures in the same type of
injuries from 1990 to 1995, with an average of greater than accident. This has been attributed to the fact that children are
60,000 injuries per year. Younger children had a higher inci- more likely to "bounce" when hit (69).
dence of upper extremity fractures and other injuries. In a later Children are twice as likely as adults to sustain a femur frac-
study, Smith anL! Shields (99) came up with some interesting ture when struck by a.n automobile, but in adulrs tibia and knee
data. Fractures, especially involving the upper extremity, ac- injuries are more common in the same type of accident. This
counted for 35% of all injuries. Interestingly, more than 50% seems to be related to where the car's bumper strikes the victim
of the injuries occurred under direct adult supervision. More (64,102). MotOr vehicle accidents do produce a high proportion
disturbingly, 73% of the parents were aware of the potential of spinal and pelvic injuries (64).
dangers of trampolines, and 96% of the injuries occurred in the
home backyard. These researchers, along with others (75),
rightly concluded that use of warning labels, public educarion,
Summary
and even direct adult supervision were inadequate in preventing
these injuries and have called for a total ban on the tecreational, The etiologic aspects of children's Fractures are summarized in
school, and competitive pediatric use of rrampolines (57,99). Fig. 1-7 and Table 1-7.
 Chapter I: The Present SttltltS of Children's Fractures 15

350 _

300 -lHHm~9
Motor Vehicle Accidents (MVA

Home

CJ '-Schooi'
Sports
279

250

200

150 --
118
103 ""
100 ""
73 ~!
50
27
.~~
16
3 " 0 o 5 6 1 ~~
o ;;

Infants Toddlers School Children

(Numbers Expressed as Total Patients)
FIGURE 1-7. The incidence of fractures in children expressed as the four common etiologic categories.
Most fractures occur at home. The numbers are expressed as total patients per each age category.
(Reprinted from Worlock P, Stower M. Fracture patterns in Nottingham children. J Pediatr Orthop 1986;
6:656; with permission.)

Less Common Etiologies velociry assault weapons. Mulriple missiles can result from a
shotgun blast or shrapnel from war weapons. Missile injuries
Ice Cream Truck
represent open fracrures with varying degrees ofsoft tissue injUlY.
M ubarak et al. (87) reponed on ice cream cruck-related acci- The incidence of gunshot wounds in children has become in-
delHs in which children, distracted by ice cream crucks, were creasingly common in the United States (l07).
struck by an oncoming vehicle, sustaining pelvic and lower limb
fracrures. The vision of oncoming drivers was often blocked by Gunshot and Firearm Injuries
the large size of the ice cream rruck parked by the curb. In a sad reflecrion of the changing times and the newly pervasive
gun culture, firearms are determined to be second only to motor
vehicles as the leading cause of death in youths. In considering
Water Tubing
the prevalence of firearms in the United States, ir has been esti-
Parmar et al. reponed serious injuries sustained during water mared thar rhere are about 200 million privately owned guns
rubing (the pulling of an inner tube behind a power boat) (90). in the United States and that approximately 40% of U.S. house-
holds comain firearms of some rype (66). The incidence of gun-
shor wounds in children has become increasingly common in
Gunshot (Missile) Wounds: Definition the United States (l07).

Gunshor or missile woul1ds arise from objecrs projected inco Etiology

space by an explosive device. The missiles may be single or multi- In rwo reports from inner-ciry hospitals in the United States
ple. Sil1gle missiles valY from low-velociry hal1dgul1s to high- in rhe 1990s, most injuries resulted from random violence to
16 GenrrrlL PrincipLes

union. Considering the magnitude of many of these injuries,

TABLE 1-7. SUMMARY OF ETIOLOGIC FACTORS
the infection rate for extremity wounds was low (about 7.3%).
IN CHILDREN'S FRACTURES
This low tate was probably due to a vigorous and aggressive
Home environment program of acute wound management (82,101,107). The type
Injuries of missile did not seem to have any relation to the developmem
83% of all children's injuries
of an infection (107).
Fractures
37% of all children's fractures In Lerrs and Miller's 1976 series, one sixth of the patients
School environment had some type of growth disturbance (82). In a third of their
Injuries patients, the missile was only in close proximity to the physis.
Overall rate, 2.8%-9.2% annually In a 1995 report by Washington and co-workers, the incidence
53% related to athletic events
Peak age: middle-school group of missiles affecting the physis was exactly the same (107). How-
Fractures ever, all were a result of a direct injury to the physis by the
Occur in only 5%-10% of all school-related injuries missile. None of their patients with growth arrest had proximiry
About 20% of all children's fractures missile wounds. The higher incidence of growth abnormalities
Motor vehicle accidents (MVA)
in the 1976 series was due to the larger number of shotgun
Injuries
Children only 10% of all MVAs and hunring rifle injuries, which dissipate more of their energy
Of children's MVAs, only 17-18% were occupants; remain- peripheral to the missile track.
der were vehicle/pedestrian or vehicle/bicycle In two of the studies in which patients were followed closely,
Fractures all of the fractures ultimately heaIed (82,107).
Higher incidence of femur fractures in vehide pedestrian
accidents in children
Children have a higher incidence of spinal and pelvic frac- Prevention
tures with MVAs than with other mechanisms In an excellent reporr in 1999, Freed et al. (74) analyzed the
magnitude and implications of the increasing incidence of fire-
arm-related injuries in children. They suggested a product-ori-
ented approach, focusing on the gun, in an attempt to provide
an efficient strategy ofgun control and hence reduce the disturb-
ing trend of firearm-related injuries and death among youths.
innocem bystanders; the prime example was "drive-by shoot-
Rather than modifying behavioral or environmentaI issues,
ings" (101,107). Few were self-inflicted, either volumarily or
which are more complex, chey suggested focusing primarily on
accidentally. In a 1976 report on patiems in a relatively rural
strategies that offset the accessibiliry and design of firearms. In
setting in Canada, almost all the missile injuries were accidemal,
brief, these strategies included the following:
having been caused by the patient or a close friend or relative
(82). Reducing the number of guns in the environment through
In the urban setting, handguns and ri Res are the mosr com- restrictive legislation, gun buy-back programs, gun taxes, and
mon weapons (101,104,107). In rhe rural setting, the most com- physician counseling.
mon weapon is a shotgun (82). The firepower of these weapons Modifying the design of guns to make them more child-proof
has changed over the years. [n one urban hospital reponing and preventing unauthorized and unintended use.
gunshot wounds from 1973 to 1983, most of the injuries were
from .32- or .38-caliber weapons; only 5% were high-caliber or
high-velocity weapons (88). In a larer srudy of gunshot wounds
from the same institution from 1991 to 1994, the incidence of
Falls
injuries from high-caliber and high-velocity weapons (e.g." .357 FaIls can vary in severiry from a simple fall while running, to a
Magnum, AK-47, and other assault rifles) had increased to 35% fall of great magnitude, such as from a third story window. Falls
(108). are often classified as the most common cause of injuries. Falls
In the urban serring, the victims' ages ranged from 1 to 17 are more likely ro be a cause of injury in the younger than in
years, and most of the injuries were in children 12 to 14 (88, the older child. Falls in the home are usually associated with
101,104,107). In the rural setting, the patients were younger; furniture or stairs; outside the home, most falls involve play-
the average age was 9 years (82). ground equipmenr (76,77).
Of 839 children sustaining gunshot wounds, 274 (32.6%) In falling from great heights, adults often land on their lower
involved the extremities (88,101,104,107). Of the gunshot extremities, accounting for the high number of lower exrremiry
wounds that involved the extremities, 51.3% produced signifi- fractures, especially the calcaneus. Children tend to fall head
cant fractures (82,101,107). No single bone seemed to predomi- first, using the upper extremities co break the faJI. This accounts
nate, although a great majority of the fractures were distal to for the larger number of skull and radial fracrures in children.
the elbow (88,101,104,107). Femoral fracrures are also more common in children falling from
great heights. In contrast co adults, spinal fractures are rare in
Complications children who fall from great heights (61,84,97,100). In one
The two most common complications were growth arrest and study, children falling three stories or less all survived (61). Falls
infection. Other complications include delayed union or ma1- from the fifth or sixth floor resulted in a 50% mortaliry rate.
 Chapter /: The Present Status of Children '$ Fractures 17

Intrinsic Causes (115). Recently, the American Academy of Orthopaedic Sur-

geons has produced a program designed to decrease the incidence
Nutrition
of playground injuries. These programs offer background data
In a scudy in Spain, a significanr difference in the fracrure rate
and guidelines for various activities, but their effectiveness has
was found when cities with a high calcium content in their water
not yet been fully srudied.
were compared with those with a lower calcium content. With all
other factors being equal (e.g., fluoride contenr, socioeconomic
background), children who lived in the cities with a lower cal-
Local Community Participation
cium content had a higher fracture rate (I05). To be effective, accident prevention programs require local par-
An increase in the consumption of carbonated beverages has ticipation and cooperation. They must be broad based, and they
been shown to produce an increased incidence of fractures in requite considerable efforr by members of the local community.
adolescents (111). In the United States, one effective program is the New York
Health Department's "Kids Can't Fly" campaign, developed in
Bone Density response ro the large number of injuries and deaths from children
Bone density may be a factor, bur the data are unclear. Landin falling out of apartment house windows in the 1970s (20).
and Nilsson (80) found that the mineral content of the forearms This extensive program consisted of a good reporring system
was lower in children who sustained fractures from mild trauma from hospital emergency rooms, with follow-up by public health
rhan in children who had never sustained fractures. It was not personnel; a strong media campaign to educate the public; a
significantly different, howevet·, in those sustaining fractures door-to-door hazard identification program; and the distribu-
from severe rrauma. This study used measurements of bone den- tion oflow- or no-cost, easily installed window guards to families
sity of the corrical bone in the fOtearms. Cook and co-workers in high-rise apartmems. The city required landlords to provide
(67), using measurements of bone density obtained from trabec- window guards in apartments where children 10 years or
ular bone in the spine and femoral neck, found no difference younger lived. The success of this program was demonstrated
between children who had sustained fractures and those who by a 50% decrease in reponed falls after 3 years and a 96%
had nor. decrease after 7 years 016,120).
Over the past 30 years, Sweden has developed broader based,
community-oriented programs to decrease the incidence of all
Premature Infants types of childhood injuries (I 17). The development of these
Fractures not related to birth trauma reporredly occur in 1% ro pilot programs has been relatively easy in a coumty like Sweden
2% of low-birth-weight or premature infants during their stay because the population is homogeneous, the incidence of poverty
in a neonatal intensive care unit (60). Using a combination of is low, and the government is stable. The Swedish program had
the clinical history, radiographic appearance, and laboratoty a three-pronged approach: injuty surveillance and prevention
data, these infants have been found to have evidence of bone research; establishment of a safer environmem for chi ldren
loss from inadequate calcium and phosphorus intal<e. Correcting through legislative regulation; and a broad-based safety educa-
the metabolic status of rhese 10w-birth-weigJu infants, wirh spe- tion campaign. These programs have produced positive results.
cial emphasis on calcium and phosphorus intake, appears ro Schelp demonstrated a 27% reduction in home accidems in the
decrease the incidence of repeat fractures and to improve the municipality of Falkoping only 3 years after the establishment
radiographic appearance of their bony tissues. Once the meta- of a community-wide campaign (19).
bolic abnormalities are corrected, this temporary deficiency One of the most dramatic changes came in the prevention
seems to have no long-term effects. When premature infants of drowning. In Sweden, 100 children drowned in 1954; by
were followed into later years, there was no difference in their 1988, the number had decreased to 10 (I 17). In the same time
fracture incidence when compared with that of children of nor- period, there was only a 5% decrease in the number of childhood
mal birth weight (68). drownings in the United States. The decrease in drowning did
not result from establishing new, sophisticated emergency medi-
cal services or intensive care units in hospitals; it came by teach-
PREVENTIVE PROGRAMS ing children to swim and promoting the use of life jackets on
toddlers playing near the water. In addition, there was a public
One of the major goals of studying the incidence of fractures is education campaign in the mecUa locally and nationally.
ro identiJY problem areas; it is hoped that by targeting these Effective prevemion programs require local community par-
areas, programs can be designed to decrease the risk [1Ctors. ticipation and education. All the articles, lectures, and pamphlers
in the world cannot help unless local communities make the
necessaty changes to decrease accident risks.
National Campaigns
Several safety programs have been started by national organiza- APPENDIX A: FRACTURE COURSES
tions. The foremost is the American Academy of Pediatrics,
which has committees on accident and poisoning prevention. 1. The 1st Swedish International Seminar on "Treatment of
This group has produced guidelines for athletics (I 14), play- Fractures in Children," Institute for Medical Postgraduate Edu-
grounds (118,121), trampolines (112,113), and skateboards cation, Uppsala, Sweden, May 27-30, 1990
18 General Principles

2. Seminario de Actualizacion, en "Fracturas del Nino," The Present Status of the Incidence of
Madrid, Spain, Ocrober 29-30, 1994 Fractures ill Children
3. Operative Management of Children's Fractures-An In- 22. Akbarnia B, Torg JS, Kirkparrick], et al. ManifeStarions of rhe bar-
teractive Course, The University of Texas Health Science Cen- tcred-child syndrome. J Bone Joint Stlrg {Am} 1974;56: 1159.
ter, San Antonio, Texas, August 8-9, 1997 23. Andren L, Borgstrom KE. Seasonal variation of epiphysiolysis of rhe
4. First Caribbean Children's Fracture Course, Port-au- hip and possihility of causal factor. Acta Orthap Seand 1958;28:22.
24. Beckman F, Sullivan J E. Somc observarions on fractures oflong bones
Prince, Haiti, April 15-18, 1998
in children. Am] Surg 1941 ;51 :722.
5. Third Seminario Imernacional sobre Fracturas en el Nino, 25. Bisgard JD, Martenson L Fractures in children. Surg Gynecol Ob.rtet
Madrid, Spain, October 29-30 19.37;65:464.
26. Buckley SL, Gorscil<lil C, Rohenson W Jr, er al. The relationships of
skeleral injuries wirh rraullla score, injury severiry score, lengrh of
hospital sray, hospira! charges, and mortaliry in children admitted to
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20. Rockwood CA Jr, \'(/i1kins KE, Beaty ]H, eds. Fractures in children, J Trauma 1977;17:351.
4rh ed. Vol II!. Philadelphia: Lippincorr-Raven, 1996. 51. Rivara FP, Bergman AB, LoGerfo Jp, er al. Epidemiology of childhood
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wirh elbow exrension. J Bone Joillt SUig {Br} 1991;73:299. 502.
 ChajJter J: The Present Status of Childrm 's Frrrl'tures 19

52. Rohl L. On fractures rhrough rhe radial condyle of rhe humerus in rance of passive and acrive injury prophylaxis for inline skaring. Knee
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457. 80. Landin LA. Nilsson BE. Bone mineral comenr in children wirh frac-
54. Shank LP, Bagg R], Wagnon]. Etiology of pediauic fractures: rhe WITS. Clin Ortbop 1983;178:292.
farigue factors in children's fractures. Prcsellted ar Narional Confer- 81. lenaway DO, Ambler AG, Beaudoin DE. The epidemiology of
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55. Tiderius C], bndin L, Dtlppe H. Decreasing incidenc~ of fracrtlres 82. Lerrs Rivr, Miller D. Gunshor wounds of rhe exrremiries in children.
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58. Wong PCN. A compararive epidemiologic srudy of fi-actures among 86. 1\1[orr A, Evans R, Rolfe K, er al. Parrcrns of injuries ro children on
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88. Ordog GJ, Prakash A, Wasserberger], er al. Pediarric gun,hor wounds.
] Trauma 1987;27: 1272.
Etiology of Fractures 89. Osberg ]S, Schneps SE, Di Scala C, Li G. Skareboarding: more dan-
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] Pedilltr Ortho! 1988;8:4 I. 90. Parmar P, Lens M, ]arvis]. Injuries caused by warer rubing. J Pediflt/'
61. Barlow B, Neimirska M, Gandhi RP, et al. Ten ye;ns of experience Orthop 1998;18:49.
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70 I. South Med] 1998;91: 1033.
63. Boyce WT, Boyce WT, Sprunger LW, er aI. Epidemiology of injuries 93. Rogers GB. Bicycle helmer use pauerns among children. Pediflt/'ics
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64. Buckley SL, Gorschall C, Roberrson W]r, er al. The rc:larionships of 94. Scgns M]M, Wink 0, Clevers GJ. Bicycle-spoke injuries: a prospec-
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hospiul sray, hospiral charges, and monalirj' in childrcn adl1lirred ro 95. Sheps SB, Evans GO. Epidemiology ofschool injuries: a 2-ycar experi-
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usc following a decade of helmer promorion in Vicroria, Ausrralia-an and adolescenrs. J Traulitfl 1996;40:997.
evaluarion. Areid Anal Prell J996;26:325.
97. Sieben RL, leavirr ]0, French ]H. Fa.lIs as childhood accidents: an
66. Cook 1'], Ludwig]. Gun,' in America. Washingron, DC: Police Foun-
increasing urban risk. Pedifltrics J 971 ;47:886.
darion, 1996.
98. Smirh GA. Injuries to children in rhe unired srares relared ro [['ampo-
67. Cook SO, HardingAF, Morgan El, er al. Associarion of bone mineral
lines, 1990-1995: a narional epidemic. Pediat:rics 1998; I 0 1:406.
density and pediatric fracrtlres.] Pedifltr Orthop 1987;7:424.
99. Smirh GA, Shields B]. Trampoline-relared injuries to children. Arch
68. Dahknburg SL, Bishop N], Lucas A. Pue prerenn infants ar risk for
Pediatr Adou:>'c Med 1998; 152:694.
subscquenr fracrure' Arch Dis Child 1989;64: 1384.
100. Smirh MD, Burrington ]0, Woolf AD. Injmies in children susrained
69. Dcrler RW, Silva J ]r, Holcrofr ]. Pedesrrian accidents: adulr and
in free falls: an analysis of 66 cases.] ji-fluma 1975;15:987.
pediarric injuries.] Emerg Nled 1989:7:5.
101. Srucky W, Loder RT. Exrremiey gunshor wounds in children.] Pedifltr
70. D'Souu LG, Hynes DE, McManus F, er aI. The bicycle spoke injury:
an avoidable accidenr? Foot Ankle 1m 1996; 17: 170. Orthop 1991; 11 :64.
71. Feldman W, Woodward CA, Hodgson C, er al. Prospecrive srudy of 102. Topolcski T, Schlesinger I, Wexler LM, er al. Motor vehicle injuries
school injuries: incidence, eypes, rdared facrors and initial manage- in pediarric rrauma pari ems. Presenred ar rhe American Academy of
mene. Can Med AHoc] 1983; 129: 1279. Orrhopaedic Surgeons Annual Meering, Orlando, 1995.
72. Finvers KA, Strorher RT, Mohradi N. The effecr of bicycling helmers l03. US Public Healrh Service. Healthy People 2000: national health promo-
in prevenring significant bicycle-relared injuries in children. Gin] rion and disease prevention objecrives. Washington, DC: DHSS Publi-
Sport Med 1996;6: 102. cation no. PH58 90-50212, 1990.
73. Fountain]L, Meyers Me. Skareboarding injuries. Sports Med 1996; 104. Valentine], BJocker S, Chang ]HT. Gunshot injuries in children.]
22:360. 'Ji-aumfl 24:952, 1984.
74. Freed LH, Vernick ]S, Hargarrcn SW. Prevenrion of flrearrn-relared 105. Verd VS, Dominguez 5], GOl1ZakL QM, er al. Association berween
injuries and dearhs among yourh. A prodtlcr-orienred approacb. Pedi- calcium conrelH of drinking war,"I" and fracwres in children. An Efp
atr Clin North Am 1998;45:427. Pl'difit/· 1992;37:461.
75. Furnival RA, Sn'eer KA, Schunk ]E. Too many pediarric rrampoline 106. WaJrzman Ml, Shannon M, Bowen AP, er aI' Monkey bar injuries:
injuries. Pediatrics 1999;103:57. complicarions of play. Pediat:rics 1999; I 03:58.
76. GaJlagher SS, Finison K, Guyer B, er a1. The incidence of injuries 107. Washington ER, Lee WA, Ross WA]r. Gunshor wounds to rhe ex-
rtITlong 87,000 Massachtlserrs children and adolescenrs: restllrs of rhe uemiries in children and adolescelHs. Or/hop Clin North Am 1995;
1980-81 sratewide childhood injury prevenrion program surveillance 26:19.
sysrem. Alii] Pub Health 1984;74:1340. 108. Weiss B. Bicycle-rclared head injuries. Clin Sports Med 1999; 13:99.
77. Garrerrson LK, Gallagher SS. Falls in children and yourb. P£'diatr 109. Wesrfelr ]ARN. Fnvironmenral facrors in childhood accidenrs: a pro-
Clin North Am 1985;32: 153. specrive swdy in Goreborg, Sweden. Acta Paediarr 5cand 1982;(suppl
78. ]erosch J, Heidj"nn J. Thorwesren L, er al. Injury p;llll"l"nS in aLcep- 291).
20 General Principles

110. Worlock P, 5rower M. Fracture p<ltterns in Noningham children. J 1 15. American Academy of Pediatrics, Comminee on Accidenr and Poison
Paliatr Orthop 1986;6:656. Prevenrion: skateboard injuries. Ped/an'ics 1989;6: 1070-1071.
Ill. Wyshak C, Frisch RE. Carbonated beverages, dietary calcium, rhe 116. Barlow B, Neimirska M, Gandhi RP, er al. Ten years of experience
dierary calcium/phosphorus ratio, and bone fracrures in girls and boys. with failis from a height in children.] Perlialr 5111g 1983; 18:509.
] Adolesc fJetllth 1994; 15:210. 117. Bergman AB, RivaJa FP. Sweden's experience in reducing childhood
injuries. Pediatrics 1991 ;88:69.
118. Reichddcrfer TE, Overback A, Grecnsher]. Unsafe playgrounds. Pe-
Preventive Programs dintrics 1979;64:962.
119. Scheip l. 'J 'he role of organizations in community participation-pre-
112. American Academv of Pediatrics, Comminee on Accidenc and Poison vention of accidental injuries in a rural Swedish municipality. Soc Sci
Prevcnrion: rramp~lines. Evansron, I\linois, September 1977. Med 1988;26: I087.
113. American Academy of Pediatrics, Comminee on Accident and Poison 120. Spiegel CN, Lindaman FC. Children can't fly: a program ro prevem
Prevenrion: trampolines II. PedinNics 1981;07:438. childhood morbidity and mortality from window falls. Am] Dis Child
114. American Academy of Pediatrics, Comminee on Pediatric Aspects 1977;67:1143.
of Physical Fitness, Recreation and Sporrs: competitive athletics for 121. Werner P. Playground injuries and volunrary product standards for
children of elementary school age. Pediatrics 1981 ;67:928. horne and public playgrounds. Pediatrics 1982;69: 18.
 THE BIOLOGIC ASPECTS OF
CHILDREN'S FRACTURES
EDWARD W. JOHNSTONE
BRUCE K. FOSTER

THE IMMATURE SKELETON MECHANISMS Or BO E GROWTH

Endochondral Ossi ficatjon
A ATOMIC R.EGION OF TH ~ CHILD'S BO ES Regularory Mechanisms in the Physis
Epiphysis Membranous Ossification
Physis Remodeling of Bones
Mewphysis
FRACTURE REPAIR
Diaphysis
Osseous Healing
The Periosteum
Cellular Response ro Trauma
Apophysis
Physeal Healing Patterns
Remodeling of Bones in Children After Injury
TH ' MOL -,CULArZ B E
Molecules of the Carrilage and Bone Mauices HE Ul"URE F FRA TURE REPAIR

THE IMMATURE SKELETO osseous maturation. Salter-Harris type I injuries are common in
infants, and types II, HI, and IV become more common as the
Compared with the relatively static, mature bone of adults, the secondary ossification center enlarges and physeal undulations
changing structure and funnion, both physiologic and biome- develop. Joint injuries, dislocations, and ligamentous disruptions
chanica!, of immature bones make them susceptible ro different are much less common in children; it is more likely thar one of
patterns of failure, Even the types of fracture patterns within a the contiguous physes will be damaged. Changing trabecular
given bone demonstrate temporal (chronobiologic) variations and cortical structures affect metaphyseal and diaphyseal fracrure
that may be correlated with progressive anaromic changes affect- patterns, and the variable size of rhe secondary ossification center
ing the epiphysis, physis, metaphysis, and diapl1ysis at macro- affects susceptibility ro physeal and epiphyseal injuries.
scopic and microscopic levels. The options of treatments available for the treatment of skele-
Skeletal trauma accounts for 10% to 15% of all childhood tal injuries in children are expanding. Most notable is the intro-
injuries (60,128,129,131,171). Fractures of the immature skeJe- duction of growrh facrors, such as rhe bone morphogenic pro-
ron differ from those of the mature skeleton (6,128,129). Frac- teins (BMPs), for the induction of bone formation either in
tures in children are more common and are more likely ro occur non-healing defecrs or for bone fusions. It has become necessary
after seemingly insignificant trauma. Fractures may involve the for the orthopaedic surgeon to have a good knowledge of rhe
various growth mechanisms: Physeal disruptions make up about biological aspects of fracture repair. This chapter covers the basic
15% of all skeletal injuries in chiJdren (128,129,131,132,157). biology of bone growrh and fracture repair, including the roles
Damage involving specific growth regions, sLlch as the physis or of growrh facrors and the extracellular marrix.
epiphyseal ossification center, may lead ro acute or chronic
growth disturbances (127,128,166,190). The pl1ysis is con-
standI' changing, both with active longitudinal and latitudinal
(diametric) growth and in mechanical relation to other compo- ANATOMIC REGIONS OF THE CHILD'S
nents. PhyseaJ fracture patterns vary with the extent of chondro- BON
The major long bones of children can be divided inro four dis-
tincr, constanrly changing anaromic areas: the epiphysis, physis,
f.dward W. Johnstone: Dcp~rrJl)enl of Orrhopaedic Surgery, \X/olllcn's ~nd
metaphysis, and diaphysis (86). Each region is prone ro certain
Childrcn's Hospiral. Adelaide. South Australia.
Bruce K. Foster: Oeparrmenr of Orthopaedic Surgery. Wome,,'s and Chil- patrerns ofinjLIJy; the intrinsic susceptibility changes with ph}'si-
dre,,'s Haspira!. Adelaide. Sourh Auslr~lia. ologic and biomechanical changes during postnaral develop-
22 General Principles

menc. The four regions onglnate and become modified as a

result of the basic endochondral ossification process. Subse-
quently, they are supplemented by membranous bone formation
along the metaphyseal and diaphyseal shafts. Finally, the regions
are remodeled to create mature cortical and trabecular bone.

Epiphysis
At birth, each epiphysis (except the distal femur) consists of a
completely cartilaginous structure at the end of each long bone
(Fig. 2-1), the chondroepiphysis. The corresponding ossifying
structure is the chondro-osseous epiphysis. At a time chatacteris-
tic for each of these chondroepiphyses, a secondary center of
ossificarion forms and gradually enlarges until the cartilaginous
area has been almost completely replaced by bone at skeletal
maturiry. This chondro-osseous rransformation is vascular-de-
pendent (Fig. 2-2). Only arricular carrilage remains at maturity.
As the ossification center expands, it undergoes structural
modifications. The region adjacent to the physis forms a disrinct
subchondral plate parallel to the metaphysis, creating che radio-
graphically characteristic lucent physeal line. The appearance of
the ossification centers differ in cerrain chondroepiphyses, a fac-
tor chac must be considered when diagnosing fractLIres of these
regions. The ossification center imparts increasing rigidiry to the
more resilient epiphyseal cartilage as the secondary osseous tissue
expands (176).
The external surface of an epiphysis is composed of either
FIGURE 2-1. Chondroepiphyses of the distal femur and proximal tibia.
These structures have an extensively developed vascular system (carti- articular cartilage or perichondrium (Fig. 2-3). Muscle fibers,
lage canals) before secondary ossification. tendons, and ligaments may attach directly to the perichon-
drium, which is densely contiguous with rhe underlying hyaline
cartilage. The perichondrium contributes to the continued cen-

FIGURE 2-2. Early formation of the secondary ossification center within the epiphyseal cartilage. This
usually occurs in a region well vascularized by cartilage canals (open arrows). One of the canals sends
a branch into the hypertrophic cells (solid arrow), triggering the ossification process.
 Chapter 2: The Biologic Aspects of Children's Fractures 23

FIGURE 2-3. As the epiphysis matures, the ossifica-

tion center expands and progressively follows the con-
tours of the chondroepiphysis. The epiphyseal surface
is either articular cartilage or perichondrium along the
outer surfaces, as in the medial (solid arrows) and lat-
eral (open arrows) malleoli.

trifugal enlargement of the epiphysis. It also blends impercepti- the physeal conrour. The changing size of the secondary ossifica-
bly into the periosteum. This perichondrial/periosteal tissue con- tion center more effectively demarcates the physeal COntour on
tinuity contributes to the biomechanical strength of the rhe epiphyseal (germinal layer) side. As this center of ossification
epiphyseal/metaphyseal junction at the zone of Ranvier. enlarges cenrrifugally to approach the physis, the originally
When the hyaline cartilage of the chondroepiphysis first spherical shape of the ossification center flattens and gradually
forms, there are no easily demonstrable histologic differences develops a contOur paralleling the metaphyseal COntour. Similar
between the cells of the joint surface and the rest of the epiphy- contOuring also occurs as the ossification center approaches the
seal cartilage. However, at some point, a finite cell population lateral and subarticular regions of the epiphysis (Fig. 2-4). The
becomes stabilized and physiologically different from the re- region of the ossification center juxtaposed to the physis forms
maining epiphyseal canilage. McKibbin (l04) established that a discrete subchondral bone plate that the essential epiphyseal
these twO cartilage types are different physiologically and, by blood vessels must penetrate to reach the physeal germinal zone
implication, biochemically. If a contiguous core of articular and (Fig. 2-5). Damage to this osseous plate in a fracture may cause
hyaline cartilage is removed, turned 180 degrees, and reinserted, localized physeal ischemia.
the rransposed hyaline cartilage eventually will form bone at the If a segment of the epiphyseal vasculature is compromised,
joint surface, whereas the transposed articular cartilage remains whether temporarily or permanently, the zones of cellular
cartilaginous and becomes surrounded by the enlarging second- growth associated with tl1ese particular vessels cannot undergo
ary ossification center. Normally, articular cartilage does not appropriate cell division. In contrast, unaffected regions of the
appear capable of calcification and ossification. As skeletal matu- physis continue longitudinal and latitudinal growth, leaving the
rity is reached, a tide mark progressively develops as a demarca- affected region behind (Figs. 2-6 and 2-7). The growth rates of
tion between the articular and calcified epiphyseal hyaline carti- the cells directly adjacent to rhe affected area are more mechani-
lage. caJJy compromised than cellular areas farther away. The differen-
An important aspect of McKibbin's experiment was an expla- tial rather than uniform growth results in an angular or longitu-
nation of nonunion of certain fractures in which the fragment dinal growth deformity, or both (24,132).
may be rotated, causing the articular surface ro lie against me- Interruption of the metaphyseal circulation has no effect on
taphyseal and epiphyseal bone. Union is unlikely in such a situa- chondrogenesis within the germinal zone or the sequential carti-
tion because the articular surface is incapable of a reparative lage maturation within the hypertrophic zone of the physis (see
osteogenic response, an essential component of bone healing. Fig. 2-6). However, the subsequent transformation of cartilage
to bone (primary spongiosa) is blocked (I82). This causes widen-
ing of the affected area, because more cartilage is added to the
Physis cell columns but none is replaced by invasive metaphyseal vessels
The growth plate, or physis, is the essential structure adding and bone. Once the disrupted metaphyseal circulation is reestab-
bone through endochondral ossification (I2l, 126,130,166). lished, this widened, calcified region of the physis is rapidly
The primary function of the physis is rapid, integrated longitudi- penetrated and ossified, returning the physis ro its normal width.
nal and latitudinal growth. Injuries to this component are unique This is the mechanism seen in growth plate fractures and in
to skeletally immature patients. fractures of the metaphysis. The metaphyseal blood supply is
Because the physeal cartilage remains radiolucent, except for temporarily blocked by separation or impaction, and requires 3
the final stages of physiologic epiphysiodesis, its exact location to 4 weeks for restoration. If the circulatory compromise has
must be inferred from the meraphyseal contour, which follows been caused by a metaphyseal fracture, there also may be a tem-
24 General Prillciples

~ .. ~::".J.•. (~ ; ••: .- ;.:;i.:~~::.:.~~ ..•....

.\~~'''o'': ::t:-\~·o"o·o"o-'::~U"Cr'l~&'i,'
\, ':: ~ "'. ~~., ...• ~': ;) ~:~...
(

'. ;::'~
.
. . >.....':.r""
;. (
, ~

.\\: ~\
'.
A B "'I
\

c
Central Ischemia
FIGURE 2-6. Patterns of response to ischemia of the epiphyseal (A,B)
versus metaphyseal (C,D) circulatory systems. Metaphyseal ischemia is
usually transient; epiphyseal ischemia is usually severe and permanent.

FIGURE 2-4. Distal fibula, showing the variably undulated physis, in-
cluding a mammillary process (arrow). The physeal and epiphyseal carti-
lage turns proximally at the medial region (lappet formation) to partici-
pate in the formation of the distal tibiofibular articulation. Note the
difference in the subarticular subchondral bone, which has formed a
thick plate, compared with the thin, outer subchondral bone.

. /

FIGURE 2-5. Epiphyseal circulation (solid arrows) in a toddler. These

supply the germinal/dividing zones of the physis. The open arrow indi- FIGURE 2-7. Histologic section showing an area of central ischemic
cates the early ossification center. As this area enlarges, it will incorpo- growth arrest (arrow). The infarcted area of cartilage is left behind as
rate the epiphyseal vessels. the rest of the physis continues longitudinal growth.
 Chapter 2: The Biologic Aspects of C!1I"/dl"l'Il 's Fraft/lres 25

poraly halt ro bone form arion in the transielldy ischemic portion .E

of the metaphysis. This leads to an apparent sclerosis when the
bone is compared with the adjacent vascularized metaphysis, A
which undergoes a relative disuse osteoporosis. Compromise of
Pc
the metaphyseal circulation has minimal, if any, effect on physeal p
development, particularly when compared with the major detl·i-
mental effects of epiphyseal circularory compromise.
The effectS of physeal ischemia have been studied extensively
by Trueta and coworkers (180-183). Disrupting the epiphyseal
circulation leads ro either partial or complete cessation of
growrh. The central region seems more sensitive ro ischemia
than the periphery, which may have a variable capaciry ro recover
through continued latitudinal growth (112,125). Ischemic com-
promise leads ro different rates of growth across the affected
physis and significant changes in physeal contour (19). Some
changes may be caused by venous stasis rather than arterial dam-
age (78).

Metaphysis
The metaphysis is a variably contoured flare at each end of the
diaphysis. Its major characteristics are decreased thickness of the
cortical bone and increased trabecular bone in the secondary
spongiosa. Extensive endochondral modeling centrally and pe-
ripherally initially forms rhe primary spongiosa, which then is
remodeled into the more mature secondary spongiosa, a process
that involves osteoclastic and osteoblastic activity. The metaphy-
ses ex.hibit considerable bone turnover compared with other re-
gions of the bone, and this facror is responsible for the increased
uptake of radioneuclides in technetium 99m bone scans (105). FIGURE 2-8. Cortical fenestration (solid arrows) of a metaphysis. Note
The metaphyseal cortex also changes with time. Compared the interdigitation of periosteal (Ps) tissue with the fenestrations. The
with the confluent diaphysis, the metaphyseal cortex is thinner periosteum blends into the periochondrium (Pc). Extensive vascularity
is often present in this region (open arrows). (E, epiphysis; P, physis; Z,
and is more porous (trabecular fenestration; Fig. 2-8). These zone of Ranvier; L, ring of Lacroix.)
cortical feneStrations contain flbrovascular soft tissue elements
that connect the metaphyseal marrow spaces with the subperios-
teal region. The metaphyseal cortex exhibits greater fenestration
near the physis than in the diaphysis, with which it gradually regIOns to abnormal stress and predispose to certain fracture
blends as an increasingly thicker, dense bone (Fig. 2-9). As tem- modes.
poral longitudinal growth continues, conical fenestration be- Although the periosteum is attached relatively loosely to the
comes a less dominant feature, and the overall width of the cortex diaphysis, it is firmly fixed to the metaphysis because of the
increases, creating a greater morphologic transition between the increasingly complex cominuity of fibrous tissue rhrough rhe
juxtaphyseal and juxtadiaphyseal corrices. The metaphyseal re- meraphyseal fenestrarions. Such intermingling of endosteal and
gion does not develop extensive secondary and tertiary haversian interosseous fibrous tissues with the periosteal rissue imparts
systems until the late stages of skeletal maturation. These micro- additional biomechanical strength to the region (170). The peri-
scopic anatomic changes appear to be directly correlated with osteum subsequendy arraches densely into the peripheral physis,
changing fracture patterns and are the reason why torus (buckle) blending into the zone of Ranvier as well as the epiphyseal peri-
fractures are more likely to occur than complete metaphyseal or chondrium. The fenestrated metaphyseal cortex extends to the
epiphyseal/physeal fraCtures. physis as the thin osseous ring of Lacroix.
Anorher microscopic anaromic variarion in rhe metaphysis The meraphysis is rhe sire of exrensive osseous modeling and
occurs at the junction of the primary spongiosa and the hypertro- remodeling, both peripherally and centrally (Fig. 2-10). The
phic region of the physis. In most rapidly growing bones, the metaphyseal cortex is fenestrated, modified trabecular bone on
rrabeculae tend to be longitudinally oriented. However, in which the periosteum deposits membranous bone to thicken the
shorter growing bones, such as the metacarpals and phalanges, cortex progressively. Similar endosteal bone formation occurs.
trabecular formation is predominandy horizontal. As growth de- As this metaphyseal region thickens, the trabecular bone is pro-
celerates in adolescence, a similar horizontal orientation may be gressively invaded by diaphyseal osteon systems, nor unlike os-
seen in the major long bones. These variations in trabecular teons traversing the fracture site in primary bone healing. This
orientation affect the responsiveness of metaphyseal and physeal converts peripheral trabecular (woven or fiber) bone to lamellar
26 GeneraL PrincipLes

\ .
' , As in the diaphysis, there are no significant direct muscle
0 ~L - :Hrachments ro the metaphyseal bone. Instead, muscle fibers pri-
marily blend into the periosteum. The medial diStal femoral
I l.. attachment of the adducror muscles is a significant exception.
'-. ~. Because of extensive remodeling and insertion of muscle and
tendon in this area, the bone often appears irregular and may
be misinrerpreted as showing chronic trauma (i.e., a stress frac-
rure), infection, or a tumor.

Transverse Lines of Park and Harris

Many bones exhibit rransversely orienred, dense trabecular linear
bone patterns within the metaphysis. These lines usually dupli-
cate the contiguous physeal COntour. They may appear after
trauma, particularly when the child has been immobilized in
bed (e.g., rraction for femotal fracture), and they also may appear
after genetalized illnesses or even localized processes within the
bone (e.g., osteomyelitis) (1,62,137,138). The lines result from
a temporalY slowdown of notmal longitudinal growth after in-
jury or illness, and they often are called Harris growth slowdown
or arrest lines (Fig. 2-11). Because of the slowdown, the trabecu-
lae of the primary spongiosa become more uansversely than
longitudinally oriented, creating a temporary thickening in the
FIGURE 2-9. Section of distal tibia showing the transition (solid ar·
rows) of cortical bone from the dense, remodeled diaphysis (diamonds) primary spongiosa adjacent ro the physis. Once the normal lon-
to the fenestrated metaphysis (open arrows). Note the progressive girudinal growth tatc resumes, longitudinal trabecular orienta-
change from a relatively thin periosteum over the diaphysis to a much
tion is restored. The thickened, transversely oriented osseous
thicker one at the metaphysis.
plate is left behind, ro be gradually remodeled as primary spongi-
osa becomes secondary spongiosa.
Usually, transverse lines are distributed relatively symmerri-
cally through the skeleron and occupy identical sites in the corre-
(osteonal) bone, which has differenr biomechanical capaCities,
sponding bones on the twO sides of the body. They are thickest
and thus progressively rransforms metaphyseal correx into dia-
physeal cortex as longitudinal growth conrinues. A rorus (buckle) in metaphyses that grow most rapidly, such as the distal femur
ftacture is most likely ro occur in a metaphyseal region with a and proximal tibia. In the metaphyses with slowest growth, they
trabecular, fenestrated, compressible cortex. may not form at all, or they are exceedingly thin and lie at the
very end of the shaft, directly under the provisional zone of
calcification. These transverse lines parallel the contours of the
physeal pl'Ovisional zone of calcification. \'V'hen several transverse
lines are present, they tend to be parallel. The lines nearest the
end of the shaFt ordinarily are the thickest and wideSt; lines away
from the physes tend to be thinner and less distinct and are
usually broken and irregular. As they eventually become part of
the elongating diaphysis, they disappear completely with endos-
teal remodeling.
Park 037,138) found that temporary longitudinal growth
arrest of a bone was a prerequisire for rhe formarion of a trans-
verse line. During this initial phase of growth sroppage Ot slow-
down, a chin, transverse, osseous template was formed along [he
zone of prolifetative cartilage. When longitudinal growth in the
proliferating cartilage resumed (the recovery phase), the process
became visible radiographically as a transverse line.
More rapidly growing bones are associated with longitudi-
nally oriented trabeculae in the juxtaphyseal region; slower grow-
ing bones, particularly the proximal radius, metacarpals, meta-
FIGURE 2-10. Extensive modeling and remodeling of the medial (M) tatsals, and phalanges, normally have a greater amount of
versus the lateral (L) cortex of the distal femur may create irregularities rransvetscly oriented primary spungiosa (118), making trans-
that have been misinterpreted as fracture, stress fracture, infection,
and tumor. Note the well·formed subchondral bone at the periphery verse septa a normal finding. These particular bones do nor have
of the epiphyseal ossification center. a sufficient diFference in the orientation of trabeculae ro manifest
 rhapter 2: The BioLogic Aspects of ChiLc/reJi '$ FracllI res 27

A B
FIGURE 2-11. Histologic section (A) and x-ray study (B) of a distal femur showing a typical Harris line
(arrows). This formed during an acute illness and chemotherapy for leukemia. The child then resumed
a more normal pattern of growth until her death from leukemia about 14 months later.

transverse lines on radiographs. However, if growth slows in rhat characterisrically lacks haversian systems. The neonatal fem-
the rapidly growing areas normally characterized by longirudinal oral diaphysis appears to be rhe only area exhibiring any signifi-
orientation of trabeculae (e.g., distal femur), then more primary cant change from this feral osseous state to a more marure bone
spongiosa bone is formed in a transverse orientation (127). This with osteon sysrems (lamellar bone) before binh (Fig. 2-12).
bone can be quite thick, and probably relates co the duration Periosreum-mediated, membranous, apposirional bone for-
of the biologic stress. Once normal rates of longitudinal growth mation wirh concomirant endosreal remodeling leads to enlarge-
and trabecular orientation are reestablished, rhe rransversely ori· ment of the overall diamerer of the shaft, variably increased widrh
ented sepral, juxraphyseaJ plare is a contrasr ro the preexisting of rhe diaphyseal cortices, and formation of the marrow cavity.
longitudinally oriented rrabeculae and appears on radiographs Marure, lamellar bone with intrinsic bue constantly remodeling
as a specific transverse line. As remodeling occurs, with migration osteonal paccerns progressively becomes rhe dominant fearure
of the epiphysis away from this region, and with conversion of (Fig. 2-13).
primalY spongiosa to secondary spongiosa, there is a gradual The developing diaphyseal bone in a neonare or young child is
breakup of this transverse trabecular orientation. extremely vascular. When analyzed in cross section, it appears
much less dense than rhe maturing bone of older children, ado-
Useful to Assess Growth After Injury lescents, and adults. Subsequent growth leads to increased com-
These biologic marker lines are important in analyzing the effects plexity of the haversian (osteonaJ) systems and rhe formation
of a fracture on growrh. They can be measured and rhe sides of increasing amounts of extracellular marrix, causing a relative
compared ro corroborate femoral overgrowrh after diaphyseal decrease in cross-sectional porosity and an increase in hardness,
fracrure and eccentric overgrowth medially after proximal ribial factors rhat constantly change the child's suscepribiliry to differ-
metaphyseal fracrure. A line that converges toward a physis sug- ent fracmre parrerns. Certain bones, especially the tibia, exhibit
gests localized growrh damage rhar may resulr in an osseous a significant decrease in vascularity as the bone macures; rhis
bridge and the risk of angular defOl·mity. factor affects rhe rare of healing and risk of nonunion.
The vascularity of the developing skeleton consrantly
Diaphysis changes. In experimental studies, significant chronobiologic
changes in flow patterns were found in the developing canine
The diaphysis consticutes rhe major ponion of each long bone. tibia and femur (89,90,105,106,161). In parricular, there was a
It is principally a product of periosteal, membranous osseous dramaric decrease in tibial circulation with increasing skeletal
tissue apposition on the original endochondral model. This leads maturation. This also occurs in humans, which helps to explain
to the gradual replacement of the endochondral!y derived pri- the increasing delay in fracture healing and the increased inci-
malY ossification center and primary spongiosa; rhe larter is re- dence of nonunion of the tibia in adolescents and adults. A poor
placed by secondalY spongiosa in the metaphyseal region. At vascular response could impair rhe early, crucial stages of callus
birth, the diaphysis is composed of laminar ((-etal, woven) bone formation.
28 Gmeral Principles

A .'

FIGURE 2-12. Sections of the femur at the level of the lesser

trochanter at birth (A) and age 7 years (8). At birth, some corti-
cal thickening and osteon remodeling is evident laterally; the
rest of the cortex is irregular. By age 7 years, extensive thicken-
ing and remodeling of the cortex has taken place. B

A B
FIGURE 2-13. Transverse sections ofthe tibial diaphysis in a neonate (A) and at age 2 years (8). A thick
periosteum is evident in A (open arrows), in association with a rapidly forming anterior cortex. At age
2 years, new subperiosteal (membranous) bone is being added to the cortex (solid arrow).
 Chapter 2: The Biologic Aspects of Children's Fractures 29

Other researchers have suggested that adequate vascularity usually remains intact on the concave (compression) side of an
was a major factor in fracture heaJing,(150,151,184,190,194), injlllY. This intact periosteal hinge or sleeve may lessen the extenr
but they did not consider chronobiologic changes in blood flow of displacemenr of the fracture fragments, and it also can be
patterns. used to assist in the reduction, because the intact portion con-
tributes to the intrinsic stability. Because the periosteum allows
The Periosteum some tissue continuity across the fracture, the subperiosteal new
bone that it forms quickly, bridges the fracture gap and leads
A child's periosteum is thicker, is more readily elevated from to more rapid long-term stability. The periosteum may be specif-
the diaphyseal and metaphyseal bone, and exhibits greater os- ically damaged, with or without concomitant injury to the con-
teogenic potential than that of an adult (126). The periosteum tiguous bone. Such avulsion injuries may lead to the formation
is loosely attached to much of the shaft of the bone, but it of ectopic bone (120). In contrast, severe disruption of the peri-
attaches densely into the physeal periphelY (the zone of Ranvier; osteum, as in an open injury, may impair the fracture healing
Fig. 2-14) through intricate collagen meshworks, thereby playing response. Complete loss of a bone segment, with the periosteal
a role in fracture mechanics and treatment of growth mechanism sleeve reasonably intact, may be followed by complete reforma-
injuries (170). The thicker, stronger, more biologically active tion of the missing bone (16).
periosteum affects fracture displacement, reduction, and the rate
The periosteum, rather than the bone itself, serves as the
of subperiosteal callus formation. It also may serve as an effective
origin for most muscle fibers along the metaphysis and diaphysis.
internal restraint in closed reductions.
This mechanism allows coordinated growth of bone and muscle
Because of its contiguity with the underlying bone, the perios-
units; this would be impossible if all the muscle tissue attached
teum is usuaJly injured to some extent in all fractures in children.
directly to the developing bone or cartilage. Exceptions include
However, because the periosteum more easily separates from the
the attachment of muscle fibers near the linea aspera and into
bone in children, there is much less likelihood of complete
the medial distal femoral metaphysis. The latter pattern of direct
circumferential rupture. A significanr porrion of the periosteum
metaphyseal osseous attachment may be associated with signifi-
cant irregularity of cortical and trabecular bone. Radiographs
of this area often are misinterpreted as showing a neoplastic,
osteomyelitic, or traumatic response, even though they exhibit
only a variation of skeletal development.

Apophysis
Because of the differi ng histologic composition of the tibial tu-
berosity (fibrocartilage instead of columnar cartilage; Fig. 2-15),
failure patterns differ from those in ocher physes. This area devel-
ops primarily as a tensile-responsive structure (i.e., an apophysis).
However, the introduction of an osseous secondary ossiflcation
center initially in the distal tuberosiry interposes osseous tissue,
which tends to fail in tension and which may lead to avulsion
of parr of this ossification center (Fig. 2-16). Healing of the
displaced fragment to the underlying undisplaced secondary cen-
ter creates rhe symptomaric reactive overgrowth known as an
Osgood-Schlatter lesion (119,123). Similarly, in adolescents, ex-
cessive tensile srress may avulse the entire tuberosiry during the
late stages of closure (124).

THE MOLECULAR BONE

Molecule of the Cartilage and Bone
Matrices
The Cartilage Matrix

FIGURE 2·14. Simulated type 1 epiphyseal (E) displacement from the

The cartilage marrix is synthesized by chondrocytes. The main
metaphysis (M). Note the thick periosteum (arrow) and its contiguity constituents of the cartilaginous matrix are collagens (mainly
with the cartilage of the epiphysis (radiopaque here because of the type II) and proteoglycans. AJrhough collagen type II provides
cartilage and air contrast). In the body, however, the similar soft tissue
radiodensities of cartilage, ligament, muscle, and so forth blend to- structural srrength, rhe proteoglycans have structural and regula-
gether, making them radiolucent. tory effects. The structural effects of proteoglycans arise through
30 Genna! PrincipleJ

", ...,
\
, \
I." , .'
"," I,..
\
• I,
\
II,

, I \ \'
\
-\
\
\ \ \
,\

A B

,,

FIGURE 2-15. Histology of a typical apophysis,

the tibial tuberosity (tubercle). A: Attenuated
columnar cartilage adjacent to the main proxi-
mal tibial physis. B: Fibrocartilage and minimal
hypertrophic matrix in the mid-tuberosity re-
gion. C: Fibrocartilage and membranous ossifi-
c cation in the distal end of the tuberosity,

binding ro the collagen components and the water-binding

properties rhat provides resilience ro compression. RegularolY

~'1'~~~
effecrs include growth facror interactions, cell matrix interac-
tions, and regulation of collagen fibril size. Specific molecules
expressed and their functions are listed in Table 2-1.

&~
W'?I
";'-'~:' ...... ~ ...... :.
. ~_ a.,...-:"'
.... '" '. -' •• ' ,',' ,;;};
The Bone Matrix
Except for a small percentage of molecules from the circulation
.. ~l:::-.t.;~···..c--,"'".• ,.... 77;. and preexistent matrices thar may become entrapped, the bone
}.:·is~:~l;¥f~·>I.··:··~t matrix is almost entirely synthesized by osteoblasts. The compo-
::.. .~~'t'...,l:-"·"",'v~~
:':' :\\o;.l"\~
~-'I
.,...~ ... -:' -:',:1 )'~4~ "~:'"
sition of the bone matrix was ourlined by Buckwalter and associ-
r:.. '. ".r.'. ·.'''<'.ii?~A Ossicle
t

. ',:1' ~~::·.i6~7~? " ,

ates (20). Briefly, bone marrix is a composite material composed
;r~~<:f·':..~~~;(;. . .~.~ ~:: t of an inorganic (mineral) portion and an organic porrion. The
"t:.~ .v~~~/r;'1-!J /1
LI'> II' ~ """.;r .Jl.~ /f(~
':"~~' ~ "~I
. ' '. I
composite Structure provides physical strength and resilience to
~",;,:::,~;~~~ fracture. Bone with deficient inorganic mineral content is plia-

~~/;f/1~Fl'/;;¥f::(i;,'<separalion
' ';'.' J1 ,/':,,-;,/V
ble, and bone with deficient organic content is britde.

~
The composition of living bone is 60% to 70% inorganic
•
. "'~~v~lfl
~; ~.\
~,
. ..·1I1JO/:P:/''''
''.1
Tuberosity
componenrs, 5% to 8% water, and the remainder is organic
(76). The inorganic porrion is mainly hydroxyapatite, with some
~/~\t.4'::·'A carbonate and acid phosphate groups. It has also been suggested
c ~~~l:'\':l<l' thar bone crystals do nOt contain hydroxyl groups and should
Physis
be termed apatite rather than hydroxyapatite (20). The organic
FIGURE 2-16_ Avulsion (tension) failure of the developing ossification porrion is composed of collagen type I (90%) and noncoUage-
center of an apophysis. The degree of displacement determines the
likelihood of healing and the symptoms and size of the final lump, nous proteins. The noncollagenous prOtein portion includes a
typical of an Osgood-Schlatter injury. /lumber of proteins and proteoglycans rhar perform strucrural
 C!Japter 2: The Biologic Aspects of Child/'en S Fractures 31

TABLE 2-1. MATRIX MOLECULES OF CARTILAGE

Component Site of Expression Within Physis and Proposed Functions

Collagens
Collagen II (fibril) Predominate collagen of all Imparts strength, site of initial
cartilage mineralization (113, 143)
Collagen IX Proliferative zone of the Associates with the surface of the
physis collagen II fibril (78)
Collagen X (short Hypertrophic cartilage Minera'lization (52, 71, 80)
chain collagen)
Collagen XI (fibril) Proliferative and Collagen fibril size (191)
hypertrophic zone of the
physis
Proteog Iyca ns
Aggrecan Throughout cartilage Imparts resistance to compression.
Forms aggregates with hyaluronic
acid and link proteins (23, 113,
159)
Decorin (DS-PG2) Within chondrocytes and Collagen fibril size and TGF-j3
the Interterritorial activity (7, 67, 744)
capsules of the upper
proliferative
chondrocytes
Biglycan (DS-PG1) Territorial capsules of the TGF-,B activity (67)
upper proliferative
chondrocytes
Fibromodulin Collagen fibril diameter and binding
of cells to the matrix (66)
Matrix Gla protein Cartilage Inhibits mineralization (92)

and regu]arory funcrions. Acrual molecules and funcrions are

oudined in Table 2-2 and in rhe following secrion.

Matrix Constituents
Alrhough ir is nor a complere lisr, rhe following provides an TABLE 2-2. COMPOSITION OF BONE
example of rhe major proreins found wirhin bone and canilage
marrices. Component Proposed Functions

Collagens
Collagens Collagen I Imparts strength, site of initial
Collagens are a Family of proreins coded by ar leasr 19 disrincr mineralization
genes. Members are expressed in mosr tissues. Collagens have a Collagen V Provide the inner core of the
rriple helical region rhar arise from rhe repeared winding of collagen fibril (8, 46)
Collagen VI Cell attachment
rhree collagen molecules around a common axis. Collagens are Collagen XII Collagen fibril size
symhesized as a propepride rhar is ohen glycosylared. Collagen Proteoglycans
is secrered From cells and is processed in rhe extracellular space. Decorin (DS-PG2) Collagen fibril size, TGF-,B activity
The processed collagen forms inw subunirs rhar rhen undergo (162, 163)
Biglycan (DS-PG1) Collagen fibril assembly, TGF-,B
flbt-illogenesis (Fig. 2-17). The facr rhar rhe final fiber is com-
activity (164, 195)
posed of many individual molecules accounts for rhe observed Fibromodulin Collagen fibril diameter, binding
dominant negarive murarions rhar can be observed wirhin rhe of cells to matrix molecules (66)
collagen family (74). The incorporarion of individual molecules Osteocalcin (bone Binds hydroxyapatite (146, 587)
thar comain murarions rhar afFecr rhe packing of rhe peprides Gla protein)
Matrix Gla protein Controls mineralization (92, 146)
inro rhe rriple helix can disrurb rhe srrucrure of rhe whole fiber.
Osteonectin Binds calcium (11)
The molecular srrucrures rhar arise are in rhe form of fibrils or Osteopontin Cell attachment (102).
Ilerlike srrucrures. [n realiry, rhe mulrimeric fibet·s observed in
vivo arc ofrell composed of a number of difterenr collagens (5).
32 Gel/eml Principles

11' terminal Propetide : ••- - - - Mature Collagen Molecule - - -•• : C terminal Propetide
,,, ,
,
, :,
' ..- - - - - - - - - - - - - -..... ,
Triple helical region :
'

1 fibrillogenesis

FIGURE 2-17. Collagens are synthesized as a pro peptide that is often glycosylated (not shown). The
collagen molecule has a triple helical region that arises from the repeated winding of three collagen
molecules around a common axisis. The processed collagen forms into subunits that then undergo fibril-
logenesis.

Collagen [ype [ is the main collagen found in bone and other and bigJycan have side chains ofdermatan sulfate, and betaglycan
tissues. It is composed of twO 0'1 (I) and one O'2(I) polypep[ides. has chondroitin and heparin sulfate chains. Fibromodulin has
The collagen eype I flbets aet as si[es for initial mineralization side chains of Im'atan sulfate. The territorial capsules of the
and provide tensile strength to [he bone. Mutations in the pro- chondrocytes in the upper proliferative region of the physis s[ains
peptides can cause a variety of phenoeypes affec[ing mineraliza- for biglycan, the inrerrerritOrial matrix stains for decorin (7).
tion and bone fragiliey, the mos[ severe being osteogenesis imper- These proteoglycans have a structural role but are also known
fecta. In contrast, collagen type II is a triple helical molecule to inreract with growch factOrs (7,67,144).

ma[ is composed of [hree 0'1 (II) polypeptides and is expressed

wi[hin cartilage. It is the main fibril-forming collagen in cani- Other Noncollagenous Proteins
lage. Mutations cause Langer-SaJdino achondrogenesis and Osteocalcin is also known as bone Cia protein. It has [hree
spondyloepiphyseaJ dysplasia congenita (27,45). residues of gamma-carboxyglutamic acid chat enable it to bind
Other collagen eypes, such as V, IX and Xl, associate with to hydroxyapatite. It is thought to playa role in mineralization

the collagen fibers. They may influence coHagen diame[ers and of the bone matrix (146,147), but tne exact mechanism and
interact with other matrix molecules. Mu[ations in eypes IX funccion are undetermined (35,63).
and Xl can result in a number of clinical manifestations (134). Osteonectin has the ability to bind calcium and collagen type
Collagen type X is associated with the matrix of hypenrophic I, and may enable the process of mineralization thac is initiated
chondrocytes and is involved with the mineraliza[ion process on che colJagen type [ fibers (II).
(80,81,139). Mutation causes spondylometaphyseal dysplasia Osteopontin is thought to be critically involved with [he
(74), but the deletion of the encoding gene resulTs in mild binding of osteoclasts (70,149), cells that degrade to the bone
matrix (103).
changes (73,155).
Matrix Cia protein is an inhibitor of calcification. The carti-
lage of mice lacking this protein undergoes sponraneous calcifi-
Proteoglycans cation (93).
Proteoglycans are present in large amounts within all connective
tissues. Pro[eoglycans are proteins [h.at have ei[her one or a num-
ber of polysaccharide chains linked to a prorein core. The poly- Growth Factors
sacch.aride's glycosaminoglycan side chains are either heparin, Within an individual, cell-to-cell communication occurs be-
heparin sulfate, chondroitin sulfate, derma tan sulfate, or kera[an tween neighboring cells and between cells that are separa[ed by
sulfate. The glycosaminoglycans differ in the composi[ion of an almost complete body length. Communication signals take
their cons[ituenr disaccharide structures. They can combine with me form of diffusible molecules which pass between the cells or
other molecules within [he mauix to form macromolecular by cell surface-bound receptor-ligand interactions (88,193). In
structures (49) (Fig. 2-18). addition, neighboring celJs can pass information betw'een one
Proceoglycans are a critical component of cartilage and bone another via their gap junctions (48). These channels enable the
(23,113,144). The pro[eoglycans presem in the physis include passage of small molecules, including calcium ions, bet\veen
latge proteoglycans like aggrecan as well as smaller pro[eoglycans neighboring cells. Calcium is a key second messenger that pro-
such as decorin, biglycan, and possibly, flbromodulin. Decorin vokes a number of cellular events (lID).
 Chapter 2: The Biologic Aspects of Children:( Fractl/res 33

Aggrecan (macromolecular form)

Aggrecan
(monomer)
+- Glycosaminoglycan
side chains

Decorin L Biglycan t--

FIGURE 2-18. Proteoglycans are proteins, which have either one or a number of polysaccharide (glyco-
saminoglycan) chains linked to a protein core. Aggrecan is present in cartilage and has the ability to
form macromolecular structures with hyaluronic acid and link protein. Decorin and biglycan are present
in bone and cartilage matrix.

Hormones are a group of diverse molecules that are secreted skeletal deformities including Pfeiffer's syndrome (FGFRI),
by endocrine glands and are transporred to their effect target Crouzon's and Jackson-Weiss syndromes (FGFR2), and achon-
tissues by body fluids. They coordinate body functions in com- droplasia (FGFR3).
plex otganisms. Hormones can be in the form of amino acid To date, the fibroblast growth factor family comprises at least
derivatives (e.g., epinephrine) polypeptides (e.g., somatotropin nine members including acidic fibroblast growth factor (FGF-
or growth hormone), glycoproteins (e.g., foUicie-stimulating I), basic fibroblast growth factor (FGF-2) (10,15,47,97,111,
hormone), steroids (e.g., testosterone), or fa try acids (e.g., prosta- 156,172,174,199). Additional fibroblast growth factors exist
glandins). that have far less homology. FGF-I and FGF-2 are present in
Growth factors and hormones may circulate in a free form the extracellular matrix of bone (64).
or be bound to carrier molecules or the extracellular matrix The FGFs are also complicated by the presence of alternative
(136). The binding of growth factors and hormones to other forms of the specific forms of FGF-l and FGF-2. FGF-l is
molecules may result in inhibition of the degradation, delivery, rypically 140 amino acids in length, but larger forms of 160 and
and controlling of activity. Many gtowth factors, including the 154 amino acids have been identified (27,43,53,61). FGF-2 is
fibroblast growth factors, transforming growth factor-13 (TGF- normaJly translated as an 155 amino acid molecule, bur through
/3), and insulin-like growth factors, can be bound to the matrix. the use of alternative start codons, another three higher molecu-
Cell activation usually requires the factors to bind to receprors lar weight forms have been identified.
on the cell surface, although a number of hydrophobic hormones The acidic and basic forms ofFGFs are well conserved across
pass directly through the outer membrane and bind to intracellu- species. Comparing the amino acid composition of FGF-l and
lar receptors (31,44,99,116) (Fig. 2-19). FGF-2 from different species, Hearn found a 92% sequence
A degree of redundancy often exists in that a gene knockout identiry between human and bovine acidic fibroblast growth
for one particular growth factor may result in only slight changes factor. Only 2/l55 and 3/155 amino acids differ in human and
in the phenorype observed. A good example is the double mutant bovine, and human and ovine, forms of basic fibroblast growth
ofBMP-5 and 7, which is lethal during embryonic development, factor, respectively (65).
but a null muration in either one has little effect (169). Six receptor molecules have been identified so far. FGF tecep-
rors can be divided into twO groups by the relative affiniry of
the ligands ro thei r receprors.
Fibroblast Growth Factors
The biologic effects of the fibroblast growth factors are wide- Transforming Growth Factor
spread. Fibroblast growth factors are angiogenic and can influ- The TGF-13 superfamily is composed of more than 24 members
ence mitosis and differentiation in many cell types. The receptors (68). They are subdivided inro families including TGF-I3, in-
to these growth factors have been implicated in a number of hibin, decapenraplegic protein/vegetal hemisphere 1 (DPP/
34 General Principles

Growth Factor Growth Factor

(Inactive) (active)
Binding Proteins

. Sequestered Activated
i.at cell surface Receptor Binding Protein
potentates cell
altachmel1t~__~

FIGURE 2-19. The figure shows aspects of growth factor interactions. Any particular growth factor will
possess only a subset of such interactions. Growth factors may require activation (e.g., TGF-,B). Binding
proteins may sequester or protect the growth factor. The binding protein may also potentate the binding
of the growth factor to the surface receptor (e.g., FGF and heparin). Cells may also sequester the growth
factor at the cell surface.

Vgl), and mUllerian-inhibiring subsrance. Members of rhe TGF-,B may bind to cellular receprors, of which there are ar
TGF-,B and the DPPlVgl families have critical funcrions in the least nine. However, mosr of the acrions are mediated rhrough
developmem of the skeJeron, its growth and maintenance, and twO receptors termed recepror ! and 2. Receprors 1 and 2 ,Ire
fracture repair. The bone morphogenic proreins (except for members of the serinelrhreonine kinase family (l00). TGF-,B
BMP-1) are members of rhe DPPlVgl family and are discussed receptor type 3 is a membrane-bound pwteoglycan termed be-
in the nexr secrion. raglycan. Beraglycan is thoughr ro act as a TGF-,B cell surface
All TGF-,B family members except TGF-,B4 are syll[hesi7.ed reservoir and is nor involved wirh signal transduction itself. Be-
as large precursor forms rhar are processed ro acrive forms. The raglycan has rhe possibility of binding FGF rhrough the heparin
acrive form is either a heterodimer or homodimer. It is rhoughr sulfate chains and may present TGF-,B in conjunCtion with FGF
thar the pro-region may eirher help in rhe folding of rhe proreins ro the cell (l00). TGF-,B also binds ro the small proteoglycans:
during symhesis or comrol activity. In the case ofTGF-,B!, the biglycan, decorin, and fibromodulin (67). The small proteogly-
pro-region and a second glycoprorein can also bind ro rhe active cans bind TGF-,B through rhe leucine-rich repeats in rheir pro-
facror ro form a latent complex. Members of the TGF-,B family tein cores and are thoughr to sequester TGF-,B in rhe matrix.
are highly expressed in bone (TGF-,Bl,TBG-,B2). Imporrant in They also compere wirh betaglycan in binding TGF-,B. Decorin
fracmre repair, TGF-,Bl and TG F-$2 are also released in large has the ability to negatively regulate rhe activity ofTGF-,B (13,
quantities during platelet activation. 160).
Aparr from rhe presence of rhe growrh facror irself, rhe pres-
ence or absence of rhe latenr complex conuols rhe activity of Bone Morphogenic Proteins
TGF-,Bl. TGF-,B members can also be sequestered in the marrix. The bone morphogenic proteins and their onhopaedic relevance
The active TGF-,Bl complex call be released from the latell[ have recently been reviewed by Schmitt and colleagues (160).
complex by extreme pH or by catalytic methods. This is particu- The bone morphogenic prOteins (excepr BMP-1) represent a
larly imporrall[ in fracture repair and bone remodeling. The group of relared growth f:1Ctors that have critical roles in the
acrivation oflarell[ TGF-,B is likely to be critical in the induerion cell proliferation and differentiation of a number of cell types
of fracrure repair and osteoblast function. including mesenchymal cells, chondrocytes, and osteoblasts (28,
The acrive TGF-,B molecules may also be bound and their 82,83,J 86). They have roles in embryo and feral developmenr,
activity COntrolled by a number of matrix molecules, including bone growth, and fracture repair. They also include a number
beraglycan and decorin (l 00,197). A1rernatively, the active of growrh facrors (BMP-2, BMP-7) (OP-I), which are being
 Chflpter 2: The Biologil-" Aspect; Ill" Children)- Fra(furei 35

proposed for the rrearment of fraermes and rhe esrablishment rhe periosteum. Similarly, membrane-derived bones may grow
of bone fusions. and elongare by an endochondral process (126,130).
BMPs exisr as glycosylated dimers. Thineen have been identi-
fied so far, bur owing ro sequence homology, only BMP-2
Endochondral Ossification
rhrough 9 can be classed as members of rhe TGF-,B family.
Parricular BMPs produce ecrapic canilage or bone when im- Endochondral ossification is rhe process by which bone forms
planred subcuraneously (2,188). Like the orher growrh facrors via a canilaginous inrermediare. The physis besr reAeers rhis
discussed so far, rhe BMPs have a number of binding proreins process. Physes are remporary carrilaginous rissue siruared be-
borh in the inrracellular marrix and on rhe cell surface. A secrered rween the primary and secondalY ossification cencers of all long
glycoprorein rermed noggin can bind and inacrivare BMPs (50). bones. From 9 to 10 weeks' gestational age ro skeletal maruri ey
Chordin is a similar protein rhat mosr likely has a similar func- at 15 ro 17 years, they are responsible for the longirudinal growth
rion (142). It has been proposed thar these proreins control of bone. The physis can be divided inro at least three zones.
BMP acriviey and may also serve as a mechanism for esrablishing The reserve zone is situated on rhe epiphyseal side and conrains
gradienrs of BMPs across rhe embryo during developmenr. Ac- small, spherical cells randomly disrribured rhroughout rhe zone.
rive BMPs bind ro hererorerrameric serinelrhreonine kinase re- In the adjacent proliferarive zone, chondrocyres undergo mirosis
ceprors. The nonacrivated receprors exisr as eype 1 and 2 recepror and are organized imo columns running parallel to rhe axis of
proteins, rhe eype 2 recepror aurophosphorylares. Once rhe li- bone growth. Cells in the proliferative zone mature and eventu-
gand binds, the rwo receprors are brought rogether and the re- ally increase ro 5 ro 10 times rheir volwne in rhe hypertrophic
cepror eype I porrion is phosphorylated. Only afrer the recepror region. Marrix vesicles are also deposited wirhin rhe longirudinal
eype 1 is phospholylared is a cellular response achieved. Intracel- septa of the physis. Matrix vesicles are membrane-encapsulared
lular activarion is via the inrracellular proreins termed SMADs srrucrures rhar are thoughr to concentrate calcium and phos-
(rhe humor equivalent of rhe MAD (mothers againsr decapen- phare. Enzymes such as alkaline phospharase conven organic
raplegic) prorein), but orher inhibirors can srill come inro play. phosphares ro inorganic phosphate. The longirudinal septum
Exposure of the cell ro a number of other growth facrors (includ- around rhe rerminal hypenrophic chondrocyres mineralizes, and
ing cer-l) can inhibit the acrivarion of the cell by BMPs (140, this mineralized man'ix forms the templare for new bone deposi-
160). rion in rhe meraphysis (Fig. 2-20).
Associared with rhese changes in cellular arrangemenr and
volume, rhe matrix in rhe physis also undergoes a continual
Angiogenic Growth Factors modification in contenr. The two major macromolecules of car-
Angiogenic facrors are growth facrors that promote neovasculari- rilage marrix produced by rhe chondrocytes are rhe proreoglycans
zation. They are critical in fraerure repair. The invasion of the (predominantly aggrecan with lesser amounts of decorin, bigly-
metaphyseal vascular supply is crucial ro endochondral ossifica- can, and fibromodulin) and rhe collagens (rypes II, IX, X, and
rion, and fracrure repair does nor occur without an adequate XI). The major change in physeal proreoglycan srrucrure occurs
vascular supply. Ir is probably nor by accidenr rhat a number as chondrocytes organize into columns in the proliferative zone.
of angiogenic facrors such as TGF-,B and FGF-2 are sequestered Addirional variation occurs in the hypenrophic region, where
in the bone marrix. Angiogenic facrars act directly or indirectly the glycosaminoglycan sulfarion parrern demonsrrares differ-
on endothelial cells, promoting proliferation and migrarion of ences between the pericellular and exrracellular spaces and rhe
rhe cells into areas in which rhey are released. Angiogenic facrors appearance of a uniq ue collagen (eype 10) is observed. The small
acring indirectly by recruiting macrophages monocyres, in rum, proreoglycans-decorin, biglycan, and fibromodulin-are also
release their own direct-acting angiogenic facrors (165). differenrially expressed across rhe physis, alrhough derailed srud-
Direcr-aering angiogenic facrors include plateler-derived en- ies of rhese proteoglycans have nor been done (see Table 2-1).
dothelial growth facrors (PDEGFs), TGF-,B, and FGF-2 ro name The cellular changes and associated marrix alterations are
bur a few. Indirect aering angiogenic facrors include TGF-,B and geared roward producing a microenvironmenr within the hyper-
rumor necrosis facror-a (TNF-a). rrophic zone of the physis, which is conducive ro marrix mineral-
izanon.

MECHA ISMS OF BONE GROWTH Regulatory Mechanisms In the Physis

Hormones, for example, normal growrh hormone, have a global
Because bone is rigid, it cannot grow by incernal expansion and effecr on physcal funerion rhroughour rhe body, bur many
bone growth is achieved by adding newly synrhesized bone ro growrh facrors aer locally. The action of rhese growrh facrors
existing bone by two mechanisms: endochondral ossification and have ofren been derermined in vitro and in vivo and can ofren
imramembranous ossification. These mechanisms are named by present conAiering resulrs due ro experimental design and
the intermediare srructures, that must be passed ro form rhe models used. Mosr invesrigations have concenrrared on rhe effeer
bone. The producrion of any parricular bone after inirial differ- of single or, in some cases, two growrh facrors. However, it is
enciation may involve discrete, juxtaposed, or incerspersed areas likely rhar endochondral ossification is conrrolled by a large
of each basic parrern. Endochondral-derived bones generally number of growrh facrors whose acriviry is controlled by a large
have membranous ossification by aJJpositional bone growrh from number of binding proreins borh wirhin rhe marrix and on rhe
36 Cenerrll Principles

Zones

Acts as a source of stem cells for the

Resting

J production of the chondrocyte columns below.

Chondrocytes undergo mitosis, and

while doing so produce a matrix of
predominately collagen type II, and
Proliferative various proteoglycans. Non-collagenous
proteins are also produced that organize
the matrix and regulate the mineralization
process.

The chondrocytes undergo a rapid

increase in size and produce
Hypertrophic collagen X. Mineralization occurs
between the chondrocyte columns.
Most chondrocytes undergo apoptosis.

FIGURE 2-20. The figure shows the process of endochondral ossification within the physis. Although
not as organized, endochondral ossification follows a similar pattern during fracture repair.

chondrocyte surface. Cellular response is determined by parallel in achondroplasia, conseant activation ofFGF receptor (FGFR3)
processing of the intracellular signals that are induced by a num- is inhibirory (87,95). FGF/heparin sulfate interaerion is probable
ber of active growth factors binding to their speciflc receptors. in the differentiation of the physeal chondrocytes because the
Presented is an outline of the likely actions of a number of key cominuous exposure of FGF-2 inhibits chondrocyte differemia-
growth factors on endochondral ossification. It is not complete, tion in vitro and inhibitOts of glycosaminoglycan sulfation (in-
and the models will continue to change. cluding heparin sulfate) restOte the diffcrcmiation process. Addi-
BMP-2 and 7 promote proliferation and matrix synthesis in tional sulfate permits glycosaminoglycan sulfation and returns
undifferentiated chondrocytes (40,84). J t is believed thar once the effect of FGF-2 (30).
the chondrocytes start differentiating, the expression of noggin Vitamin 0 metabolites and parathyroid hormone have roles
inhibits the continual outgrowth of the undifferentiated chon- in calcium mobilization within the body, but they also influence
drocytes (18). The prechondrocytes may also respond to growth endochondral ossification. Parathyroid hormone and pararhy-
hotmone (117,133). Once the chondrocyte has lost itS resting roid hormone-related protein (PTHrp) can inhibit the matura-
phenorype, insulin like growth factOr-l (IGF-1) may act as a (ion of chondroc)'tes. It is posrulated that physcal chondrocytes
stimularor of proliferation and differentiation (117,176). EGF regulate the local production of PTHrp by secreting a protein
can augmenr IGF stimulation by increasing the exptession of (Indian Hedgehog). This protein stimulates the chondrocyte co
the IGF-1 receptOr (12). Although the chondrocytes synrhesize produce PTHrp, which slows the maturation of proliferative
large quantities of matrix moJecules, they also synthesize FGF- chond rocytes co hypertrophic form (85,187). Expression of the
1, FGF-2, TGF-,B, and a number ofehe BMPs (16,25,29). These mRNA for BMP-6 peaks before mineralization (25) (Fig. 2-21).
molecules can ace in an aurocrine manner, but many are seques- AI(hough the chondroc)'tes of the physis will proliferate and
tered intO ehe newly forming cartilage marrix. FGF-2 in low form a cartilaginolls matrix with only the epiphyseal vascular
doses is mirogenic for the chondrocyees (94); however, as occurs supply, the metaphyseal vessels are critical for the mineraJization
 Chapter 2: The Biologic Aspects of Children j. Fractures 37

Intramembranous ossificarion occurs when osreoprogeniror

BMP-7 cells are formed from the overlying tissue. The osteoprogenitor
BMP-2 cells continue ro differentiate into osteoblasrs, which produce a
Growth Hormone marrix rhar undergoes mineralizarion.

IGF-l Remodeling of Bones

FGFI The first bone to be laid down either from the physis or in the
FGFII fracture callus is woven bone, which is remodeled to lamellar
TGF-fJ bone. AJrhough cancellous bone can be remodeled and obrain
Growth Hormone its nutrients from rhe surface, corrical bone is remodeled into a
IL-l complex structure of osreons thar together form rhe corrical
Vitamin D bone. Osteons are [lIbular structures that interconnecr. They
EGF (stimulates IGF receptor) consist of layers of ordered lamellar bone around a cenrral canal.
The central canal con rains blood vessels, lymphatics, and in some
IGF-l cases, nerves (20).
PTH, PTHrp Bone is constandy remodeled by osreoclasts and osreoblasts.
FGFII The bone is encapsulated by bone-lining cells rhat have the po-
TGF-fJ renrial to become activated osteoblasts. The bone-lining cells,
like osreocytes, have slender cellular processes thar make conract
IL-l with the osreocytes wirhin rhe mineralized bone. Osteocyres are
Vitamin D rhought to arise from osreoblasrs rhar have become entrapped
during bone formation. Jr has been proposed thar the bone-
lining cells need to erode the osteoid rhat covers rhe underling
FIGURE 2-21. Growth factors that control or influence maturation and bone for osreoclasts to bind 007,108). Osteoclasts are bone-
proliferation are shown. See the text for specific actions. degrading cells rhat are produced from rhe hematopoietic path-
way. On activation, they bind to rhe surface of the bone and
secrete enzymes into the space beneath. The space is acidic and
conrains many proteolytic and bone degrading enzymes (98).
process (183). Metaphyseal vascular invasion occurs at the hy- The acidic pH and proteases are thought to release and acrivare
perrrophic-metaphyseaJ inrerface. The endorheliaJ cells mosr rhe sequestered TGF-,B, resulring tn rhe differentiarion and acti-
likely invade as a consequence of angiogenic facrors presenr in vation of rhe bone-lining cells ro os reo blasts and OntO osteocyres
the marrix or secrered by the chondrocytes rhemselves. Both (41,42,101). The osreoblasts rhen lay down new osteoid, and
TGF-,B and FCh are known to be angiogenic. It is interesting subsequent mineralization results in bone. AJd10ugh ir is usually
that an oversupply of FGF-2 infused inro the physis induces accepred rhat rhe osteoblast activiry and osteoclast acrivit)' are
vascular invasion from rhe metaphysis only; even if the FGF-2 linked, discussion srill exists about the signals that derermine
is presenr at the epiphyseal side of the physis, rhe epiphyseal rhe equilibrium thar is required ro keep the bone densiry ar
vessel will not invade (4). Although it is often stated thar rhe functional levels. The osreocytes may be rhe mechanosensory
metaphyseal vessels provide the necessary nutrients for the min- sysrem. Osreocytes also possess cellular processes thar connecr
eralizarion process, it is possible that they provide additional osteocytes to one another and to rhe bone-lining cells above (32)
growth facrors that initiate the mineralizarion process. (Fig. 2-22). It is possible thar the osreocytes are responsible for
The vascular supply also brings osteoblasts, osreoclasts, and sensing bone srress; if undue stress is derected, they favor bone
orher cell rypes. The osteoclasts degrade the mi neraJized carrilage deposirion, whereas if a lack of srress is derected, they favor bone
marrix while osreoblasts lay down new bone that is also rich in resOrptIon.
growth facrors such as TGF-,B, FGf-2 and the BMPs.

FRACTURE R PAIR
Membranous Ossification
All axial and appendicular skdetal e1emenrs are involved in sec- Injuries ro rhe developing skeleton may involve osseous, fibrous,
ondary membranous ossification. The diaphyseal correx of devel- and carrilaginous tissues. Healing of rhese tissues differs, depend-
oping tubular bone is progressively formed (modeled) by the ing on both the rype of rissue and rhe remporal marurarion.
periosteum and modified (remodeled) by rhe re-formation of
osteons. This peripheral periosteal process of membrane-derived
ossification is extensive and rapid in fracture healing in infants
Osseous Healing
and young children. The replacement process also may be seen The progressive changes of the normal process of osseous fracture
when portions of the developing metaphysis or diaphysis are healing, wherher in rhe diaphysis, metaphysis, or epiphyseal ossi-
removed for use as bone grafts. ficarion cellter, may be grouped convenienrly inro a series of
38 G'eII<"rfz! Principles

Pre-osteoclast

Bone erosion releases sequested

growth factors such as TGF - fJ
that stimulate osteoblast
differentiation and proliferation.
Bone lining cells degrade
the osteoid covering the Osteobfasts lay down new
bone, and in doing so osteoid that willfater
expose sites for mineralize.
osteoclasts to bind.
Osteoclast

Osteocytes may act as meclJanosensory

devices that determine stress levels
within the bone. Bone is remodeled to
form a structure that reflects its stress load.
-+----- Osteocytes'

FIGURE 2-22. Osteoclasts and osteoblasts constantly remodel bone. Osteocytes exist within the bone.
Bone-lining cells need to erode the osteoid that covers the underling bone for osteoclasts to bind.
Osteoclasts bind to the surface of the bone and secrete enzymes into the space beneath. The acidic pH
and proteases are thought to release and activate the sequestered TGF-,B that results in the differentia-
tion and activation of the pre-osteoblasts to osteoblasts. The osteoblasts then lay down new osteoid,
and subsequent mineralization results in bone.

phases that occur in a reasonably chronologic sequence (104, and fixed in close proximity. Secondary osreonal union occurs
152,154). Several facrars that influence bone healing can be if cortical bone is laid down berween two segments of fracrured
idenritied from clinical observation as well as experimenral work, cortical bone before callus formarion. NonosreonaJ union occurs
and these facrors must be raken inro accounr when rrearing child- through endosteal and periosteal callus formation (58).
hood fracrures on a rational basis, Many experimenrs have been Fracture repair in rhe immature skeJeran can be divided inra
performed on animals, alrhough because of differences in macro- three closely inrcgrated, but sequenrial, phases: the inflammaralY
scopic and microscopic bone strucrure and skeletal homeosraric phase, the reparative phase, and the remodeling phase (Fig. 2-
mechanisms, they may respond differently rhan skeletally imma- 23). In children, the remodeling phase is temporally much more
rure humans (137,148,168,171,175,185,196). Funhermore, extensive and physiologically more active (depending on rhe
mosr experimenrs have been performed on skeletally marure ani- child's age) than the comparable phase in adulrs. The remodeling
mals, and such data are not always relevanr ra fracrure healing plusc is furrher modified by the effects of the physis responding
in the developing skeleran. In addition, certain areas of rhe devel-
to changing joint reaction forces and biologic stresses to alrer
oping skeleran, particularly the physis and epiphyseal hyaline
angular growth dynamics. This occurs even when the fracrure
cartilage, probably do nor heal by classic callus formation. In
is mid-diaphyseal.
fact, when rhis rype of osseous (callus) repair occurs in rhese
cartilaginous regions, significanr growth deformiries may resulr
owing ra formarion of an osseous bridge berween the secondary
ossificarion center and rhe metaphysis (see Chaprer 5). Cellular Response to Trauma
As in adults, rhere are rhree basic mechanisms of fracrure Inflammatory Phase
repair: primary osteonal, secondary osreonal and nonosreonal.
PrimalY osreonal fracture he,tling occurs when cortical bone is Immediarely after a fracture through any of the osseous portions
laid down wirhour any intermediate, and therefore hardly any of rhe developing skeleron (diaphysis, metaphysis, or epiphyseal
callus forms; ir is only possible if cortical bone is repositioned ossification cenrer), several cellular processes begin.
 Chapter 2: The BioLogic Aspects of Children J' Pram/res 39

Non-Osteoneal Healing Process

Monocytes • Mesenchymal cells

Macrophages
PD ECGF ---~)- Neovascularization

~
. TGF-~etc..
Recruitment
(

. '. .~
. '
";" ~.,
~
.~'
~ , ~'
. \~Platelets
Removal of necrosed tISsue Coagulation ~ .. Hemorrhage
and synthesIs of a matrix 'C: ,
permissive for chondrogenesis - : : : : -
and osteoblast mediated
bone formation.
-=:.
"'.--:::::-'~
Cell necrosIs
.~ ~'" -
-===-
A

Recruitment
Mesenchymal cells
Mesenchymal cells " " ' - -

(
t
Fibroblast Osteoblast
• ,.~?; ~ .,~ ~..... t.;:,-~,.; r$~) _, ;" ~~

... <:!~ ._. ~. ,) .L)I ,~. /~"'~~l ~

Collagen I and III
t -'j

1
Chondrogenesis

t
Endochondral Intramembranous
ossification ossification

c
FIGURE 2-23. The figure demonstrates the three phases of fracture repair (A) inflammatory phase, (B)
reparative phase, and (e) remodeling phase. The inflammatory cells remove the debris from the fracture
site and, together with the fibroblastic cells, develop the site into a matrix that will support the cells
that enable new bone to be formed. The mesenchymal cells are recruited by the release of growth
factors in the fracture site. The mesenchymal cells may differentiate into osteoblasts that produce bone
in a membranous fashion. Alternately the mesenchymal cell may become chondrogenic and produce
bone by the endochondral pathway. Remodeling begins with resorption of mechanically unnecessary,
inefficient portions of the callus and the subsequent orientation of trabecular bone along the lines of
stress.
40 General Principles

Hematoma Formation mation of the woven bone of the provisional (primary) callus.
Bleeding of the damaged periosteum, contiguous bone, and soft Initial invasion and cell division are around the damaged bone
tissues stans the process of repair through the release of growth ends but proceed centrifugally away from the fracture site, thus
factors, cytokines, and posteoglandins. If the fracture is localized placing the most mature repair process closest to the fracture
to the maturing diaphysis, there is bleeding from the haversian site. However, bone formation occurs only in the presence of
systems, as well as from the multiple small blood vessels of the an intact, functional microvascular supply. If the vascular supply
microcirculatory systems of the endosteal and periosteal surfaces is deficient, then this modulation of cartilaginous to osseous
and contiguous soft tissue anastomoses (56). In the region of tissue cannot readily occur.
the metaphysis, this bleeding may be extensive because of the
anastomotic ramifications of the peripheral and centtal metaphy-
Reparative Phase
seal vascular systems. A hematoma accumulates within the med-
ullary canal at the fracture site, beneath the elevated periosteum. Cellular Organisation
and extraperiosteally whenever the periosteum is disrupted dur- The fracture hematoma is the area in which the early stages
ing the fracture. In contrast to adults, the periosteum strips away of healing occur (145). Osteogenic cells proliferate from the
easily from the underlying bone in children, allowing the fracture periosteum to form an external callus and, to a lesser extem,
hematoma to dissect along the diaphysis and metaphysis; this is from the endosteum to form an internal callus. However, when
evident in the subsequent amount of new bone formation along the periosteum is severely disrupted, healing cells must differen-
the shaft. tiate from the ingrowth of undifferentiated mesenchymal cells
However, the dense attachments of the periosteum into the throughout the hematoma. By 10 to 14 days in a child, the
zone of Ranvier limit subperiosteal hematoma formation to the fracture callus consists of a thick, enveloping mass of peripheral
metaphysis and diaphysis. Because the perichondrium is densely osteogenic tissue that is beginning to be evident radiographically.
attached, this type of hemorrhagic response is uncharacteristic This new bone is primarily woven (fiber) bone (l 0 1,114,150,
of the epiphyseal ossification center, thus limiting its contribu- 151).
tions to callus formation and any inttinsic stabilization effect. The next step in osseous fracture healing is cellular organiza-
Further, because of the partially or completely intracapsular na- tion (33). Duting this stage, the circumferential tissues serve
ture of some epiphyses, propagation of a fracture into the joint primarily as a fibrous scaffold ovet which cells migrate and orient
allows decompression of some of rhe bleeding into the joinr, to induce a stable tepair. This pluripotential mesenchyme is
again limiring rhe porential volume for eventual callus forma- theoretically capable of modulation into cartilage, bone, or fi-
tion. brous tissue (54,57,135). The mesenchymal cells are tecruited
Coagulation and plateler activarion stop rhe blood loss but by the release of growth factors in the fracture site. Members of
also produce both inflammatory mediatots and angiogenic fac- the BMP family, and possibly their inhibitors, are likely to be
tors. Endothelial cells respond and increase the vascular perme- involved in the recruitment and differentiation of the mesenchy-
ability, and allow the passage of leukocytes, monocyres, and mal cells. The mesenchymal cells may differentiate into osteo-
macrophages into the fracture site. Neovascularization is also blasts that produce bone in a membranous fashion or may be-
initiated. Angiogenic factors like platelet-derived growth factor come chondrogenic and produce bone by the endochondral
(PDGF) and TGF-p, also promote osteoblast recruitment and pathway. Both mechanisms usually are present in a fracture cal-
activation. lus, and the degree to which each is ptesent depends on the type
of bone, age, degree of fixation, level of bone loss, and ttauma.
Local Necrosis In children, because of the osteoblastic activity, the periosteum
The blood supply is temporarily disrupted for a few millimeters contributes significantly to new bone formation by accentuating
on either side of the fracture, creating juxtaposed, avascular tra- the normal process of membtanous ossification to supplement
becular and cortical bone (55) and producing local necrosis. It the cellular otganization within the hematoma, which is going
is likely that the necrosis also results in the release of sequestered through a cartilaginous phase (58,59). The region around the
growth factors (e.g., IGF-l, TGF-I3, FGF-l, and FGF-2) from fracture site thus repeats the process of endochondral ossifica-
the bone. These growth factors may help in promoting differen- tion, in close juxtaposition to membranous ossification from the
tiation of the surrounding mesenchymal cells into bone-forming elevated periosteum. Similar processes occur within the medul-
cells. lary cavity. An integral part of the reparative process at this stage
The inflammatory cells remove the debris from the fracture is microvascular invasion, which occurs very readily in children
site and, with the fibroblastic cells, develop the site into a matrix because of the state of vascularity within and without the bone
that will support the cells that enable new bone to be formed. and surrounding soft tissues (26) . Vessels come from the petios-
This initial matrix often contains collagens rype I, III, and V. teal region as well as from the nutrient artery and endosteal
vessels.
Organization of Hematoma Until this bone goes through the final stages of maturation,
The initial cellular repair process involves organization of the it is still biologically plastic and, if not protected, may gradually
fracture hematoma (39,55,62,69). Fibrovascular tissue replaces deform, especially in an active young child after early release
the clot with a matrix rich in collagens 1, III, and V. This matrix from an immobilization device. Even in a cast, this plasticity
allows chondrogenesis or imramembranous bone formation. may allow deformation from isometric muscle activity.
Such mechanisms eventually lead to mineralization and the for- Clinical union is attained when the fracture sire no longer
 Chapter 2: The Biologic Aspects 0/ Chiidren J' Fmetures 41

moves and is noc painful co anempts at manipulation, although tem that must be replaced. This is a much longer sequence of
it is by no means tescored co its original strength at this time. events and is not a major method of bone repair in children,
With time, the primary caUus is gradually replaced. This is en- except when the fracture involves densely cortical regions such
hanced in the child because appositional growth and increasing as the femora.! or tibial shafts. McKibbin (104) presented an
diameter envelop rhe original fracture region, the canilage and extensive discussion of this process, which is sometimes refetred
woven bone have been replaced by mature, lamellar bone, and to as primary bone union because no imermediate cells are in-
the fracrure has consolidated and essencially returned co most volved.
of its normal biologic standards and response co stress.

Physeal Healing Patterns

Remodeling Phase
The physis has a limited ability to repair; it primarily heals by
The last phase (remodeling) begins with resorption of mechani- increased endochondral bone and cartilage formation, and grad-
cally unnecessary, inefficient portions of the callus and the subse- ual reinvasion by the disrupted metaphyseal vessels to replace the
quent orientation of trabecular bone along the lines of stress. temporarily widened physis eventua.!ly. Very little experimental
The remodeling phase is the longest of the three phases and in work, mostly in rats, has been directed at assessing the posrrrau-
children may continue uncil (and beyond) skeletal maruration matic cellular response patterns of the physis (17).
in response co constantly changing stress patterns imposed by Depending on the level of cellular injury within the physis,
concillued skeletal growth and development. Initially, new bone three types ofchandro-osseous heaLing may occur. First, when the
is laid down by both the fracture callus and the more extensive fracture occurs through the cell columns, hea.!ing occurs primar-
but confluent subperiosteal tissue. This bone is randomly ori- ily by continued, relarively rapid increases in the number of cells
ented and cannot withstand all biologic stresses imposed on it. within the columns, causing moderate widening of the physis.
However, as the bone grows diamerrica.lly in the diaphyseal or Because there are some small epiphyseal vessels in this region,
metaphyseal regions, this new bone is gradually and increasingly some damaged rissue may be resorbed early in the healing pro-
incorporated into the preexisting cortica.! bone, aJigned in accord cess. These vessels also exhibit a hyperemic response, increasing
with predominant stress patterns, and replaced by physiologic ceJlular proliferation rates, especially in the peripheral zone of
remodeling processes. The degree of remodeling and progressive Ranvier. The metaphyseal response parallels this, in that an in-
replacement of fracture callus is greater in younger children, who creased rare of bone replacement of the hypertrophic chondro-
have an immense capacity for growth and change. cyte also occurs. Once the level of fracture fibrosis and debris
The criticaJ step berween the reparative and remodeling within the physis is encountered, the vessels rapidly invade to
phases is the establishment of an intact bony bridge berween reach the rest of the maturing cell columns. These cellular re-
the fragments. Because this involves the joining of separated sponse parrerns lead to restoration of normal anatomy within 3
segments of hard tissue, the whole system must become immo- to 4 weeks (153).
bile. Once the bridge has been established-provided that ade- Second, when the fracture occurs through the transition of
quate, continued mechanicaJ protection is given-subsequent hypertrophic cells to primalY spongiosa (the mosr commonly
biologic failure is unlikely. If the two or more fracture fragments involved cellular level), there may be marked separation, with
remain connected by the periosteum or related material, as is the gap filled by hemorrhagic and fibroblastic tissue. This region
likely in a child, it is easy co see how reparative activity could may progressively form disorganized cartilaginous tissue, nor un-
be conducted from one side to the other relatively easily and like the initial, disorganized cartilaginous callus around a diaphy-
rapidly. seal fracture. Meanwhile, cellular proliferation, cell column for-
The intact bone must then readapt co functional demands. mation, hypertrophy, and calcification continue on the
This is much easier in children, whose skelecons are actively and epiphyseal side of the disorganized callus, leading to widening of
continually remodeling in response to stress, than in adults, who the physis. A vascular invasion of the remnants of hypertrophic,
have more static skelecons. The processes of replacement and calcified cartilage also rapidly occurs on the metaphyseal side of
repair are continuous and concomitant in the normally develop- the fracture. However, once metaphyseaJ vessel invasion reaches
ing skeletOn. The mechanisms involved in fracture healing essen- the disorganized carrilaginous callus, vascular-mediated bone re-
tially are no different than most of the active maturational pro- placement is temporarily slowed, because there is no pattern of
cesses. These processes are much more acrive in children and cell columns to invade in an organized fashion. As the callus
are more active in the metaphysis than in the diaphysis. cartilage matures and calcifies, the metaphyseal vessels begin to
The fracture remodeling process differs in cortical or cancel- invade and replace the cartilage wirh bone irregularly (21). This
lous bone. Both involve a process of simultaneous bone remova.! caJIus may be variably thick, depending on the degree oflongitu-
and replacement by the osteoclasts and osteoblasts through the dina.! and lateraJ displacement and periostea.! continuity with the
accompanying blood vessels. In cancellous bone of the metaphy- physeal periphery. The caJius is replaced at different rates, and
sis or the endosteal surface of the diaphysis, the cells are never the invading metaphyseaJ vessels reach the norma.! cell columns,
very far away from blood vessels, and the whole process of appo- which have been maturing in a normal sequence but without
sirion and replacement may occur on rhe surface of the trabecu- osseous replacement. This widened physis is rapidly invaded by
lae. However, in compact bone, the more deeply placed cells the vessels and replaced by primary spongiosa, and normal phy-
require the presence of an adequately funcrioning perfusion sys- sea.! width is progressively restored.
42 ("eneral Principles

The callus in the subperiosteal region contributes [0 early taphyseal bone, and thereby enhances the risk of forming an
stabiliry. This region heals by vascular invasion of the callus [0 osseous bridge between the two regions.
form trabecular bone between the original metaphyseal cortex
and the subperiosteal membranous bone forming cominuously
external [0 the metaphyseal cartilaginous callus. These three mi- Remodeling of Bones in Children After
croscopic bone regions progressively merge and remodel, making Injury
the region srrong biomechanically. With further growth and In a growing child, the normal process of bone remodeling in
remodeling, this coalescem bone is completely replaced. These the diaphysis and metaphysis (particularly the latter) may realign
initial cellular replacemem processes in both metaphyseal and initially malunited fragments, making absolutely accurate ana-
physeal regions probably take 3 [0 6 weeks. However, remodel- tomic reduction less imporram than in a comparable injury in
ing may cominue for months to years, and it enhances the capac- an adult. However, although some residual angular deformities
ity for spontaneous correction of many residual deformities. undergo spontaneous correction, accurate anatOmic reduction
Third, when the injury extends across all cell layers of the should be the goal whenever possible (51,122,129). Bone and
physis, the repair processes differ slightly. Fibrous tissue initially cartilage generally remodel in response to normal stresses of body
fills the gap between separated physeal components, whereas weight, muscle action, and joint reaction forces, as well as inuin-
rypical callus formation occurs in the contiguous metaphyseal sic control mechanisms such as the periosteum, The potemial
spongiosa or epiphyseal ossification cemer. If large surfaces of for spontaneous, complete correction is grearer if the child is
nonossified epiphyseal cartilage also are involved, fibrous tissue younger, the fracture site is closer to the physis, and there is
initially forms in the intervening region. The reparative response relativc alignmem of the angulation in the normal plane of mo-
shows irregular healing of the epiphyseal and physeal cartilage, tion of the joint. This is particularly evident in fractures involv-
with loss of normal cellular architecture. Within the central phy- ing hinge joims such as the knee, ankJe, elbow, or wrist, in which
seal regions, diametric expansion of cell columns is minimal, so corrections are relatively rapid if the angulation is in the normal
closure of a large defect by physeal cartilage is unlikely. The gap plane of motion. However, spomaneous correction of angular
will remain fibrous, but with the potemial to ossify. Toward the deformities is unlikely in other directions (relative [0 normal
physeal periphery, diametric expansion is more likely, but still joint motion), such as a cubirus varus deformiry following a
may not lead to closure of large cartilage gaps by progressive supracondylar fracture of the humerus. Similarly, rotational de-
replacemem of fibrous tissue. This replacement process essen- ftrmities usual0' do not correct spontaneously.
tially requires the germinal and hypertrophic cell regions [0 dia-
metrically expand by cell division, maturation, and matrix ex-
pansion. The imervening fibrous tissue may disappear through
Growth Stimulation
growth, but only if the gap is narrow. Because blood supply is Fracrures may stimulate longitudinal growth by increasing the
minimal in this region, the fibrous tissue similarly is not well blood supply to the metaphysis, physis, and epiphysis, and at
vascularized, and significam cell modulation, especially [0 osteo- least on an experimemal basis, by disrupting the periosteum and
blastic tissue, is less likely in the short term. However, the larger its physiologic restraint on the rates of longirudinal growth of
the gap filled with fibrous tissue and the longer the time from the physes (34). Such increased growth may make the bone
fracture [0 ske!'etal maturiry, the greater the likelihood of devel- longer than it would have been without an injury (9,36,184).
oping sufficient vasculariry to commence an osteoblastic re- Eccclltl'ic overgrowth may also occur; this is particularly evident
sponse and to form an osseous bridge. Further, in young children in tibia valgum following an incomplete fracture of the proximal
with minimal epiphyseal ossification, the blood supply [0 the tibial metaphysis.
physeal germinal region is nO( as well defined, whereas once the
ossification center expands and forms a subchondral plate over
the germinal region, microvasculariry probably increases and the THE FUTURE OF FRACTURE REPAIR
chances for vascularization and ossification of the fibrous region
increase. This explains the delayed appearance of the osseous Bone grafts contain bone growth factors rhat normally induce
bridge. bone formarion and have the appropriare osteoconducrive ma-
If accurate anatOmic reduction is performed, a thin gap trix. Autogenic grafts also contain osreogenic cells. Bone grafts
should be present rhat should fill in with minimal fibrous tissue, are effecrive, but there are difficulties in obtaining safe and relia-
allowing progressive replacement of the tissue by diametric ex- ble tissue. Although rhe mechanisms of fracrure repair are nor
pansion of the physis and comiguous epiphysis. However, if the fully understood, the level of understanding has enabled key
fragment has been partially or completely devascularized by molecules to be targeted as therapeutic in controlling and pro-
either the initial trauma or subsequem dissection [0 effect an moring fracrure repair. Filler compounds have been developed
open reduction, cellular growth and diametric and longitudinal that either stimulate mesenchymal cells, leading to new bone
expansion may not occur. This increases the chances of cellular formation (osrcoinductive) or enable the bone-forming cells to
disorganization, fibrosis, and evemual osteoblastic response. infilrrate and incorporare ,into bone (osteoconductive).
Failure to correct anatOmic displacement, especially in Salter- Specific growth Factors have been targered for their abiliry
Harris rype 4 growth mechanism injuries, increases the possibil- to promote bone formation. Two growth factors (BMP-2 and
iry of apposition of the epiphyseal ossification center and me- Ostegenic Prorein-1) (BMP-7) show grear promise for their abil-
 C/.Iapln 2.' The BioLogic Aspects vI Children J' Fraflures 43

iry to promote fraceure repair (83,84,90,96,173,192). A number 9. Bisgard JD. Longirudinal overgrowrh of long bones wirh special refer-
ences ro fracrures. Sttrg G)'Ileco! Obsta 1936;62;823-835.
of others, such as TGF-,B, IGF, PDGFs, and FGF-2, also may
10. Bohlen P, Baird A, Esch F, et al. Isolarion and partial molecular
prove to be useful. characteriurion of piruitary fibroblast growth facror. Proc Nat! Acad
TGF-,B plays a major role in fracture repair by promoting Sci USA 1984;81:5364-5368.
proliferation and differentiation of the mesenchymal cells. Exog- 11. Bolander ME, Young MF, Fisher LW, er al. Osteonectin cDNA se-
enous TGF-,B administration can initiate the repair process and quence reveals porenrial binding regions for calcium and hydroxyapa.
rire and shows homologies wirh borh a basemenr membrane prorein
callus formation in uninjured bone (75). The addition ofTGF-
(SPARC) and a serine proreinase inhibitor (ovomucoid). hoc Nat!
,B to fractures promotes wound repair and results in a larget, Acad Sci USA 1998;85;2919-2923.
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in non healing bone defects. PDGF also increases callus size but insulin-like growrh facror-! in rhe regulation of growth plare chondro-
does not improve the fracture mechanically (l15). Growth hor- cyres. Exp Cell Res 1997;234;1-6.
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on fracture repair. Although growth hormone produces inconsis- mental kidney disease. Nature 1992;360;361-364.
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many reviews on the use of growth factors for fracture repair growth facror-beta is produced by chondrocytes and acrivated by ex-
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 PAIN RELIEF AND RELATED
CONCERNS IN CHILDREN'S
FRACTURES
JOSEPH R. FURMAN

Gum 1 ES AND PRI CIPLES OF S DATIO Barbiturates

CHlLDRE Propofol
Definitions REGIONAL ANESTHESIA IN THE CHILD WlTH A
Monitoring MUSCULOSKELETAL INJURY
Parienr Assessment Regional Anesthetic Agent
Oral Intake Precaurions Local Anestheric Toxicity
Hemodynamic Status Intravenous Regional Anesthesia
Coexisting Nonmusculoskeletal Injuries Local Infilrration Anesthesia: HematOma Block
Status of rhe Airway Femoral Nerve Block
Treatment Facility
POSTOPERATIVE A ALGE IA I THE CHILD
SEDATIVE MEDICATIONS WITH A MUSCU OSKEL TAL INJURY
Nirrous Oxide Posroperative Analgesia With Opioids
Ketamine Posroperative Analgesia Wirh Nonsteroidal Antiinflammarory
Benzodiazepi nes Drugs
Opioids Postoperative Analgesia With Local Anesrhetic Agents
Chloral Hydrare TREATMENT OF POSTOPERATIVE AU$EA

Providing pain relief is one of rhe many imporrant pans of rhe of postoperative nausea. The author hopes that the orthopaedic
management of children's fractures. In addition, because having practitioner will find this chapter of significant benefit, not only
a fracture reduced is nor only painful but also frightening to in the emergency room setting bur also in the office and on the
many children, providing young parients with adequate sedation hospital ward.
and amnesia are additional welcome elements of good care.
However, rhe correct use of any of the available medicarions for
obraining these goals muSt involve an appropriate undemanding GUIDELINES A D PRINCIPLES OF
of proper dose, desired effects, and untowaJd side effects. The SEDATION IN CHILDREN
purpose of this chapter is to provide a thorough source of infor-
mation regarding safe and effective analgesia and sedation for Definitions
children with fractUres. This chapter discusses the concept of
The practitioner must recognize that sedation describes a contin-
sedation and its definitions, the various medications used to
uum ranging from neal" wal<efulness to complete loss of con-
achieve the sedation state, and the various medications used to
sciousness (Fig. 3-1). Terms used to describe various stages along
achieve analgesia, including both systemic medications and local
this continuum have included conscious sedation, deep sedation,
anesthetics. Intravenous regional anesthesia (Bier Blocks), hema-
and general anesthesia (63).
toma blocks, and femoral nerve blocks (for femur fractures) are
Sttictly speaking, the term conscious sedation means a phar-
discussed in depth. The management of postoperative pain is
macologically controlled altered state of consciousness in which
discussed, along with the treatment of the troublesome side effect
patients maintain their ability to respond purposefully to verbal
commands. For nonverbal patients or young infants, conscious
sedation implies the ability to respond purposefully to physical
stimulation, not simply by reflex withdrawal to pain. U nfortLI-
Joseph R. Furman: Stat Anesthesia, San Antonio, Texas. nately, most physician and nursing personnel tend to use the
50 General flriJlicipies

Protective reflexes maintained : Loss of reflexes TABLE 3·1. RECOMMENDED DISCHARGE

Patent airway _ 1 ____ Unable to maintain airway CRITERIA AFTER SEDATION
Responds appropriately : Impaired response
I 1. Cardiovascular function and airway patency are satisfactory
I
1 and stable.
Conscious I
I
2. The patient is easily arousable, and protective reflexes are
sedation I intact.
Awake or 3. The patient can talk (if age appropriate).
"sedation 4. The patient can sit up unaided (if age appropriate).
analgesia" 5. For a very young or handicapped child incapable of the usu-
ally expected responses, the presedation level of responsive-
ness or a level as close as possible to the normal level for that
child should be achieved.
6. The state of hydration is adequate. *
FIGURE 3-1. Sedation and analgesia for procedures is a continuum.
(Reproduced with permission from American Society of Anesthesiolo- * Adequate hydration may be achieved with intravenous fluids.
gists from ASA 1997 Annual Refresher Course lectures. Sedation and There is no specific requirement that children be ablEi to tolerate
Analgesia in Pediatric Patients for Procedures Outside the Operating oral fluids before discharge from a treatment facility. Children
Room. Richard F. Kaplan, M.D. No. 221) who are nauseated, or actively vomiting should be treated and
observed until this problem resolves (see sect'ion on treatment of
postoperative nausea).
Guidelines for monitoring and management of pediatric patients
during and after sedation for diagnostic and therapeutic
term "conscious sedation" w mean anything shon of a general procedures. Pediatrics 1992;89:1110-1115, with permission.
anesthetic. For such reasons, the consensus of the 1996 report
by rhe American Society of Anesrhesiologists Task Force on
Sedarion and Analgesia by Non-Anesthesiologim (l08) is that
the term conscious sedarion, alrhough in common usage, is im-
precise. This reporr recommends replacing the term conscious
sedation wirh the more descriprive rerm sedarion/analgesia (Fig. of qualified personnel who are competenr in rhe use of moniror-
3-1). Whatever rhe preferred term, the important point w recog- ing devices, and capable of recognizing the clinical signs of airway
nize is that the safesr level of sedation is rhat which permits or hemodynamic instability. AJthough skill in ar least pediauic
purposeful response ro verbal or physical stimulation. Ir is at basic life support is necessary (63,119), training in pediatric
rhis level of sedarion rhat the risk of hypovenrilarion, apnea, or advanced life support (PALS) is cerrainly desirable. In the au-
cardiovascular instability is minimal. Unforrunarely, and realisri- thor's opinion, rhis training should be considered absolurely nec-
cally speaking, such relarively lighr levels of sedation are wtally essary. The orrhopaedic surgeon must always demand, and have
inadequare for the performance of a painful procedure such as available, skilled health professionals, either physicians or nurses,
rhe reducrion of a fracrure. AJso the younger and less cooperarive co assisr in obsenTing the parient and rhe monitors during proce-
the parient, rhe less likely thar so-called conscious sedation can dures requiring medications rhar arc known ro depress respira-
realistically be achieved ar aJI (92). Therefore, it is very likely wry or cardiovascular funcrion. Having one person performing
thar for orrhopaedic procedures, chiJdren may have w be sedated borh the surgical procedure and moniroring the patient is a
w levels at which they are nor easily responsive w verbal stimula- practice rhar should be strongly discouraged in all bur the mosr
tion, and as such, at increased risk for respirarolY and cardiovas- desperare circumstances.
cular compromise. Even in children in whom lighr levels of Oxygenarion, venrilarion, and circularion are the three pa-
sedarion ([[ue conscious sedation) is possible, uninrended overse- rameters rhat require careful assessment. For the most parr, mon-
darion may occur wirhour warning. Oversedation may lead w iroring remperarure is usually of minimal imporrance. The major
(a) loss of rhe airway, (b) impaired protective reflexes leading w exceptions, of course, are children who arrive in the hospiral
the possibility of aspirarion of gasrric conrents, and (c) cardiopul- either severely hyporhermic or febrile.
monary arresr (Fig. 3-1). Ir is for rhese reasons thar careful moni- Moniroring oxygenation requires conrinuous pulse oxime[Jy
roring of sedared parjents as prescribed in standard guidelines and conrinual visual inspection of the patient. Nore rhar the
(l08) is absolutely imperarive. term continuous moniroring refers ro a constanr measuremenr
undertaken for a period of time wirhout interruprion. Conrinual
moniroring refers w an assessment taken at frequent regular
Monitoring intervals.
Obviously, rhe purpose for moniwring sedated patients is w The value of pulse oximetry as an early detecror of impeding
provide timely derecrion and correction of abnormaliries in re- hypoxemia has been well demonstrated (34). The problem with
spiratory and cardiovascular function. The monitoring process relying on visual inspection alone w derermine adequacy of oxy-
begins before the administration of any sedarive medicarions. genation is rhat cyanosis is both a late and variable sign of hypo-
Moniwrjng conrinues unabared ulHil the patient returns ro base- xemia. Demonstrable cyanosis requires rhe presence of ar leasr
line presedation level of consciousness and is ready for discharge. 5 g of desaturared hemoglobin per deciliter. Therefore, for exam-
Acceprable discharge criteria are noted later (Table 3-1). ple, a parient with a hemoglobin level of 10 g/dL would rheoreri-
Of viral importance ro the moniroring process is the presence cally nor even appear cyanotic unril rhe oxygen saturation level
 Chapter 3: Pain ReLiefand ReLated Concerns in Children '5 Fractures 51

(Spoz) plummets to 50%. For this same reason, a severely ane-

TABLE 3-2. NORMAL VALUES FOR HEART RATE
mic patient may never develop visible cyanosis even at profound
BY AGE
levels of hypoxemia. To add to a potentially confusing situation,
the ambient light (especially fluorescent light) in many clinical Range
environments may make any patient appear cyanotic (33). Age (beats/min)
Therefore, pulse oximetry is essential in all heavily sedated pa- Newborn 110-1'50
tients to detect abnormalities of oxygenation rapidly. 1-11 months 80~150
Note, however, that the pulse oximeter is not perfect. Factors 2 yeilrs 85-125
that affect the accuracy of the pulse oximeter include patient 4 75-115
movement (33), direct bright light on the probe (21), and mal- 6 65-110
8 60-110
position of the probe (9). CorreCt probe placement, shielding
the probe site from bright light, and gende restraint of the moni-
toring site should improve the dependability of this aJJ-impor-
Rasch DK, webster DE. Clinical manual of
pediatric anesthesia.
New York: McGraw-Hili, 1994:16, with permission.
tant monitor.
Monitoring ventilation goes hand in hand with monitoring
oxygenation. Monitoring ventilation requires close obsetvation
of the patient and either intermirrent or continuous auscultation
of breath sounds. A sedated ch ild's head may flex forward easily,
producing airway obstruction as the child begins to fall asleep Auscultation with the precordial stethoscope is valuable in the
(33). Maintaining patients in the so-called sniffing position helps monitoring of both ventilation (breath sounds) and circulation
prevent airway obstruction (Fig. 3-2). The sniffing position con- (hean sounds). Its use is encouraged in the monitoring of deeply
sists of elevating the patient's head with pads under the occiput, sedated patients (63).
keeping the shoulders flat on the table, and ex.tending the head Monitoring circulation for most sedated children consists of
at the atlanto-occipital joint (I 34). Children younger than 3 intermirrent determination of heart rate and blood pressure (63).
years of age have a relatively large head in proportion to the size For children, normal values for heart rate and blood pressure
of their trunk and do not require padding under the occiput vary with age (Tables 3-2 and 3-3). A simple formula for calcu-
(35). Along with continual assessment of the child's head posi- lating the normal systolic blood pressure and lower limit of nor-
tion, any restraining devices should be checked and rechecked mal for systolic blood pressure in children by age is worth memo-
to ensure that they are not contributing to either airway obstruc- rizing (Table 3-4). Electrocardiographic (ECG) monitoring is
tion or restriction of chest movement (63). especially important for the child with an underlying histOly of
a significant cardiac dysrythmia or known ECG abnormality
such as long QT syndrome, or history ofWol ff- Parkinson-Whi te
syndrome. In the absence of monitor artifact, the pulse oximeter
provides continuous assessment of heart rate. Deeply sedated
children should have blood pressure and hean rate and respira-

TABLE 3-3. NORMAL VALUES FOR BLOOD

PRESSURE BY AGE

Blood Pressure (mm Hg)

Age SystoliC Diastolic

Full-term infa nt 60 (45)* 35
3-10 day 70-75 (50) 40
6 mo 95(55) 45
4 yr 98 57
6 yr 110 60
8 yr 112 60
12 yr 115 65
16 yr 120 65

* The .numbers in 'parentheses refer to mean arterial blood

pressure.
Steward DJ: Manual of pediatric athesthesia. New York: Churchill:
FIGURE 3-2. The sniffing position. In an adult or in an older child, a Livingstone. 1990:24, and Rasch DK, Webster .DE. Clinical Manual
folded sheet or towel under the occiput, plus moderate head extension of Pediatric Anesthesia. New York: McGraw-Hili, 1994:17, with
at the atlanto-occiptal joint, helps to maintain an open airway. In a permission.
child younger than 3 years of age, the relatively large head size in
proportion to the trunk makes occipital padding unncessary (35).
52 General Priniciples

before elective surgery, and solid food to 8 hours before elective

TABLE 3-4. CALCULATION OF NORMAL BLOOD
surgery (50).
PRESSURE BY AGE
Emergency patienrs are definitely at risk for aspiration (143).
80 + (2 x ilge in years) = normal systolic BP for age Sedatives depress the protecrive reflexes (63). Caution is neces-
70 + (2 x age in years) sary to avoid the morbidity and possible mortality of aspiration
= lower limit of normal, systolic BP for age
pneumol1la.
It is known rhat in trauma parients, the time interval between
Rasch DK" Webster DE. Clinical Manual of Pediatric Anesthesia.
New York: McGraw-Hili; 1994:197, with permission. last oral inrake and time of injury is a cricical factor in the
retention of gastric contents (99). It is clear that children injured
within I to 2 hours after eating presenr with large gastric volumes
(19). Although fasting cal1 reduce an injured child's gastric vol-
ume (95), it is not clear how long of a fast is ideal. Also, in the
presence of pain, anxiety, and wirh the administration of opioid
tory rare rneasurernenrs determined and recorded ar leasr ar 5-
pain relievers, all of which may occur in the patient with a
minure inrervals (63). For children under conscious sedarion
fracrure, gastric emptying may be radically slowed (57). If the
(sedarion/analgesia), the frequency of vital sign determination
procedure can wait, it is safe to say rhat a fasting period is in
is ar rhe diSCI'erion of rhe physician (63).
order. Starting inrravenous fluids to prevent dehydration is im-
Ir is imporranr to emphasize again rhar monitoring rhe pa-
portant. Note that ar present, chere is no reliable method of
tient must conrinue unril rhe patienr meets preset discharge crire-
assessing the volume of gastric conrenrs, alrhough differenr
ria (Table 3-1) (63). Often, when a surgical procedure is over
methods have been suggested (55). Patient hunger on presenta-
and parienrs are no longer being actively stimulated, uninren-
tiona I deep sedation wirh resulring airway obstruction and apnea tion for surgical treatment is noc a good indicator of an empry
may occur. Therefore, ir is essential ro remain vigilanr until sromach (95).
the parienr recovers completely from their sedative medications. In the author's opinion, the safest recommendations regard-
Note thar the time to recovery varies depending on rhe amounr ing sedarion of patients with a pocenrial full stomach are as
and rype of sedative medication given, and rhis poinr should follows:
be r:Jlcen inro account when planning a sedacion regimen. The
1. If possible, postpone the procedure, even for as little as 4
durarion of aerion of particular sedarives and sedative combina-
hours.
tions are discussed separately.
2. Use the lighrest effective level of sedation. Titrate sedacion
to effect, and avoid large bolus doses of medicarions.
Patient Assessment 3. Consider the administrariol1 of medications to reduce gascric
Only afrer careful parienr assessmenr can rhe pracrjrioner decide volume (metoclopramide) or to increase gastric pH (hista-
whether sedarion in an emergency room setting, where rile air- mine-2-recepror blockers). These medications, when indi-
way is unconrrolled and unprorecred, is feasible and safe. Admin- cated, should be administered intravenously I hour before
isrering sedarive medicarions wirhour flrsr evaluaring a parienr sedative medications are given. The appropriate dose of met-
is an invirarion for disasrer. 11' is imporrant first to be aware oclopramide (Reglan) is 0.15 mg/kg. The usual adulr dose
of rhe child's medical hisrory, previous allergic or adverse drug for metoclopramide is 10 mg, which should be more chan
reacrions, currenr medicarions, and presence of coexisring dis- sufficient for any child. Famoridine (Pepcid), a histamine-
eases before proceeding wirh deliberare alreration of a parienr's 2-receptor blocker, may be given in a dose of 0.3 to 0.4 mg/
srare of consciousness (63). In addirion to rhese basic details, kg intravenously, with a maximum dose of 20 mg.
rhe patienr wirh musculoskelcral injuries has ro be evaluared for 4. Within 15 minutes of administering sedation, consider rhe
rime of last oral inrake, hemodynamic srarus, presence of other use of oral nonpaniculace alHacids (Bicitra, sodium citrate)
injuries, and status of the airway. to raise gasrric pH. Unfortunarely, these medications are nor
velY palatable.
Oral Intake Precautions 5. Note that pregnancy, morbid obesity, gastroesophageal re-
In rhe management of elecrive parients, significanr pulmonary flux, bowel obsuucrion, and increased intracranial pressure
aspiration is rare in pediatrics (143). al1 magnifY rhe risk of regurgitation and aspiration of gastric
Note rhar for e1eerive patienrs, multiple studies suppOrt and contents. Therefore, additional caution is necessary in man-
encourage the liberal inrake of clear liquids up unril 2 ro 3 hours aging patiems with any of these conditions. Patients with
before scheduled surgery in othelwise healthy children (32,95, coexisting bowel obsrrucrion should nor be sedated, and pa-
122,129). Acceptable clear liquids are appJe juice, water, sugar tients with increased intracranial pressure should not be se-
water, and gelatin. Milk (including breast milk), milk products, dated without the input and knowledge of the :mending neu-
and juices with pulp are not clear liquids. For elective patients, rosurgical staff.
most pediatric al1esthesiologisrs now adhere to the so-called 2- 6. If treatment cannot wait and the surgical procedure or the
4-6-8 rule regarding oral inrake. This rule restricts clear fluids patient is not amenable to regional ancsrhesia, the safest ap-
to 2 hours before elective surgery, breast milk to 4 hours before proach is a general anesthetic with a rapid sequence induction
elective surgery, baby formula (cow's milk formula) to 6 hours and a protected airway (endorrache:d ruhe). This approach
 Chapter 3: Pain Reliefand Relaied Concerns in Children's Fractures 53

is also safest for uncooperative children who urgently need

TABLE 3·5. AIRWAY MANAGEMENT
a computed tomography (Cf) scan, an magnetic resonance EQUIPMENT
imaging (MRI) scan, or other detailed diagnostic studies.
Ventilation Face Masks*
Infant, child, small adult, medium adult, large adult
Hemodynamic Status Breathing bag and valve set
Oral airways
The magnitude of blood loss from a child's injuries is not always Infant, child, small adult, medium adult, large adult
readily apparent. In children, long bone fractures and head inju- Nasa I airvyays
ries may easily have associated large concealed hemorrhages (140, Small, medium, large
153). It is important to assess the patient's volume status accu- Laryngoscope handles
Laryngoscope blades
rately before administering sedative medications. In a hypovo- "Straight (Miller) No.1, 2, 3
lemic child, sedatives may interfere with catecholamine- Curved (Macintosh) No.1, 2, 3
mediated compensatory mechanisms and produce profound he- Endotracheal tubes
modynamic instabiliry, leading to cardiovascular collapse. 2.5-,-6.0 uncuffed
6.0-8.0.cuffed
Note that in an injured child, blood pressure monitoring
Appropriate-sized styletsfor endotracheal tubes
alone does not provide a good indication of the patient's under- (must be lubricatecf before insertion)
lying volume status (105,155). Children maintain a normal Appropriate-sized suction catheters for endotracheal tubes
blood pressute for their age in the face of large intravascular Yankauer-type suction
volume deficits (155). More reliable signs of ongoing hypovo- Nasogastric tubes
(10-18 French)
lemia in children include sinus tachycardia, mottling, cool ex-
Nebulizer set-up for treatment of bronchospasm
tremities, poor urine output (less than 1 to 2 mLlkg/h), and
altered state of consciousness. Each of these signs can imply
* The correct-sized ventilation face mask will fit over the child's
poor perfusion of different organ systems [skin, musculoskeletal face from the br.idge of.-the nose to the c1eft.of the chin. This
system, kidneys, and central nervous system (CNS), respec- guideline' is also correct when using patient-administered nitrous
oxide analgesia. .
tively). Volume replacement, not sedation, should be the initial . Guidelines for monitoring and management of pediatric patients
goal in the management of hypovolemic children. during and after sedation for diagnostic and therapeutic
procedures. Pediatrics, 1992;89: i 110-1115, with permission.

Coexisting Nonmusculoske1etal Injuries

Serious head injury accounts for 70% of pediatric trauma deaths
(30,105). Respiratory deptession from sedation, with resultant
hypercapnia and hypoxia, may aggravate an underlying closed
head injury and worsen its prognosis (153). In addition, any
pharmacologic change in the parient's state of consciousness may
confuse the neurologic evaluation. Other injuries to major body
cavities or injuries associated with major blood loss should be
assessed carefully before any sedative medicarions are adminis- TABLE 3-6. VASCULAR ACCESS EQUIPMENT
tered.
Intravenous catheters
(24-16 gauge)*
Status of the Airway Intraosseous bone-marrow needle
Intravenous tubing
A tenuous airway can easily become a completely obstructed Pedi.atric drip (60 dropslmL)
airway in a sedated child. There are common problems in chil- Pediatric burette-type
dren associated with airway obstruction. For example, children Adult drip (10 drips/mL)
Intravenous fluids
with large tonsils and adenoids may have Obstructive sleep apnea Lactated Ringer's
(89). Obstructive sleep apnea, which is associated with a history Normal.s.aline
of loud snoring and daytime sleepiness, may be acutely exacer- Miscellaneous equipment
bated with the administration of sedative medications (36). Tourniquets "
Alcohol wipes
Othet potentially dangerous problems include micrognathia
Arm boards
(shorr jaw), limited abiliry to open the mouth, and limited move-
ment of the neck, either congenital or acquired (12).
* In resuscitation situations, no more tl1an90 sec should be spent
attempting to gain peripheral venous access. If attempts have
been' unsuccessful, then central venous· cannula"tinn, intraosseoUs
Treatment Facility cannulation, or peripheral.venous cutdown should be done
according to the E!.xpertise of available personnel.
What about the medical faciliry where the child is receIving (Guidelines for monitoring and management of pediatric patients
during and after sedation for diagnostic and therape'utic
treatment? On-site resuscitation equipment, including equip- procedures. Pediatrics, 1992;89:1110-1115, with permission.
ment for airway management (Table 3-5) and equipment for
vascular access (Table 3-6) must be available for children of all
54 General Priniciples

ages and sizes (63). In addition, a positive pressure oxygen deliv- Ketamine
ery system capable of delivering at least 90% oxygen for at least
Ketamine, which is structuraJly related to phencyclidine, was
60 minutes must also be readily available (63). A working sucrion
first synrhesized in 1963. Developed to produce the "anesrhetic
appararus (63) must be easily accessible ro handle patient secre-
state (analgesia, amnesia, loss of consciousness and immobility)"
tions, as well as for unexpecred regutgitation and vomiting.
without total CNS depression, it was approved for general clini-
These recommendations are essentiaJ for patient safety and for
cal use in 1970 (31,157).
optimum patient cate.
The commercial prepJration ofketamine is a racemic mi.xture
of twO optical isomers with differing activity (157). Ketamine
is typicaJly administered intravenously or intramuscularly (59,
SEDATIVE MEDICATIONS 136). RectaJ (118), oraJ (64,145), and intr:masaJ adminisrration
(54) have been described in the literature.
Having now considered the preliminary step of patient assess-
Ketamine is metabolized in the liver, primarily by N-methyla-
ment, the practitioner must now decide which sedative or seda-
tion to norketamine. Norketamine has about one third the seda-
tives co use. The ideal sedative should be easy ro administer,
tive and analgesic potency ofketamine. As such, ketamine should
quick in onset, devoid of side effects, and rapid in termination
be administered cautiously or in reduced doses to patients with
of effects. The abundance of refetences in the literarure excolling
impaired hepatic function.
the virrues of differenr sedative drugs and drug combinations is
Intravenous ketamine, I to 2 mg/kg, produces unconscious-
the best indicaror that we do not yet have the ideal sedative.
ness wi th in 30 co 60 seconds (136). PeaJ{ plasma concen rrations
Each of the drugs that is discussed has only some of the properties
occur wirhin 1 minute. Return of consciousness occurs within
of an ideal sedative medication. Also, patients demonstrate great
10 to 15 minures, although complete recovelY may be delayed
variability in response co medications. It is imporrant ro treat
(136). Dose requirements and recovelY rimes from ketamine are
each patienr as an individuaJ and to not expect to be able ro fit
age relared (24,87).
every child wirh a fracrure inro any particular sedation regimen.
Ketamine has been found co have interactions at multiple
For patients who cannot be adequately sedated, the orthopaedic
binding sites, including N-methyl-D-asparrate (NMDA) and
surgeon should consult an anesthesiologist for provision of a
non-NMDA recepcors, nicotinic and muscarinic cholinergic re-
brief, well-conrrolJed general anesthetic.
ceptors and opioid recepcors (83). Agonist actions of ketamine
on opioid receptors play only a minor role in its analgesic effects
Nitrous Oxide (83). Note that naloxone, a narcotic antagonist rhat is further
discussed in rhe section on opioids, does nor reverse the anaJgesic
Self-administered 50% nitrous oxide (50% nitrous oxide and
effect of ketamine (83). The psychotomimetic effects of keta-
50% oxygen) has been found ro be moderately useful in provid-
mine, however, may involve interacrion wirh a specific subclass
ing sedation and analgesia for the reduction of children's frac-
of opioid receptors known as kappa receptors (83). For analgesia,
tures. Evans and co-workers (45) found it to be comparable in
the main sire of action is the NMDA receptor. The reader is
efficacy to intramuscular meperidine (2 mg/kg) and prometha-
referred to other sources for further informarion on this topic
zine (I mg/kg). However, in a different srudy, Hennrikus and
(83).
co-workers noted that 46% of their patienrs experienced signifi-
cant pain with nitrous oxide alone as a sedative and analgesic
for fracture reduction (67). Patients with completely displaced
Central Nervous System Effects of Ketamine
radius and ulna fractures had a statistically higher incidence of
failure to achieve analgesia (67). Willi the addition of a hema- Ketamine produces a state known as dissociative anesthesia. Dis-
toma block (discussed in a subsequent section), Hennrikus and sociative anesthesia refers to a cataleptic state characterized by
his coinvestigators were able co obrajn a 97% incidence of ade- functional and electrophysiologic dissociation between the thaJa-
quate sedation and analgesia (66). This srudy does illustrate the moneocortical and limbic systems (I 57). Patients keep their eyes
important point that where possible, the use of regional anesthe- open and exhibit a slow nystagmic gaze. Corneal and pupillary
sia, in combination with aJmost any sedation regimen is an excel- reflexes remain intact. Generalized hypertonicity may be present.
lent way to enhance pain relief and co minimize the need for Even though ketamine has effects on nicorinic acetylcholine re-
systemic sedative and analgesics. ceptors in skeletal muscle, this effect is of minor significance,
In generaJ, nirrous oxide is a weak sedative and analgesic. It because ketamine increases muscle tone by central mechanisms
does have the advantages of rapid onset, relative ease of utiliza- (83). Patients receiving ketamine may exhibit purposeful move-
tion, and rapid termination of effects (88). Because it diffuses ments bur not necessarily in response ro surgical stimulation
rapidly into enclosed air-filled spaces, its use is conrraindicated in (157).
patients with bowel obstruction or pneumothorax (88). Nitrous Ketamine's anaJgesic effect is inrense and may ourlast its seda-
oxide is aJso contraindicated in patients with aJtered intracraniaJ tive effect (59). In one study of minor surgical procedures with
compliance (88). keramine anesthesia, no additionaJ analgesics were required for
Alrhough nitrous oxide is perhaps a useful part of the sedation 24 hours posroperatively (69). Amnesia persisrs for about one
armamentarium, this aurhor does not believe that the literature hour after apparent recovelY from ketamine (136).
supports the use of nitrous oxide aJone as a reliable sedative and Emergence phenomena are relatively rare in children, al-
anaJgesic for pediatric orthopedic procedures. though young adulrs are especially susceprible to this problem
 Chapter 3: Pain Relief and Related Concerns in Children's Fractures 55

(69). Changes in mood and body image, out-oE-body experi- never be given in an unmonitored setting, such as a patient's
ences, floating sensations and frank delirium are all possible room on a regular hospital ward, or a clinic that does not have
(157). Emergence phenomena result from misinterpretation of appropriate monitoring and resuscitation equipment (see the
auditory and visual stimuli at the neurologic level (157). Al- first parr of this chapter).
though usually terminating within 24 hours (136), prolonged
emergence phenomena lasting as long as 10 to 12 months have
been reported in children (102). An increased incidence of emer- Cardiovascular Effects of Ketamine
gence reactions is seen in patients older than 16 years, female Ketamine stimulates rhe sympathetic nervous system and leads
patients, patients who have received doses of intravenous keta- to the release of endogenous catecholamines. Through such an
mine above 2 mg/kg, and patients with a history of abnormal effect, ketamine produces a dose-dependent increase in heart
personalities (157). There is no evidence that emergence in a rate and blood pressure (144), and therefore, it is useful in the
quiet environmenr decreases the incidence of this problem (157). operating room in patients with mild hypovolemia. As a byprod-
Benzodiazepines (e.g., diazepam and midazolam) are the most uct of its sympathetic stimulation, ketamine produces bronchod-
effective treatment for ketamine-induced delirium and halluci- ilation, and as such, it has been useful in the anesthetic manage-
nations (157). In fact, the administration of a benzodiazepine ment of patients with asthma (88). However, because ketamine
3 to 5 minutes before ketamine is effective in almost entirely is a direct myocardial depressant, its administration to patients
eliminating the possibility of emergence delirium (88). who are profoundly hypovolemic, and whose sympathetic ner-
Transient diplopia (31), ataxia (60), and disequilibrium (60) vous system is already maximaJiy stimulated, will lead to cardio-
may occur after ketamine use. Early attempts at ambulation vascular collapse. The reader is reminded that any sedation given
should be discouraged (60). Ketamine does not induce seizures to a hypovolemic parient must be administered very judiciously
and is not necessarily conuaindicated in patients with an under- and preferably after the volume srarus is corrected.
lying seizure disorder (157).
Ketamine is contraindicated in patients with increased intra-
cranial pressure or with abnormal intracerebral compliance. Review of Relevant Literature (Ketamine)
Thus, parients who have sustained a head injury as part of their
In 1990, Green and co-workers reviewed a collective experience
ongoing trauma should not receive this drug (144). It is inrerest-
of nearly 12,000 children sedated with ketamine for various
ing to note that there are some reportS actually suggesting that
there is a neuroprotective effect for ketamine (83). However, procedures (60,61). In 1998, Green and coworkers (62) pub-
lished their experience with 1,022 pediatric patients aged 15
the recommendation that ketamine be avoided in head-injured
patients still stands firm for now. years and younger sedated with ketamine 4 mg/kg intramuscu-
larly for a variery of emergency room procedures, consisting
mainly of laceration repairs and fracture reductions. From this
Respiratory Effects of Ketamine group of patients, the authors reported twO cases of apnea, four
Ketamine can have some potentially troublesome effects on the cases of lalyngospasm, one case of respiratory depression, and
airway. It causes the production of increased salivary and tra- seven cases of partial airway obstruction (e.g., airway malalign-
cheobronchial secretions, which can lead to coughing, laryngo- ment) responding co repositioning of the head. They also re-
spasm, and airway obstruction. This problem may be especially ported a 6.7% incidence of vomiting but no cases of aspiration.
treacherous in patients with an ongoing respiratory infection. In an interesting study by Kennedy and colleagues (81), inn'ave-
Glycopyrrolate (Robinul), an antisialogogue, should be adminis- nous ketamine combined with midazolam (Versed) was com-
tered 3 to 5 minutes before ketamine (at the same time that the pared with fentanyl combined with midazolam in the manage-
benzodiazepine is given) to ameliorate this problem (88). The ment of pediatric fractures. This particular study is further
dose for glycopyrrolate is 5 to 10 ,ug/kg, given intravenously. discussed later.
For large children, a dose of 0.2 mg (200 ,ug) of glycopyrroJate
given intravenously is sufficient. Unless there is some other
strong indication for its use, ketamine should be avoided in ~ AUTHOR'S PREFERRED METHOD
patients with ongoing infections of the respiratolY tract. ,~ OF TREATMENT
Although ketamine does not usually produce significant
depression of ventilation (136), apnea has been teported with Salient points regarding the safe use ofketamine are summarized
its administration (37). Apnea is more likely to occur when the in Table 3-7. Monitoring and procedural guidelines for deeply
drug is given intravenously in rapid boluses (37) or in combina- sedared patients (63) should be followed whenever ketamine is
tion with other respiratOry depressants (136). However, there used. If used intramuscularly, the dose should be limited to 4
are reports of apnea in otherwise healthy children sedated in the mg/kg. If the drug is used intravenously, the total dose should
emergency department with intramuscular ketamine alone in be limited to 2 mg/kg. The reader is reminded to use glycopyrro-
the usual recommended dosage (96,126). late, and to consider strongly the administration of midazolam
In addition, ketamine does not protect against aspiration of (Versed) 0.05 to 0.1 mg/kg for the prevention of agitation and
gastric contents (26,141). In this regard, ketamine is no different delirium. Note that there is an increased risk of respiratory
from any other sedative and analgesic except maybe for self- depression whenever more than one sedative medication is ad-
administered 50% nitrous oxide in oxygen. Ketamine should ministered. Note also [hat no reversal drug exists for ketamine.
56 GmeraL PrillicipLes

is 4.8 minutes for mida20lam versus 1.6 minutes For diazepam

TABLE 3-7. KETAMINE IN PEDIATRIC
(25). Thetefore, when titrating midazolam for sedation, it is
SEDATION
important ro wait 5 minutes between doses.
I. Methods of Administration and Dosage
A. 1M, 4 mg/kg
B. IV, 1-2 mg/kg Central Nervous System Effects
C. PO, 6-10 mg/kg
D. Rectal, 5-10 mg/kg Anxiolysis and centrally mediated relaxation of skeletal muscle
II. Contraindications rone is presumed ro occur from a benzodiazepine-induced in-
A. Altered state of consciousness
B. Increased intracranial pressure
crease in the availabiliry of glycine inhibitory neurotransmitter
C. Active upper respiratory infections (increased quantity of (33). Facilitating the action of the inhibirory neurotransmitter
secretions and possible increased risk of laryngospasm) gamma-aminobutyric acid (GABA) is responsible for the seda-
D. Full"stomilch tive eFFects of benzodiazepines (133). It remains unclear what
E. Prior unfavorable experience with ketamine
the site of action is for the production of amnesia (33).
F. Patients> 16 yr old (increased incidence of emergence
phenomena)
Note that midazolam and diazepam produce direct depres-
III. Advantages sion of the central respiratolY drive (54) and that apnea may
A. Provides sedation, amnesia, intense analgesia occur (l8,72,113), especially after parenteral administration of
B. Sympathetic-mediated activity may be beneficial for chil- these drugs. Although it is generally considered very safe, orally
dren with asthma.
administered midazolam has been reported to produce airway
IV. Disadvantages
A. Increases production of saliva and tracheobronchial se- obstruction in a child with congenital airway anomalies (85). In
cretions. Coadministration of glycopyrrolate 0.01 mg/kg general, the incidence of respiratory complications increases with
recommended. the presence of major vital organ disease (72). However, even
B. Potential for loss of the airway from: in healthy adult volumeers, inrravenous sedation with midazo-
1. Laryngospasm secondary to increased secretions
lam (0.1 mg/kg) can depress the vemilarory response to hypoxia
2. Aspiration from laryngeal incompetence
3, Apnea (3). Concomitant administration of opioids (72,133,161)
C. Emergence phenomena: Rare in young children. No ad- greatly increases rhe risk of respiratory complications. Therefore,
vantage to quiet environment. Midazolam may help, but extra vigilance and careful titration of medications to effect are
may contribute to oversedation. even more Important when using more than one sedative or
analgesic medication.

Other Systemic Effects

With careful titration, significant hemodynamic changes are un-
Benzodiazepines
usual with midazolam (113). Loss of protective airway reHexes
Initial imerest in the use of benzodiazepines developed when is also unlikely under these circumstances (13) as long as the
these drugs were noted to exert taming effects in animals (33). physician pays careful attemion to the effects of each incremental
Ben20diazepines provide anxiolysis, hypnosis, cenrraJly mediated dose on the patient's state of consciousness. Caution is always
(40) relaxation of muscle tone, anregracle and retrograde amne- urged if the patient's stomach is Full. Slurring of speech is a
sia, and anticonvulsant activity (113). Benzodiazcpines have no rypical sign of sedation with benzodiazepines (113). Children
analgesic activity and require supplementation For painful proce- may also exhibit loss of anxiety, unsolicited smiling, and even
dures (33). laughter.
In reporting their experience with 2,617 children sedated for
endoscopic procedures, Massanari and co-workers (91) nored
Pharmacology that 36 patients exhibited paradoxical reactions to midazolam,
including inconsolable crying, combativeness, and agitation.
Midazolam (Versed) is the primary ben20diazepine used For pe-
The authors of this study were able to treat these reactions with
diatric sedation. It oFFers several advantages over other benzodi-
flumazenil, a benzodiazepine antagonist, which is further dis-
azepines (58). It is water soluble and, therefore, usually rela-
tively painless on injection (113,158). It does occasionally cause cussed below.
discomfort on injection, although the pain is not as severe as
that with diazepam (Valium). At physiologic pH, mida20lam
Review of Relevant Literature (Midazolam)
becomes highly lipid soluble, facilitating transport into the CNS
and onset of sedative effects (l58). Initial recovery, which is due In children, midazolam can be administered by oral, nasal, sub-
to redistribution of the drug away from the CNS, occurs in lingual, intravenous, intramuscular, and rectal routes (88). A
about 30 minutes. The elimination half-life of mida20lam is liquid oral formulation, whose concentration is 2 mg midazo-
significantly shorrer than that of diazepam (58). On a milli- lam/mL, now exists in the United States. It is marketed as Versed
gram-per-milligram basis, midazolam is at least twO ro three Syrup 2 mg/mL and is manuFactured by Hoffman-LaRoche
times as potent as diazepam (56). Electroencephalographic pharmaceuticals. lf this formulation is not available at a partiCL1-
(EEG) studies indicate that the blood-brain equilibration time lar location, rhen the practitioner can order the paremeral form
 Chrlprn 3: J)ain Re/ielrT/ul Relared COllcerm iii Chi/dreils Fractures 57

this amount is usually limited ro 20 ro 25 mg. Note that analgesic

TABLE 3-8. BENZODIAZEPINES IN PEDIATRIC
SEDATION supplementation in the form of either local anesthetics, opioids,
or both is required for painful procedures. Patients who receive
I. Method of Administration parenteral benzodiazepines must be monirored with pulse ox-
A. Diazepam: 0.1 to 0.3 mg/kg IV or PO. 1M administration imetry, because oxygen desaruration may occur (125).
should be avoided because it is painful.
B. Midazolam
1. PO, 0.5-0.75 mg/kg Drug reversal
2. Nasal, * 0.3-0.4 mg/kg
3. 1M, 0.03-0.1 mg/kg Flumazenil (Romazicon) reverses the sedative effects ofbenzodi-
4. IV, 0.05-0.1 mg/kg azepines (76,82,107). The flumazenil dose for children is 10
II. Contra indications ttg/kg intravenously. Flumazenil administration may then be
A. Previous unfavorable experience with benzodiazepines
continued at 5 ttg/kg/minute until the child awakens, or uneil
B. (?) Early pregnancy (possible teratogenicity)
C. Altered state oT consciousness a total dose of 1 mg has been given (77). The elimination half-
III. Advantages life of flumazenil is 30 minutes, compared with 1 ro 2 hours
A. Generally provide excellent sedation and amnesia for midazolam. Patients who receive flumazenil should be ob-
B. Revers;ble if necessary (fILJmazenil, 10 ,ug/kg) up to a total served fot at least 2 hours before discharge ro ensure that rese-
dose of 1.0 mg)
dation from the original benzodiazepine does not occur. In the
IV. Disadvantages
A. No analgesic effect author's opinion, the use of flumazenil should be limited to
B. Respiratory depression, especially with parente'ral admin- , situations of relative or absolute benzodiazepine overdose leading
istration to respirato'y or hemodynamic compromise. Routinely reversing
C. Combination with narcotics may lead to oversedation or benzodiazepines is both unnecessary and, in the absence of per-
respi ratory arrest
sistene monitoring, potentially dangerous.

* Many children find the intranasal administration of midazolam

to be very unpleasant..This method of administering midazolam is
not recommended. ~ AUTHOR'S PREFERRED METHOD
,~ 0 F TREATMENT
Salient points regarding the use of midazolam and orher benzo-
diazepines are summarized in Table 3-9. AJthough supplemental

(usually the 5 mg/mL concentration) ro be mixed in 5 ro 10

mL of a sweet-tasting syrup (l06). Acetaminophen syrup or
ibuprofen syrup are useful vehicles for mixing parenteral midazo- TABLE 3·9. OPIOIDS IN PEDIATRIC SEDATION
lam, keeping in mind the appropriate pediatric doses of acet-
aminophen and ibuprofen (Table 3-8). The author's personal I. Method of Administration
preference is to mix the midazolam in 3 ro 5 mL of Tylenol A. Morphine: 0.05-0.1 mg/kg 1M or IV
B. Meperidine: 0.5~1.0 mg/kg 1M or IV
syrup. For nasal administration, which the author does not rec-
C. Fentanyl: In increments of 0.001 mg/kg IV (maximum
ommend, rhe parenteral preparation is used with no additives. total dose, 0.004-0.005 mg/kg)
The reason for discouraging the use of nasal midazoJam is be- D. Nalbuphine: 0.1 mg/kg 1M or IV
cause most children find its administration ro be very unpleasant. Patients younger than 3 mo old should be given no more than
In one study, 84% of children given intranasal midazolam cried half of these doses initially. IV titration to desired effect is the
ideal way to administer all sedative medications.
in response to administration of the medication (80). Although
II. Contraindications
sublingual administration is a good idea from a pharmacologic A. Altered state of consciousness
point of view (see discussion under morphine), it requires a B. Previous unfavorable experience. (excludes that medica-
degree of patient cooperation that may be difficult to reliably tion only)
obtain in children. In other words, an uncooperative child may C. Sedation for nonpainful procedure
III. Advantages
be unwilling or unable to hold a medication under his or her
A. Provide excellent analgesia
tongue. B. Reversible if necessary (naloxone 0.001-0.005 mg/kg IV
Hennes and colleagues (65) have used oral midazolam to titrated to effect)
allay the anxiety of children requiring laceration repair in the IV. Disadvantages
emcrgency department. Farovich and Jacobs (47) also noted de- A. Risk of respiratory depression and apnea
B. Increased risk of respiratory depression and apnea when
creased anxiety in children requiring laceration repair after oral combined with other sedatives
midazolam versus in a comrol group that received only a placebo. C. No amnestic effects
Note that if the practitioner decides to use orally administered V. Additional Side Effects (more likely when used in recurrent
midazolam, the appropriate dose is 0.5 to 0.75 mg/kg (48) and doses for treatment of pain)
Nausea, vomiting, pruritus, constipation, decreased gas-
a waiting period of 10 ro 30 minuees is required for onset of
tric motility
effects. The maximum amount of midazolam that should be
administcrcd orally has not been determined, but in practice,
58 General Prilliciples

analgesia is required for painful procedures, such as rhe reducrion (38). The overall incidence of true allergic reactions ro opioids
offractures, the anxiolysis and amnesia thar midazolam produces is very small (38).
make ir an excellent medicarion for children wirh onhopaedic
injuries. Careful inrravenous rirrarion of midazolam in incre-
ments of 0.05 mg/kg may be undertaken, combined wirh a re- Meperidine
gional anesrhetic block (Bier block, hemaroma block, for exam- The use of meperidine (Demerol) parallels that of morphine.
ple) for pain relief. The aurhor believes rhar oral midazolam, The initial intravenous or intramuscular dose is 0.5 ro 1.0 mg/
with irs mandarory 10- ro 30-minute wairing period. and with kg. Again, the dose should be reduced by at least one half in
its lack of titratability ro effect, is probably best reserved for use infants younger rhan 3 months of age (114). Normeperidine, a
as a preoperative medicarion before elecrive surgical procedures. meraboJic breal<down product of meperidine, has been associ-
Also, for emergency patients, intravenous rirration is the besr ated wirh seizures, agitation, rremors, and myoclonus (68,78).
and most efficienr way ro achieve desirable levels of parient seda- Meperidine is nor recommended for patients wirh an underlying
tion and cooperation. The combination of midazolam and seizure disorder. Accumulation of normeperidine is more likely
opioids is discussed in the nexr seerion. in siruarions of prolonged meperidine adminisrrarion. There-
fore, meperidine should be used cauriously, if ar all, in rhe trcar-
ment of chronic pain (33). As wirh morphine, meperidine may
Opioids produce hypotension due ro various mechanisms (8). Hisramine
Opioids include all exogenous subsrances, narural or synrheric, release has also been reponed wirh meperidine (8).
rhar bind to specific receprors and produce morphine-like effecrs
(38). There are several rypes and subrypes of opioid receprors
(8,138). Opioids vary in rheir respecrive affini ry for recepror Fentanyl
rypes, accounting for rhe difference in side effeers. Opioids are Fentanyl is a synthetic narcoric 100 rimes more porent rhan
classified as pure recepror agonisrs (e.g., morphine, meperidine, morphine and 1,000 rimes more porent rhan meperidine on a
fenranyl), agonisr-anragonisrs (e.g., nalbuphine), or pure anrago- milligram-per-milligram basis. Fenranyl is highly lipid soluble
nisrs (e.g., naloxone) (38). and rapidly penerrares rhe CNS (8). When adminisrercd in low
doses, irs durarion of aerion is from 30 ro 45 minures. For seda-
rion, fentanyl is given intravenously in increments of 0.5 ro 1
Opioid Agonists
,ug/kg. The maximum roral dose is 4 ro 5 ,ug/kg (33). As a
All opioid agonisrs produce dose-dependent respirarOlY depres- preoperarive medication, fentanyJ is availabJe in an oral raspberry
sion and apnea (138). Nausea and vomiring occur because oE flavored lollipop known as rhe Fentanyl Oralet (88). Currently
direer srimularion of the chemorecepror rrigger zone in rhe floor available sizes for the Oraler are 200 ,ug, 300 ,ug, and 400 ,ug.
of rhe founh ventricle of the medulla oblongata (138). As a preoperarive medicarion, rhe recommended dose ranges
from 10 ro 20 ,ug/kg. Troublesome side eEfcers ofrhis prepara-
rion include nausea and vomiring, prurirus, and oxygen desatura-
Morphine rion (121).
Morphine is a well-known analgesic. It is usually administered Reonser of respirarOlY depression up ro 4 hours after fentanyJ
administration has been reponed (131). Glotric closure (5), and
intravenously or intramuscularly, although sublingual and reeral
muscular rigidiry (6,120,128) can occur, especially, aJrhough
routes have been described (33). Oral morphine is usually used
nor exclusively, with adminisrrarion of higher doses. Respirarory
for long-term pain control in patients with severe, chronic pain.
arresr may occur, especially wirh rhe coadminisrrarion of orher
Renal administration of morphine is not recommended because
sedarives (61). For rhese reasons, fentanyl should be ri rrated
ir has been associated wirh delayed absorption, deJayed respira-
rory depression, and death (33,58). In general, rectally adminis- slowly ro effect.
rered medications are absorbed unpredictably (135) and access
of the medication ro the reeral mucosa may be variabJy impeded
Opioid Agonist-Antagonists
by reeral srool content.
The usual starting dose for intravenous or intramuscular mor- A so-called ceiling effecr or limir on rhe degree of respirarolY
phine is 0.05 ro 0.1 mg/kg. In infanrs younger [han 3 momhs depression has been demonstrated for various opioid agonisr-
old, the dose should be reduced by at leasr one half because of anragonists, including nalbuphine (116) and burorphanol (149).
increased susceptibiliry ro respirarory depression (14). Mor- Nalbuphine and morphine have rhe same analgesic porency on
phine should be reserved for painful procedures lasting a[ leasr a milligram-per-milligram basis (114). Nalbuphine has a shoner
30 minutes (33). Morphine is nor very lipid soluble, and its eliminarion half-life (73). Opioid agonisr-antagonists have no
delay in leaving the CNS accounts for a potential durarion of particular advantage over properly dosed opioids (38). The
aerion of3 to 4 hours (8,33). Hyporension secondary ro vasodila- major problem with opioid agonist-antagonists is that rheir ceil-
tion, histamine release, or vagally mediated bradycardia can ing effect on respirarolY depression is often accompanied by a
occur even with the administrarion of smalJ doses of morphine ceiling etTen for analgesia (138). Also, agonist-anragonisls re-
(8). Hisramine release along the course of [he vein inro which duce the analgesic effectiveness of pure agonists (e.g., morphine,
the morphine is adminisrered is nor by itself an allergic reacrion meperidine, fenranyl, codeine) if additional analgesia is required
 Chapter 3: Pain Relief and Related Concerns in Children s Fractures 59

(38). In patients who ate receiving opioids on a long-term basis, dures in children, a combination of a benzodiazepine and a nar-
adminisrration of opioid agonist-antagonists can precipitate cotic is probably ideal (110,127,161), as long as the principles
acute withdrawal symptoms (38). of careful titt'ation and close patient monitoring are observed.

Drug Reversal With Opioid Antagonists • AUTHOR'S PREFERRED METHOD

Naloxone (Narcan), which has no agonist activity of its own, ,~ OF TREATMENT
displaces opioids from opioid receptors (138). Note that rapid
reversal of narcotic effects may precipitate severe hypertension, Salient points regarding the use of opioids as well as opioid and
pulmonary edema, ventricular or supraventricular irritability, benzodiazepine combinations for pediatric sedation are summa-
seizures, and cardiac arrest (7,44). Dysphoria, nausea, and vom- rized in Tables 3-10 and 3-11. Opioid and benzodiazepine com-
iting may also occur. Acute narcotic withdrawal in this situation binations provide amnesia, analgesia, and sedarion. The tradeoff
reflects sympathetic nervous system stimulation from abrupt re- is that of additive respiratOry depression and additive depression
versal of analgesia and sudden perception of pain (8). Therefore, of protective airway reflexes. In borh elective and emergent situa-
naloxone should be titrated to effect (telief of respiratOry depres- tions, rhe practitioner must
sion) in incremems of 1 to 5 ,ug/kg intravenously. Naloxone 1. Thoroughly evaluate the patient, as has been discussed earlier
has a duration of action of 30 to 45 minutes, and resedation is in the chapter.
possible. Close patient observation is required, and supplemental 2. Follow standard practice guidelines for deep sedation (63).
naloxone doses may be necessary. Current dosage tecommenda- 3. Pay careful attention to dosing limits (Table 3-11).
tions in cases of frank opioid intoxication are significantly higher 4. Be cerrain rhat both flumazenil and naloxone are available.
(43). Caution is always advised against precipitating acute nar- These medications are to be used strictly for the treatment of
cotic withdrawal. The first priority in the treatment of narcotic absolute or relative overdose ofbenzodiazepines and opioids,
overdose is a patent, weJl-maintained airway. respectively. Do not use these medications to expedite dis-
Similar to the situation with flumazenil for reversal of benw- charge from the emergency room.
diazepines, the author believes that the routine use of naloxone
to reverse narcotic sedative medications is unwarranted and, for
reasons noted earlier, potentiaJly dangerous. Naloxone use Midazolam and Ketamine Compared With
should be reserved for situations of ailway compromise brought Midazolam and Fentanyl
on by telative opioid overdose, and it should never be urilized as While studying a group of 260 children berween the ages of 5
a way of expediting patient discharge after a procedure requiring and 15 presenting for the emergency room reduction of frac-
sedation.

Review of Relevant Literature (Opioids)

With careful monitOring and judicious administration, combi- TABLE 3-10. FENTANYL AND MIDAZOLAM IN
PEDIATRIC SEDATION"
nations of opioids for analgesia and benwdiazepines for amnesia
and anxiolysis are probably the most useful sedatives in existence i. Method of Administration
today for the management of children's fractures. Varela and IV titration to effect
co-workers (150) reported exceJlent patient and physician satis- A. Midazolam: In increments of 0.05 mg/kg to a maximum
0f 0.1 mg/kg. Wait 5 min b.etween doses.
faction using intravenous meperidine and midazolam for intra-
B. Fentanyl: Begin 5 m.in after last midazolam dose.. Give
venous sedation for the closed reduction offractures in children. in increments of O.OO.lmg/kg to a maximum of 0.003
In this particular investigation, the average meperidine dose was mg/kg. Wait 2 to 3 min between doses..
1.47 mg/kg and the average midazolam dose was 0.11 mg/kg. II. Contra indications _
There were no episodes of apnea or cardiorespiratory complica- A. Altered state of consciousness
B. Previous unfavorable experience with either medication
tions. These investigators stress that careful patient monitoring
C. Specific contraindicationsto benzddiazepines or
is importam, not only during but after the procedure as well. opioids (see Tables 3-9 and 3-10).
lmravenous morphine 0.1 mg/kg plus midawlam 0.1 mg/kg III. Advantages -
is another useful sedation mixture for children with fractures, A. Provides sedation, amnesia (midazolam), and analgesia
especially when combined with a hematoma block (personal (fentanyl)
B. Reversible if necessary (see Tables 3-9 and 3-10).
communication, ). Edeen, M.D.). The hematOma block is dis- IV. Oisadvantilges
cussed later in the chapter. With this particular approach, the A. Additive- respiratory depressant effects
midazolam is administered first, followed by the morphine about B. Additive depressant effects on protective airway
5 minutes later. The hematoma block is performed, and the reflexes with increased risk for regurgitation and
fracture is then reduced. Again, careful patient monitOring as aspiration of gastric contents'
previously outlined is essential to good care.
In the absence of specific contraindications, including ten- * An'excellent review of the advantages -and problems associated
with this drug regimen is provided by Yasterandcolleagues 135,
uous ailway status, unstable hemodynamic status, or histOry of
specific aJlergic reactions, for the petformance of painful proce-
60 General PrinicipleJ

gospasm. Vomiting occurred more often in the group taking

TABLE 3-11. CHLORAL HYDRATE IN PEDIATRIC
SEDATION
ketamine, and group taJ(jng the ketamine had a longer mean
time to recovery and discharge.
I. Method of Administration This is a very detailed study thar looks very closely at two
20 to 75 mg/kg orally or rectally (maximum single dose, 1.0 viable regimens for sedation of children with fractures. Again,
g. If a second dose is given, the maximum total dose is
either 100 mg/kg or 2.0 g, whichever is lower).
with careful monitOring and careful attention to drug tin'ation,
Ik Contra indications the practirioner may wish to ny both to determine which is
A. Compromised hepatic function more useful in their individual practice. The authors of this
B. History of obstructive sleep apnea* study favor the ketamine and midazolam regimen and provide
C. Previous unfavorable experience with chloral hydrate
good evidence for their conclusions (81).
III. Advantages
No specific advantages for sedation and treatment of
children with fractures
IV. Disadvantages Pediatric Cocktail
A. Prolonged time to peak effect (as long as 60 min)
8; Difficult to titrate
The so-called pediatric cockcail (OPT) or "lyric" cockcail is a
C. Prolonged observation period required mixture of meperidine (Oemerol) and two phenothiazines: pro-
methazine (Phenergan), and chlorpromazine (Thorazine). For
* Caution is required when using any sedative medication in multiple reasons, this sedative regimen should be avoided. Pro-
patients with obstructive sleep apnea. longed and profound sedation occur, often far outlasting the
procedure for which the sedation was intended. One study has
reported a mean total recovelY time of 19 hours, plus or minus
15 hours, in children receiving OPT in the emergency depart-
ment (142). Orthostatic hypotension is possible, because pro-
methazine and chlorpromazine are alpha-adrenergic blockers
[Ures, Kennedy and coworkers (81) compared the effeCtiveness of (33). Severe respiratory depression and death, both during and
two regimens for sedation and analgesia. For tne first reduction after the procedure, have occurred in patients sedated with DPT.
attempt in each patient, all of the children initially received All three medications in this mixture lower rl1e seizure threshold,
midazolam 0.1 mg/kg (maximum dose of 2.5 mg) at 3-minure and phenothiazines can produce dystonic reacrions (33). Note
intervals until either objective signs of onset of drug effect devel- that there is no reversal agem for phenothiazine overdose.
oped (slurred speech, glassy eyes) or unril three doses of midazo-
lam were given. One minute after the administration of the last
dose of midazolam, half the patients began receiving fentanyl,
titrated in increments of 0.5 ,ug/kg until either a decreased re- • AUTHOR'S PREFERRED METHOD
sponse to verbal or painful stimulation was noted, or a maximum ,~ OF TREATMENT
dose of2 ,ug/kg had been administered. The maximum amount
of fentanyl used was 100 ,ug. The otner half of the patients, The author strongly believes rhat the use of the pediatric cocktail
instead of receiving femanyl, were given ketamine, titrated in should be abandoned (127),
incremems of 0.5 ,ug/kg, using the same criteria as for femanyl
to determine onset of effecL Ketamine tirration continued, if
Chloral Hydrate
necessary, until a maximum amount of2 ,ug/kg had been given.
All of tne patients who were given ketamine also received glyco- Of greatest use in sedating children for nonpainful diagnostic
pyrrolate, 5 ,ug/kg as an anrisiaJogogue. Additional amouncs of procedures such as radiographic studies, chloral hydrate is ad-
midazolam and the study drug were given if analgesia and seda- ministered in a dose of 20 to 75 mg/kg orally or rectally. The
tion were judged to be insun:;cient or if additional reduction maximum single dose is 1 g, If more than one dose has to be
attempts were necessary. Treatmenr failures occurred in those given, the upper limit for the rotal dose is either 100 mg/kg or
parienrs who experienced significant adverse drug effects or who 2 g, whichever is lower.
obrained insufficient sedation and analgesia. Although, theoretically, rectal dosing should be more effi-
Patient distress was quamified using various behavioral scales. ciene, because of the lack of a first pass hepatic effect (135), 30
The reader is referred to the article itself for more derailed infor- ro 60 minutes may elapse before chloral hydrate rakes effeer no
mation about the measurement process (81). Whereas preseda- marter how it is administered. Children receiving chloral hydrate
tion scores were basically the same for both groups, during frac- musr be observed for at least several nours. Respirarory depres-
ture reduction, rhe investigatOrs reported a significantly Jower sion is unusual, but children with sleep apnea and adenotonsillar
score of patient distress for the children receiving midazolam hypertrophy may be particularly vulnerable ro airway obstruc-
and ketamine than for rhose receiving midazolam and fentanyl tion after sedation with chloral hydrate (16). At least one death
(81). In general, tne ketamine and midazolam combination was has been reported following its use (74), These problems empha-
favored by parents and by the involved orthopaedic surgeons size that even sedatives thought to have little risk of producing
(81). On the other hand, however, C\.vo patienrs receiving mida- respirarory depression must be administered under properly su-
zolam and ketamine required brief assisted ventilation with a pervised conditions (63) and with strict adherence ro dosage
bag, valve, and mask apparatus, and one patient developed lalyn- guidelines.
 Chapcer 3: Pain Relief and ReLated Concerns in ChiLdren:r Fractures 61

~ AUTHOR'S PREFERRED METHOD not be used in the management of children with fractures in an
,~ OF TREATMENT emergency room setting. First and foremosr, ir is easy to sud-
denly lose the airway in a patient given propofol. Therefore, this
Chloral hydrare is of minimal use in rhe sedation and treatment drug has really should be administered by an anesthesiologisr
of patients with fractures. It provides no analgesia, and ir lacks (79). Second, the drug provides no analgesic effecr and, rhere-
the rapidity of onser and rirrarability of intravenous opioids and fore, has ro be combined with an opioid, which, in turn, will
benzodiazepines. The pracritioner should be familiar with rhis inrensify rhe respiratory depressanr effects of propofol. Third,
medicarion, however, because it remains in common use for in children, the administrarion of propofol is associated wirh
nonpainful pediatric procedures. Salient features regarding its opisthotOnic posturing and myoclonus (88), which is certainly
adminisrration are summarized in Table 3-12. nor helpful in the reduction of a fracrure. Propofol has vasodila-
tory and negarive inorropic effects, which can lead to hypoten-
sion (88). Finally, there is some concern thar propofol may be
Barbiturates associated with seiwres (88), although Momora and co-workers
In general, barbirurates have a lower margin ofsafety than benzo- (97) have used propofol to Stop seiwre activity from local anes-
diazepines (132). In addition, barbiturates seem to lower the theric overdose.
pain threshold, and are therefore a poor choice for producing
sedarion in the presence of a painful condition, such as a fracture • AUTHOR'S PREFERRED METHOD
(132). With these points in mind, barbiturates should nOt be ,~ OF TREATMENT
used for sedating children with fractures.
Regarding children with fractures, propofo] should be reserved
Propofol for administration in the operating room as part of a regimen
of general anesthesia by an anesthesiologist.
Propofol is a substituted isopropyl phenol rhat is a rapid-acting
intravenous anesthetic (136). Because it is virtually insoluble in
aqueous solutions, it has to be dissolved in lecithin-containing REGIONAL A ESTHESIA IN THE CHILD
formularions. The orthopaedist may have seen this whirish medi- WITH A MUSCULOSKELETAL INJURY
carion administered by the anesrhesiologisr in the operating
room, where it has gained the popular name of "milk of am- Within the limitations and guidelines that are discussed later,
nesia." the use of regional anesthesia ro relieve pain in children with
Propofol has a fasr onset of action, owing to its high lipid musculoskeletal injuries is reasonable and worthwhile.
solubility, and an exrremely short durarion of action. Awakening
is rapid, wirh litde to no "hangover" effect as seen with other Regional Anesthetic Agents
drugs (136). Ir also has antiemetic effects (88). Regional or local anesthetic medications prevent nerve impulse
However, rhere are several reasons for which d1e drug should propagation by interfering with the function of rhe sodium chan-
nel on the axonal membrane (139). Commonly used local anes-
rhetics have either an amino amide or amino esret linkage in
their molecular structure (146). Amino amide local anesthetics
include lidocaine (Xylocaine), bupivacaine (Marcaine, Sen-
TABLE 3-12. MANIFESTATIONS OF LOCAL
ANESTHETIC TOXICITY· sorcaine), mepivacaine, prilocaine, etidocaine, and the relarively
new agent ropivacaine. Amino ester local anesthetics include
1. Numbness of the lips and tongue, metallic taste in the mouth. procaine (Novocain), chloroprocaine, tetracaine, benzocaine,
2. Lightheadedness
and cocaine.
3. Visual and auditory disturbances (double vision and tinnitus)
4. Shivering, muscle twitching, tremors (initiar tremors may in- Medications within each group have important intrinsic dif-
volve the muscles of the face and distal parts of the extremi- ferences in potency, durarion of action, and porential for roxicity
ties) (36,146). For example. lidocaine is significantly less toxic a drug
5. Unconsciousness than bupivacaine bur it also has a shorrer durarion of action.
6. Convulsions
7. Coma An important feature of ropivacaine is that even rhough its dura-
8. Respiratory arrest tion of action is similar to bupivacaine, ir produces Jess CNS
9. Cardiovascular depression and collapse toxicity and less cardiac toxicity (123). Durarion of acrion for
rhe various local anesrhetic medications is also determined in
* With gradual incr~ases in plasma concentration, these signs and part by the type of regional block performed. For example, single
symptoms may occur.in order as listed. With the sudden dose brachial plexus blocks tend to have a far longer duration
development of high plasma concentrations of a local anesthetie
agent, the first manifestation of toxicity may be a convulsion, than do single dose epidural or subarachnoid blocks (36).
respiratory arrest, or cardiovascular collapse. In young children, or
in children who are heavily sedated, subjective evidence of
impending local anesthetic toxicity (manifestations 1, 2, 3) may be Local Anesthetic Toxicity
difficult to elicit..
Ar least three types of adverse reactions can occur from local
anesrheric agents. Clinically, the most important is systemic tox-
62 General Prinicipln

icity of rhe CNS and cardiovascular sysrem from relarive over-

TABLE 3-14. MAXIMUM RECOMMENDED
dose inro rhe circulation. This type of reacrion is nor a medica-
DOSES OF COMMONLY USED
rion allergy bur simply a Function of placing roo much LOCAL ANESTHETICS IN
medicarion inro rhe bJoodsrream. Note rhat in rhe presence of CHILDREN
a major artery, even a few drops of local anesrhetic can lead
Injection Dose
ro seizure acrivity. An example of rhis problem is seen in the
(mglkg)
performance of stellare ganglion blocks in rhe neck for rhe man-
agement of reflex symparheric dystrophy of rhe upper extremity, With
where rhe verrebral anery can be accidentally entered during Agent 'Plain Epinephrine*
administration of the medication. Lidocainet (Xylocaine) 5 7
In mosr cases, however, the severity of systemic toxicity is Bupivacaine+ (Marcaine, 2.5 3
directly relared ro rhe concentrarion of local anesthetic in rhe Sensorcaine)
bloodsrream (Table 3-13) (36). Seizures and cardiac arrest may Mepivacaine (Carbocaine) 4 7
be rhe initial manifesrarions of systemic roxicity in patients who Prilocaine§ 5.5 8.5
rapidly arrain a high serum level of medication (42,98,109).
Agents with greater intrinsic potency, such as bupivacaine and * The addition of epinephrine (vasoconstrictor) reduces the rate of
local anesthetic absorption into the bloodstream, permitting use
etidocaine, require lower levels for producrion of symptoms (36). of a higher dose.
Dysrhyrhmias and cardiovascular toxiciry may be especially se- t For IV regional anesthesia (Bier blocks), the maXimum lidocaine
dose is 3 mg/kg. Preservative-free lidocaine witho'ut epinephrine
vere with bupivacaine, and resuscitarion of rhese parients may should be used for either Bier blocks or hematoma blocks.
be prolonged and difficulr (2,36). * Owing to its cardiotoxicity, bupivacaine should never be used for
IV regional anesthesia or for hematoma blocks.
The prevention and rrearment of acure local anesrheric sys- § Of the amide local anesthetics, prilocaine is the least likely to

temic toxiciry are outlined in Table 3-14. produce eNS and cardiovascular toxicity. However, a byproduct of
prilocaine metabolism may lead to severe methemoglobinemia in
A1rhough rhe potenrial for CNS roxicity may be diminished young children. Prilocaine is, therefore, contraindicated in children'
wirh barbirurares or benzodiazepines, given either as premedic- younget'than 6 mo old.
ations or during rrearmenr of convulsions, rhese measures do
nor alrer rhe cardiotoxic rhreshold of local anesrhetic agents.

With rapid and appropriare rrearmenr, rhe fatality rare from

TABLE 3-13. PREVENTION AND TREATMENT OF local anesrhetic convulsions should be greatly decteased (36).
ACUTE LOCAL ANESTHETIC Ie is absolutely essential ro sray wirhin accepted dose limits
SYSTEMIC TOXICITY when using any local anestheric (Table 3-15). To aid in dose
Preventive Measures calculations, a simple formula for convening percent concenrta-
rion to milligrams to millilirer is provided in Table 3-16.
1. Ensure ava,ilability of oxygen administration equipment, air-
way equipment, suction equipment, and medications for AJrhough rare, rrue immune-mediared allergic reacrions ro
treatment of seizures (diazepam or midaiolam, thiopental, local anesrherics are possible, more commonly wirh amino esrers
succinylcholine). rhan wirh amino amides (22,52). The reader is referred to other
2. Ensure co'nstant verbal contact with patient (for symptoms of sources for the derailed managemenr of allergic or anaphylacric
toxicity) and monitor cardiovascular signs and oxygen satura-
tion. reacrions (28,100).
, 3. Personaily' prepare the dose of local anesthetic and ensure it' Local nerve damage and reversible skeleraJ muscle changes
is within the accepted dosage range. have been reported from rhe use of local anesrherics (36).
4. Give the anesthetic slowly, and fractionate the dose.

Treatment Intravenous Regional Anesthesia

1. Establish a clear airway; suction if required.
2. Give oxygen by face mask. Begin artificial ventilation if neces- Intravenous regional anesthesia was firsr described by Augusr
sary. Bier in 1908 (15). Although ir declined in popularity as brachial
3. Give diazepam 0.1-0.3 mg/kg IV in incremental doses until
convulsions cease. Midazolam (0.05-0.1 mg/kg) may be used
instead, also in increments until convulsions cease.
4. Thiopental in increments of 1-2 mg/kg IV may be used to
control the seizures.
TABLE 3-15. CONVERSION FORMULA FROM %
5. Succinylcholine (1 mg/kg IV) may be used if there is inade-
CONCENTRATION TO
quate control of ventilation with the other medications. Arti- '
MILLIGRAMS/MILLILITER
ficial ventilation and possibly·endotracheal intubation are re-
quired after using succinylcholine. ' Percentage concentration x 10 = Number of mg/mL
6. Use advanced cardiac life-support measures as necessary to
support the cardiovascular system (more likely with local an- Examples: 0.25% bupivacaine has 2.5 mg bupivaca'ine/mL;
esthetics of increased potency, such as bupivacaine). 2% lidocaine has 20 mg lidocaine/mL.
 Chapter 3: Pain Reliefand Related Concerns in Children's Fractures 63

TABLE 3-16. PARENTAL OPIOID DOSING

SCHEDULE FOR ANALGESIA IN
CHILDREN*

IMt: Morphine, 0.1 ~0.15 mg/kg q 3-4 h

Meperidine, 1.0-1.5 mg/kg q 3-4 h

IV: Morphine, 0.05-0.1 rhg/kg. q 2 h

Meperidine, 0.5-1.0 mg/kg q 2 h

* Infants < 3 mo old should be dosed in increments of one third

to one half because of increased risk of respiratory depression.
t Intramuscular dosing should rarely be used.
Adapted from Roger, l.and Mora, M. Acute postoperative and
chronic pain in children. In Rasch, D.K. and Webster D.E. eds.:
Clinical manual of pediatric anesthesia. New York: McGraw-Hili,
1994:297, with permission,
FIGURE 3-3. Intravenous infusion for fluids, sedative medications, and
if necessary, resuscitative medications has been started in the contralat-
eral hand. A pulse oximeter probe is present on the patient's index
finger.

plexus blocks were developed, it was revived in 1963, when its

safe and successful use for the reduerion of forearm fracrures in 1. Confirm the immediate availability of a funerioning posi-
adults was reported (70). Since then, mulriple reporrs have ar- tive-pressure oxygen delivery system, as well as appropriate
rested to its usefulness in the rreatment of upper limb injuries airway management equipment (Table 3-5) (63). Also, con-
in adults and children (10,17,29,46,53,104,147). firm the immediare availability of medications for the rreat-
The mechanism of action is uncertain. It may involve borh ment of anesthetic-induced convulsions (Table 3-13).
direer transport of local anesthetic to major nerve trunks or rhe 2. Start an intravenous infusion in the contralateral arm (Fig.
blockade of small nerve endings (53). 3-3). A patent intravenous line is of paramount imporrance
Intravenous regional anesthesia is reliable, wirh a higher suc- in treating the complicarions of this block. Obtain a baseline
cess rate than other approaches to upper extremity blocks (53). ser of vital signs, including systolic and diastolic blood pres-
Orher advantages include its simplicity, rapidity of onset, and sure. Monitor pulse oximetry (Fig. 3-3) as well as the ECC
rapidity of recovery. Rapidity of recovery may be considered continuously (Fig. 3-4).
borh an advantage as well as a disadvantage, because, with local
anestheric alone, the analgesic effect is lost once rhe tourniquet
is deflated. A recent report in adulrs examined the addition of
rhe nonsteroidal antiinflammatory medication ketorolac (Tora-
dol) to the local anesthetic solurion for intravenous regional
anesrhesia and found thar patients did obtain prolonged analge-
sia after the tourniquer was released (124). However, no pediatric
studies have been performed on this drug combination.
Intravenous regional anesthesia is unsuitable for lesions above
rhe elbow (71). In addition, if the fracture involves the supracon-
dylar area of rhe humerus, the cuff may limit the degree of
hyperflexion needed to produce an adequate reduction. Intra-
venous regional anesthesia is contraindicared in patients with
underlying heart block, known hypersensitivity to local anes-
thetic agents, and seizure disorders (71). Although not tOtally
contraindicated, caution is urged when using rhis technique
in patients with underlying hemoglobinopathies such as sickle
cell disease.

•
\...~
AUTHOR'S PREFERRED METHOD
OF TREATMENT --
FIGURE 3-4. Continuous display of the electrocardiogram (top wave-
form) and continuous display of the plethysmographic tracing from
The basic steps involved in performing an intravenous regional the pulse oximeter (second line). Intermittent blood pressure reading
block are as follows: is displayed.
64 Genna/ I'rinicipLes

3. Selecr an appropriare rourniqueL An orrhopaedic rourni-

quet rhar can be fasrened securely should be used. Because
Velcro may become less adhesive wirh time, check the
tenacity of the rourniquet before use. As an added safety
measure, the rourniquet may be covered with strong adhe-
sive tape or an Ace bandage after application. The rourni-
quet should fully encircle rhe arm and overlap back on
itself by at least 6 cm (personal communication, K.E.
Wilkins, M.D.). The arm may be minimally padded
with cast padding underneath the rourniquet (17). If a
pneumatic rourniquet is used, the physician must be
familiar with the location of the rourniquet pressure gauge
(Fig. 3-5) (29) and valves, because these features may
vary in location from model ro model. Narrow-cuffed
double rourniquets may nOt effectively occlude arterial
Aow, and their use has been discouraged (71). Tourniquer
discomfon should not be a problem during shorr proce-
FIGURE 3-6. Venipuncture for administration of local anesthetic has
dures. If this problem develops, a second tourniquet can been performed with a butterfly needle. An intravenous catheter may
be applied distaUy over rhe anesrhetized area of the be more secure than a needle, which can become dislodged from within
arm. the vein.

4. Palpate rhe radial pulse of the injured limb.

5. Place and secure a shorr 22-gauge cannula in a vein on
rhe dorsum of the hand of the fracrured limb. A 23-gauge
burrerfly needle may also be used (Fig. 3-6). Note that al-
though ir may be possible ro "rhread" a butrerfly needle
securely into a large vein, burrerfly needJes may stiU slip our vein or even an antecubital vein can be used. However, the
of the vein more easily rhan a plastic intravenous catheter. use of proximaJ veins in the arm may result in a less effective
The author recommends the use of intravenous catheters block (71).
whenever possible. If a distal vein is unavailable, a proximal 6. Wirh the courniquer deflated, exsanguinate the limb by
vertically elevating it above the level of rhe hearr for 60
seconds.
7. Rapidly inflare the rourniquer to a pressure of 225 to 250
mm Hg or 150 mm Hg above rhe patienr's syscolic blood
pressure (51). Check for disappearance of the radial pulse.
Cross-clamping rhe tubing of the cuff after inflation is dis-
couraged (71), because it might prevent detection of a smaJ I
leak. Constant observation of the cuff pressure gauge is rec-
ommended.
8. Lower the extremity and slowly inject the local anesrhetic.
It is recommended that this injection be done over a
period of 60 seconds. A concenrration of 0.5% plain
lidocaine (5 mg/mL) is used (Fig. 3-7). Bupivacaine is
contraindicared for rhis block because of irs cardiocoxicity.
To prevent thrombophlebitis, the local anesthetic solution
must be free of any additives or preservatives (71). In
different studies, the recommended dose of lidocaine has
varied from 1.5 co 3.0 mg/kg 00,17,29,46,53,104,147).
A dose of 1.5 mg/kg appears to bc safc and effecrive,
and may produce a decreased incidence of complications
(17). One srudy has recommended a maximum lidocaine
dose of 100 mg for this block (46). The skin of the
extremity becomes motrled as the drug is injected. The
patienr, unless he or she is very sedated, and the parents,
if they are watching, should be warned that rhe extremity
will look and feel scrangely (personal communicarion,
FIGURE 3-5. Tourniquet controls may vary in position from model to K.E. Wilkins, M.D.). Analgesia and muscle relaxarion
model. It is imperative for the practitioner to be aware of the function
of each of the controls to avoid accidental premature deflation of the develop within 5 minures of injection (71). Note that
tourniquet. for fractures ar the wrist, placement of a regular penrose
 Chapter 3: Pain Reliefand Related Concerns in Children's Fractures 65

FIGURE 3-9. Hematoma block performed with the last 2 mL of the

intravenous lidocaine solution to enhance analgesia at the fracture site.
FIGURE 3-7. Preservative-free 0.5% lidocaine without epinephrine for
intravenous regional anesthesia.

12. Release the cuff at the end of the operation, or at the

end of a 15-minute interval, whichever is longer. Cuff
deflation, followed by immediate reinflation, as a method
of delaying systemic absorption of local anesthetic is im-
drain tourniquet around the distal forearm may improve
practical because it cannot be done rapidly enough to
distribution of the local anesthetic solution at the fr~crure
prevent significant entry of local anesthetic into the general
site (Fig. 3-8) (personal communication, K.E. Wilkins,
circulation (71).
M.D.).
13. Monitor the patient closely for at least 15 minutes for any
9. To improve analgesia for fracture redunion, the last 2 mL
complications related to the block. The treatment of local
of local anesthetic solution may be injected directly into
the fracture hematoma (Fig. 3-9) (personal communication,
K.E. Wilkins, M.D.). The technique of local infiltration
anesthesia, or hematoma block, is discussed further in a
subsequent section of this chapter.
10. Perform the surgical procedure (Fig. 3-10).
11. Leave the cuff inflated for at least 15 minutes (71), even if
the surgical procedure takes less time.

FIGURE 3-8. Penrose drain tourniquet on the forearm to improve dis- FIGURE 3-10. Fracture reduction under appropriately monitored seda-
tribution of local anesthetic at the fracture site. tion and intravenous regional anesthesia.
66 General Priniciple.f

anesthetic-induced systemic toxiciry has been discussed

(Table 3-13).
] 4. Ofcourse, depending on whatever sedation has been admin-
istered, the patient should be monitOred until discharge cri-
teria are met (Table 3-1)
An assistant must be presem to watch the patient, the tOurni-
quet, and the monitOrs at all times.

Local Infiltration Anesthesia: Hematoma

Blod{
HematOma block has been successfully used in the treatment of
distal forearm fractures (27,94). This simple technique involves
injecting local anesthetic intO the fracture hematOma, the loca-
tion of which is confirmed by aspirating blood into the syringe
(Fig. 3-9). When done alone, 1% lidocaine in a dose of] to 2
mg/kg is used (94). As indicated earlier, when combined with
a Bier block, the last I to 2 mL of local anesthetic solution
are used. Although the medication is rapidly absorbed imo the
circulation, the resulting systemic blood levels of 10caJ anesthetic
are well below those required for eNS tOxiciry (94). Hematoma
blocks may be used in patients who have received a regional
block yet still have residual pain at the fracture site.
AJioto and co-workers (4) have described the use of an inuaar-
tiCLdar hematOma block for the manipulative reduction of ankle
fractures in a popuJation group that included both children and
adults. The youngest patient in their study group who received
a hematOma block was 12 years old. The technique they describe
consisted of a direct injection of 2% lidocaine 1 mg/kg (the
amhors used 2 mg lidocaine per pound) intO the tibiotalar joim
space. Absolute sterile technique was used, with the skin overly-
ing the fracture site being prepared with a povodine-iodine
preparation. A 22- or 25-gauge needle was used for the injection
of the local anesthetic solution. The authors of this investigation
recommend directing the needle in a slightly cephalad direction
to avoid injury to the talar and tibial articLilar surfaces. Aspiration
of blood was used to confirm ently into the intraarricular space.
The injection was performed only if no resistance was encoun-
tered. A minimum of ] 5 minutes was aJlowed to pass after the
injection, during which time the patient was closely obstl"ved
and monitOred for any evidence of local anesthetic systemic tOx-
iciry (see earliet). The injection was considered adequate if the
patient was subsequently able to elevate the injured limb off the
bed withom assistance and petfotm active ankle dorsiflexion
and plantarflexion. The authors of this investigation found the
intraarricular ankle hematOma block to be safe, effective, and
well tOlerated by patients (4). Although some of their patiems
tolerated the injection and the subsequent fracture reduction
without the use of any other supplementaJ analgesics or sedatives,
most children would probably require the same rype of sedation
that would be used before performing a Bier block or a hema-
tOma block of the upper extremiry. FIGURE 3-11. Barbotage. When performing a hematoma block, the
local anesthetic is given by barbotage. A: Half the anesthetic is injected
in the hematoma. B: The blood from the hematoma is withdrawn until
• AUTHOR'S PREFERRED METHOD the original volume is regained. C: This mixed material is repeatedly
\..~~ OF TREATMENT injected and reaspirated until the anesthetic is dispersed in the hema-
toma. The final aspirate should contain a volume equal to the original
anesthetic. Thus, the final volume of fluid in the hematoma has not
Full aseptic technique, including adequate skin preparation and been increased.
the use of sterile gloves, is recommended. The incidence ofinfec-
 Chapter 3: fain ReLie/and ReLated Concerm ill Children's FraCtures 67

cial in order to minimize side effects from anyone particular

approach (e.g., the use of NSA1DS to decrease the incidence of
nausea, vomiting, or even respiratory depression from opioids).
The end point is to make patients comfortable while minimizing
adverse reaC[ions.

Postoperative Analgesia With Opioids

Opioids have long been the mainstay of postoperative analgesia.
It is important for the practitioner to understand the rationale
Medial Lateral behind different dosage regimens to maximize pain relief for the
FIGURE 3-12. Section of right thigh immediately below the inguinal patient.
ligament, showing femoral nerve under cover of fascia iliaca and its
block by a barrage technique. (Reproduced with permission from Anes-
thesia, 1977, Volume 32, page 577. Analgesia in Patients with Fractured
Shaft of Femur. F.R. Berry, M.D.) Intermittent Dosing
AJthough commonly used, traditional intermittent as-needed
dosing of intramuscular and intravenous opioids (Table 3-17)
makes little pharmacologic sense for control of severe pain (49,
tion from introduction of a needle into the hematoma is greatly 148). Wide variations in plasma opioid levels occur, leading to
decreased if antiseptic precautions are taken (75). The hematoma periods of sedation alternaring with prolonged periods of no
is localized by aspirating blood into the syringe. The local anes- pain relief at all (49). In addition, for pediatric care, intramuscu-
thetic solution is given gradually by alternate injection (barbo- lar dosing is a particularly poor choice (148), because children
tage) of a small amount of medication and withdrawal of a small often chose to hide their pain rather than risk having to undergo
amount of hematoma until all of the medication has been given an injection. The end result with intermittent dosing, especially
(Fig. 3-11). In the case of the intraarticular hematoma block at
the ankle (4), a slow direct injection is used, with careful ECC
monitoring for any evidence of dysrhyrhmias.
Reported complications with hematoma blocks in the upper
extremiry include compartment syndrome (162), temporary pa- TABLE 3-17. PATIENT·CONTROLLED
ralysis of the anterior interosseous nerve (162), and increased ANALGESIA IN CHILDREN
incidence of carpal tunnel syndrome (84).
Loading dose: Morphine, 0.025-0.05 mg/kg
Maintenance dose: Morphine, 0,01-0.02 mg/kg
Lockout interval: 6-10 min
Femoral Nerve Block 4-hr maximum: Morphine, 0.4 mg/kg/4 h
Treatment of Side Effects
Berty (14) has described a technique of rapid analgesia for pa-
Pruritus
tients with a fracture of the femoral shaft using 1 % lidocaine Diphenhydramine (0.5 mg/kg IV) OR
with 200,000 epinephrine or 1.5% lidocaine with 1: 200,000 Low-dosenaloxone (0.5-1.0 ,ug/hr)
epinephrine deposited at the femoral nerve, just below the ingui- Nausea/vomiting
nal ligament (Fig. 3-12). As always, the anesthetic dose should Metoclophramide (0.1 mg/kg IV) OR
Droperidol (10-30 ,ug/kg IV or 1M) OR
remain within accepted limits. For lidocaine with epinephrine, Ondansetron (0.15 mg/kg IV over 15 min)
7 mg/kg is the permissible dose limit. Low-dose naloxone as for pruritus
Cooperation and tolerance among young children for re- Urinary retention «1 mUkg/h in the face of adequate fluidin-
gional blocks varies, so careful patient selection is advised. take)
Low-dose naloxone infusion as above
Respiratory depression
Vital signs: specify parameters that require treatment and
method for contracting responsible physician.
POSTOPERATIVE ANALGESIA IN THE Stop PCA pump.
CHILD WITH A MUSCULOSKEL TAL Give 100% oxygen and maintain the airway.
Give naloxone (1-5 I.£g/kg IV bolus). Repeat as needed.
INJURY Consider naloxone infusion (3-5 ,ug/kg/h).

Safe and effective postoperative analgesia in children with mus-

Rogers J, Moro M. Acute postoperative and chronic pain in
culoskeletal injuries can be accomplished with opioids, nonste- children. In. Rasch ORe and Webster DE, eds. Clinical manual of
roidal antiinflammatory agents (NSAlDS), or local anesthetic pediatric anesthesia. New York, McGraw-hili, 1994:298, with
permission.
agents.
Simultaneous use of more than one modaliry may be bendi-
68 General Priniciples

with imramuscular narcotics, is unnecessalY undertreatment of individuals, alrhough careful assessment of each individual situa-
paIn. tion is required.
When compared with tradirional inrermittent dosing, im-
proved pain conn'oJ and greater parient satisfaction have been
Patient-Controlled Analgesia demonstrated (J 1). Note that further improvement in pain relief
Patient-controlled analgesia (PCA) is a sensible approach ro the may be achieved with rhe addition of a continuous background
problems inherent with imermirrent as-needed dosing of opioids in fusion of opioids to maintain the plasma concentrations of
(49). With PCA, intravenous self-ritration of small doses of the analgesic during sleep. However, adding a background infu-
opioids ar frequent intervals eliminates rhe wide variations in sion may increase the risk of opioid-associated nausea, sedation,
plasma drug levels seen with imermirrent dosing (49). It also and hypoxemia (39,159).
aJlows patients to gain control over their pain managemem (23), Conceivably, for younger chi Idren or for chiJdren othelwise
which may be of psychological importance to the parimt's well- unreJiably capable of pushing rhe button on the PCA cord, "par-
being. em-controlled analgesia" may be useful. The author has used
PCA was first evaluated in adolescents in 1987, after several this approach in a patient as young as 1 1/2 years of age. In this
years of successful use in adulrs (23). Since then, this modality particular situation, however, the parents were very motivated
has been used for children as young as 6 years of age (11). and inrelligent, and had done this before for their child after
Depending on rhe intelligence and cooperative ability of rbe another surgical procedure. In general, PCA is safest when only
child, it is conceivable that PCA could be used for younger the patient is opel'ating the device.

TABLE 3-18. DOSING SCHEDULES AND FORMULATIONS FOR ORAL OPIOIDS IN CHILDREN

Agent Dose Pediatric Formulations·

Codeinet 0.5-1.0 mg/kg q 4 to 6 h (max. single dose, 15 mg/5 mL oral solution

60 mg)
Codeine with acetaminophen (Tyl,enol with 0.5-1.0 mg/kg codeine q 4 to 6 h + 10-15 12. mg codeine + 120 mg acetaminophen/5
Codeine, Phenaphen with Codeine, mg/kg acetaminophen q 4 to 6 h mL solution
Capital with Codeine) Tylenol (300 mg) + Codeine tablets #1: 7.5
mg, #2: 15 mg, #3: 30 mg, #4: 60 mg
Hydrocodone with acetaminophen (Lortab, Adult dose: hydrocodone 5-10 mg q 4 to 6 2.5 mg hydrocodone/5 mL +
Anexsia, .Co-Gesic, DuoCet, Hy-Phen, h. acetaminophen 120 mg/5 mL (Lortab
Vicodin) Children (only antitussive dose is Liquid)
published): 0.6 mg/kg day divided in
three to four doses/day.
<2 yr: Do not exceed 1.25 mg/dose.
2-12 yr: Do notexceed 5 mg/single dose.
>12 yr: Do not exceed 10 mg/single dose.
Meperidine .(Meperidine HCI, Demerol HCI)t 1.1-1.8 mg/kg q 3 to 4 h 50 mg meperidine/5mL solution
Max. single dose 100 mg
Morphine (morphine sulfate, Raxanol)t 0.2-0.4 mg/kg q 4 h (Adult dose is 10-30 10 10 mU5 mL and 20 mg/5mL solution
mg q 4 h) Absorption from the GI tract is
variable.
Hydromorphone (Dilaudid, Hydromorphone Optimum pediatric dosage for analgesia 5 mg hydromorphone/5 mL solution
HCI)t not established.
Antitussive dose is:
6-12 yr: 0.5 mg q 3-4 h
> 12 yr: 1 mg q 3-4 h
Oxycodoneand Aspirin:j: (Percodan-Demi)t§ 6-12 yr: ~ tablet q 6 h Oxycodone§ + 325 mg aspirin
>12 yr. ~ tablet q 6 h

* This table does not provide an exhaustive list of all available oral opioids and oral opioid/nonsteroidal anti·inflammatory drug combinations. A
complete discussion and complete lists of all respective formulations may be found in AHFS Drug Information '94.
t Denotes a schedule I drug, for which a triplicate prescription is required.
:j: Owing to an assoCiation with Reye's syndrome, medications containing aspirin should be expressly avoided in children with flulike symptoms or
children with chickenpox.
§ Percodan-Demi contains 2.25 mg oxycodone hydrochloride and 0.19 mg oxycodone terephthalate + 325 mg aspirin;
Adapted from Opiate Agonists. In McEvoy CK, Litvak K, WeishOH, Jr, eds. AHFS Drug Information '94. Bethesda, MD American Society of HospitaJ
Pharmacists; 1994; Taketomo, C.K., Hodding JHJ, Kraus, OM: Pediatric dosage handbook, 2nd ed. Hudson, OH. Lexi-Comp, 1993: Ragers J., and Moro,
M.: Acute Postoperative and Chronic Pain in Children. In Rasch, DK, Webster DE (eds.): Clinical Manual of Pediatric Anesthesia. New York: McGraw-
Hill, 1994, with permission.
 Chaptel' 3: Pain Reliefand ReLated Concerm in Children 5 Fractures 69

Parameters that musr be considered are the loading dose, the based on patient response. The use ofNSAIDS (see the following
maintenance dose, and the lockout intervaJ (the period during seccion) as parr of the anaJgesic regimen may be helpful in reduc-
which no further adminisrration of medication will occur despite ing or eliminating rroublesome opioid-related side effects.
attempts ro do so by the patient), and the 4-hour maximum
dose (Table 3-18). For PCA, morphine is more effective than
Other Modes of Opioid Administration
meperidine (J 51). Opioids orher than morphine should be used
only for patients aJlergic ro morphine (20), or for whom mor- EpiduraJ opioids are being used in children after major surgelY
phine produces inrolerable side effecrs. Whenever possible, rhe with excellent results (112). The author encourages close cooper-
persistent use of one medication helps avoid dosing errors (20). ation between surgeons and anesthesiologists ro avail children
The use of rhe PCA pump should be explained ro patients of this modaliry of analgesia whenever feasible.
preoperatively. Effective use of a loading dose will avoid the
problem of having ro play catch-up with out-of-control levels
Postoperative Analgesia With Nonsteroidal
of pain.
Antiinflammatory Drugs
Mishaps have occurred with PCA pumps due to program-
ming errors (156), so ward personnel must be (Otally familiar NSAIDs have moderately good analgesic properties (148). Un-
with the equipment. Treatment of opioid-re1ated side effects is like opioids, which produce analgesia by effects on CNS recep-
outlined in Table 3-18. tors, NSAIDs act peripherally by inhibiting prostaglandin syn-
thesis and decreasing inflammation (137,152). Inflammarory
mechanisms play an important parr in the pathogenesis of post-
Oral Administration of Opioids
operative pain (148), and therefore, the use of NSAIDs maJ<es
Oral dosing of opioids is exrremely useful for the continued good sense in the postoperative setting. AJso, aJthough NSAIDs
managemenc of diminishing posroperacive pain, once oral anal- have some rroubling side effeccs of their own, they do not pro-
gesics are rolerated. SeveraJ oraJ analgesics are available, and their duce respirarolY depression, nausea, and vomiting, which are
appropriate use is summarized in Table 3-19. None of these some of the bothersome features ofopioids. Thus, using NSAIDs
medications is devoid of side effects, including mood changes, either as an adjunct or as a substitute for opioids where feasible
nausea, vomiting, constipation, dizziness, and prurirus. The oc- should decrease or eliminate the possibiliry of drug-induced nau-
currence and degree of side effecrs vary from patient ro patient, sea, vomiting, or respirarory depression in the surgical patient
so the physician should be prepared ro change dosing regimens (148).

TABLE 3-19. DOSING SCHEDULES AND FORMULATIONS FOR NSAIDS IN CHILDREN

Agent Dose Formulations *

Ibuprofen (oral) 5-10 mg/kg q 6 h (published dose is for treatment of 100 mg/5 mL suspension
fever, not specifically for analgesia) Tablets: 200, 300,400,600,800 mg
Naproxen (oral) 5-7.5 mg/kg q 12 h 125 mg/5 mL suspension
Tablets: 250, 375, 500 mg
Ketorolac (1M, IV) 0.5 mg/kg q 6 h Injectable 30 mg/mL
Choline Magnesium 50 mg/kg/day 500 mg salicylate/5 mL solution
Trisalicylate (Trilisate) (oral}t Divided into 2 or 3 doses (maximum daily dose, 2.25 g) Tabl.ets: 500, 750, ;000 mg
Salsalatelf (oral) (Disalcid) Pediatric dose not published; adult maintenance dose is Tablets: 500, 750 mg
2-4 g/day. .
Acetaminophen:!: (oral, rectal} 10-15 mg/kg q 4-6 h 80 mg/0.8 mL drops
80 mg chewable tablets
160 mg/5 mL solution
325, 500 mg-tablets
120-, 325-, 650-mg suppositories

* An exhaustive listing of available formulations for NSAIDs may be found in AHFS Drug Information '94.
t Although they are salicylates, choline magnesium trisalicylate and salsalate do not crossreact with aspirin and may be used in patients allergic to
aspirin.As many as 28% of children with asthma may be in this group of patients. Owing to an association with Reye's syndrome, saficylates should
be avoided in children with. flu-Uke symptoms or chickenpox.
* Acetaminophen is considered a member of this class of medications, even though it mainly acts centrally and it only very weakly inhibits
prostaglandin synthesis. Acetaminophen also does not crossreact with aspirin and may be used in patients allergic to aspirin.
(Adapted from Nonsteroidal Anti-Inflammatory Agents. In McEvoy, GK, Litvak, K, and Welsh, OH, Jr. eds. AHFS Drug Information '94. aethesda, MD:
American Society of Hospital Pharmacists, 1994; Walson, P.O., and Mortensen, M.E.: Pharmacokinetics of common analgesiCS, anti-inflammatori.es
and antipyretics in children. Clin Pharmacokinet 17:116-137,1989, with permission.
70 General Priniciplej

Potential side effects of this class of drugs include platelet

TABLE 3-20. PHARMACOLOGIC APPROACH TO
dysfunction, gastritis, and acute renal dysfunction (93,152). A
POSTOPERATIVE NAUSEA *
history of sensitivity to aspirin or a history of nasal polyps may
be associated with potentially fatal cross-sensitiviry to other Agent Dosage Route
NSAIDs (1,137). In children with asthma, the prevalence of
Promethazine 0.25-0.5 mg/kg IV or per rectum
aspirin sensitivity may be as high as 28% OIl). Therefore, asth- (Phenergan)
matic children should probably receive only those NSAIDs that Metoclopramide 0.1 mg/kg (maximum IV
do not cross-react with aspirin. These medications include acet- (Regian) dose, 5 mg)
aminophen, salsalate (Disalcid), and choline magnesium trisali- Ondansetron 0.15 mg/kg (maximum IV
(Zofran) dose, 4 mg)
eylate (Trilisate) (30) (Table 3-19).
In a child with a chronic underlying bleeding disorder,
* Additional helpful measures include ensuring adequate IV
NSAIDs are not necessarily contraindicated. Consultation with hydration, avoiding forced oral fluids until the patient is hungry,
the child's hematologist is advised regarding the use of specific and avoiding forced early ambulatien, especially when opioids are
given for pain relief.
medications in this class.
Ketorolac, unlike other NSAIDs, can be administered not
only orally but also intravenously and intramuscularly. A loading
dose of 1.0 mg!kg may provide similar analgesia as 0.1 mgt
kg of morphine (90). The pharmacology of ketorolac has been
extensively reviewed (86), and both its mode of action and
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anesthetic practice. Philadelphia: JB Lippincott, 1987: 2-34. premedication. Can J Anaesth 1993;40: 119-121.
136. Stoelting RK. Nonbarbiturate induction drugs. In: Pharmacology and 155. Wenzel RC. Anesthesia for pediatric trauma. In: Steen JK, Grande
physiology in anesthetic practice. Philadelphia: ]E Lippincott, 1987: CM, eds. Trauma anesthesia. Balrimore: Williams & Wilkins, 1991:
134-147. 312-329.
137. Stoelting RK. Nonopioid and nonsteroidal analgesic, antipyreric, and 156. Whire PF. Mishaps with patient-conrrolled analgesia. Anesthesiology
anti-inflammatory drugs. In: Pharmacology andphysiology in anesthetic 1987;66:81-82.
practice. Philadelphia: JB Lippincott, 1987:240-250. 157. White PF, Way WL, Trever AJ. Ketamine-its pharmacology and
138. Stoelting RK. Opioid agonisrs and antagonists. In: Pharmacology and therapeuric uses. Anesthesiology 1982;56: 119-136.
physiology in anesthetic practice. Philadelphia: JB Lippincott: 1987: 158. Wright SW, Chudnofsky CR, Dronen SC, et al. Comparison of mida-
69-101. zolam and diazepam for conscious sedarion in rhe emergency depart-
139. Strichartz GR. Neural physiology and local anesthetic action. In: ment. Ann Emerg Med 1993;22:201-205.
Cousins MJ, Bridenbaugh PO, eds. Neural blockade in clinical anesthe- 159. Wu MYC, Purcell G]. Patient-controlled analgesia-the value of a
sia and management ofpain. 2nd ed. Philadelphia, ].B. Lippincott, background infusion [Letter.] Anaesthesia and Intensive Care 1990;
1987:24-45. 18:575-576.
140. Striker TW. Anesthesia for trauma in the pediatric patient. In: Gre- 160. Yaster M, Maxwell LG. Pediarric regional anesthesia. Anesthesiology
gory GA, ed. Pediatric anesthesia, 2nd ed. New York: Churchill-Liv- 1989;70:324-338.
ingstone, 1989:1273-1288.. 161. Yasrer M, Nichols DG, Deshpande JK, Wetzel RC. Midazolam-fen-
141. Taylor PA, Towey RM. Depression of laryngeal reflexes during keta- tanyl intravenous sedation in children: case repon of respiratory arrest.
mine anaesthesia. Br Med] 1971 ;2:688-689. Pediatrics 1990;86:463-467.
142. Terndrup TE, Dire DJ, Madden CM, et al: A prospecrive analysis J 62. Younge D. Hemaroma block for fractures of rhe wrist: a cause of
of intramuscular meperidine, promethazine, and chlorpromazine in compartment syndrome. J Hand Surg 1989; 14B: 194-195.
 MANAGEMENT OF THE MULTIPLY
INJURED CHILD
VERNON T. TOLO

I CIDENCE OF I JURIE NO ORTHOPAEDIC CO DITION OF THE

Trauma MULTIPLY I JURED CHILD
Fracrures Head Injury
Child Abuse Peripheral Nerve Injuries
Abdominal Trauma
COMMON MECHANISMS OF I JURY Genirourinary Injuries
Falls
Far Embolism
Motor Vehicles
N utrirional Requirements
R LE OF THE PEDIATRIC TRAUMA CE ITER
ORTHOPAEDIC MANAGEME T OF THE
INITIAL RE USCITATION A D <VALUA ION MULTIPLY INJURED CHILD
The Child is Different Timing
Fluid Replacement Pelvic Fractures
Open Fractures
EVALUATION AND ASSESSME T
Trauma Raring Systems STABILIZATION OF FRACTURES
Physical Assessment Beneficial Effects
Imaging Srudies Outcomes of Treatment of the Multiply Injured Child

INCIDENCE OF INJURIES Multiple injuries in teenagers more closely mirror the causes
in adults. In the adolescent age group, alcohol abuse now is
Trauma considered a major factor in over a third of injuries resulting
The most common cause of death in children over the age of from accidents (55). Orthopaedists treating teenagers involved
1 year is trauma, not only in the United States but worldwide. in vehicular accidents need to be aware of the potenrial alcohol
Estimates of cost to the American public for the care of pediatric use in this age group and be prepared to refer adolescents for
trauma range from over $1 billion (53) to $13.8 billion (56) appropriate counseling to avoid future accidents and injuries.
annually. Although isolated long bone fractures still comprise
the bulk of orthopaedic injuries in children, a surprising number
of these young patients have multiple system injuries. Fractures
The cause of death from trauma in children generally is severe Although they are rarely the cause of mortality in a child with
head injury. Boys are injured twice as often as girls and may multiple injuries, fractures and other injuries to the musculoskel-
account for even a greater proportion of hospital admissions etal system are commonly a major part of the injuries (12,18,
related to pediatric trauma. Blunt trauma is the mechanism of 20,63). In one series from a pediatric trauma center treating
injury in most children and preadolescents, whereas penetrating children with polytrauma, femoral shaft fractures accounted for
trauma more often is the source of mulriple injuries in adults. 22% of the fractures and 9% of the fractures were open (12).
Although blunt trauma in the youngest children often is due ro Although they are less common, fractures of the spine, pelvis,
child abuse, vehicular accidents and falls from a height account and scapula and clavicle were associated with longer Stays in the
for cl1e more severe multiple injuries in the rest of childhood hospital and in the intensive care unit, in addition to having the
(12).
highest associated mortality rates.
Knowledge of fracture associations leads to improved diag-
nostic skill and fracture care. Femoral and adjacent pelvic frac-
Vernon T. Tolo: University of Somhern California School of Medicine; tures often occur together. If a pedestrian child has been struck
Division of Orthopaedics, Children's Hospital, los Angeles, California. by an automobile, [here often are fractures in the ipsilateral
76 GeneraL PrincipLes

upper extremity and lower extremiry (11). The coexistence of a increasing public sentiment to require seat belt use on school
femoral fracture and a head injury indicates substantial high- buses, a policy that has been in place for handicapped student
energy trauma and has a more guarded prognosis than does transport for some time.
either of these injuries alone. The most important point is that some type of restraining
system should be used by people of all ages when in a vehicle.
Although teaching children better safety while on foot or on
Child Abuse bicycles mayor may not be effective in changing the incidence
Child abuse continues to be a societal problem that crosses all of injury, the safety of automobile travel can certainly be im-
socioeconomic and ethnic groups. This diagnosis must be sus- proved by entorcement of the use of reStraints by all-both
pected in all cases of multiple injuries in children younger than young and old.
2 years of age, if there is no obvious and witnessed plausible
explanation of the injuries. Abuse continues to be the most com- ROLE OF THE PEDIATRIC TRAUMA
mon cause of traumatic death in infants and toddlers. Abuse CENTER
should be considered a possible cause of injury in a.ll young
children with multiple long bone tractures in association with Atter tne rapiel ttansport of wounded soldiers to a specialized
head injury. Even a single long bone fracture associated with a treatment center proved very effective in improving survival in
head injury or abdominal injury should raise suspicion ot child the militalY setting, trauma centers, using the same principles
abuse. Although the cornerfracture usually is thought of as being of rapid transport and immediate care, have been established
most characteristic of child abuse, the most common fracture througnoLlt the United States. These trauma centers are sup-
caused by abuse is a single transverse fracture of the temur or pOITed by the stares on the premise that the first hour after injury
humerus, not multiple fractures (42). Although. tib fractures is the most critical in influencing the rates of survival from the
occur in only about 5% of children with multiple injuries from injuries. Rapid helicopter or ambulance transport to an on-site
trauma of other causes, t'hey are more common in child abuse team ot trauma surgeons in the trauma center has led to an
(25,63). Whereas blunt compressive trauma to the t'horax from improvement in the rates of acLlte survival after multiple injuries
other causes may result in \ateral rib fractures, the rib fractures have occurred.
seen in child abuse are posterolateral and adjacent to the trans- The first trauma centers focused on adult patients, because
verse processes of t'he thoracic spine. more adults than children are severely injured. However, pediat-
ric trauma centers have been established at several medical cen-
ters across the United States with the idea that the care of pediat-
ric polytrauma patients differ from the care given to adults and
COMMO MECHANISMS OF INJURY that special treatment centers are important for optimal results
Falls (33,34). The American College of Surgeons has established spe-
ciftc criteria for pediatric trauma centers, which include the same
Falls are one of the two primaly mechanisms of multiple injuries principles of rapid transport and rapid treatment by an in-house
in children (12,28,72). Occurting more often in younger c'hil- surgical team as in adult trauma centers. A pediatric general
dren, these injuties are either due to the direct impact or to surgeon is in the hospital at all times and heads the pecliatric
deceleration forces present at the time of landing. Direct impact trauma team. This surgeon evaluates the child first while the
usually causes fractures, whereas internal injUly more often re- other surgical specialists are immediately available as needed.
sults trom t'he post-impact forces. Falls through a second floor General radiographic services and compmed tomography capa-
window that may be next to a bed often occur in toddlers and bility must be available at all times for patient evaluation and
younger children. Altnough a variety of injuries can resulr from an operating room must be immediately available.
these falls, the position of the body at impaer and rhe surface Although there is some evidence that survival rates for severely
on which tne child lands are important factOrs that affect the injured children are improved if the children are brought to a
injUlY severity (28). pediatric trauma center rather than a community hospital (77),
the costS associated with such a centet (particularly the on-ca'll
COStS of personnel) have limited the number of pediatric trauma
Motor Vehicles centers. Knudson et aL (44) studied the results of pediatric multi-
Accidents involving motOr vehicles account for most multiple- ple injUly care in an adult level [ trauma center and concluded
system injuries in school-age children and preadolescenrs. These that the results were comparable to national standards for pediat-
injuries occur when a vehicle strikes a child on foot or riding a ric trauma care. The use of a general trauma center for pediatric
bicycle, or when the child is a passenger in a car involved in an trauma care may be an acceptable alternative if it is not feasible
accident. to fund a separate pediatric trauma center.
Whereas most states require that infants and toddlers be re-
strained in car seats when riding in a car, standard aduJc shoulder INITIAL RESUSCITATION AND
and lap belts do not adequately testrain children who are too big EVALUATION
for car seats and tOO small for the standard restraints. Adjustable
restraints to accommodate the size of the car occupant better Regardless of the mechanism causing the multiple injuries, the
have been proposed to solve this problem. In addition, there is initial medical management focuses on the life-threatening, non-
 ClJapter 4: Management of the Multiply Injured Child 77

orthopaedic injuries ro stabilize the child's condition (56). The by early placemenr of a central venous catherer during initial
responsibility for the initial life-saving resuscitation rarely is the resusciration. Similarly, a urinary carheter is essential during the
responsibility of the orrhopaedisr. The initial role of the or- resusciratlon ro monlror urine output as a means of gauging
thopaedist generaUy is ro rreat the extremity injuries, even if this adequare organ perfusion.
just consists of temporary spline application to allow patiene
transport to the trauma center or even around the hospital for
imaging studies. It is recommended, however, that the orthopae- EVALUATION AND ASSESSMENT
dist stay up to date in principles of resuscitation of children to
be prepared if the occasion arises when these are needed.
Trauma Rating Systems
Mrer the initial resuscitation has stabilized the injured child's
condition, ir is essenrial ro perform a quick bur rhorough check
The Child Is Different for orher injuries. A number of injury raring systems have been
The initial steps in resuscitation of a child are essenriaUy the proposed, but the Injury Severity Score (ISS) is a valid, reprodu-
same as those used for an adult (2,20,56). In severe injuries, the cible rating system rhar can be widely applied in rhe pediarric
establishmenc of an adequate airway immediately at the accident polyrrauma serring (Table 4-1) (91). Another injury raring sys-
site often means the difference between death and survival. The rem for children rhat has been shown ro be valid and reproduci-
cervical spine needs to be stabilized for transport if the child is ble is rhe Pediarric Trauma Score (PTS) (Table 4-2) (81). The
unconscious or if neck pain is presenr. A special transport board injlllY raring sysrem chosen varies among rrauma cenrers, bur
with a cur-out for the occipital area is recommended for children wherher the ISS or PTS is used, these systems allow an objective
younger rhan 6 years of age, because the size of the head at this means to assess mortality risk at the rime of inirial rrearment,
age is larger in relation to the rest of the body. If a young child as well as aJlowing some degree of predicrion of future disability.
is placed on a normal transporr board, the cervical spine is flexed Head injury is mosr ofren evaluared and rared by rhe Glasgow
because of this larger head size, a position that is best avoided Coma Scale (GCS), which evaJuares eye opening (l ro 4 poinrs),
if a neck injury is suspected (37). moror funcrion (l ro 6 poims), and verbal function (l ro 6
poinrs) on a totaJ scale of 3 to 16 poims (Table 4-3) (80). There
are some limirations in the use of rhe GCS in children who are
Fluid Replacement preverbal or who are in rhe early verbal stages of development,
Once an adequate airway is established, the amount of hemor- bur in orher children, rhis rating system has been a useful guide
rhage from the injury, either internally or externaUy, should ro predicring early morraJity and larer disabilil")1. As a rough
be assessed. This blood loss should be replaced initially wirh guide in verbal children, a GCS score of fewer rhan 8 points
imravenous crystalloid solurion. In younger children, rapid in- means a significantly worse chance of survival for rhese children
travenous access may be difficult. In this situarion, rhe use of rhan for those wirh a GCS above 8 poinrs. The GCS should be
imraosseous fluid infusion should be considered for administra- nored on arrival in the rrauma cenrer and should be repeated 1
tion of borh fluid and medications. Guyer al. (32) reported hour afrer rhe child arrives ar rhe hospital. Serial changes in
successful intraosseous infusion inco the tibias of 15 children the GCS, either better or worse, corre!are wirh improvemenr or
between rhe ages of 3 months and 10 years. The imraosseolls worsening of the neurologic injUlY. Repeated GCS assessmenrs
needles were placed by prehospital and hospital personnel, and over rhe initial 72 hours after injury may be of prognosric signifi-
colloid, crystalloid solmion, and blood were all given by rhis cance. In addition ro rhe level of oxygenarion presenr ar rhe
route. No compl ications occurred in the surviving chi Idren. Biel- inirial presenration ro rhe hospital, the 72-hour GCS motor
ski et al. (7), in a rabbir ribia model, likewise demonstrated no response score has been nored ro be very predicrive of later per-
adverse effects on the histology of bone or the adjacent physis manenr disability as a sequel ro rhe head injury (58).
with intraosseous injection of various resuscitation drugs and
fluids.
Because dearh is common if hypovolemic shock is not rapidly
Physical Assessment
reversed, the child's blood pressure musr be maineained ar an In a child wirh mulriple injuries, a careful abdominal examina-
adequate level for organ perfusion. Mosr mulriply injured chil- rion is essential ro allow early detection of injuries to the liver,
dren have sustained blunt trauma rather than penerrating inju- spleen, pancreas, or kidneys. Ecchymoses on rhe abdominal wall
ries, and most of the blood loss is internal from visceral injury must be noted, because rhis is often a sign of significant visceral
or from pelvic and femoral fractures. Because of this problem, injuty (75). Swelling, deformity, or crepims in any exrremity is
rhe blood loss may be easily underestimated at first. Despirc the nored, and appropriare imaging studies are arranged ro evaluate
need to stabilize the child's blood pressure, caurion needs ro be potenrial exrremity injuries more fully. If exrremity deformity
exercised in children wirh head injuries so that over hydrarion is presenr, ir is importanr to determine whether or not rhe frac-
is avoided, because cerebraJ edema is bener u·eared wirh relarive ture is open or closed. Sires of exrernal bleeding are examined,
fluid restriction. Excessive fluid replacement also may lead to and pressure dressings are applied to prevenr further blood loss.
Furrher internal fluid shifts, which ofren produce a drop in rhe It has been reponed rhat the presence of a pelvic fracture and
arterial oxygenarion from inrersritial pulmonary edema, espe- one or more orher skeletal injuries should serve as a marker for
cially when there has been direcr rrauma ro rhe thorax and lungs. rhe presence ofhead and abdominal injuries (89). Major arrerial
The appropriate amounr of fluid replacemenr can besr be guided injuries associared wirh fracmres of rhe exrremity Llsually are
78 General Principles

diagnosed early by the lack of a peripheral pulse. However, ab-

TABLE 4-1. INJURY SEVERITY SCORE
dominal venous injuries following blunt trauma are less common
and are less commonly diagnosed before exploratory laparotomy.
Abbreviated Injury Scale (AIS)
About half of abdominal venous injuries have been reported to
The AIS classifies injuries as moderate, severe, serious, critical,
and fatal for each of the five major body systems. The criteria be fatal, so the trauma surgeon needs to consider this diagnosis
for each system into the various categories is listed in a series of in children who continue to require substamial blood volume
charts for each level of severity. Each level of severity is given a support after the initial resuscitation has been completed (62).
numerical code (1-5). The criteria for severe level (Code 4) is The initial splinting of suspected extremity fracrures is rou-
listed below. tinely done by the transporting team members at the scene of
(AIS) Severity
Severity Category/Injury Policy the accident. However, once the injured child is in the hospital,
Code Description Code the orthopaedist should personaJly inspect the extremities to
4 Severe B determine the urgency with which the extremity injuries need
(Life-Threatening, to be definitively treated. Most important are whether or not a
Survival Probable) vascular injuly has occurred and whether the fracrure is open
General or closed. Any neurologic deficit also is noted to documenr the
Severe lacerations and/or avulsions with dangerous hemor- extremity function before any treatment. The back and spine
rhage. should be carefully examined. If there is not an open fracture
30-50% surface seconds or three degree burns.
and jf the distal peripheral vascular funcrion is normal, there is
Head and Neck less urgency in treating the fracture and splinting will suffice
Cerebral injury with or without skull fracture, with unconscious- until the other organ system injuries are stabilized.
ness> 15 min, with definite abnormal neurologic signs; posttrau-
matic amnesia 3-12 h.
Compound skull fracture, Imaging Studies
Chest
Radiographs
Open chest wounds; flail chest; pneumomediastinum; myocar-
dial contusion without circulatory embarrassment; pericardial Imaging srudies need to be performed as quickly as possible after
injuries. the initial resuscitation and physical examination are complete.
Abdomen Any extremity suspecred of having a significant injury should
Minor laceration of intra abdominal contents (ruptured spleen, be examined radiographically to assess the degree of injury. If
kidney, and injuries to-taill of pancreas) the child has a head injuty or if neck pain is noted on the
Intraperitoneal bladder rupture examination, a lateral cervical spine radiograph is obtained. If
Avulsion of the genitals
Thoracic and/or lumbar spine fractures with paraplegia the lateral cervical spine radiograph is normal, no further views
of the cervical spine are needed at this stage. If a cervical spine
Extremities injury is present, the lateral radiograph of this area almost always
Multiple closed long bone fractures will detecr it. If there is suspicion of a cervical spine injury on
Amputation of limbs.
the neutral lateral view, a lateral cervical spine radiograph in the
Injury Severity Score (ISS) flexed position, with the orthopaedist supervising the amount
The injury severity score (ISS) is a combination of values obtained of flexion, will help detect any cervical instability. The cervicaJ
from the AIS. The ISS is the sum of the squares of the highest spine of a young child is much more flexible than the cervical
AIS grade in each of the three most severely injured areas. For
spine in an adult. Under the age of 12 years, the movement of
example, a person with a laceration of the aorta (AIS = 5), multi-
ple closed long bone fractures (AIS = 4), and retroperitoneal C I on C2 during flexion of the neck can normally be up to 5
hemorrhage (AIS = 3) would have aninjlury severity score of 50 mm, whereas in adults, this movement should be less than 3
(25 + 16 + 9). The highest possible score for a person with mm. Likewise in this young age group, C2 can move up to 3
trauma to a single area is 25. The use of the injury severity scale mm forward on C3 during neck flexion. No forward movement
has dramatically increased the correlation between the severity
and mortality. The range of severity is from 0 to 75. of C2 on C3 should be present in a skeletally mature individual
when the neck is flexed. This so-called pseudosubluxarion of C2
Committee on Medica-I Aspects of Automotive Safety: Rating the on C3 in a child should nor be diagnosed as instability that
severity of tissue damage I. The abbreviated scale. lAMA 11971;215: requires trearment because this is a normal finding in most young
277-28; Baker 5P, O'Neill B, Haddon W Jr. and Long WB. The children (16). Because ir is difficulr to detect a fracrure of rhe
Injury Severity Score: A method for describing patients with
multiple injuries and evaluating emergency care. 1 Trauma 14: thoracic or lumbar spine clinically, radiographs of this area, pri-
187-196, 1974, with permission. marilya lateral view, should be assessed, particularly in a coma-
tose child.

Computed Tomography
Compured tomography (CT) is essential in evaluaring a child
with multiple injuries. If a head injury is present, the CT of rhe
head will detect skull fractures and intracranial bleeding. \'V'irh
 Chapter 4: Management of the Muftip!y Injured Child 79

T~BLE 4-2. PEDIATRIC TRAUMA SCORE*

Category

Component +2 +1 -1

Size 2::20.kg 10-20 kg <10 kg

Airway Normal Maintainable Unmaintainable
Systolic BP $90 mm Hg 90-50 mm Hg <50 mm Hg .
CNS Awake Obtunded/LOC Coma/decerebr;3te
Open wound None Minor Major/penetrating
Skeletal None Closed fracture Open/multiple fractures
Total

* This scoring system in~ludes six common determinants of the clinical condition in the injured child,
Each of the six determinants is assigned a grade: + 2, minimal or no injury; + 1, minor or potentially
major injury; -1, major, or immediate life-threatening injury. Thescoring system is arranged in a
manner sta·ndard'.with advanced trauma life-support protocol, and thereby provides a quick aSsessment
scheme. The ranges are from - 6 for a severely traumatized child to + 12 for a least traumatized child.
This system has been confirmed in its reliability as a predictor of injury. severity. From Tepas, JJ Mollitt DL
Talbers JL and Bryant M. The Pediatric Trauma Score as a predictor of injury severity in the injured child.
) Pediatr Surg, 22:14-18, 1987, with permission.

abdominal swelling, pain, or bruising, a CT of the abdomen the initial radiographs, a CT of the pelvis will help to determine
provides excellent visualization of the liver and spleen and allows the need for operative treatment of this fracture and the length
quantification of the amount of hemorrhage present. Because of time protection from walking is needed. If an abdominal CT
most hepatic and splenic lacerations are rreated nonoperatively is being done to evaluate visceral injury and there is suspicion
at present (13,38,71), the CT scan and serial hematocrit levels of a pelvic fracture, it is simple to request that the abdominal
are used to determine whether surgical treatment of these visceral CT be extended distally to include the pelvis. A CT of a fractured
lacerations is needed. If a pelvic fracture is seen or suspected on vertebra will provide the information needed to classify the frac-
ture as stable or unstable and determine whether operative rreat-
mem is needed.

TABLE 4-3. GLASGOW COMA SCALE* Intravenous Pyelography

Response Action Score

There is a strong correlation of urologic injury with antenor
pelvic fractures, as well as with liver and spleen injury. Although
Best motor response Obeys M6 CT and ultrasonography are used to evaluate renal injuries, the
Localizes 5 inrravenous pyelogram still has a role in helping to diagnose
Withdraws 4
bladder and urethral injuries (61).
Abnormal flexion 3
Extensor response 2
Nil 1
Verbal response . Oriented V5 Radionuclide Scans
Confused conversation 4
Inappropriate words 3 Bone scans have a limited role in the acute evaluation of a child
InCOmprehensible sounds 2 with multiple injuries. In conjunction with a skeletal survey, a
Nil 1 technetium-99m bone scan is routinely used in children with
Eye opening .spontaneous E4 suspected child abuse to detect previously undetected new or
To speech 3
To pain 2
old tractures. Heinrich et aL (36) reported that bone scans in
Nil 1 48 children with multiple injuries often demonstrated an unsus-
pected injury. Nineteen previously unrecognized fractures were
* This scale is used to measure the level of consciousness using the identified by obtaining radiographs of the areas with increased
eye opening, best verbal, and best motor response.s. The range of isotope uptake. Of [heir 48 patients, six had a change in their
scores are from 3 for the most severe to 15 for the least involved.
This is a measure of level and progJession of changes in . orthopaedic care as a result of this bone scan, although this
consciousness. From Jeannett E. Teasdale JB. Galbra.ith 5, et al. treatment was usually simple cast application of a nondisplaced
5evere mood injuries in thre·e countries, ) Neural Neurasurg
Psychiatry (1977)40:291-298, with permission.
franure. Nonetheless, the bone scan can be a valuable screening
tool in a child with multiple injuries from any cause. In some
insrances, [he bone scan can be useful to differentiate a normal
80 GeneraL Principles

variarion in skeleral ossificarion (normal uprake) from a fracwre depanmenr or rrauma cenrer and a low GCS score 72 hours
(increased uptake), particularly in an exrremiry or a spinal area after rhe head injury.
where pain is present. Despire rhe facr rhat excellenr moror recovery is expecred in
mosr children afrer a head injulY, Greenspan and MacKenzie
reponed rhat 55% of children in rheir series had one or more
Magnetic Resonance Imaging healrh problems ar I-year follow-up, many of which were reJa-
rivety minor (29). Headaches were presenr in 32% and exrremiry
Magneric resonance imaging (MRI) is used primarily for rhe
complainrs in 13% of parienrs. The presence of a lower exrremiry
detccrion of injury ro rhe brain or rhe spine and rhe spinal cord.
injury wirh a head injulY led ro a higher risk of residual problems.
In young children, rhe bony spine is more elasric rhan rhe spinal
Because of rhe more oprimisric ourlook for children wirh
cord. As a resulr, a spinal cord injury can occur wirhour an
head injuries rhan for adulrs wjrh similar injuries, orrhopaedic
obvious spinal fracwre in children wirh mulriple injuries, panic-
care must be provided in a rimely way, and the orrhopaedist musr
ularly in automobile accidenrs (4,24). In rhe SCIWORA (spinal
base rhe orthopaedic care on rhe assumprion rhat full neurologic
cord injury wirhour radiographic abnormaliry) syndrome, MRJ
recovery will ensue. Wairing for a child ro recover from a coma
is valuable in demonsrraring the site and exrenr of spinal cord
is nor appropriare, and comarose children rob'ate general anes-
injury and in defining rhe level of injury to rhe disks 0[' vertebral
rhesia well. The orrhopaedic injury musr be rreared in rhe same
apophysis. A fracrure rhrough the venebral apophysis is similar
way rhar ir would be in an alert injured child ro obrain the besr
ro a fracture through the physis of a long bone and may nor be
ourcome. Unless rhe musculoskeleral injuries are [I'eared wjrh
obvious on planar radiographs.
the assum prion rhar full neurologic recovelY wiJ I rake place, long
MRl also is velY useful in evaluaring knee injuries, parricu-
bone fracwres may heal in angled or shorrened posirions. Once
larly when a bloody knee effusion is present. If blood is presenr
neurologic recovery occurs, rhe primary functional deficit will
on knee arrhrocenresis, MRI can assisr in diagnosing an injury
rhen be from ill-managed orthopaedic injuries rarher rhan from
ro rhe cruciate ligamenrs or menisci. [n addirion, a chondral
rhe neurologic injury.
Fr:1Cwre rhar cannor be seen on romine radiographs may be
demonsrrared by MRl.
Intracranial Pressure

Ultrasonography Afrer a head injury, inrracraniaJ pressure measuremcnrs are com-

monly monirored ro prevenr excessive intracranial pressure,
Ulrrasound evaluation has been shown 1'0 be an accurare means which may lead ro furrher permanenr disabiliry or dearh. Nor-
of derecting hemoperitoneum following injury. Some rrauma mally, inrracranial pressure does nor exceed 15 0101 Hg, and all
cenrers have replaced perironeal lavage and laparoscopy wirh arremprs should be made ro keep rhis pressure under 30 mm
serial ulrrasound evaluarions ro moniror liver, spleen, pancreas, Hg afrer a head injury.
and kidney injury in children wirh mulriple injuries (13,38,71). This is accomplished by e1evaring rhe head of rhe bed ro 30
One of rhe problems wirh ulrrasonography is rhe operaror-de- degrees, lowering rhe pe02' and resrricring inrravenous fluid
pendenr nawre of rhis imaging srudy. As a resulr, CT is more adminisrrarion. Venrilaror assisrance is used ro lower rhe peo2'
ofren used for assessmenr and moniroring of visceral injury in which, in [Urn, helps lessen cerebral edema. If rhe orher injuries
children susraining mulriple injuries, and a recenr comparison allow and adequate blood pressure is susrained, Auid rem-icrion
of CT and ulrrasonography demonsrrared rhe superioriry of CT is also preferred to lessen the cerebral edema. Elevation of serum
for diagnosing visceral injury in children wirh polyrrauma (70). norepinephrine has been shown ro correlate well wirh rhe sever-
iry of head injulY in parienrs wirh injUlY of multiple organ sys-
rems (94).
Morion at rhe sire of a long bone fracrure will cause an eleva-
NONORTHOPAEDIC CONDITIONS IN
rion of rhe inrracranial pressure in children wirh mulriple inju-
THE MULTIPLY INJURED CHILD
ries. Because of this problem, long bone fracrures musr be immo-
Head Injury bilized ro limir fracrure morion unril definirive fracrure care can
be provided. Inirial immobiliz<lrion usually is accomplished by
Prognosis for Recovery
splinring or casring of rhe fractures, or by use of rracrion for
Head injuries occur in children with mulriple injuries even more femoral shaft fracrures. The use of exrernal or inrernal fixarion
ofren than orrhopaedic injuries. Ir has been clearly demonsrrared of fractures should be srrongJy considered ro help comrol eleva-
rhar a child recovers more quickly and more fuJJy from a signifl- rion of inrracranial pressure. Fracrure srabilizarion also aids in
canr head injlllY rhan does an adulr (18,50,93). Even children dressing changes for rhe rrearmenr of adjacem sofr rissue injury
who are in a coma for several hours ro several days ofren recover as well as allowing in-hospiral rranspon for imaging srudies and
full motor funcrion. Mild cognirive or learning deficits may per- orher necessary rrearmenrs (84,85).
sisr however, so educarional resring needs to be considered for
children who have had head injury and coma. The rwo factors
Secondary Orthopaedic Effects of Head Injuries
rhar have been idenrifled ro produce poorer functional recovelY
and more severe permanenr neurologic deficirs are a low oxygen A head injury can have larer impacr on rhe managemenr of
sarurarion level ar rhe rime of presenrarion ro rhe emergency mL1sculoskeleral injuries, even afrer the <leU re phase has passed.
 Chapter 4: Management of the MuLtiply lrl:jured Child 81

Persistenr spasticity, the developmenr of contractures, hetero- child with new swelling of the extremity are a new long bone
tOpic bone formation in soft tissue, and changes in fracture heal- fracture or a deep venous thrombosis (79).
ing rates are all seen in children with sequelae of a head injuty. Observation and excision are the rwo primary approaches
taken in managing heterotopic bone formation in an injured
Spasticity. Spasticity may develop within a few days of head child. If the child remains comatose, usually little treatmenr is
injury. The early effect of this spasticity is to cause shonening administered. There is no conclusive data to suppOrt medical
at the sites of long bone fractures if traction or splint or cast treatment if an early diagnosis of heterotopic bone formation is
immobilization is being used. If fracture displacement or short- made. However, it may be useful to try to block some of the
ening occurs in a circumferential cast, the bone ends may cause heterotOpic bone formation by use of salicylates or nonsteroidal
pressure poinrs berween the bone and the cast, leading to skin antiinflammatOry medication once an early diagnosis is estab-
breakdown at the fracture site, with a higher risk for deep infec- lished. If the child has recovered from the head injuIY and has
tion. Even with skeletal traction for femoral fractures, fracture heterotOpic bone that does not inrerfere with rehabilitation, sur-
shortening and displacement will occur as the spasticity over- gical excision is not warranted. If there is significant restriction
comes the traction forces. Once spasticity develops and long of joint motion from the heterotopic bone, this bone should be
bone fractures displace, internal or external fixation is needed excised to facilitate rehabilitation. The timing of the heterotopic
to maintain satisfactOry reduction. This operative stabilization
bone excision is somewhat controversial, but current thinking
should be performed as soon as the spasticity becomes a problem leans toward resection whenever heterotopic bone significantly
for fraccure reduction because fracture healing is accelerated by interferes with rehabilitation, rather than wairing for 12 to 18
a head injury (83-85). months until the bone is more mature. After surgical excision,
it is essential to use salicylates or nonsteroidal antiinflammatory
drugs immediately after the excision and for several weeks there-
Contractures. The persistence of spasticity in the extremities after to block new heteroropic bone formation at the operative
often leads to subsequent contractures of the joints spanned by site. Mital et ai. (59) reported success in preventing recurrence
the spastic muscles. Contractures can arise quite quickly, and of heterotopic bone after excision by use of salicylates at a dosage
early preventative stretching or splinting should begin while the of 40mg/kg/day in divided doses for 6 weeks postoperatively.
child is in the intensive care unit. Nonselective mass action mus-
cle activity associated with brain injury can be used to help
Fracture Healing Rates. For reasons that are not entirely clear,
prevent these early conrractures. If the child lies in bed with the
long bone fractures heal more quickly in children and adults
hips and knees extended, there will usually be a strong plan-
who have associated head injuries. It has been demonstrated
tarflexion of the feet at the ankles from the spasticity. If the hip
that polytrauma patients in a coma have a much higher serum
and knee are placed in a flexed position, it will be much easier
calitonin level than do conscious patients with similar long bone
to dorsiflex the foot at the ankle, so positioning in this way will
fractures, but how or whether this finding influences fracture
prevent early equinus contractures from developing so quickly.
healing is still unclear (22).
Stretching and splinting can often be effective in preventing
contractures, but if these measures are not successful, there
should be no hesitation to treat these contracrures surgically if
Peripheral Nerve Injuries
they are interfering with subsequent rehabilitation.
Although persistent neurologic deficits in a child who has multi-
Heterotopic Bone Fonnation. HeterotOpic bone may form in ple injuries usually are sequelae of a head injury, peripheraJ nerve
the soft tissues of the extremity as early as a few weeks after a injury should be carefully assessed as the rehabilitation process
head injury with persistent coma. Usually, this is in the vicinity proceeds. In one clinical review of brain-injured children, 7%
of the hip or elbow but may occur elsewhere as well. There is had evidence of an associated peripheral nerve injury docu-
some evidence that heterotopic bone formation can be stimu- mented by eJectrodiagnostic testing (66). The peripheral nerve
lated by surgical incisions. In head-injured teenagers who injUlY most often is associated with an adjacent fracture or with
undergo antegrade reamed femoral intramedullary nailing of a stretching injuty of the extremity. It is important to recognize
femoral fractures, heterotopic bone often forms at the nail inser- these injuries, because surgical peripheral nerve repair with nerve
tion site that later restricts hip motion (41). Obtaining weekly grafts offers excellent chances of nerve function recovelY in
serum alkaline phosphatase levels on a child with persistent coma young patients, if the nerve injury does not recover on its own.
may allow early detection of the heterotOpic bone, although
alka.l'ne phosphatase is also elevated during healing of fractures.
A sudden increase of alkaline phosphatase a few weeks after the
Abdominal Trauma
onset of coma, even with fractures co-existing, may mean that Abdominal viscera, both solid and hollow, are at high risk of
heterotopic bone is starting to form and a more careful examina- significant injury in children with multiple skeletal injuries. Ab-
tion of the extremities is in order (59). Technetium-99 bone dominal swelling, tenderness, or bruising are all signs of injury.
scans show increased isotope uptake in the soft tissue where CT or ultrasonography evaluation has largely displaced perito-
heterotopic bone forms, and this imaging study should be con- neal lavage or laparoscopy as the initial method of evaluation of
sidered if new swelling is noted in the extremity of a comatose abdominal injury. Abdominal injury is not unusual if a child in
child. Other diagnoses that must be considered in a comatOse an accident has been wearing a lap seat belt (87). Bond er al.
82 General Principles

(0) noted that the presence of multiple pelvic fractures strongly Nutritional Requirements
correlated (80%) with the presence of abdominal or genitouri-
Multiple injuries place large caloric demands on the body. If an
nary injury, whereas the child's age or mechanism of injury had
injured child requires ventilatOr suppOrt for several days, c~loric
no such correlation with abdominal injury rates. The usual ptac-
inrake via a feeding tube or a central intravenous catht,ter is
tice is to treat hepatic and splenic lacerations nonopetatively, by
neccssary to improve healing and help prevent complications
monitoring the hematOcrit, by repeating the abdominal exami-
from developing. The baseline caloric needs of a child can be
nation frequenrJy, and by serial CT scans or ultrasound examina-
determined based on the weight and age of the child. Children
tions (15,17). Once the child's overall condition has stabilized,
on mechanical ventilation in a pediatric intensive care unit have
the presence of abdominal injuries that are being observed
been shown to require 150% of the basal energy or caloric re-
should not delay the fracture care as long as the child is stable
quirements for age and weight (82). The daily nitrogen require-
enough to undergo general anesthesia.
ment for a child in the acure injury phase is 250 mg/kg.

Genitourinary Injuries
ORTHOPAEDIC MANAGEMENT OF THE
Injuries to the genitourinary systcm generally occur in conjunc- MULTIPLY INJURED CHILD
tion with pelvic fractures. Most injuries to the bladder and ure-
thra are associated with fractures of the anterior pelvic ring (5). Timing
The injury is usually at the bulbourethra, but the bladder, pros- Because fractures are rarely life-threatening in children with mul-
tate, and other portions of the urethra can also be injured. If tiple system injuries, splinting of the fractures will generally suf-
rhe injury is severe, kidney injury may also occur, but most fice as the initial orthopaedic care needed, while the child's over-
urologic injuries that occur with pelvic fractures are distal to the all condition is srabilized. When is the optimal time for me
uretcrs (I). definitive treatment of the fracture or fractures and whar is that
Tears of the vagina and resultant vesicovaginal fistulae may optimal treatment? Should the child have all fractures treated
be :lssociated with displaced fractures of the anterior pelvic ring. operatively to allow mobilizarion out of bed, as is commonly
If rhe iliac wings are displaced or the pelvic ring shape is changed, recommended in adults with multiple fractures, or is a combina-
it is important to reduce these fractures to teconstitute the birth tion of operative and nonoperative management more appropri-
canal in female patients. There are increased rates of caesarean ate? Are there times when implants used in adults can also be
section in young women who have had a pelvic fracture com- used in children, or should separate pediatric implants be used
pared with those without this injury (19). when operative treatment is chosen) How rigid does fraCture
It is important to inform adolescent females with displaced fixarion need to be in children?
pelvic fractures of this later potential problem with vaginal de-
livery.
Pelvic Fractures
Fractures of the pelvis are common in children and adolescentS
Fat Embolism
with multiple injuries. The central injuries to the spine and
Although En embolism and acute respiratory distress syndrome pelvis have been reported to be associated wirh the most intense
are relatively common in adults with multiple long bone frac- hospital care and higher mortaliry rates than orher injury combi-
turc~, they are rare in young children and uncommon in teenag- nations (12). The immediate problem often is cO[ltrol of b'leed-
ers (51). When they are present, the signs and symptoms are ing, either from the retroperitOneum near the fracture or from
the same as in adults: axillary petechiae, hypoxemia, and radio- the peritoneum from injured viscera (40). However, death of
graphic changes of pulmonalY infiltrates appearing within sev- children with pelvic fractures appears to be caused more often
etal hours of the fractures (30). It is likely that some degree of by an associated head injury rather rhan an injury to the adjacent
hypoxemia develops in some children after multiple fractures, viscera or vessels (60).
but the full clinical picture of fat embolism seldom develops. If The fractures of the anterior pelvic ring are the primary cause
a child wirh multiple fractures but without a head injury devel- of urethral injUly (1,5). Bilateral anterior and posterior pelvic
ops a change in sensorium and orientation, hypoxemia is most fractures are most likely to cause severe bleeding (57), although
likely the cause, and arterial blood gases are essential ro deter- death from blood loss in children is uncommon (60). Injury to
mine the next step in management. The other primal» cause the sciatic nerve or rhe lumbosacral nerve roots may result from
of mental status change after fractures is overmedication with hem ipelvis displacement th rough a vertical shear fracture. In
narcotics for pain control. bcr, nonorthopaedic injuries associated with pelvic fracrures led
I f fat em bol ism is diagnosed by low Jevels of arteriaJ oxygena- to long-rerm morbidity or mortaliry in 30% of patienrs (11 of
tjon, the treatment is the same as in adults. Usually, this manage- 36) in one published review of pediatric pelvic fractures (26).
ment consists of endotracheal intubation, positive pressure venti- Most pelvic fractures in children are treated nonoperatively.
lation, and hydration with intravenous fluid. The effect of early In a child or preadolescent, an external fixator can be used to
fracture stabilization, intravcnous alcohol, or high-dose cortico- close a marked pubic diastasis or to control bleeding by stabiliz-
steroids on the syndrome of fat embolism has nor been studied ing rhe pelvis for transport and other injury care. The external
well in children with multiple injuries. fixator will not reduce a displaced vertical shear fracture, bur
 Chapter 4: Management of the Multiply Injured Child 83

the stabiliry provided is helpful [Q comrol the hemorrhage while comminution. There is adjacent soft tissue injury, including skin
the child's condition is stabilized (69,86). flaps or skin avulsion and a moderate crushing component of
adjacent soft tissue is usually present.

Open Fractures
Type 111 and Subgroups. The most severe open fractures are clas-
Background. Most serious open fractLlres in children result sified as rype III, with associated subgroups A, B, or C, with
from high-velociry blum injury involving vehicles. However, the letters indicating increasing severiry of injury. These fractures
many low-energy blunt injuries can cause punctLlre wounds in typically result from high-velociry trauma and are associated with
the skin adjacent to fractures, especially displaced radial, ulnar, extensive soft tissue injury, a large open wound, and significant
and tibial fractures. It has been estimated that in children with wound contamination. In a type IlIA fracture, there is soft tissue
multiple injuries, about 10% of the fractures are open. When coverage over the bone, which often is a segmental fracture. In
open fractures are present, 25% to 50% of patients have addi- a rype IIIB fracture, bone is exposed at the fracture site, with
tional injuries involving the head, chest, abdomen, and other treatment typically requiring skin or muscle flap coverage of the
extremities. bone. Type IIlC fractures are the most severe and, in addition
to extensive soft tissue loss and contamination, have an injury
Wound Classification. The classification used to describe the to a major artery in that segment of the extremiry.
soft tissues adjacent to an open fracture is based primarily on This classification is widely used and has been shown to corre-
the system described by Gustilo and Anderson (30,31). Primary late in adults with sequelae of the injury, including the potential
factors that are considered and ranked in this classification sys- for infection, delayed union, nonunion, amputation, and resid-
tem are the size of the wound, the degree of wound contamina- ual impairment. Probably due to the better vascular supply to
tion, and the presence or absence of an associated vascular injury the extremities of children, the final functional results of type
(Table 4-4). III fractures in children appear to be superior to results after
similar fractures in adults.
Type [ Type I fractures usually result from a spike of bone
puncturing the skin (inside-out). The wound is less than 1 cm
in size, and there is minimal local soft tissue damage or contami-
nation. ~ AUTHOR'S PREFERRED METHOD
,,~ OF TREATMENT
Type 11. A rype II wound is generally larger than 1 cm and is
associated with a transverse or oblique fracture with minimal Three Stages. I consider the treatment of open fractures in chil-
dren to be similar to that for open fractures in adults. The pri-
mary goals are to prevent infection of the wound and fracture
site, while allowing soft tissue healing, fracture union, and even-
tual return of optimal function. My initial emergency care in-
TABLE 4-4. CLASSIFICATION OF OPEN cludes the so-called ABCs of resuscitation, application of a sterile
FRACTURES povidone-iodine (Betadine) dressing, and preliminary alignment
Type I An open fracture with a wound <.1 cm long and and splinting of the fracture for patient transport. If profuse
clean bleeding is present, a compression dressing is applied to limit
Type II An open ,fracture with a laceration >1 cm long blood loss. In the emergency room, masks and gloves should be
without extensive soft-tissue damage, flaps, worn as each wound is thoroughly inspected. Tetanus prophy-
or avulsions
Type III Massive soft tissue damage, compromised laxis is provided, and the initial dose of intravenous antibiotics
vascularity, severe wound contamination is given. The dose of tetanus tOxoid is 0.5 mL intramuscularly
marked fracture instability to be given if the patient's immunization status is unknown, or
Type I.IIA Adequate soft tissue coverage of a fractured if it is more than 5 years since the last dose. The second stage
bone despite extensive 50ft tissue laceration
of management is the primary surgical treatment, including ini-
or flap's, or high-energy trauma irrespective of
the size of the wound tial and (if necessary) repeat debridemem of the tissues in the
Type IIiB Extensive soft"tissue i'njury 1055 with periosteal area of the open fracture until the entire wound appears viable.
stripping and bone exposure; usually The fracture is reduced and stabilized. If the bone ends are not
associated with massive contamination covered with viable soft tissue, muscle or skin flap coverage is
Type IIiC Open fracture .associated with arterial injury
requiring repair considered. My third and final srage of this management is bon)'
reconstruction as needed if bone loss has occurred and, ulti-
mately, rehabilitation of the child.
Adapted from Gustilo RB; Mendoza RM, Williams DN. Problems in
the management of type .111 (severe) open fractures: a new
classification of type III open fractures. J Trauma 1984;24:742-746;
Gustilo RB, Anderson JT: Prevention of infection in the treatment Cultures. The role of cultures obtained in the emergency room
of 1025 open fractures. of long bones, retrospective and is controversial. Cultures in this setting are probably of little use
prospective analyses. J Bone Joint Surg. Am 1976;58:453-458, with
perm·ission. in future management of the open fracture. The cultures for
characterizing the bacterial contamination present are better ob-
tained in the operating room at the time of debridement (45).
84 General Principles

Antibiotic Therapy. Antibiotic therapy decreases the risk of ture, I always bring the proximal and distal bone ends into the
infection in children with open fractures. Wilkins and Patzakis wound for visual inspection. This often means that the open
(92) reported a 13.9% infection rate in 79 patients who received wound needs to be extended somewhat, but that is preferable
no antibiotics after open fractures, whereas there was a 5.5% to leaving the fracture site contaminated. I carefully remove devi-
infeC[ion rate in 815 patients with similar injuries who had anti- talized bone fragments and contaminated cortical bone with cu-
biotic prophylaxis. Bacterial contamination has been noted in rettes or a small ronguer. If there is a possibly nonviable bone
70% of open fractures in children, with both gram-positive and fragment, judgment is needed as to whether this bone fragment
gram-negative infections noted, depending on the degree of should be removed or left in place. My experience is that recon-
wound contamination and adjacent soft tissue injury. I limit struction of a large segmental bone loss has a better outcome in
antibiotic administration generally to 72 hours after surgical children than in adults, because children have a better potential
treatment of the open fracture. for bone regeneration and have better vascular supply to their
For all type I and some type II fractures, I use a first-genera- extremities. As with all diaphyseal debridements, I identify and
tion cephalosporin. For type III and some more severe rype II protect major neurovascular structures in the area of the fracture.
fractures, I use a combination of a cephalosporin and aminogly- I consider the debridement complete when all contaminated,
coside (cephalothin 150 mg/kg/day q8h, and gentamicin). For dead, and ischemic tissues have been excised; the bones ends are
farm injuries or grossly contaminated fractures, penicillin is clean with bleeding edges; and only viable tissue lines the wound
added to the cephalosporin and aminoglycoside. All antibiotics bed.
are given intravenously and for 72 hours. Oral antibiotics are I usually use a pulsed lavage system to irrigate the open frac-
occasionally used if significant soft tissue erythema at the open ture with 10 L of sterile normal saline. In the past, I have used
fracture site remains after the intravenous antibiotics have been bacitracin and polymyxin antibiotics in this irrigation solution
completed. but irrigate only with the normal saline. The antibiotic addition
I continue the antibiotic regimen beyond 48 to 72 hours if is more costly, and I believe that the key is local irrigation and
rhere is (a) delayed wound closure, (b) open reduction and inter- debridement to allow the intravenous antiobiotics to reach the
wound and comrol the infection. I obtain cultures from the
nal fixation of fractures, and (c) secondary bone reconstruction
depths of the wound near the fracture ends just before the irriga-
procedures.
tion. If repeat debridement is needed, cultures are again obtained
and are often useful in guiding the final antibiotic coverage used.
Debridement and Irrigation. I consider debridement and irri- After thc debridement and irrigation are complete, I try to
gation of the open fracture in the operating room to be the most use the local soft tissue to cover the neurovascular structures,
important step in the primary management of open fractures in the tendons, and the bone ends. If local soft tissue coverage is
children. Some authors have reported that significantly higher inadequate, consideration should be given to local muscle flaps
infection rates occurred if debridement and irrigation were done or other coverage methods. The area of the wound that has
more than 6 hours after open fractures in children (46). A recent been incised to extend the wound for fracture inspection can be
report, however, demonstrated an overall 1% to 2% infection primarily closed with interrupted nylon sutures. The remaining
rate after open long bone fractures, with no increased rate in wound that is open is dressed with a moistened Betadine dress-
infection if the debridement was delayed even as long as 24 ing, which is changed the following day. If the wound appears
hours (76). I believe that it is important to perform the debride- clean, sequential wet-to-dry saline dressings are used until wound
ment and irrigation as quickly as is feasible, but a modesr delay healing occurs. If the wound does not appear clean at 48 hours,
may not lead to severe consequences or chronic infection. The repeat debridement in the operating room is carried out. This
debridement needs to be performed carefully and systematically cycle is repeated until the wound can be sutured closed or has
to remove all foreign and nonviable material from the wound. a split thickness skin graft or local flap to cover it.
My order of debridement typically is
Fracture Stabilization. Fracture stahilization in children with
1. Excision of the necrotic tissue from the wound edges open fractures decreases pain, protects the soft tissue envelope
2. Extension of the wound to adequately explore the fracture from further injury. decreases the spread of bacteria, allows sta-
ends bility important for early soft tissue coverage, and improves the
3. Debridement of the wound edges to bleeding tissue fracture union rate.
4. Resection of necrotic skin, fat, muscle, and contaminated In general terms, my principles for stabilization of open frac-
fascia tures in children include allowing access to the soft tissue wound
5. Fasciotomies as needed and the extremity to allow for debridement and dressing changes,
6. Thorough pulsatile irrigation of the fracture ends and wound allowing weight bearing when appropriate and preserving full
motion of the adjacent joints to allow full functional recovery.
Because secondary infection in ischemic muscle can be a [ often use casts or splints to stabilize type I fractures and
major problem in wound management and healing, I ensure occasionally type II fractures with relatively small wounds and
that all ischemic muscle is widely debrided back to muscle, which minimal soft tissue involvement. Most of these injuries involve
bleeds at the cut edge and contracts when pinched with the the radius or ulna in the upper extremity or the tibia in the lower
forceps. extremity. [n the forearm, a flexible intramedullary implant in
When I am debriding and irrigating an open diaphyseal frac- either the radius or ulna or both, provides enough stability of
 Chapter 4: Management of the Multiply Injured Child 85

the fracture to allow dressing changes through the cast or splint. hood that autogenous graft will fill in a bone defect if there is
Splint or cast immobilization generally is not satisfactoty for the a well-vascularized bed from the muscle flap. Free flaps, espe-
more unstable type II and most type III injuries. cially from the latissimus dorsi, are useful in the mid-tibial and
For intramedullaty fIxation, I prefer flexible titanium im- distal tibial regions to decrease infection rates and improve the
plants of 2 mm to 4 mm diameter for stabilizing open fractures union rates. Vascularized fibular grafts rarely are used acu tely to
in the forearm when reduction of either the radius or ulna frac- reconstruct bone defects but may be useful in later reconstruC-
ture is unstable. The ulnar implant is inserted proximally, tion, after soft tissue wounds are healed.
whereas the tadial implant is inserted just proximal to the distal For the rare bone loss defect in a child, I rely on [he healing
radial physis. One or both bones can be stabilized, and the im- capacity of young periosteum and bone and the vascular supply
plants removed easily after fracture healing. I also use these flexi- of a child's extremity. An external fixator is used to hold the
ble intramedullary nails more often for type I and some type II bone shonened about 1 to 2 cm to decrease the size of the bone
fractures of the femoral shaft. For type III fractures, especially loss. In a growing child, 1 to 2 cm of overgrowth can be expected
if there is a large or contaminated soft tissue wound present, I in the subsequent 2 years after these severe injuries so the final
sti Il prefer to use external fIxation. leg length will be satisfactory. Autogenous bone graft can be
External fIxation is my treatment of choice for most type II used early, but if there is surviving periosteum at this site, I have
and type III fractures of the tibia and femur in children. The been surprised by how much new bone the child has formed,
benefitS of external fixation include easy access to the wound somerimes to the extent that bone grafting is unnecessary. In
for debridement and dressing changes plus any soft tissue or bone teenagers with bone loss, once the soft tissue has healed, bone
reconstrucrion needed. External fixation allows patient rranspon transport using eicher a uniplanar lengthening device or an I1i-
around the hospital for other reasons associated with the multi- zarov device is my preferred method of reconstruction, although
ple injuries. External fIxation preserves the length of the long use of an allograft or vascularized fibular graft may be considered.
bone at the appropriate level and allows weight bearing relatively
soon after the injury. I fInd that a uniplanar frame is best for Amputation. In the most severe of open fractures, attempts
moS[ fractures and is relatively easy to apply. For some segmental should generally be made to preserve all extremities, even with
fractures in the metaphysis and diaphysis, as well as soft tissue those type lIIC open fractures that are usually treated with pri-
injuries, the IJizarov device may be a better choice. mary amputation in adults. Wounds and fractures that do not
I use open reduction and internal fIxation for open intraanic- heal in adults often heal satisfactorily in children and preserva-
ular fractures. If the fracture involves the physis, I avoid threaded tion of limb .length and physes are important in young children.
pins or screws across the physis and use smooth Steinmann pins If amputation is absolutely necessalY, as much length as possible
for stabilization, if needed. For fracrures that involve the metaph- should be preserved. For example, if the proximal ribial physis
ysis and diaphysis, I may combine open reduction and internal is preserved in a child with a shon proximal tibial stump at age
fixation with external fixation. For diaphyseal fractures in pre- 7 years, 3 to 4 inches more growth of the tibial stump can be
teens, I ptefer flexible inttamedullaty nails to compression plates expected by the time skeletal maturity is reached. As a result,
for internal fIxation of type I and type II fractures. For treatment this below-knee amputation would likely be superior in final
of a floatingjoint, usually the knee or elbow, I cany out operarive function to a knee disarticulation done at the time of injury.
stabilization of at least one and usually both fractures (9,49). Although amputations performed to treat congenital limb
deficits are usually done through the joint to limit bone spike
Wound Management. I prefer to provide soft tissue coverage formation at the end of the stump, I prefer to maintain maximal
of the open fracture and adjacent soft tissue defect by 5 to 7 possible length if amputation becomes necessary as a result of a
days after the injury. The wound is debrided every 48 hours severe 10) LI ry.
until it is clean, if the initial dressing change indicates residual
necrotic tissue. In the lower extremity, the fractures are externally
Management o/Other Fractures. When a child with an open
fixed when appropriate, and I attempt to obtain early soft tissue
fracture is brought to the operating room for irrigation and
coverage to limit the risk of later infection. Most type I wounds
debridement of the open fracture, the orthopaedist should take
heal with local dressing changes. For some type II and type lIlA
advantage of the anesthetic and treat the other fractures as well,
fractures, I use delayed wound closure or a split-thickness skin
whether operative treatment or closed reduction and casting is
graft over underlying muscle cover.
needed.
Large soft tissue loss is most often a problem with types IIIB
and me fractures. In the proximal tibia area, I often work with
the plastic surgeons to provide a gastrocnemius rotational flap,
followed by secondaty coverage of the muscle with a skin graft. STABILIZATIO OF FRACTURES
In the middle third of the leg, a soleus flap is used with skin
graft coverage, whereas a vascularized free muscle transfer is nec-
Beneficial Effects
essary if local coverage is inadequate. In addition to promoting fracture healing, fracture stabilization
The flaps and grafts I use for reconstructing severe injuries also provides a number of nononhopaedic benefits to a child
are either muscle flaps or composite grafts. For a massive loss with multiple injuries. PulmonalY contusions at the time of in-
of soft tissue and bone, composite grafts of muscle and bone jury often lead to increasing respiratOry problems in the first few
often are necessary. The younger the child the better the likeli- days after injury (65). If the lungs have been severely contused,
86 General Principles

protein leaks into the alveolar spaces, making ventilation more intramedullary implant passed across the fracture site under fluo-
difficult. Surfactant dysfunction follows and is most abnormal roscopy to stabilize the fracture (48). The ulnar implant is placed
in patients with the most severe respiratory failure (67). As the from proximal to distal and is inserted in the lateral proximal
time from the injury increases, pulmonary function deteriorates metaphyseal area. The radial implant is contoured before inser-
and general anesthesia becomes more risky. In patients with tion in the radial aspect of the distal radius, just proximal to the
severe pulmonary contusions and multiple fractures, the use of distal radial physis. Stability of both fractures may be achieved
extracorporeal life support may be the only treatment available by instrumenting only the radius or the ulna, but both bones
to allow patient survival (74). may require implant fixation. A cast is used for further immobili-
In adults with multiple injuries, early operative stabilization zation. The implants are easily removed from the wrist area and
of fractures decreases pulmonary and other medical complica- the elbow region 6 to 12 months after insertion and after fracture
tions associated with prolonged bed rest that is a part of nonoper- healing has taken place.
ative fracture treatment (6). Most adult trauma centers follow Despite the utility of flexible intramedullary implants for sta-
the treatment protocol of early fracture stabilization, even bilizing forearm fractures in children, the radius and ulna in
though Poole et al. (68) reported that, despite early fracture young patients have significant remodeling capacity and not all
stabilization simplifying patient care, pulmonary complications fractures require anatomic reduction. A closed reduction and
in patients with marked chest trauma were not prevented and the cast immobilization often is sufficient treatment. Complications,
course of the head injury was not affected. In children, medical including loss of reduction, infection, hardware migration, nerve
complications are less common so the recommendations to man- injury, and delayed union, have been reported with the use of
date early fracture stabilization are somewhat more difficult to pediatric intramedullary implants in the forearm, though 95%
support in the young patients. Nonetheless, bruises on the chest of patients (19 of 20) had excellent or good results on folIow-
or rib fractures should alert the orthopaedist to potential pulmo- up (21).
nary contusions as a part of the injury complex (64). Initial If flexible intramedullary nails are used in the femur, the most
chest radiographs may not clearly demonstrate the degree of common insertion site is the medial and lateral metaphyseal
pulmonary parenchymal injury, and arterial blood gas determi- region of the distal femur, just proximal to the physis. Two rods
nations are more useful in estimating the anesthetic risk of these are used to cross the fracture site and obtain purchase in the
patients during operative care of the fractures. proximal femur, usually with one at the base of the femoral neck
and the other at the base of the greater trochanter. A cast is not
Timing. In a child with multiple closed fractures, splinting is necessary postoperatively, although a fracture brace can be used
needed at the time of the initial resuscitation. Definitive treat- to help control rotation at the fracture site and provide some
ment should proceed expeditiously once the child's condition patient comfort during early walking. The implants are removed
has been stabilized. Loder (52) reponed that in 78 children with before 1 year from the time of fracture fixation (35,39).
multiple injuries, early operative stabilization of fractures within The use of reamed antegrade intramedullary rods to treat
the first 2 or 3 days after injury led to a shorter hospital stay, a femoral shaft fractures in the pediatric population should be
shorter stay in the intensive care unit, and a shorter time on reserved, in my view, for those at least older than the age of 11
ventilator assistance was needed. In addition, there were fewer years who probably have closure of the proximal femoral physis.
complications in those who underwent surgical treatment of the In younger children, rod insertion at the piriformis fossa may
fractures less than 72 hours after injury. Although there may interfere with the vascular supply to the femoral epiphysis, may
have been other factors besides the timing ofsurgery that affected cause growth arrest of the greater trochanter apophysis with re-
the eventual outcomes in this study, it would seem prudent to sultant coxa valga, or may interfere with the appositional bone
try to complete the fracture stabilization within 2 to 3 days from growth at the base of the femoral neck, thereby thinning this
the time of injury. region and potentially predisposing the child to a femoral neck
fracture (14). The specific indications for intramedullary fixation
Operative Fixation. The type of operative stabilization of of the femur are discussed in more detail in Chapter 22.
closed fractures oflong bones in multiply injured children com-
monly depends, as in other orthopaedic arenas, on the training,
experience, and personal preference of the orthopaedist. The Compression Plates. Some have advocated the use of compres-
most common methods used are intramedullary rod fixation, sion plates to stabilize long bone fractures, especially in the femo-
external fixation, and AO compression plating, though ral shaft, in children with multiple injuries. Kregor et al. (47)
Kirschner wires or Steinmann pins may be used in conjunction reported an average overgrowth of the femur of 9 mm, and all
with casts. fractures healed in a near-anatomic position. The disadvantages
of compression plating is the need for more extensive operative
Intramedullary Rod Fixation. There has been a recent increase exposure at the site of the fracture and the usual need to remove
in the use of flexible intramedullary rods of2- to 4-mm diameter the plate once healing is complete. In addition, refracture may
for stabilization of unstable closed fractures of the radius and occur through the screw holes left after plate removal if physical
ulna in patients up to the early teenage years and for stabilization activity is resumed too quickly. Stiffness of adjacent joints is
of closed femoral shaft fractures in patients berween the ages of rarely a problem in children unless there has been an associated
5 and 11 years (85,90). severe soft tissue injury. As a result, the number of cortices the
Forearm fractures generally can be reduced closed, with the screws cross on each side of the fracture may be fewer in children
 Chapter 4: Management of the Multiply Injured Child 87

rhan in adutrs, because a casr or splim is routinely used in young demonsrrated rhar 6 months after injury 8% ro 19% of injured
patients. children and adolescents had some significant limitation (27).
Although some authors have recommended open reduerion Whichever method of fracture rreatment-operative or non-
and compression plare flxarion of displaced radial and ulnar operarive-is chosen for a child with mulriple injuries, ir is impor-
fractures (95), I prefer flexible imramedullary nails, as noted taO[ rhat rhe orthopaedist be involved in rhe care of rhe child
earlier. The use of compression plares in rhe forearm requires a from the start. While recognizing rhe need to care for rhe orher
larger operarive incision wirh rhe resulranr scar and a second organ system injuries rhe child has susrained, ir is important [Q
exrensive procedme for plate removal. I do nor believe rhar rhe advocare for the expeditious and appropriare rrearmeO[ of the
healing capability of rhe young child requires rhe rigid flxarion fraccures thaI' are present. Failure [Q do so will leave rhe multiply
of compression plaring [Q obrain fraerure union. injured child wirh musculoskeleral disability once healing of the
orher injuries occurs. Nrer mulriple injuries, rhe most common
External Fixation. The mosr common indicarions for use of long-term problems relate to eirher sequelae of the head injury
exrernal flxarion in a child wirh mulriple injuries include open or of rhe orrhopaedic injuries.
fracrures wirh signiflcanr soft tissue injury, fracrures in associa-
rion with a head injury and coma, and so-called floating knee
fractures of the femur and ribia (3,8,9,43,49,69,73,84). The use
of an external flxator in rhese circumsrances allows the child ro
REFERENCES
be rransporred for imaging studies or ro rhe operaring room 1. Abou-Jaoude WA, Sugarman JM, Fallat ME, Casale A]. IndicatOrs of
for managemenr of nonorrhopaedic injuries. A unilareral flxaror genitourinary rract injury or anomaly in cases of pediatric blunt trauma.
generally is sufflcienr ro hold rhe fracrure reduced in rhis age J Pedian· Surg 1996;31 :86-89.
group. 2. Armstrong PF. Initial management of the multiply injured child: the
ABCs. [nstruct Course Lect 1992;41:347-350
When applying the external flxaror, rhe pin si res should be
3. Aronson J, Tursl<), EA. External fixation offemur fractures in children.
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The exrernal flxaror usually is lefr in place until fracrure heal- 8. Blasiet RD, Aronson J, Tursky EA. External fixation of pediatric femur
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menr has resolved (such as waking from coma or healing of skin 9. Bolln WW, Durbin RA. Ipsilateral fractures of the femur and tibia in
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10. Bond 5J, Gotschall CS, Eichelberger MR. Predictors of abdominal
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 PHYSEAL INJURIES AND GROWTH
ARREST
HAMLET A. PETERSON

PHYSEAL FRACTURES Metabolic Abnormaliry

Historical Review Cold InjUlY (Frosrbite)
Classification Heat Injury (Burns)
Epidemiology (The Olmsted County Study) Elenrical Injuries
Evaluation Laser Injuries
Treatment Stress Injuries
Prognosis Longitudinal Compression (Salrer-Harris Type V)
Developmental Physeal Abnormaliries
COMPLICATIONS Iarrogenic Injuries
OTHER PHY EAL FRACTURES PHY EAL ARREST
Disuse Etiology
Radiation Assessment
Infection Management
Tumor
COMPUCATIO S
Vascular Impairmenr
Neural Involvement RESULTS

The growth plate (physis) of an epiphysis or an apophysis may premature physeal arrest. Injuries at specific anatomic sites are
be injured in various ways (1-4). The mosr common injUlY is discLlssed in their respective chapters.
fracture, bur orher insulrs such as disuse, radiarion, infection,
rumor, vascular impairment, neural involvemenr, merabolic ab-
normaliry, frostbite, burns, electrical injuries, laser injuries, PHYSEAL FRACTURES
chronic srress, and iarrogenic injury can also damage rhe physis
sufflcienrly ro inrerrupt growrh. Historical Review
When the enrire growrh plate is arrested, bone lengrh is re-
Fractures of the physis have been of interest since anriquiry.
rarded. If rhe physis ar each end of a bone is arrested, longitudinal
Hisrorians note the fable of the Amazons, whose custom of sepa-
bone growth ceases completely. When the bone is compared
rating the epiphyses of newborn males ensured female supremacy
with the contralateral mare, there is a discrepancy in bone length.
and beaury. Hippocrates receives credit for the flrsr written med-
In the forearm or lower leg, the length inequaliry can also be
ical account of rhis injury (5,6). A Neapolitan surgeon, Marcus
relative to the ipsilateral companion bone (the radius and ulna
Aurelius Severinus, noted the problem of separarion of the proxi-
or ribia and fibula, respectively).
mal and distal tibial epiphyses in 1632. Written observations,
When only part of the physis is damaged, length retardation
case reports, articles, theses, and rreatises followed and are best
can be accompanied by angular deformiry as the undamaged
summarized in Poland's 1898 book Traumatic Separation ofthe
porrion of the physis continues to grow. The deformiry and
Epiphysis (6).
lengrh inequaliry depend on the site (specific bone), the location
within the site, the extenr (quantiry), and rhe duration of rhe
physeal damage. Classification
This chaprer is an overview of physeal injuries and is divided
inro three parts: physeal fractures, orher physeal injuries, and Early Classifications
Poland's book (6) established the fracture as a significant and
not rare entiry. He documenred four specific injuries, provided
Hamlet A. Peterson: Division of Pediatric Onhopaedic Surgery, Mayo drawings of each, and rhereby produced rhe first rrue classifica-
Clinic, Rochester, Minnesota. tion (Fig. 5-1). Following Roentgen's discovery of the x-ray
92 General Principles

II III IV
FIGURE 5-1. Classification of Poland (1898). (Redrawn from Peterson HA. Physeal fractures: part 3,
classification. J Pediatr Orthop 1994;14:439-448; with permission.)

I II III IV V VI
7.4% 31.0% 50.0% 6.1% 4.2% 1.3%
FIGURE 5-2. Classification of Bergenfeldt (1933), with percentage of each type. (Redrawn from Peterson
HA. Physeal fractures: part 3, classification. J Pediatr Orthop 1994;14:439-448; with permission.)

(l895), rhe subjecr was srudied more sciemifically; before this, these three types of fracrures in a general conrexr, Airken's rhree
all observarions were made from compound fracrW"es, dissections types of fracrures became rhe srandard by which most physicians
of pariems with fatal injuries, or oflimbs with rraumatic ampum- reponed physeal fracrures.
rions (7-32).
In 1933, Bergenfeldr documemed radiographically 310 phy-
seal injuries in 295 pariems and defined six types (Fig. 5-2). Salter-Harris Classification
These six types included rhe firsr three of Poland and added a In ] 963 Salter and Harris (28) published rheir classic arricle,
fracrure rhrough the epiphysis, metaphysis, and physis. These "Injuries Involving rhe Epiphyseal Plare," in which five types
four fracrures subsequently were used by Salrer and Harris (28) of injuries were described (Fig. 5-4). The fJrsr four types are
as rheir first four types. a combinarion of rhose described by Poland (types I [Q I11),
In 1936, Airken (7) described rhree types of physeal fractures Bergenfeldr (types 1 [Q V), and Airken (rypes 1 [Q III). Salrer
of the disral ribia (Fig. 5-3), rwo of which (l and II) wm de-
and Harris added rhe concept of compression injllly, which rhey
scribed by Poland, and rhe rhird, by Bergenfeldr. Aitken docu-
designared type V. They proposed rhar rhe mechanism of rhis
memed the same rhree physeal fractures in the disraJ fern ur (l0)
injury is by 10ngirudinaJ compression, which damages rhe ger-
and the proximal tibia (9). Mrer his] 965 article (8) discllssing minallayer of physeal cells. Because rhere was no osseous injury,
radiographs ar rhe rime of injury were by definirion normal.
This differs from rhe crushing of physeal cells mar can occur
wirh any pl1yseaJ fracrure, as described by Lens (18). Because
no srrucrurc is broken, rhis is nor a fracture; rhe term "injury"
seems more appl·opnate.
Salter's associ are, Mercer Rang (26) added an injury in 1969
that has become known as a Salrer-Harris, or Rang, type VI.
This was described as a rare injury produced by a direcr blow
[Q the periosteum or perichondrial ring (Fig. 5-5). It was never

specified wherhcr the damage was produced by peripheral rrans-

II III verse compression of physeal cells or ischemia due to vascular
changes. Because no mention was made of open trauma, it is
FIGURE 5-3. Classification of Aitken (1936). (Redrawn from Peterson
HA. Physeal fractures: Part 3, classification. J Pediatr Orthop 1994; assumed rhar these were closed injuries. Like a Salter-Harris type
14: 439-448; with permission.) V, rhis should also be called an injury rarher rhan a fracrure,
 Chapter 5: Physeal Injuries alld Growth Arrest 93

II III IV V
FIGURE 5-4. Classification of Salter and Harris (1963). (Redrawn from Peterson HA. Physeal fractures:
part 3, classification. J Pediatr Orthop 1994;14:439-448; with permission.)

~ AUTHOR'S CLASSIFICATION
because nothing is broken and the original radiograph is normal.
Other authors (2,3,19-21) have interpreted this injury as an
avulsion of the perichondrial ring with ponions of arrached me-
raphyseal and epiphyseal bone, while still considering it a Salter- In 1994, a new classification (24) based on the first population-
Harris or Rang rype VI. Alrhough drawings have been provided, based epidemiologic study (Fig. 5-6) arranged fracture rypes
the only case depicted radiographically (3) is an open lawn from the least involvement or damage to the physis (rype I) to
mower excision of the metaphysis, physis, and epiphysis; rhis is the greatest involvement (rype VI).
more appropriately classified as a part missing (see Classification Type I is a transvetse fracture of the metaphysis with fracture
later). None of these Rang rype VI injuries were found in a line or lines extending to the physis (Fig. 5-7) (23). There is no
recent population-based study of 951 cases. Neither Salrer (29) fracture along the physis and no displacement of the epiphysis
nor Rang (27) included this rype in subsequent publications. on the metaphysis (Fig. 5-8). There may be a small eccentric
The Salter-Harris classification gained widespread acceptance conical fragment not attached to either the epiphysis or the
throughout the world 0-4). In recent years, however, several metaphysis. Comminution is common (Fig. 5-9), and com-
amhors have deviated from this classification. In 1980, Weber pounding is rare. The mecl1anism of injury is most likely longitu-
(32), who was unable to find any type V injuries, returned to dinal compression as evidenced by the conical torus or budJing,
the Aitken classification. In 1983, Rang (27) noted that the widening of the metaphysis, or comminution. Radiographs 2 to
Aitken classification is "widely used," and in 1993, Kling (17) 4 weeks after injury rypically show trans metaphyseal sclerosis
stated that the Aitken classification is "now used in Europe." indicative of a healing compression fracture (Fig. 5-8B). This
Other authors (12-14,19-21,30,32), finding the classification fracture made up 15.5% of fractures in the Olmsted Counry
incomplete or lacking in substantiation of prognosis, have devel- population study, bm it is probably much more prevalent, be-
oped new classifications, notably Ogden (19-21) in 1981 and cause metaphyseal fractures were not reviewed and neither the
Shapiro (30) in 1982. hand surgeons or the pediatric onhopaedists were aware of this
The classification of physeal fracrures is a work in progress. fracture before the study. The most common sites are the distal
This search for a classification that will allow the collection of radius, finger phalanges, and metacarpals. Nonoperative treat-
meaningful statistical data and a bener means of communication ment by dosed reduction and immobilization usually results in
is a progressive quest for knowledge. This knowledge, in tum, a good outcome. Only one patient with this fracture rype (0.7%)
should improve criteria for prognosis, management, and recom- was treated surgically in the Olmsted Counry study. Premature
mendations for follow-up of patients with physeal fractures. physeal closure occurred in five (3.4%) adolescents, none of
whom required rreatment.
Type II is a separation of part of the physis, with a ponion
of the metaphysis anached to the epiphysis (Thurstan Holland
sign). Involvement and potential damage of rhe physis may be
minimal (Fig. 5-10A) or nearly all the physis may be disrupted,
leavi ng only a small meraphyseal fragment (Fig. 5-lOC). Most
commonly, the metaphyseal potion attached to the physis is a
quarter to a third the width of the physis (Fig. 5-1 OB). Although
attention is usually focused on the size of the metaphyseal frag-
ment, the more important factor is the amount of physeal tissue
VI disrupted. Indeed, the Thurstan Holland metaphyseal fragment
may be so tiny that it is nOt seen on routine anteroposrerior or
FIGURE 5-5. Physeal injury of Rang (1969). (Redrawn from Peterson
HA. Physeal fractures: part 3, classification. J Pediatr Orthop 1994; lateral radiographs (Fig. 5-10C). Tangential (oblique) views may
14:439-448; with permission.) be necessary to reveal the fragment. In this context, it differs
 94 General Principles

II III IV V VI

METAPHYSIS METAPHYSIS PHYSIS EPIPHYSIS METAPHYSIS PHYSIS

~PHYSIS & PHYSIS & PHYSIS & PHYSIS MISSING
& EPIPHYSIS
Poland II Foucher I Poland III &IV
Bergenfeldt II & III Poland I Bergenfeldt IV Bergenfeldt V
Aitken I Bergenfeldt I Aitken II Aitken III
Salter & Harris II Salter & Harris I Salter & Harris III Salter & Harris IV

FIGURE 5-6. Classification of Peterson. (Redrawn from Peterson HA. Physeal fractures: part 3, classifica-
tion. J Pediatr Orthop 1994; 14.439-448; with permission.)

A B C o
Metaphysis ~ physis
Epiphysis & physis intact
FIGURE 5-7. Peterson type I fracture of the metaphysis with extension to the physis. A: Torus or buckle
complete transmetaphyseal fracture with one or more fracture lines extending to the physis. The fracture
does not extend along the physis, and the epiphysis is not displaced on the metaphysis. The metaphysis
is frequently wider than normal. The transmetaphyseal fracture is a compression fracture, often best
visualized 2 to 4 weeks postfracture as an increased sclerotic osseous density. B: Transverse metaphyseal
compression fracture with peripheral cortical fragment. This fragment may be displaced eccentrically,
indicating disruption of the physis in this area. C: Complete transverse metaphyseal fracture with fracture
line extension to the physis. D: Comminuted fracture of the metaphysis with multiple fracture extensions
to the physis. None of these fractures meets the requirements of a type II fracture, which is a fracture
of only part of the metaphysis extending to and along the physis. The designations A to D are not an
attempt to subdivide or classify this fracture type but are used only to show the multiple possibilities.
(Redrawn from Peterson, HA. Physea I fractures: part 2, two previously unclassified types. J Pediatr Orthop
1994;14'431-438; with permission.)

FIGURE 5-8. Peterson type I fracture in the distal ra-

dius of a 6 + 5-year-old boy. A: AP view shows com-
plete transverse metaphyseal fracture with longitudi-
nal extension to the physis. The metaphysis is wider
than normal, and the epiphysis is not displaced on the
metaphysis. B: AP view 34 days postfracture shows
healing sclerosis transversely and longitudinally at
sites offracture. (From Peterson HA. Physeal fractures:
part 2, two previously unclassified types. J Pediatr Or-
A,S thop 1994;14:431-438; with permission.)
 ChftPlel' 5: Physeallnjuril's and Growth Arrest 95

A B

FIGURE 5·9. Peterson type I fracture in the distal radius of a

14+ l-year-old boy. A: AP view shows comminuted displaced
fracture of metaphysis. Longitudinal cortical buckling fracture
on radial side extends to the physis. B: AP view during reduc·
tion in fingertrap traction. Transmetaphyseal fracture with ex-
tension to physis and no displacement of epiphysis is now evi-
dent. The metaphysis is wider than normal. Fractured ulnar
styloid. C: AP view, 14 months postfracture. There is normal
function, and the distal radial physis is open and growing.
Nonunion of ulnar styloid is seen. (From Peterson HA. Physeal
fractures: part 2, two previously unclassified types. ) Pediatr
c Orthop 1994;14:431-438, with permission.)
 96 Cenfral Principles

litde from a eype III injui)' (Fig. 5-6), which involves complete
physeal disruption wich no osseous fracture. Type II (Fig. 5-
10e) and III injuries can be managed similarly, usually by closed
reduction and immobilization. There are no recorded cases of
premature physeal closure between the metaphyseal fragment
and the epiphysis. Brashear, applying longitudinal compression
by bending the knee joints of rats, produced a eype II fracture
each time. None of these fractures developed physeal closure at
A B c the compression si te (metaphyseal fragment/epiphyseal imer-
FIGURE 5-10. Peterson type II physeal fracture. See text for discussion. face). If premature physeal closure occurs, it is at the site of
(Redrawn from Peterson HA. Physeal fractures: part 3. classification. J the sharp edge of the fractured meraphysis, which excoriates or
Pediatr Orthop 1994;14:439-448; with permission.)
compresses the physis (18).
Regardless of the amount of physis disrupted, the essential
features of a eype II injui)' are disruption of part of the physis

FIGURE 5-11. Salter-Harris I fracture of the distal radial physis

in a 7 + 6-year-old girl with subsequent physeal arrest and bar
excision. A: AP and lateral show dorsally displaced distal radial
epiphysis. B: Seven and a half weeks postinjury. Physis and me-
B taphysis are irregular and sclerotic. (Figure continues.)
 Chapter 5: f'hyseal Injuries IIlld Growth Arrest 97

C D
FIGURE 5-11. (continued) C: One year postfracture there is relative overgrowth of ulna. D: Age 14 + 4
years after physeal bar resection. The patient is normally active, participating competitive volleyball,
and is asymptomatic. The distal radius is growing (greater than 100%) faster than the ulna, as evidenced
by the reduction of the ulnar plus deformity and the increasing distance between the metal markers.
The Cranioplast plug stayed with the epiphysis.

berween the epiphysis and the metaphysis, however small this more common in older children. The disrupted articular surface
may be; fracture of only part of the metaphysis, with a metaphy- requires anatomic reduction and maintenance of reduction,
seal fragment attached to the physis; and no continuiry from the often by open reduction and internal fixation. Premature growth
epiphysis to the intact major metaphyseal/diaphyseal complex. arrest is common, but it usually is complete rather than parcial,
Comminution and open fracture are uncommon. This fracture and rarely causes angular deformiry. Most children with this
is the most common type in all previous series and is made up injury are relatively mature, and bone-length discrepancy is un-
53.6% of fractures in the Olmsted Counry study. The most common. Significant length discrepancy occurs only in young
common site is in finger phalanges, where ir occurred 47.6% of patients (Fig. 5-12). This fracture made up 10.9% of fractures
the time. Initial management was surgical for 23 (4.5%) patients. in the Olmsted Counry study. The mosr common sires are the
Thirry-three (6.5%) developed premature physeaJ closure. finger phalanges and the distal tibia (medial malleolus and lateral
Twelve (2.4%) underwent late surgical correction. plafond). Eighteen fractures (17.3%) were created initially by
A type III injury is a separatiori of the epiphysis from the surgery, and 15 (14.4%) underwent late surgery.
diaphysis through any of the layers of the physis, disrupting the Type V is a fracture that traverses the metaphysis, physis,
complete physis (Fig. 5-6). This injUlY is rarely open and cannot epiphysis, and usually the articular carrilage (Fig. 5-6). The tri-
be comminuted. The only anatOmic variations are the different plane fracture (22) meets all of these criteria (Fig. 5-13) and is
layers of the physis through which the fracture traverses. At therefore a complex rype V fracture, which is othelwise depicted
present, this can be determined only histologically. In twO stud- in only one plane, usually the sagittal. Comminution and open
ies, the transphyseal fracture was histOlogically nared to involve injuries are common. Type V fractures are best managed by
all zones of cartilage cells (germinal, proliferating, hypertrophy- anatomic reduction and maintenance of reduction to align both
ing, and provisionally calcified) (16,31). This helps explain why the articular cartilage and the growth cmtilage. This is particu-
premature growth arrest may occur following fractures along the larly true in the young patient with significant growth remaining.
physis (Fig. 5-11). This injury made up 13.2% of physeal injuries This usually requires open reduction and internal fixation. Pre-
in the Olmsted County study. It occurs most commonly in mature growth arrest is common and occurs even with anatomic
the distal fibula. Thirceen acute fracrures (10.3%) were [l'eated reduction. This fracture made up 6.5% of fraCtures in the
surgically. Nine patients (7.1 %) had late corrective surgelY. OlmSted County study. The most common sites are the dista.l
Type IV is a fracture of the epiphysis extending to and along humerus (lateral condyle), finger phalanges, and distal tibia,
the physis (Fig. 5-6). It may be comminuted or "double." Open where the fracture pattern is variable (11). Twelve fractures
fractures are uncommon. Because this fracture most often occurs (19.4%) were created initially by surgery, and 12 (19.4%) were
when part of rhe physis, usually central, has begun to close, it is treated by subsequem surgery.
98 General Principles

B c
FIGURE 5-12. Salter-Harris III fracture, distal radius in a 9+ 1-year-old girl with subsequent physeal
arrest and bar excision. A: Patient fell 8 feet, landing on her outstretched right hand. Fracture of the
epiphysis extending to the physis (arrow) might be better visualized with additional oblique radiographs
or tomograms. B: Two years 6 months postfracture (age 11 + 7). Physeal bar medial distal radius. The
right radius is 23 mm shorter than the left. The ulnae are of equal length. C: MRI transverse depiction
of distal radial physis using 3-D rendering (ANALYZE) shows linear bar comprising 10.5% of the physis.
 Chapter 5: Physeai lnjttries and Growth Arrest 99

D E
FIGURE 5-12. (continued) D: Physeal bar excised through peripheral approach and cavity filled with
Cranioplast. Metal markers 11 mm apart. Note normal growth (relative overgrowth) of ulna. E: Eighteen
months after bar excision (age 13 + 2). The distal right radius has not only resumed normal growth, but
is growing faster than normal (greater than 100%), as evidenced by improvement of radial-ulnar length
discrepancy. The metal markers are 29 mm apart. The radial articular angle is improved, and remodeling
has resulted in a more ulnarward position of the proximal metal marker.

Type VI is a fracture in which part of the physis has been not until years later. This fracture made up only 0.2% of frac-
removed or is missing (Fig. 5-14) (23). Usually an accompanying tures in the Olmsted Counry study, but it is more common
part of the epiphysis or metaphysis, or both, is also missing. among referral patients. All type VI injuries require initial sur-
This occurs only with open fractures such as those caused by gery, at least wound care; most if not all require late recon-
lawn mowers, farm machinery (e.g., auger, corn picker, power structive or corrective surgery, especially those in young children.
take-off, corn sheller), snowmobiles, gunshors, and motorboat
propellers (Fig. 5-15). Premature partial closure of the remaining
Salter-Harris Type \I, Present Status
exposed surface of the physis nearly always occurs but sometimes
The Salter-Harris rype V injury is not included in this new
classification of fractures because with this injury, there is no
fracture. Because the radiograph taken at the time of injury is
AP Lat. normal and growth arrest is discovered only in retrospect, this
entiry, if it exists at all, cannor be suspected during the evaluation
or treatment of an acute injury. Therefore, it is included in the
later section, "Other Physeal Injuries."
Comparison of classifications may have more than historical
value. New mechanisms of injUlY and new or improved imaging
techniques may lead to the inclusion of new fracture types, or
of a previously described but discarded fracture rype.

II Epidemiology (The Olmsted County Study)

FIGURE 5-13. Triplane fracture (1957). (Redrawn from Peterson HA.
Physeal fractures: part 3, classification. ) Pediatr Orthop 1994; Mann and Rajmaira (35) reported that of 2650 long-bone frac-
14:439-448; with permission.) tures in children, about 30% involved the physes (33-39). Wor-
 100 General Principles

FIGURE 5-14. Peterson type VI fracture of the physis with a portion of the
physis missing. A: Longitudinal fracture with piece comprising epiphysis, physis,
and metaphysis missing. In rare cases a portion of the diaphysis may also be
missing. The absent portion may vary in location and in size from small to large.
Common mechanisms of injury are from lawn mowers, snowmobiles, automo-
biles, farm implements, and motorboat propellers. B: Penetrating injury may
remove physeal cartilage, along with adjacent epiphyseal and metaphyseal bone
in any plane. A transverse orientation of penetration causes the most severe
physeal damage. The most common penetrating object is a bullet. C: Lacerating
injury directly in the plane of the physis, removing some or all of the physis with
relatively little damage to the epiphysis or metaphysis. This injury is rare. The
A B C designations A to C are not an attempt to subdivide or classify the fracture type
but are used only to show the multiple possibilities. These fractures have only
one criterion: part of the physis is missing. A physeal bar invariably develops,
sometimes years postfracture. (Redrawn from Peterson HA. Physeal fractures:
part 2, two previously unclassified types. J Pediatr Orthop 1994; 14.431-438;
with permission.)

FIGURE 5-15. Peterson type VI fracture

of the proximal tibia in a 10+4-year-old
girl. A: Standing teleoroentgenogram.
Right genu varum following removal of
right proximal tibial medial condyle in
lawn mower accident that occurred at
age 4 + 11 years. Patient had previously
undergone proximal tibial valgus osteot-
omy and physeal bar excision. Note lat-
eral subluxation of tibia on femur. B: To-
mogram confirms recurrent physeal bar
medially. Note this relative overgrowth
of the unopposed medial femoral con-
dyle. This patient was treated by bracing
and, at age 13, by medial tibial cadaver
allograft and physeal closure of the lat-
eral side of the proximal tibia, with con-
comitant physeal arrest of the contralat-
A,S eral normal proximal tibial physis.
 Chapter 5: Physea! Injuries and Growth Arrest 101

adjusted incidence of physeal fractures was 279.2 per 100,000

TABLE 5-1. NUMBER AND SURGERY OF
person-years (95% confidence interval, 261.4 ro 296.9). frac-
PHYSEAL FRACTURES ACCORDING
TO PETERSON CLASSIFICATION tures occurred approximately equally on right and left limbs
(52.6% versus 47.4%, p > .05). The most common site was the
Immediate Late phalanges of the fingers, which accounted for 37% of all physeal
Number Surgery Surgery fractures, followed by the distal radius (18%) (Table 5-2). The
Types (%) (%) (%)
diStal end of each long bone was fractured more frequently than
I 147(15.5) 1 (0.7) . 0(0) the proximal end. Seventy-one percent of fractures occurred in
II 510 (53.6) 23 (4.5) 12 (2.4) the upper extremity, 28% in the lower extremity, and 1% in
III 1Z6 (13.2) 13 (10.3) 9 (7.1)
the axial skeleton.
IV 104 (10.9) 18 (17.3) 15 (14.4)
V 62 (6.5) 12 (19.4) 12 (19.4)
VI 2 (0.2) 2 (100) 1 (50)
Total 951 (100) 69 (7.3) 49 (5.2) Evaluation
The hisrory of injuty and the clinical evaluation (symproms and
* Data pertain to physeal fractures among children in Olmsted
County; Minnesota, 1979-1988. . physical findings) usually define appropriate body pans for ra-
FromPeterson HA. Physeal fractures: part 3, classification. ) Pediatr diographic evaluation (40-71). Radiographs in two planes, usu-
Orthop 1994; 14:439-448. .
ally anteroposterior and lateral, are sufficient ro determine the
fracture type and the management plan for most fractutes. If
the radiographs are indeterminate, oblique or three-quarter views
should be taken (51,63,64). Occasionally stress views, romo-
grams, arthrograms, computed romography (CT) scans, mag-
lock and Srower (39) reponed that of 826 fractures of aJl bones neric resonance imaging (MRJ), or ultrasound is needed to ade-
in children, 18.5% involved rbe physes. An epidemiologic s[Udy quately display the fracture. Stress views are most useful when
of physeaJ fractures was performed over a lO-year period in the injury is near a uniplanat joint (e.g., the elbow, knee, or
Olmsted County, Minnesota, from 1979 to 1988 (Table 5-1) ankle) (51). Tomograms help delineate fragmentation and orien-
(38). This was the first population-based study in which both tation of fragments. CT scans may best reveal the complexities
the numeraror (fractures) and denominaror (population at risk) of triplane fractures (22,64). Ftactures involving a large volume
were known. No referraJ cases were included, thereby omitting of cartilage, such as the proximal or distal humerus in infants,
preselected difficult or high-risk cases. in the past were best appreciated by arthrography (40,41,49,56,
Of the 951 physeal fractures in the study, the maJe-ro-female 57,71). Recently, this method has been replaced by MRl (54,
ratio was 2: 1. The incidence rates were highest among boys age 55,64,65,70) and ultrasound (43,52,57). MRJ has also been
14 and girls ages 11 and 12 (Fig. 5-16). The overall age- and sex- used in older children with acute injuries ro identify possible

1,400

n=951
1,200
o Boys
0
0 1,000 m Girls
0
0

-
0 BOO
T"""

<l>
0
c 600
<l>
"0
'0 400
c

200

0
0 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Age
FIGURE 5-16. Incidence of physeal fractures by gender for 1-year age groups with all types of fractures.
Boys peak at age 14 years, and girls peak at age 11 to 12 years. (From Peterson HA, Madhok R, Benson
JT, et al. Physeal fractures: part 1, epidemiology in Olmsted County, Minnesota, 1979-1988. ) Pediatr
Orthop 1994;14:423-430; with permission.)
102 General Principles

TABLE 5-2. SITES AND TYPES OF PHYSEAL FRACTURES AMONG CHILDREN IN OLMSTED COUNTY,
MINNESOTA, 1979-88 AND SALTER-HARRIS CLASSIFICATION WITH TWO NEW TYPES
(A AND B)

. Type I Type II Type III Type IV Type V Type A TypeS All Types

Skeletal Site n % n % n % n % n % n % n % n %

Phalanges (fingers) 21 2.2 243 25.6 42 4.4 12 1.3 36 3.8 2 0.2 356 37.4
Distal radius 27 2.8 84 8.8 3 0.3 56 5.9 170 17.9
Distal tibia 6 0.6 45 4.7 26 2.7 19 2.0 8 0.8 104 10.9
Distal fibula 32 3.4 30 3.. 2 1 0.1 2 0.2 3 0.3 68 7.2
Metacarpal 2 0.2 27 2.8 7 0.7 1 0.1 24 2.5 61 6.4
Phalanges (toes) 6 0.6 30 3.2 8 0.8 4 0.4 7 0.7 55 5.8
Distal humerus 8 0.8 5 0.5 1 0.1 21 2.2 2 0.2 37 3.9
Distal ulna 5 0.5 7 0.7 9 0.9 6 0.6 27 2.8
Proximal humerus 4 0.4 13 1.4 1 0.1 18 1.9
Distal femur 4 0.4 6 0.6 3 0.3 13 1.4
Metatarsal 2 0.2 6 0.6 1 0.1 0.1 3 0.3 13 1.4
Proximal tibia 3 0.3 3 0.3 1 0.1 0.1 8 0.8
Proximal radius 1 0.1 3 0.3 1 0.1 0.1 6 0.6
Proximal ulna 1 0.1 3 0.3 4 0.4 .
Clavicle. medial 3 0.3 0.1 4 0.4
Pelvis 2 0.2 1 0.1 3 0.3
Clavicle. lateral 1 0.1 1 0.1 2 0.2
Proximal femur 1 0.1 1 0.1
Proximal fibula 1 0.1 1 0.1
Total 126 13.2 510 53.6 104 10.9 62 6.5 147 15.5 2 0.2 951 100.0

No type V fractures were observed.

* Type A: Fracture of the metaphysis to the physis; type 1 in Peterson classification
t Type B: Part missing; type 6 in Peterson classification.

physeal damage (44,53,59,60,67,70) and is recommended pri- rion and casring usually achieve sarisfacrolY posirion and aJign-
marily ro identify complex fractures (60). The role of scimigra- menr of rhe fragmenrs (Figs. 5-8 and 5-9). Fracrures of rhe
phy (47,68) in assessing acute physeaJ fracwres is yet ro be deter- metaphysis and physis heal rapidly, and casr immobilization for
mined. 3 to 4 weeks is usually sufficienr. Because rhe physis is involved
in the injury, growth arresr is possible (3.4% in the Olmsted
Treatment srudy), and rhese fracrures need follow-up long enough ro ensure
thar normal growth has resumed. This period varies depending
The goal of rreatmenr of all physeal fractures is ro main rain
on rhe patient's age and rhe sire and severiry of injury; at least
function and normal growth (72-79). Maimenance of growrh
3 months is appropriate for most patients, longer for patients
is obviously more imponam in a young child rhan in an older
wirh comminuted or markedly displaced fracwres.
adolescent, who has little growrh remaining. Consistem artain-
mem of rhese goals is most likely when all Struccures are anaromi-
cally reduced. Thus, the goal becomes ro obrain and maintain Salter-Harris /I
anaromic reducrion. This may be done by closed or open means. Most type II fractures can be reduced easily with closed manual
All reducrions, wherher closed or open, should be gentle ro pre- reduction. Scraping of rhe metaphyseal fragmem across rhe in-
vem damage ro rhe deliGne physeal canilage. Forceful, repeared raCt physis can be decreased by good patient relaxation to reduce
manipularions should be avoided. During open reducrion, plac- muscle tension. This is probably besr achieved by general anes-
ing direcr pressure on the physis with insrrumems should be thesia or a nerve block such as an axillary or lumbar epidural
avoided. block. The metaphyseal fragment usually prevents overreduction
Physeal fractures should be reduced immediately, because
(Fig. 5-10A and B). The intacr periosteum on the side of the
delay makes reducrion more diHiculr. The younger rhe child,
meraphyseal fragment imparrs further stabiJiey to the reduced
rhe more rapidly the healing callus blends wirh arricular and
fracture, and internal fixation is often unnecessary.
physeal canilage, making reducrion diHiculr.
In a young parient, incomplere reduction may be more ac-
ceptable than repeated overzealous manipulation, which may
Type I (Metaphyseal Compression With Extension
cause gouging of rhe physis. In an older patiem, a more accurate
Into the Physis)
reducrion is necessary because spomaneous correction with
The rype I fracrure has rhe leasr porential damage ro rhe physis growth is less likely. Occasionally, a eype II fracture can nor be
and rherefore needs rhe leasr aggressive rreatmenr. Closed reduc- satisfactorily reduced. A common example is the disraJ tibia,
 Chapter 5: Physeal Injuries and Growth Arrest 103

where periosreum becomes impinged ar rhe fracrure sire. Ten- Salter-Harris IV

don, nerve, and vascular-sr[Ucrure impingemenr also has been
For rhe rype V fracrure, anaromic reducrion and maintenance of
reponed ar various sires; rhese rypes also need surgical exuica-
reducrion are essential ro align borh rhe physis and rhe arricular
rion. If rhe reduced fragmems are unsrable, imernal f1xarion is
surface. If rhere is any displacement, open reducrion and imernal
appropriare. This is besr accomplished by pins or screws from
fixarion are usually required. Closed reduction wirh percurane-
meraphysis ro metaphysis, avoiding rhe physis. Occasionally, rhe
ous imernal fixarion may be acceprable in some siruarions (77).
meraphyseal fragmenr a((ached ro rhe epiphysis (Thuman Hol-
Imernal fixarion is besr accomplished from epiphysis ro epiphysis
land sign) is so small rhar ir cannor be inrernally fixed ro rhe
or metaphysis co meraphysis, particularly in young children.
main meraphysis (Fig. 5-IOC). In rhis case, small-diamerer,
Growth arresr is likely, and rhese fracrures need observarion for
smoorh pins may be placed from rhe epiphysis, across rhe physis,
ar leasr a year, even if earlier evaluarion is good.
and imo rhe metaphysis. Growrh arresr is less likely if rhe pins
avoid the perichondrial ring, are as longirudinally as feasible,
and remain in place a shorr rime, preferably 3 weeks or less. The Type VI (Epiphyseal and Physeal Loss)
insenion of biodegradable pins across rhe physis is a ;1ew concept
rhar is being evaluared, mosr imensely in Finland (72,74-76, Because eype VI fracrures are open injuries, all require inirial
78,79). Wherher these pins impart adequare srabiliry without debridemenr, ofren wirh wound packing and secondary closure
predisposing ro physeal arresr remains ro be seen. In one of rhe and sometimes wirh skin graft or flap closure. Children wirh
more recem studies, growrh an'esr was noted and the authors rhese injuries musr be followed unriJ maruriry, because mosr if
suggesred rhar rhe procedure be limired ro adolescents wirh li((le nor all develop angular deformiries and relarive shorrening of
growrh remaining (78). rhe involved bone (Fig. 5-15A). There is a high likelihood of
Type II fractures may involve a small (Fig 5-IOA) or large physeal bar formarion on rhe exposed bone surface (Fig. 5-15B).
(Fig 5-10C) portion of rhe physis; rhe more of rhe physis in-
volved, the greater the chance of growrh arresr. The prognosis Prognosis
also depends grearly on rhe site of injury. When the physis is
irregular and undulating, as in rhe disral femur or proximal ribia, The prognosis of a physeal fracrure depends on the following
displacement of rhe meraphyseal surface againsr rhe physeal sur- facrors, in descending degree of imporrance: rhe severiry of in-
face produces scraping of rhese irregular surfaces and an in- jury, including displacement, comminurion, and wherher ir is
creased likelihood of physeal arrest. A smoorh, flat physis, such open or closed; the parient's age; rhe physis injured; and the
as rhe disral radius, is much less prone ro arrest. The degree of radiographic rype of fracrure (1-4,24,28,29,38,80-82). Trear-
displacement and rhe parient's age are also obviollsly important. mem depends on these facrors and in itself has an imponam
Repeared reducrion artemprs increase rhe chance of art·est. Type bearing on rhe prognosis.
II fractures may involve only a small amounr of physis (Fig. 5-
lOA) or a large amount of physis (Fig. 5-1 OC); rhe larrer increases Severity of Injury
rhe chance of physeal damage.
The mechanism of injury may be rhought of as rhe acriviry rhe
Salter-Harris I pariem was involved in at the rime of injury (e.g., aucomobite
accidem, foorball, diving) or as an anacomic description of rhe
Type III fracrures (Fig. 5-6) are similar ro rhose rype II fracrures injULY (e.g., varus, exrension, rotation). The rerm high-velocity
which have a very small meraphyseal fragmenr (Fig. 5-1 DC). injury is ofren used co describe fracrures wirh signiflcanr displace-
Because all layers of rhe physis may be involved (Fig. 5-11), rhe mem, comminurion, and compounding. The term severity of
prognosis for growrh arresr is slighrly grearer rhan wirh rype II injuIJ! is used here co include all of these fearures and is the mosr
fracrures (Table 5-1). Type III fracrures should be managed by imporrant facror in prognosis. Any damage co or loss of the
closed reduction because inrernal f1xarion would likely require germinal or proliferarive layer of physeal cells has a negarive
crossing rhe physis. In a young child, it is berrer ro accepr an implication concerning growth.
imperfecr reducrion rhan risk rhe hazards of internal ftxarion
across rhe physis.
Age of Patient
Salter-Harris 11/
The parient's age is also imporranr. A physeal injury in a 13-
In rype IV fractures, rh.e carrilage of rhe physis and rh.e arricular year-old girl or a i5-year-old boy rarely resulrs in signiflcam
surface are borh disrupred (Fig. 5-6). The bcsr resulr is achieved lengrh discrepancy or angular deformiry, because lirde growrh
by anaromic reducrion of rhe arricular surface to reduce rhe remains. Any physeal injury in a young child, however, has rhe
likelihood of degenerarive arrhrosis and anaromic reducrion of potential for premature arresr, and appropriate follow-up is re-
the physeal carrilage ro reduce rhe chance of growth arrest. Usu- quired.
ally, rhese fracrures occur in older children, when rhe physis is
beginning to close and growrh arresr is nor a problem. Anaromic
Site of the Injury
reduction ofren requires open reduction to expose rhe articular
surfaces, especially in young children. The mosr desirable imer- The sire of injUlY influences rhe ourcome. A rype I fracrure of
nal fixarion is epiphysis ro epiphysis, if possible, especially in rhe disral femur or proximal tibia, both of which have large,
young children. undularing, multiplanar physes, are prone co an'esr, even wirh
 104 General Principles

mild separation or displacemenr. Because these sites contribute considerations from the least amount of physis involved (rype
more longitudinal growth than any other site in the body, defor- I) to the greatest amount (rype VI), it also was found co be
miry and length discrepancy are common. Conversely, the proxi- correlated co the prognosis in a general way. In the Olmsred
mal radius and ulna and distal humerus contribute so Iitde study, the amount of surgery performed, both initially at the
growth co the forearm and humerus, respectively, that injuly time of injuty and later to correct a complication, increased as
and premature arrest from any fracture rype at these sites rarely the rype number increased (Table 5-1).
causes significant angular deformiry or length inequaliry. A rype
I fractute of the distal fibula, rarely develops arrest, and ankle
valgus deformiry would occur only with arrest at a young age. COMPLICATIONS
The rroximal humerus has such good remodeling potencial that
signiflcant displacement and angulation can be accepted, even Sepsis can occur in any open physeal fracture, JUSt as in any
in older children. open diaphyseal fracrure (83-98). Practically speaking, this is
The site of the injury also dem'mines the blood supply of the seen exclusively in open injuries, primarily rype IV and VI frac-
physis. The growth-producing germinal and proliferating cells re- tures. Precautions and treatment are similar to those for any
ceive their nourishment through blood vessels from the epiphysis. other open bone or joint injury. Overgrowth after physeal frac-
If this blood supply is destroyed, these cells die and growth ceases. ture is essentially unknown, except of the capitellum in rype V
Fortunately, most epiphyses receive their blood supply directly fractures of the lateral humeral condyle, where overgrowth is
from multiple sources. When the arterial supply is limited co a few rarely sufficient to cause significant angular deformiry or length
arteries thar must reach the epiphysis by crossing the periphelY discrepancy. Hypoplasia of an epiphysis after trauma also is rare,
of the physis (e.g., the proximal femur), any displacement of the and it is usually associated with damage of the germinal layer
epiphysis may occlude the blood supply, resulting in avascular ne- of the physis or with vascular impairmenc that produces avascular
crosis of the epiphysis and physeal cell death. necrosis. The accompanying angular deformiry usually is minor,
but in the trochlea, it can be sufficient to cause ulnar nerve palsy
(92). Likewise, malunion of properly recognized and treated
Amount of Physis Injured
physeal fractures is uncommon (86). Delayed union or non-
The rype of fracrure is determined by the mechanism of injury, union of rype V fractures occurs occasionally, and has been noted
the patient's age, and the site of injury. For example, a rype II in the lateral humeral condyle (85,89), the distal femur (87),
fracture of the distal radius is common at any age; a rype II and the medial malleolus (Fig. 5-17). Nonunion may also occur
fracture of the disral humerus is rare ar aJl ages. The rype of afrer open reduction and internal fixarion (Fig. 5-18). This is
fracture also relates to the amount of physis damaged. Thus, usually treated by attempts at osteosynthesis or reconstructive
although this new classification is based primarily on anatomic surgery.

FIGURE 5-17. Nonunion of type V fracture. A: Type V fracture

of distal tibial medial malleolus in a 4-year-old boy. The frac-
ture was treated by cast immobilization. B: Age 6+ 10. Union
of the small metaphyseal fragment to the metaphysis, but
nonunion of the epiphyseal fragment to the epiphysis. There
is no physeal bar. The physis is growing more rapidly medially,
as evidenced by the growth arrest line in the metaphysis. The
upward displacement of the fragment before union of the
A,B metaphyseal fragment allows some ankle varus.
 Chapter 5: Ph)'Seal Injuries alld Growth Arrest 105

A,B c
FIGURE 5-18. Nonunion of Salter-Harris IV fracture. A: Type V fracture of distal tibial medial malleolus
in a 3 +4-year-old girl. Treatment was open reduction, excision of metaphyseal fragment, and internal
fixation. B: Five weeks postfracture, medial malleolar fragment is not united. C: Five months postfracture
there is an established nonunion.

Compartment syndrome and arterial occlusion are nor com- ture of rhe proximal femoral physis, particularly if rhe hip is also
monly associared wirh physeal fracrures bur have been reponed dislocared (95). Avascular necrosis can oCCU( ar rhe proximal
wirh fractures of rhe proximal tibia (83,93,94,97) (Fig. 5-19) (90) and rhe disral humerus (98) and at the proximal radius,
or rhe disral radius (88,91). Avascular necrosis of rhe proximal but ir is rare ar all other anaromic sites.
femoral capital epiphysis is a dreaded complication of any frac- All of these complications are uncommon. By far, the mosr
frequent complication of a physeal fracture is premarure growrh
arrest, resulting in diminished bone length, angular deformity,
or borh. This complication is so p(evalent thar it deserves special
attenrion and is discussed later in this chaprer.

OTHER PHYS AL INJURIES

JIt.~---,P-~rt--- Physis Physeal injuries, other than fracrure, that are sufficienr ro cause
premature partial or complete arrest share two characreristics:
normal radiographs at the rime of insult, and premature physeal
---"--~7'f-~~~- Epiphysis arrest noted weeks, months, or years later. These injuries are
uncommon. The injuries that meet these criteria can be c1assifted
as follows:
Popliteal artery
1. Disuse
2. Radiation
Recurrent 3. Infection
tibial artery ---1\,1\ 4. Tumor
5. Vascula( impairment
Anterior
tibial artery ----w-1~'11 6. Neural involvement
7. Metabolic abnormality
Posterior
tibial artery ----/I'll
8. Cold injury (frostbite)
9. Heat injury (burn)
Peroneal artery 10. Electric injury
11. Laser injuly
12. 5rress injury
FIGURE 5-19. Occlusion of the popliteal artery by direct pressure from 13. Longitudinal compression
posterior displacement of the proximal tibial metaphysis. (Redrawn
from Burkhart 55, Peterson HA. Fractures of the proximal tibial epi- 14. Developmental
physis. J Bone Joint Surg Am 1979;61 :996-1002; with permission.) 15. Iatrogenic
106 Co/emf Principles

Disuse predisposed the patient ro microfraerures that traversed the phy-

sis. Ross (110) suggested that the partially degenerated cartilage
Disuse of an extremity, from any cause, results in atrophy of
cannot wirhstand the abnormal stresses of a faulty gait. Dimin-
muscle and orher soft tissue (99-111). If disuse is prolonged,
ished arterial supply is a more likely possibility.
growth of bone length also is retarded. If disuse is marked, some
or all of the physis may cease growing completely. Bed rest,
cfLItches, cast immobilization, and traerion, even in the absence
of fracture, are all associated with growth arrest of the distal
Radiation
femoral physis and proximal or distal tibial physis. These modali- The growth-inhibiting and destructive effeers of x-rays on phy-
ties have been used in the management of patients with congeni- seal cartilage have been demonstrated in both animals and hu-
tal hip dislocation (100,104), rheumatoid arthritis (104), polio mans (112-131). Growth-inhibiting effeers are common when
(101,108), tuberculosis (107,111), and Penhes' disease, but are a physis is in the treatment field during therapeutic irradiation
now used more sparingly for various reasons, one of which is (115,116,119,127,129-131) but have not been shown to occur
the possibility of growth arrest. with diagnostic x-ray studies or the use of repeated romograms.
Complete closure of one or all of the physes in an extremity The main variables determining the extent of demonstrable bone
after a single diaphyseal fraerure has been reported and was at- change caused by radiation therapy are the patient's age at the
tributed to disuse of the extremity (3,61,99,102-106,109,110). time of therapy, the amount of the radiation delivered (including
Some of those multiple physeal closures have been attributed to both dose per treatment and rotal dose delivered), the field size,
Salter-Harris type V compression injuries, but it is difficult to the site to which the radiation was delivered, and the growth
envision multiple-site compression injuries with a single femoral porential of this site. The younger the patient and the greater
or tibial transverse or spiral shaft fracture. Conversely, some amount of radiation delivered, the greater is the extent of subse-
Salter-Harris type V injuries reported in the literature may have quent bone changes (Fig. 5-20). A radiation dose as Jaw as 400
been caused by posttraumatic disuse rather than sudden trau- R can produce growth retardation, and as the dose increases, so
matic physeal compression. does the extent of cellular damage and eventual development of
The precise etiology of physeal arrest associated with disuse dysplastic bone. All physes, including those in the spine, are at
is unknown. Gill speculated that the accompanying osteoporosis risk (120,124-126).

A B
FIGURE 5-20. Physeal arrest associated with radiation. A: A 5 + O-year-old with Ewing's sarcoma proxi-
mal left fibula; diagnosis was made by open biopsy. Metastasis to lung confirmed by transthoracotomy
biopsy. Patient received radiation therapy (5000 cGy to the left leg in 24 fractions over 8 weeks and
1500 cGy to the lungs in 12 fractions over 2 weeks). B: The left tibia did not grow, and at age 15 + 0, it is
still 12.2 cm shorter than the right despite numerous corrective surgical procedures. Ankle disarticulation
facilitated below-knee prosthetic fitting. The patient is tumor-free at age 22 years.
 Chapter 5: Physeal Injuries and Growth Arrest 107

A B
FIGURE 5-21. Physeal arrest associated with metaphyseal osteomyelitis. A: An infant girl had a cutdown
inserted into the right ankle saphenous vein on her second day of life. Staphylococcal osteomyelitis in
the distal right femur was treated by incision and drainage on day 17 of life. Care was taken to avoid
contact of the curet with the physis. A scanogram 4 years 11 months postoperatively demonstrates right
distal femoral valgus and relative shortening of femur (1.2 em). Coronal tomogram of right knee B:
shows central bar with tenting or cupping. A 4-year follow-up of this case following bar excision is
documented in Peterson HA. Partial growth plate arrest and its treatment. J Pediatr Orthop 1984;4:
246-258; with permission.

Infection Vascular Impairment

Septic arthritis and metaphyseal osteomyelitis often are followed The germinal and proliferative layers of physeal cartilage cells are
by physeal arrest (132-143). Because the inrerval between infec- primarily responsible for longitudinal bone growth (151-160).
tion and physeal arrest may be years (Fig. 5-21), intraarticular These ceHs are nourished by vessels in the epiphysis, and any
and osseous infections need long-term follow-up. The arrest is vascular disturbance of the epiphysis can result in physeal dam-
often partial, resulting in both angular deformity and length age (157-160). Some investigators have suggested that the epi-
discrepancy. TypicaHy, there is no residual infection when the physeal blood supply is probably the most important determi-
arrest is noted. Physeal bar excision in patients with previous nant in the development of bone bridges (3,81). If the blood
infection may, however, have a higher incidence of postexcision supply to the metaphysis is also disrupted, the likelihood of a
infection. Of 178 physeal bar excisions reviewed at the Mayo bone btidge increases.
Clinic, the only three postoperative infections were in patients Arterial spasm associated with traction (154) and even the
in whom the bar was due to metaphyseal osteomyelitis. application of a cast reduces blood flow to the extremity (153),
Physeal arrest also has been reported after some systemic in- which can alter physeal growth (3,158,159). Premature physeal
fections, particularly meningococcemia (61). In this instance, closure has been documented after temporary arterial insuffi-
the arrest may be associated with vascular impairment (Fig. 5- ciency (Fig. 5-23) (155) and after intravenous fluid extravasation
22). (156). Some Salter-Harris type V and Rang type VI injuries
reported in the !iteratUl'e may have been caused by vascular dys-
function rather than by physeal germinal cell compression.
The exact mechanism of premature physeal closure with tha-
Tumor lassemia major is unknown (152). In siclde cell disease (61),
Several benign tumors often abut the physis, and the physis is there is increased viscosity predisposing ro sludging, erythrocyte
susceptible to injuty during curettage and bone-grafting proce- entrapment in small vessels, and blockade of smaH vessels pro-
dures. The physis may close even when the tumor is untreated. In ducing ischemia.
addition to unicameral cyst (145,147-150) and enchondroma
(144,146), other childhood tumors that occur near growth plates Neural Involvement
and might cause growth arrest are aneutysmal cyst, chondroblas- The etiology of impairment of physeal growth linked with nerve
roma, chondromyxoid fibroma, and fibrous dysplasia. deficits associated wi th poliomyelitis, cerebral palsy (spastic
 108 General Prillciples

FIGURE 5-22. Physeal arrest associated with sys-

temic infection. A: A 7 + O-year-old boy had menin-
gococcemia at age 2 years complicated by ischemia
of the lower extremities. He underwent fascioto-
mies, debridement of necrotic tissue, and extensive
skin grafting. The legs, however, survived with only
the loss of toes. Subsequently he had heel cord
lengthenings and soft tissue flap grafts to cover
both patellae. B: Scanogram show bilateral ankle
varus and physeal bars of the distal tibiae. He later
A,B developed a bar of the proximal left tibia.

hemiparesis), sacral rumors, and major nerve transection is un- ful serial radiographic studies are necessary before considering
known, but it is probably related ro nun'ition-more precisely, bar excision or conualateral epipbyseodesis (171).
to diminished vascular supply (161,162). The length inequality Tissue resistance to growth hormone in patients with uremia
in nerve-related disorders tends to progress slowly, and prema- has been implicated as tbe cause of growth retardation in patients
cure physeal closure is unlikely (162). Two exceptions are con- with chronic renal failure (169). Also, high doses of calcitrioJ
genital insensitivity to pain (Fig. 5-24) and meningomyelocele may directly inhibit chondrocyte auivity within physeal carrilage
(161). The growth retardation in these condi tions is partial or and adversely affect linear growth in children with end-stage
complete arrest and may be caused by increased ttauma anel renal disease (166). Insulin-like growth factor-binding proteins
repeated transphyseal fracrures in the insensate limb. may also contribute to growth inhibitors in children with
chronic renal failure (168).
With increasing use and success of bone marrow transplanta-
Metabolic Abnormality (163-173) tion, more children survive cancer. Chemotherapy and irradia-
Vitamin A intoxication can cause premature physeal arrest tion both have the potential to damage endocrine glands. which
(167-173). The marked metaphyseal and epiphyseal cupping contributes to growth impairment through epiphyseal growth
and growth retardation that sometimes occurs with vitamin C plate dysfunction (164). Immunosuppressive drugs may affect
deficiency may also produce physeal closure (170,172), the con- growth by differentially decreasing rates of cellular multiplica-
dition may correct spontaneously with an appropriate diet. Care- tion in the physis (163). The central portion of the physis is the
 Chapter 5: Physea! Injuries and Growth Arrest 109

most sensitive, and a cone-shaped epiphysis develops. This is

similar, if not identical, to the changes seen with vascular and
metabolic abnormalities.

Cold Injury (Frostbite)

Skeletal abnormalities after cold injury to the hands of growing
children are complex and unique (174-200). Premature closure
of the phalangeal physes is believed to result from direct injury
to vulnerable chondrocytes in the cartilaginous physis (195) or
from ischemic vascular changes (I 78, 182, 191,197). Children of
intermediate age (5 to 10 years) appear most susceptible, proba-
bly owing to a combination of carelessness and decreased adult
supervision. Radiographic signs of physeal closure become evi-
dent 6 to 12 months after cold exposure, and follow a parrern
of decreasing frequency from the distal to the proximal physes
(Fig. 5-25). The index and little fingers are most often involved,
FIGURE 5·23. Physeal arrest associated with temporary arterial impair-
followed by the ring finger and the middle finger (176). The
ment. At age 13 months, this girl with congenital dislocation of the thumb metacarpal, prorected by the surrounding thenar muscles
right hip had an open reduction, complicated by severing of the com- and the proximi ty of the radial artery, is rarely involved (61,187).
mon femoral artery. Multiple arterial anastomotic grafting procedures
were successful in saving the extremity. A progressive asymptomatic Presenting complaints are joint pain, stiffness, and weakness of
right ankle varus developed. This coronal tomogram at age 2 + 6 shows fingers. Late sequelae include relative shortening of digits, skin
premature partial closure of the distal tibial physis. Further documenta- redundancy, joint laxity, and degenerative joint changes (184,
tion of this case is provided in Peterson HA. Premature physeal arrest
of the distal tibia associated with temporary arterial insufficiency. J 190,200).
Pediatr Orthop 1993; 13: 672-675; with permission. The radiographic changes are characteristic. Usually, the phy-
sis disappears completely, resulting eventually in a shorr finger.

FIGURE 5-24. Physeal arrest associated with neural in-

volvement. A: A 4 + 3-year-old boy with congenital insen-
sitivity to pain. The left tibia is 22 mm shorter than the
right and has premature physeal closure at both ends.
The poorly visualized proximal tibial physis and exuber-
ant metaphyseal bone, as well as the deformity and
compression of both tali and os calcis, are typical of this
entity. B: Coronal tomogram of distal tibia shows central
physeal bar without the usual indistinct physis and exu-
berant metaphyseal bone (see proximal left tibia). The
A patient was treated with bar excision.
110 General PrincipLes

FIGURE 5-25. Physeal arrest due to cold. An 11-year-old boy 1 year after frostbite complains of swelling
and tenderness of finger joints accentuated by activity. Radiographs show absence or malformation of
the epiphyses of 12 finger phalanges and irregularity of corresponding articular surfaces. The thumbs
are normal clinically and radiographically. (From Wenzl JE, Burke EC, Bianco AJ. Epiphyseal destruction
from fros1bite of the hands. Am J Dis Child 1967; 114: 668-670; with permission.)

The physis and epiphysis often have a V shape. There may be [age is more sensitive to irradiation and cold than articular carti-
no obvious destruction of the epiphysis, but eventual prematllre lage, it may also be more sensitive to heat (207). The peripheral
fusion of part of the epiphyseal line may lead to angular defor- zone of Ranvier, being more superficial, is more readily subject
miry. The affected phalanges are shoner and smaller than nor- to the effects of heat (3). Prolonged ischemia of soft tissues
mal, and the juxtaarticular bone is expanded and irregular, with around the physis might impair physeal growth, or the restrictive
a coarse cancellous spongiosa. The same expanded and irregular or strangling effect of thick scar about the metaphysis and adja-
appearance is seen on the contiguous articular surface of the cent joint areas might inhibit physeal growth (175,202,205).
more proximal phalanx, where there is no epiphysis (3).
In children, there is a striking lack of correlation between the Electrical Injuries
extem of initial soft tissue injury and eventual skeletal changes.
Many patients do not seek medical attention for the initial in- Physeal arrest caused by electrical mjury, possibly including
jury. The relative absence of soft-tissue ischemic changes, com- lightning, is rare (208-212). Multiple factors determine the ef-
bined with late evidence of physeal damage, supporrs the hy- fects of electric current on chondro-osseous tissue: the rype of
pothesis of direct cellular damage to physeal carrilage as the likely current (alternating current is three to four times as dangerous
etiologic mech,illisrn (190). as direct current), voltage, amperage, duration of contact with.
Very few children require surgical trcatmenr (184). When rhe electric current, the parh raken rhrough the body, rhe resis-
deformities do require treatment, physeal arrest, arthrodesis, an- tance at the points of contact and exit, and the patient's general
gular osteotomy, soft tissue arthroplasry, or tenorrhaphy can be state of health (209). During electrical accidents, tissue tempera-
performed as indicated (175,189). Function of the hand, how- tures may momentarily reach several thousand degrees Celsius
ever, generally remains satisfactory without surgelY. and may cause heat-induced liquefaction and necrosis of carti-
lage and bone. In general, the tissues offering the greatest resis-
tance to tissue Flow suffer the greatest damage. Electrical injury
Heat Injury (Burn) may result in cell death or may alter cellular activiry temporarily
The mechanism causing physeal damage in severely burned or permanently (210). After electrical accidentS, rissue repair,
limbs is not well understood (3,201-207). Because physeal cani- including callus formation, is poor.
 Chapter 5: PhyseaL !njuries and Growth Arrest 111

Osseous changes in children are similar to those in adults bur bridges after fracture. Care must be tal<en when using lasers near
may also include additional abnormalities secondary to the effect physes in growing children (Fig. 5-26).
of the current on the physeal cartilage (211) The epiphyseal
center and physeal cartilage may be affected by the current, and
the metaphyseal region remodels poorly. Partial premature arrest Stress Injuries
of the distal femur has been reported (208). There are only two Widening and Irregularity
reponed cases of excision of physeal bars caused by an electrical
burn (212). Widening and irregularity of rhe physis without accompanying
displacement of rhe epiphysis have been recognized as "stress-
induced" changes in adolescent athletes (214-232). These char-
acteristics are common in the distal radial and ulnar physes of
Laser Injuries
elite gymnasts and often are bilateral (214,217,218,221,224,
A laser beam applied directly to physeal cartilage damages the 229-231). Stress injury of the distal radial physis also occurs in
cartilage selectively withour affecting the adjacent bone (213). a significant percentage (up to 25%) of none lite gymnasts (223,
The damaged physis is replaced by bone, which forms a bone 224). These lesions initially involve the volar aspect of the radial
bridge between the metaphysis and epiphysis identical to bone epiphysis and subsequently the entire physis. In about 20% of

FIGURE 5-26. Physeal arrests from laser injury. At age 5 + 6 years,

this girl had warts removed from the opposing sides of the left
dominant ring and long finger at the level of the distal interpha-
langeal joints. The parents report that the procedure was aggres-
sive and that the wounds took 3 to 4 months to heal. Physical
therapy aided in regaining joint motion. Progressive angulatory
deformity occurred. At age 6 years 2 months, corrective closing
wedge osteotomies on the middle phalanges were performed and
internally fixed with internal wire. Angulatory deformity recurred.
A: By age 10 years 9 months, there is deformity and relative short-
ening of both distal phalanges. The distal phalanx of the long
finger has a physeal bar on the ulnar side, and increasing angula-
tory deformity is anticipated. The distal phalanx of the ring physis
finger developed a bar on the radial side that caused deformity
of the distal phalanx. This physis is now completely closed, and no
further deformity or growth is anticipated. B: Normal right ring
and long fingers. C: Clinical appearance both hands (age 11 years
A,B 4 months).

c
112 Gel/era! Principles

patients, similar changes are present in the distal ulnar physis. intermittent and sustained, have been shown to injure chondro-
Similar changes involve the physes of the distal femur (226), cytes (227).
proximal tibia (219), and distal fibula (226) in adolescent run- A single episode of stress or injury could result in occult
ners, and in the proximal ulna (222) and rhe proxjmal humerus microscopic fissures within the physis, which could, in time,
in baseball pitchers (220,221) and racket spons (216). The proceed to widening of the physis and irregularity of the oppos-
changes are typically unilateral when they are associated with ing bone margins of the metaphysis and epiphysis. Bright and
throwing or racker sportS. colleagues (80) reported that histologic examination of the tibiae
of rats loaded to 50% failure energy revealed internal cracks
within the physis. These cracks appeared in all layers of the
Signs and Symptoms cartilage but were most common in the hypertrophic zone. Sub-
Patients describe pain localized to the site of the involved physis. sequent growth of the cartilage resulted in widening of the phy-
Symptoms usually develop during training and become more sis. Thus, the initial radiograph would be normal, but a subse-
intense as the workout progresses. Initially, the pain is relieved quent radiograph 2 to 3 weeks latet may demonstrate
by rest. Clinical examination reveals painful limitation of ex- radiographic changes within the physis.
t1'emes of motion ar rhe affected sire. Tenderness is localized to
the line of the physis. Treatment
The treatment of stress injuries is symptomatic and consists of
Radiographic Changes reduction or temporary cessation of the activity that created the
injury. It may take up to 6 months for the patient to become
Radiographs show evidence of widening of the physis and irregu- asymptomatic. An increased prevalence of ulnar positive variance
larity and sclerosis of the metaphysis without accompanying dis-
in gymnasts can be attribured to premature closure of the distal
placement of rhe epiphysis (Fig. 5-27). In patients with long- radial physis. Surgical arrest of the distal radius and ulna has
standing symptoms-implying continued activity-premature
been used for bilateral irregular closure of the distal radial physis
physeal arrest may occur (215,218,225). Growth arrest has nor
(215). There are no reports of bar excision for rhis problem.
been described at sites other than the distal radius.
MRJ has suggested metaphyseal and epiphyseal ischemia of
the physis (223) Ot metaphyseal injury (232). Longitudinal Compression (Salter-Harris
Type V)
The Salter-Harris type V classification (28,233-245) proposes
Etiology
that a single, sudden, longitudinal force applied to an immature
Most authors assume that these changes are due to repetitive bone can compress the physis sufficiently to kill rhe cartilage
shearing or compressive stresses, as might occur with vaulting growth cells without causing fracture of adjacent trabecular or
or floor exercises. However, traction stress, as could occur with cortical bone. Radiographs at the time of injury do not show
the uneven and parallel bars, is also possible, especially in gym- osseous abnormality. The diagnosis is suspected only months to
nasts who use dowel grips (231). Most gymnasts compete in all years later, when growth arrest becomes manifest. Salter and
events. In skeletally immature athletes, the growth plate is weal<er Harris's original drawing shows partial arrest with subsequent
than the ligaments, joint capsules, and bone about rhe joint, angular deformity. Their illustrative case (28,29) does not in-
so stresses are focused in the physis. Compressive forces, both clude the initial normal radiographs but does show a healed

FIGURE 5-27. Stress injury of the physis. Persistent wid-

ening and irregularity of the distal radial physis in a 13-
year-old female elite gymnast. A year earlier, right wrist
pain resulted in radiographs that showed similar but
less severe changes. Treatment consisting of cast and
rest resulted in improvement of both pain and radio-
graphic appearance. Return to competition resulted in
present picture. Earlier radiographs of this patient were
published in Ruggles DL, Peterson HA, Scott SG. Radial
growth plate injury in a female gymnast. Med Sci Sports
Exerc 1991 ;23: 393-396; with permission.
 Chapter 5: Pj,ysetli !r(jllrie~' and CroIL·th Arrest 113

proximal tibial fracture with many features of their type IV frac- Iatrogenic Injuries
ture (displacement and angulation of the medial condyle only).
Surgical Insults
Examples of this compression injury are rare in rhe literature.
Most cases are recorded as pan of a series with no individual In a sense, several of the above-mentioned "other physeal inju-
details; there are a few case reportS (233-236,238,245). When ries," such as those caused by cast application, traction, radiation,
details of individual cases are given, invariably it is an associated the prescribing of drugs (metabolic), and the use of laser can be
nonphyseal fracture in the extremity that has been treated by considered iatrogenic, or physician induced. The ones discussed
immobilization, cast, or traction; thus, disuse and possible arte- here (253-274) are primarily problems related to surgery. During
rial impairment are also present. In addition, in all reportS, the the treatment ofdeformity, fracture, infection, or tumor, the phy-
arrest was complete, not panial, as depicted by Salter and Harris, sis may be damaged. Subperiosteal dissection extending to the
furrher implicating the possibility of disuse or arterial insuffi- perichondrial ring of Ranvier may result in premature closure of
Ciency. that area ofthe physis. It also may be impossible to avoid the physis
during curettage of infected tissue or tumors, corrective osteOt-
omy for malunion or deformity (261,265,270,274), or internal
fixation ofphyseal fractures. Each of these procedures can damage
Developmental Physeal Abnormalities a physis sufficiently to affect growth and should be avoided when
Deformities of the proximal tibia (Blount) (246,247) and distal possible. Injury of the periphery of a physis is more likely to result
radius (Madelung) (250,251) appear to result from gradually in physeal arrest than is an insult to its center (3).
progressing physeal and epiphyseal abnormalities that may even-
tually result in partial physeal arrest (248). These conditions are Transphyseal Pins
never noted at birrh, and the etiology is unknown. Multiple factors determine whether the presence of a pin or pins
A bracket epiphysis or delta phalanx may be noticeable at across a physis will affect growth (256,271): the presence or
birth, is therefore most likely congenital, and responds well to absence of threads, the pin's obliquity to the physis, the pin's
excision of the physeal bar (252). location in the physis (central or peripheral), the number and
Preexisting bone deformity may predispose the patient to size of pins, and the amount of time the pin is left in place.
physeal fracture (249). In addition, premature physeal arrest may Usually, a single, smooth, small pin perpendicular to the center
occur at any physis at any age with no apparent etiology (04), of the physis, left in place a short time (e.g., 3 weeks), does not
although this is rare. result in physeal closure. There are exceptions (Fig. 5-28). Of

A B
FIGURE 5-28. Physeal arrest from transphyseal pin. This boy with clubfoot was treated in infancy by
serial casting. A: At age 4 + 5, he underwent osteotomy of all five metatarsals. The osteotomy of the
first metatarsal was 1 em distal to the proximal physis. The single. smooth 0.062 Kirschner wire was
perpendicular to and in the center of the proximal physis of the first metatarsal. B: Eight years after
surgery, the right proximal first metatarsal physis is closed; the length of the right first metatarsal is 53
mm, and the left metatarsal is 74 mm.
114 ;erteral Prine;pies

FIGURE 5-29. Physeal arrest from traction pin. This 11 + 6-year-old girl has developed left genu recurva-
tum following proximal tibial skeletal traction for a distal femur fracture 3 years 6 months previously
(age 8 + 0). Lateral x-ray studies of both knees showed that there is 20 degrees recurvatum of the left
proximal tibia. There is a physeal bar of the left anterior tibial tubercle.

all of rhese facrors, rhe presence of rhreads is mosr likely [0 resulr PHYSEAL ARREST
in physeal closure. The presence of a uacrion pin across, or even
close [0 a physis, is sometimes associared wirh subsequem physeal
Etiology
closure, panicularly in rhe proximal tibia (Fig. 5-29) 006,254). PI'emarure complere physeal arresr produces bone-kngrh rerar-
Whether the growth arresr is secondary [0 rhe pin or is an occulr darion with no angular deformity (275-281). If the physis ar
physeal injury associared wirh diaphyseal fracture is unknown. each end of rhe bone is arresred, rhere is no growth ar all.
Premarure panial arresr of growth of a physis rcurds bone
lengthening and may cause progressive angular deformiry of rhe
Staples involved bone. The arresr is produced when bone forms from
Sraples are commonly used ro retard longitudinal growrh or [0 metaphysis ro epiphysis, crossing the physis. This conrinuity of
conecr angular bone growrh (255,263,273). If rhey are left in bone is known as a bone bar or a bone bridge. As rhe remaining
place [00 long, they can cause permanent arrest (257). Of equal physis grows, angular deformity occurs (Fig. 5-31). The sire,
concern is the occasional peripheral bar that forms afrer sraple size, locarion, and duration of rbe bar derermine rhe clinical
removal (Fig. 5-30) (264). deformiry. If the bar is locared laterally in a pbysis-for example,
rhe distal femur-rhe normal physis medially conrinues ro grow,
producing genu valgum deformity (278-281). If rhe bone bar
Other Iatrogenic Insults is anrerior, the normal physis grows posreriorly, producing genu
recurvarum (Fig. 5-29) (254). If the bar is central, rhe periphery
Drilling across a physis is rarely done. The larger and more
numerous the drill holes, the greater the likelihood of physeal may grow, causing cupping, rcnring, or dip ddurmiry of rhe
arresr (259,260,262,269). However, drilling across the disral meraphysis, combined with relarive shonening of rhe bone bur
femoral and proximal tibial physes for anterior cruciate repair liule, if any, angular deformity (Figs. 5-21B and 5-23) (167,
has nor resulred in premarure arrest (253,267,268), probably 260,275,276).
because the drill hole is filled wirh a substance (rendon or foreign Bone bars may resulr after any injury [Q physeal cells. The
material) rhar acrs much like an interposirion marerial used for most common cause is fracture, although bars may occur afrn
bar excision. The mean growrh of the proxima,1 ribial physis of mher rypes of physeal damage [e.g., disuse, radiation, infecrion,
24 children [l'eated wirh an uncemented sliding tibial compo- rumors, vascular abnormalirics; iatrogmic injuries (see previous
nent rhar crossed rhe physis perpendicularly was 69% of rhar of secrion)]. For some bone bars, no ctiology is apparem; rhcsc
rhe contralateral normal side (258). have been calJed congenital or developmemal (e.g., from Bloum-
 Chapter 5: PbySNtI fUJlI/'ie; alld Growth A rl'fst 115

FIGURE 5-30. Physeal arrest associated with staple removal. A: Or-

thoroentgenogram. A 10+ 11-year-old girl with right spastic hemi-
paresis. Twenty-one months previously, staples were placed in the
normal left distal femur and proximal tibia, resulting in overcorrec-
tion of 11 mm (the normal left lower extremity is 11 mm shorter
than the right). The staples were removed at this time. B: Thirteen
months later at age 12 + 0, there was progressive left genu varum
relative shortening (the left lower extremity is now 23 mm shorter
than the right). Two coronal tomograms of the left knee confirm
physeal bars on the medial side of both the distal femur and the
proximal tibia. Note increasing distance between the tracts from
the tines of the staples on the lateral side of the distal femur and
proximal tibia and no increase in this distance on the medial side.
Note that the angles of the tine tracks laterally are parallel, and
medially are converging. Also note growth arrest line of the distal
femur, with growth present laterally and not medially. Therefore,
A these medial arrests had to occur at time of staple removal.

FIGURE 5-31. Physeal arrest following transphyseal fracture.

Left: A 3 + 7-year-old boy sustained a Salter-Harris IV fracture of
the distal tibia with proximal displacement of the medial malleo-
lar fragment. Treatment was cast immobilization without reduc-
tion. Right: Same child 22 months later (age 5 + 5). Note physeal
bar medially, growth arrest line perpendicular to longitudinal axis
of the tibia, asymmetric growth of remaining normal physis, pro-
ducing a 45-degree varus angulation of the physis, and adaptive
contouring of the lateral edge of the tibial epiphysis, allowing
ankle varus to be less than the physeal varus. There is normal
growth of the fibula (not overgrowth). The cartilaginous medial
malleolus is unossified. Long-term follow-up of this case has been
published in Peterson HA. Operative correction of post-fracture
arrest of the epiphyseal plate: case report with 10-year follow-up.
J Bone Joint Surg Am 1980;62·1018-1020; with permission.
116 General Principles

Barber syndrome). However, bone bars have never been reponed ro become clinicaHy manifest. Any bone bar in an infanr or
ar birrh. young child, however, is a significanr problem wirh wide-ranging
Any fracrure rhar involves rhe physis may resulr in a bone clinical effecrs. Long clinical follow-up is mandarory in rhese
bar. Posrrraumaric bars resulr from damage ro rhe germinal or children.
paJisading layer of physeaJ cells. The physeal cell damage proba-
bly occurs ar rhe rime of injury, bur ir may occur during fracrure Assessment
reduction (closed or open), or ir may be associared wirh imernal
fixarion. Bone bars can be anricipared afrer comminured rype Clinical Examination
TV and VT injuries and, if rhey are followed closely, rhey can be Bone bars are usually firsr noted clinically because of rhe angular
derccred as early as a few weeks afrer rhe injury. Some bone bars defOl'miry or relarive shorrening of the involved exrremiry
do nor become clinically evidem umi! years afrer the injury, (282-311). The history, physical examinarion, and rourine ra-
underscoring rhe need ro follow any significanr physeaJ injury diographs localize rhe involved physis. ClinicaJ evaiuarion of
for years, if nOr unril maruriry. This is parricularly rrue after limb-Iengrh discrepancy, angular deformiry, joim morion, and
meraphyseal osreomyeliris (Fig. 5-21). funcrional impairmenr should be recorded. Radiographs of the
appropriare body area musr be raken in ar leasr (WO planes,
Anatomic Factors usually coronal and sagirral. The relarion of the growrh-arrest
line, rhe physis, and rhe joinr surtlCe needs close scruriny (Fig.
Anaromic differences in rhe various physes also are imporram 5-31) (50,295,302,303). Much can be learned from good-qual-
in rhe producrion of a bone bar. Facrors include rhe size of rhe iry plain radiographs. Depending on rhese findings, addirional
physis, irs rare of growrh, and rhe conrours of rhe physis (rhar studies become appropriare.
is, wherher rhe physis lies on one plane or is irregular). Alrhough
physes of rhe phalanges and disraJ radius are by faJ rhe mOSr
Imaging Studies
frequenrly injured (33,36,38), rhey are small and uniplanar, and
are an uncommon sire of a bone bar. In conrrasr, rhe physes of Skeletal Age
the proximal ribia and disral femur are large and irregular in Skeletal age musr be determined in older children ro assess rhe
conrour (multi planar), and accounr for 60% ro 70% of rhe porenrial for remaining growrh. There mUSr be enough growrh
growrh of rheir respecrive bones. Togerher, rhey accounr for remaining (2 years or 2 cm) ro make rhe option of bar excision
only 2.2% of aJI physeal injuries (Table 5-2) (36,38,281), bur worrhwhile. Comparison of a radiograph of rhe hand wirh an
rhey are responsible for 50% of rhe bone bars requiring rrearmenr adas is rhe most commonly used (291,309).
(Table 5-3).
Leg-Length Measurements
Both rhe involved and rhe uninvolved exrremiry are measured
Influence of Age clinically, and rhe lengths are documemed by radiographs. Three
The parienr's age ar rhe rime of physeal injury is perhaps rhe radiographic merhods are in common use: releoroenrgenogra-
paramoum factor. Injury of rhe physis of a 14- or 15-year-old phy, orrhoroenrgenography, and scanography.
girl or a 16- or 17-year-old boy is of lirrle consequence because A releoroenrgenogram (293) is a single tadiograph raken from
rhey have so lirrle growrh remaining rhar deformiry is unlikely a disrance grear enough (usually 6 feer) ro reduce magnification
and ro include aJllong bones of each extremiry. Ir has rhe disad-
vanrage of magnificarion, which increases as rhe child grows,
making serial evaJuarion less precise.
An orrhoroenrgenogram (290) is a mulriple-exposure radio-
TABLE 5-3. PHYSEAL BRIDGE RESECTION graph designed ro obtain a srraighr projecrion rhrough each joinr
of rhe exrremiry ro obviare magnificarion. Ir has the disadvanrage
No. % of recording an incorrecr lengrh if rhe child moves be(Ween
exposures. AddirionaJ films are necessary ro assess aJignmenr.
Distal femur 61 34
A scanogram (308) uses an x-ray rube in lineal' morion wirh
Distal tibia 51 29
Proximal tibia 29 16 a slir diaphragm. Any movemenr by the parienr is derecred by
First metatarsal 5 3 morion. It includes all osseous strucrures so rhar any angular
Proximal femur 2 1 deformiry or bone abnormality can be derecred (Fig. 5-22B).
Distal fibula 2 1 There is no magnificarion. The film can be measured direcdy
Proximal phalanx, great toe 2 1
Distal radius 15
wirh a tape measure, and rhus can be remeasured if rhere is any
8
Distal ulna. 5 3 discrepancy wirh rhe clinicaJ findings. These rrue measuremenrs
Proximal humerus 3 2 may be compared wirh previous and future scanograms in longi-
Phalanges 2 1 rudinal srudies. The quaJiry of film derail is sufficienr so thar no
Metacarpal 1 0.5 addirional coronal view is necessary ro assess alignmenr; rhis
Pelvis (triradiate) 1 0.5
178 100 reduces expense. Scanograms are superior ro orher merhods, wirh
rhe only disadvamage being rhe modificarion of radiographic
equipmenr (306,308) (Figs. 5-15A and 5-30A).
 ()'r/prl:'r )". Ph)'sl'lll II/juries flild Grouch Arrl'.\I 117

A B
FIGURE 5-32. Metal markers using Kirschner wires. A: Close-up of a scanogram 5 months after bar
excision and insertion of Cranioplast in a girl, now age 5 + 4, whose preoperative radiographs are shown
in Figure 5-21. The physis is open, and the two metal markers inserted at the time of bar excision are
now 28 mm apart. The Cranioplast plug is close to the proximal marker and to the physis. B: Close-up
of scanogram 4 years postoperatively. Both femora had grown 9.8 cm; thus, growth of this femur is
100% of the contralateral femur. The metal markers are 83 mm apart, indicating 55 mm of growth
from the distal femur since A. The use ofthe scanogram obviates any magnification of distances between
markers. Angulation between the Kirschner wires is unchanged. The femoral shaft-femoral condyle
angle has improved from 63 degrees to 64 degrees. Note that the plug initially stayed with the epiphysis,
as evidenced by the increased distance of the plug from the proximal metal marker (compare with A).
Later, the epiphysis grew away from the plug, as evidenced by the increased distance of the plug from
the distal marker (compare with A). The ultimate distance between the markers was 110 mm. This case
was illustrated more completely in Peterson HA. Partial growth plate arrest and its treatment. J Pediatr
Orthop 1984;4:246-258, with permission.

Scanograms, having no magnification, become even more tours of the bar. Tomographic techniques include linear, circu-
valuable when analyzing growth berween rwo metal markers after lat, ellipsoidal, spiral, and hypocycloidal (306). The latter rwo
treatment (Figs. 5-22B, 5·32A,B and 5-33A,D,H) and mal<e are termed multi planar (Fig. 5-34). False-positive and false-nega-
more elaborate techniques such as stereophorogrammetry (286) tive findings have been reponed with standard uniplanar romog-
unnecessary. raphy. Thin (l-mm) multiplanar romograms raken every third
Additional methods of documenting bone length, including millimeter in rwo planes, usually the coronal and sagittal, are
CT scan, MRI, and microdose digital radiography (282,306), used ro construct a map of the physis as if it were laid out on
are not commonly used because of their COSt, poor osseous detail, a flat surface (287). The contours and area of both the bar and
or alteration oflengrh (roo long or roo shon) on the film, requir- the entire physis can then be determined. Because of the multiple
ing rhe rechnician ro derermine loci for measuring rhe length views required, the amount of radiation exposure is high (289)
ar the time of film procurement (306). Usually, films by these and the mapping is time-consuming and subject ro interpreta-
techniques cannot be measured direcrly by ruler. tion errors.

Localization of the Bar CT Imaging. CT images are difficult to make in coronal and
A documenting image (map) of rhe location, area, and contours saginal projections because of difficulry placing the body pan
of the bar is essential in determining rhe feasibiliry of bar excision in the gantry. When possible, CT scans in an axial projection
and the surgical approach. Several merhods are available, includ- show the bridge, although less clearly than multiplanar tomo-
ing romography, CT, scintigraphy, and MR!. grams (Fig. 5-35). The curs are thicker and fewer in number,
making map determination less precise than with multiplanar
Tomography. Until recenrly, tomography was the most com- romography. CT scans made in the transverse plane are difficult
monly used method of evaluating the location, extent, and con- ro interprer because of normal undulations of the physis, with
118 (;meral Principles

A,B c
FIGURE 5-33. Bar recurrence successfully treated by
bar reexcision. A: 5canogram of a girl age 4 + 7 who
had a febrile illness with swelling of the right knee in
infancy. The right leg is 35 mm shorter than the left
(femur - 19 mm, tibia -16 mm). B: Coronal tomogram
depicts bars of both distal femur and proximal tibia. C:
At the time of excision of bars and insertion of Crani-
oplast at both sites, metal markers (half of a silver vascu-
lar clip) were inserted in the center, longitudinal to each
other. The distance between the femoral markers is 17
mm and between the tibial markers 18 mm. A third
marker in the distal femur was inserted too far periph-
eral, laterally, thereby decreasing its value for measur-
ing future longitudinal growth. With growth and bone
remodeling, it became extraosseous, negating its value
as a marker. At the time of surgery, a marker was also
placed in the mid left contralateral normal tibia, which
provided useful information in assessing growth and
recurrence later. 5canograms at 6 months showed the
right leg to grow faster than the left leg (2 years 3
months postoperatively, the leg-length discrepancy had
decreased from 35 to 23 mm, and the growth of the
right leg was 121 % of the normal left). 5ubsequently,
there was progressively less growth. D: 5canogram 4
years 8 months postoperatively (age 9 + 3) shows contin-
ued growth of both operative areas (metal markers far-
ther apart) but with a progressive reduction in the rate.
During the previous 6 months, the right femur grew 15
mm, the left 17 mm, 88%; the right tibia 12 mm, the
left 14 mm, 86% for this interval. Overall growth of the
right leg since surgery is now 102% of the uninjured
left leg. E: Close-up of D shows femoral markers 78 mm
and tibial markers 52 mm apart (total growth 95 mm).
The Cranioplast plugs stayed in the metaphyses. They
did not migrate; rather, the epiphyses grew away from
them. Although the metal markers in the proximal tibia
were continuing to become farther apart, much of the
growth of the tibia was distally, as determined by com-
parison with the metal marker in the normal mid-left
tibia. This caused suspicion of a developing recurrent
bar. The lateral peripheral marker in the femur (arrow)
is now nearly extracortical because of diaphyseal re-
D,E modeling.
 Chapter 5: Physeallnjl~ries and Growth Arrest 119

F,G H
FIGURE 5-33. (continued) F: Coronal tomogram confirms recurrent bar formation in both the tibia and
femur. Note diminished cupping compared with Figure 5-33B. G: Repeat bar excision of both the proxi-
mal tibia and distal femur was performed at 9+5 years. Note clear visualization of remaining physes
of both bones. H: Scanogram at age 11 + 8 years, 7 years after first surgery. The femoral markers are
109 mm apart, and the tibial markers are 72 mm apart. All physes are closed. There has been no surgery
on the left leg and no osteotomies or lengthening on the right leg. The right leg is 26 mm shorter than
the left (femur -15 mm, tibia -11 mm). Growth of the right femur from the time of original surgery
was 14.5 cm on the right, 14.1 cm on the left (the operated right femur grew 103% compared with the
normal left). The operated right tibia grew 12.3 cm, and the left tibia grew 11.8 cm (the right tibia grew
104% compared with the left). An orthoroentgenogram sent from home at age 12 + 10 showed that
the total leg-length discrepancy was 21 mm (compared with 35 mm preoperatively). All physes were
closed, and no further treatment was recommended. There was no surgery on the normal left leg. This
case illustrates the need to follow patients continuously (6-month intervals) until maturity because bar
formation can recur at any time. Scanograms are indispensable for accurate measurement of both total
bone length and distance between markers. Placement of a metal marker in the contralateral unoper-
ated bone is the only way to determine accurately the relative growth of the operated physis and its
ipsilateral physis (same bone, other end) compared with the two physes of the contralateral bone. The
bar recurrence was successfully treated by bar reexcision. At completion of growth, growth of the
operated right leg exceeded growth of the normal left leg by 14 mm. This case was illustrated in Peterson
HA. Partial growth plate arrest and its treatment. In Morrissy RT, ed. Lovell and Winter's pediatric
orthopaedics, 3rd ed. JB Lippincott, Philadelphia, 1990.1071-1089.

FIGURE 5-34. Physeal arrest visualized by to-

mography. A: An 11 + 4-year-old boy sustained a
type V fracture of the distal radius 3 years earlier.
This coronal 1-mm-thick trispiral tomogram
shows significant deformity and growth alter-
ation, but no physeal bar. B: A cut 3 mm away
reveals a large physeal bar. It is difficult to envi-
sion a transverse (T scan in any plane that would
add information about the location, size, or con-
tours of this bar. (From Peterson HA. Partial
growth plate arrest. In: Morrissy RT, ed. Lovell and
Winter's pediatric orthopaedics, 3rd ed. JB Lippin-
cott, Philadelphia, 1990: 1071-1089; with permis-
A,B sion.)
120 G'eJll'l"f/! Pril'/('/ple.\

A B

c
FIGURE 5-35. Physeal arrest visualized by (T scans. A: Plain radiograph of an 11 + 4-year-old boy 4
months after an undisplaced type V fracture illustrates a medial bar. The growth arrest line is wider
laterally. B: Tangential coronal views of the ankle obtained by flexing the knee maximally in the gantry.
This (T scan gives no additional information compared with the plain radiograph or tomograms. C:
Transverse (T scan through the distal tibia. The physis is not visualized on any cut. The physis and bar
are poorly defined despite the fact that this should be an ideal situation (a relatively even-contoured
physis with minimal deformity caused by the bar). (From Peterson HA. Partial growth plate arrest. In:
Morrissy RT, ed. Lovell and Winter's pediatric orthopaedics, 3rd ed. JB Lippincott, Philadelphia,
1990: 1071-1089.)
 C/JajJlt'I' 5: PlIJSM/ fnjl/ries a"d (j'rowth Arrest 121

increased contour irregularity produced by the bar and its ac- ume. The result is a true anatomic image based on volume data
companying physeal COntour abnormality. The entire physis can (voxels), depicting only the physis and the physeal bar, and does
rarely, if ever, be caprured on one cur. The adjacent normal not depend on a technician rendering each image. Technician
juxtaphyseal bone sclerosis can easily mimic a bony bridge. In time is needed only to outline the periphery of the physis and
{he 1980s, CT scanning had no advantage over multiplanar to- of the bar with a computer mouse.
mography or MRl and were sometimes misleading (288,301, In comparing three-dimensional renderings and three-di-
307,310,311). The recent advent of helical computed tomogra- mensional projections, the results were similar but were more
phy has significantly improved the images so that they are now precise using three-dimensional projection. Three-dimensional
superior to tomography and rival MR imaging (299). projections are less expensive because technician interpretation
and special sof[Ware ate unnecessary. In all patients who under-
Scintigraphy. Scintigraphy, using technetium, a pinhole colli- went surgery, the bar found surgically, matched the illustration
mator, and a gamma camera aimed axially toward the epiphysis, on the image.
has been used to assess physeal bars (286,294). It can be used We have found the projection method to be the most reliable,
only when there is no bone intervening be[Ween the epiphysis safe, cost-effective, and least time-consuming method, and we
and the camera-for example, the distal femur with the knee now use it exclusively for physeaJ bar evaluation (304).
flexed. All other physes would have iurervening bone, making
the technique inapplicable. The computer-generated maps are Management
imprecise (306).
Complete Arrest
Magnetic Resonance Imaging. Adaptation of MRl for evalua- Premature complete closure of a physis causes cessation of
tion of physeal bars (301,307,310,314,315,322) has several ad- gtowth at that physis (312-346). Because the physis is com-
vantages. The images are of excellent quality, and there is no pletely closed, there is no progressive angulat deformity. Contin-
radiation (as for tomograms and CT scans). Acquisition time uing growth of the contralateral physis produces length ineqi.lal-
averages 8 minutes, and sedation is usuaJly not necessalY. Thin ity be[Ween the [WO bones involved. The amount of inequality
cutS can be assembled contiguously in any plane from the origi- is determined by the physis injured (specifically, its conttibution
nal computerized data. These produce images clearer than recon- to the growth of that bone) and the patient's age at the time of
structed CT images. The data can be processed to depict the growth cessation. In older children with Iinle growth remaining,
entire physis (and its bar) on one plane, despite contour irregu- no treatment is required, In younger children, consideration for
larities caused by the bar. This precludes the laborious and less treatment depends on the specific physis injured and the amount
accurate mapping (287) (which can also be done on the multiple- oflength discrepancy calculated to be present at maturity. Treat-
cut MRl images). Two computerized techniques are available. ment options include a shoe-lift for lower limb discrepancy,
physeal arrest of the contralateral or companion (radius/ulna
Three-DimensionaL Rendering. A computer-generated illustra- or tibia/fibula) bone, ipsilateral bone lengthening, contralateral
tion is formed by loading sagittal or coronal images from an bone shortening, or a combination. Because no physis remains,
orthogonal series into a computer work-station that courains bar excision and physeal distraction are not options.
rendering sof[Ware (the program ANALYZE is an example)
(283). Each image is processed (rendered) manually by the tech-
nician, defining the physis (this may take several hours of techni- Upper Extremity Physes
cian time). The rest of the image (bone and all soft tissue) is Complete arrest of the proximal humerus physis rarely results
then discarded. A series of sectional images of the physis is pro- in sufficient discrepancy to produce functional impairment. If
duced. The computer combines successive images into a rhree- the discrepancy exceeds 6 cm, bone lengthening may be consid-
dimensional model. When this three-dimensional model is ered (142). The contralateral humerus should never be arrested
viewed in an axial plane, the result is a physeaJ map with a defect or shortened.
corresponding to the physeal bar (Fig. 5-12C). The computer Complete arrest of the physes of the proximal radius or ulna
can determine the number of pixels in the entire physis and in likewise never causes sufficient forearm length discrepancy to
the bar, so that the bar can be calculated as a percentage of the consider physeal arrest of the contralateral forearm. Arrest of the
entire physis (Fig. 5-11C). distal radial physis at a very early age could cause sufficient distal
radial-ulnar variance to consider arrest of the distal ulnar physis,
Three-DimemionaL Projection. A computer-generated image can ulnar shortening, or even radial lengthening. Because much
also be formed from a fat-suppressed three-dimensional volume greater length occurs from the distal ends of these bones than
acquisition in the axial plane (283,304) (Fig. 5-36). Slice thick- from the proximal ends, postinjury arrest of the distal end of
ness may be as thin as 0.7 mm (skip 0, up ro 60 slices total). either is often treated by surgical arrest of the other or by length-
This three-dimensional information is processed on the MRl ening of the involved bone.
console, using maximum-intensity projection image-analysis
sof[Ware used in MR angiography (standard sof[Ware for all insti-
Lower Extremity Physes
tutions performing MR angiography). No manual segmentation
of the physis is required. The clarity of the result is improved In the lower extremities, limb-length inequality causes pelvic tilt
by excluding surrounding soft tissues from this projection vol- and spine curvature, which predispose the patient to low back
122 Gmeral Prillciples

A B

c D
FIGURE 5-36. Physeal arrest visualized by MRI. An 8-year-8-month-old-boy injured his right knee jump-
ing on a trampoline. A: He sustained a displaced type III fracture. B: Treatment was closed reduction
and percutaneous pinning. C: Two years /I months later (age 11 +0). the right femur was 32 mm shorter
than the left and there was absence of the central portion of the distal physis. Note growth arrest lines
on the proximal and distal tibia and the distal left femur but not the distal right femur. 0: Coronal MR
image shows what appears to be multiple central physeal bars.
 Chapter 5: Physel11 11ljuries and Growth Arrest 123

E G

FIGURE 5-36. (continued) E: Projection MRI shows the

distal femur and patella cartilage (gray) and central bone
(black). This volume acquisition obviates contour abnor-
malities ofthe physis and depicts structures as a flat single
plane surface. This is not a transverse cut. Thus, it is not
necessary to determine the precise longitudinal level (as
for a (T scan). The dense white images are vascular struc-
tures. F: The technician has outlined the entire physis with
a computer mouse (white line). This technique is much
more sensitive than other techniques, and the bars have
been found to be much more irregular than had been
previously thought. The irregularity of these two bars ac-
counts for the appearance of multiple bars on the coronal
MR images (0). G: The technician has outlined the medial
bar with the computer mouse. The number of voxels in
the bar compared with the entire physis is 6.3%. The lat-
eral bar measured 3.6% for a total bar of 9.9%. Note
position of the bars compared with position of the
F crossed pins on Figure 5-35B.

pain. Arrest of the capital femoral physis at a young age (e.g., be undertaken as an elective procedure, because any significant
from hip dysplasia, Perthes' disease, trauma, avascular necrosis, surgical tibial shortening will result in weakness of the anterior
or even slipped capital epiphysis) can result in significant femoral tibialis muscle and footdrop.
length discrepancy. Surgical arrest of the contralateral capital
femoral physis is not warranted because of its surgical inaccessi- Partial Arrest
bility and potential for avascular necrosis. It would be more
approptiate to have the patient wear a shoe-lift, atrest the contra- Treatment Alternatives
lateral distal femoral physis at a later date, or lengthen the ipsi- Premature partial closure of the physis can be treated in many
lateral femur at times determined by growth chatts Ot at matu- ways (280,331-333). If the patient is a teenager approaching
rity. maturity and little growth remains in the involved physis, no
Complete premature attest of a distal femoral physis can be trearment may be necessary. If the patient is young with signifi-
treated by permanent use of a shoe-lift, physeal arrest of the cant growth remaining, borh length discrepancy and angular
contralateral femoral physis, femoral lengthening, or contralat- deformity may occur. Management may require a combination
eral femoral shortening at maturity. The choice depends on the of modaliries.
degree of calculated discrepancy at maturity and the body height 1. Shoe-life. This is applicable when a lower extremity bar is
and desires of the patient. central and causes no angular deformity and the leg-length
Complete arrest of the proximal or distal tibial physis can be discrepancy is expected to be minor at maturity (2.5 cm or
treated similarly to the distal femur, with the addition of physeal less). This is the only effective nonoperative treatment and
arrest of the ipsilateral fibula if significant relative overgrowrh was used extensively for centuries before the advent of mod-
of the fibula is likely. Contralateral tibial shortening should never ern surgery.
124 GeneraL PrincipLes

2. Arrest of the remaining growth of the injured physis. This Bone shortening on the contralateral side may be considered if
should be considered in an older child with a beginning or all physes are closed or the child is nearing maturity. Bone short-
progressive angular deformity when limb-length inequality ening should be considered only for the femur, because shorten-
will be minor (lower extremity) or of relatively little func- ing of the tibia is usually accompanied by uncorrectable muscle
tional consequence (upper extremity). weakness, especially of foot dorsiflexion. Lengthening of the
3. Arrest of the remaining growth of the injured physis and femur or tibia, or repeated lengthenings, may be considered for
the physis of the adjacent bone (forearm and lower leg). discrepancies of 4 to 5 em or more. The patient's anticipated
4. Arrest of the remaining growth of the injured physis, the height at maturity is a factor in all of these instances.
physis of the adjacent bone if one is present, and the corre- Arm-length discrepancy results in functional impairment
sponding physis or physes of the contralateral bone or only when the discrepancy is extreme. Discrepancies of 10 em
bones. or less are best left untreated. Surgical shortening of the contra-
5. Open or closed wedge osteotomy to correct angular defor- lateral upper extremity has never been reported and, to the au-
mity without operative arrest of the remaining normal phy- thor's knowledge, has no application. Lengthening of the hume-
sis (336,337,346). In a young patient, the untreated bone rus (142) and forearm has been reported but carries potential
bar would reproduce angular deformity after osteotomy. morbidity and should be done only by surgeons with experience
Osteotomy can be repeated several times before attainment in the procedure.
of full growth if this method is used alone. Some final rela- All of the above-mentioned treatment options have been used
tive shortening of the involved bone should be expected. in the management of physeal bars and should always be consid-
6. Lengthening of the involved bone. ered. However, excision of the bar, when successful, may negate
7. Shortening of the contralateral or companion (ulna or fi- the need for the other modalities and their potential morbidity.
bula) bone. If excision is unsuccessful, the other options can still be used.
8. Excision of the physeal bar and insertion of an interposition
material (see later).
9. Fracture of the bone bar by physeal distraerion using an
Treatment by Bar Excision
external distractor, with or without excising the bar
(316-318,325,330,334). This has been done successfully Experimental Studies
on small bars in optimal locations. The procedure can be In animal studies, several investigators created a physeal bar,
combined with correction of both angulation and length allowed the bar to develop, excised the bar and inserted an inter-
discrepancy, but it should be done only in older children position material, and then sacrificed the animal to observe the
nearing maturity because the procedure is likely to result result (347-356). Although the results have varied, there has
in complete closure of the physis (312,321). been enough success to confirm that a bar can be successfully
10. Transplantation of an epiphysis and physis from another excised and growth reestablished. Interposition materials used
bone to fill the defect following resection of a bar. Many include bone wax, fat, cartilage, silicone rubber, and polymethyl-
experiments using various strategies have been performed, methacrylate. When no interposition material was inserted, a
with varying success (313-315,319,320,322,323,326-329, bone bar promptly reformed (269,356). Because of variables in
335,338-345) In humans, in addition to problems of vas- rhe experiments, it is difficult to determine superiority of one
cularity, growth, and tissue rejection, a major obstacle is interposition material over another.
the availability of a suitable, dispensable donor physis. With Because cartilage is the damaged tissue, cartilage would seem
ongoing advances in microvascular techniques and tissue to be the ideal interposition material. Possible sources of cartilage
rejection problems, this method might be considered in the are another physis, an apophysis such as the iliac crest, and a
future, but is now not clinically applicable. laboratory-procured chondrocyte allograft transplant (347,
11. Combinations of the above-mentioned procedures. It is un- 352-354). There are technical difficulties procuring and insert-
usual for a patient to be treated optimally with only one of ing another physis. Apophyseal cartilage may not have the same
the above-mentioned modalities. Even when bar excision growth potential as epiphyseal cartilage. Chondrocyte allograft
allows several inches of longitudinal growth, some other transplants require initial cartilage procurement, followed by lab-
modality, such as a shoe-lift, closure of the contralateral oratory time for the cartilage matrix to develop. Immune re-
physis, or osteotomy to correct angular deformity, is often sponse problems might occur if the material is transferred from
beneficial. one human to another. Nevertheless, as cartilage is the damaged
tissue, cartilage would be the ideal interposition material. It is
Functional Considerations hoped that more investigations will solve this problem in the
Leg-length discrepancy of 2.5 em or less usually causes little, if near future.
any, functional impairment or low back pain and can be left A load-sharing interposition material, such as polymethyl-
untreated, or a shoe-lift can be used on the short side. Leg-length methacrylate, may be superior in resection of large bars in
discrepancy anticipated to be 2.5 to 5 em at maturity can be weight-bearing areas (351).
managed by arrest of growth of the contralateral bone if the A study in rabbits (356) suggested that re-formation of a bar
child has sufficient growth remaining to correer the discrepancy. after excision can be inhibited by the use of oral indomethacin
 ChfJjJter 5: Physeal Injllries (]nd Growth Arrest 125

without the use of an interposition matetial. Indomethacin pro-

duces a nonspecific inhibition of osteoblastic activity that is trig-
gered by ftacture Ot poswperative inflammation. No clinical trial
o THE AUTHOR'S CLASSIFICATION

using oraJ indomethacin in conjunction with bar excision in In 1984, I grouped physeaJ bars into one of three types based
humans has been reported. Whethet indomethacin can be given on location and contour: (a) peripheral, (b) elongated, and (c)
in sufficient doses in humans to prevent the bone bat from re- cenrral (333). Subsequently, Bright (1) and Ogden (3) classified
forming without inhibiting normal bone growth remains to be these as types I, II, and III, although they used the terms linear
seen. or longitudinal instead of elongated.

Clinical Experience (357-385) Preferred Surgical Approaches

The first bone bar in a human was reported in 1967 by
I approach peripherally located bars directly from the periphery
Langenskiold (374), who described a 15-year-old boy with genu
(fig. 5-37). I am careful to excise the periosteum overlying the
recurvatum secondary to a bone bar in the anterior proximal
bar to prevent subsequent bar re-formation. Under direct vision,
tibia; the etiology was unknown. The bone bar was excised, and
the bar can then be removed until normaJ physis is visible on
the space was filled with autogenous fat. During the 1.5-year
all sides of the cavity (Fig. 5-37B). I find that opticalloupes are
follow-up, the angle of genu recurvatum improved by 10 de-
helpful and ordinary surgical light is satisfactory. The bone bar
grees, but there was no documentation of longitudinal growth.
is then removed initially using an osteotome, curet, and rongeur.
Longitudinal growth was first documented in the distal tibia
The final exposure of the normal physis is done more precisely
of a 5-year-old boy in 1968 (381). During a 10-year follow-up,
with a motorized bur. This aJlows excellent visualization of the
rhe involved tibia grew 16.7 em. Sheet Silastic and Gelfoam
physis and removal of as little metaphyseal bone as necessary,
were used as interposition materiaJs. and facilitates contouring of the cavity in the physis. The hear
generated by the bur has no apparent deleterious effect on the
Interposition Materials viability of the remaining physis.
Fat (361,368,369,371-374,384,385), bone wax and fat (212, An elongated, linear, or longitudinal, bar extends completely
252), Silastic (349,350,360,365,384), methylmethaClylate (375, across the physis and is common after Salter-Harris IV fracture
376), and Cranioplast (331-333,367,377-381) are the most (Fig. 5-38A,B,C). I first carefully evaJuate these bars with MRJ
popular interposition materials, but too few patients have been maps to determine the surgical approach and to ensure complete
followed to maturity to determine superiority of one interposi- removal of the bar. Headlamp light to illuminate the depth of
tjon material over the others. the excision is beneficial and is preferable to optic loupes.
fat has the distinct advantage of being autogenous. Centrally located bars have normaJ physis peripherally and
Langenskiold used buttock fat because of its more firm and an intact perichondrial ring of Ranvier (Fig. 5-39A). I almost
globular consistency. Fat has the disadvantage of a lack of hemos- always approach these bars through the metaphysis by removing
tasis in the resected cavity. When the tourniquet is released, fat a window of corrical bone and cancellous metaphyseal bone to
expose the bar from inside out (Fig. 5-40; Fig. 5-39B). This
tends to float out of the cavity. Closing periosteum over the
preserves the perichondrial ring of Ranvier. Again, headlamp
cavity to comain the fat predisposes the patient to new bone
light hete is extremely helpful. Mter removaJ of the entire bar,
formation peripheraJly. This is undesirable because it tends to
I am careful to inspect normal physis circumferentiaJly in the
tether growth again. The operative defect weakens the structute
of the bone, and a cast is used to protect a weight-bearing bone
from fracture (385). When fat grafts work well, the intraopera-
tive cavity enlarges as the bone (and fat graft) grow (368,369).
Poswperative fracture has been reported (368).
Silastic (l ,349,350,360,365,384) has many properries similar
to Cranioplast but has not been used since its withdrawal from
commercial markets by Dow Corning in 1987.

lIP AUTHOR'S PREFERRED

\....~ TECHNIQUE OF TREA MENT

The objectives of surgicaJ excision of a bone bar are to remove the

bar completely and to preserve as much of the normal remaining
physis as possible. This requires knowledge of surgical anatomy FIGURE 5-37. Peripheral bar shown in AP view (above). transverse sec-
(358) and careful preoperative evaJuation and planning. The tion through physis (below). A: With map of bar composed from MRI.
B: Bar exposed by direct approach. (Redrawn from Peterson HA. Partial
excision may be difficult if the bar is irregular or the epiphyseal! growth plate arrest and its treatment. J Pediatr Orthop 1984;4:246-258;
metaphyseal complex is deformed (Fig. 5-34). with permission.)
126 Gmeml Principles

FIGURE 5-38. Elongated bar extending from anterior to posterior sur-

faces. Although these three bars have the same appearance as the an-
teroposterior view (above), they have different contours and areas on
transverse orientations (below). To achieve complete bar removal with
retention of as much normal physis as possible, the bar in B would
be optimally approached posteriorly, and that in panel C anteriorly.
(Redrawn from Peterson HA. Partial growth plate arrest and its treat-
ment. ) Pediatr Orthop 1984;4:246-258; with permission.)

FIGURE 5-40. AP radiograph of distal femur of an 11 + O-year-old boy

taken at time of bar excision to document desired depth of bur, removal
of bar, and presence of remaining normal physis. Previous radiographs
of this patient are shown in Figure 5-36.
caviey. I have found that using a small (5 mm in diameter) dental
mirror (Fig. 5-39C) makes this easier.
Other authors have reponed modifications of this basic tech-
nique. Some use an operating microscope to aid visualization
of the bar (212,252,370,371,373). Ultraviolet visualization of 41C) (3). I am concerned thar the protruding physis would be
rerracycline-Iabeled bone in rabbits has been reponed to allow deprived of its blood supply and more of the physis would have
complete excision of experimentally created physeal arrests while been removed than necessary.
minimizing excision of normal physis (382). [ have not found
these modifications to be necessary and have no personal experi-
ence with them. Metal Markers
I place metal markers in the metaphysis and the epiphysis to
allow accurate radiographic measuremenr of subsequenr growrh
The Final Cavity (Fig. 5-42). These metal markers in the metaphysis and the
I always cry to make the sides of the caviey flat and smooth (Fig. epiphysis also help differentiate overgrowth of rhe physis at the
5-41A). Enlarging the caviey in the epiphysis may encourage the other end of the bone, which may falsely enhance the result. I
inrerposition material co remain across the physis, but I have try co place these markers carefully in cancellous bone, not in
not found rhis feature [Q enhance results (Fig. 5-41 B). Care contact with the cavity, because they might become attached co
must be taken not to weaken the epiphysis, predisposing it to the inrerposition material, or if fat is used, they might migrate
fracture. I do not undermine the metaphyseal and epiphyseal inro the caviey. I am also sure to place them in the same longitu-
bone away from the physis, as advocated by Ogden (Fig. 5- dinal plane proximally and distally to the defect. A position in

FIGURE 5-39. Central bar as seen anteroposteriorly (above)

and transversely (below). A: Bar in center with growth periph-
erally results in cupping or tenting of the physis. B: Excision of
central bar through window in metaphysis. C: Visualization of
the entire physis using a dental mirror. (From Peterson HA.
Partial growth plate arrest and its treatment. ) Pediatr Orthop
1984;4:246-258; with permission.)
 Chapter 5: Physeallnjuries and Growth Arrest 127

FIGURE 5-41. Contour of cavity. A: As normal physis is exposed,

a smooth surface helps to identify and visualize the physis. B: Bone
of the epiphysis may be undermined in an attempt to allow the
plug to stay with the epiphysis as the bone grows in length. If this
is done, a small rim of epiphyseal bone (arrow) should be pre-
served to maintain viability of the physis. C: Undermining bone
away from the physis may improve visualization of the physis but
will deprive it of its blood supply. (Redrawn from Peterson HA.
Partial growth plate arrest and its treatment. J Pediatr Orthop
1984;4:246-258; with permission.)

rhe cenrer of rhe bone is preferable because eccenrric markers so that no postoperative immobilization is necessary; and there
may become exrraosseous due ro growrh and meraphyseal re- are no apparenr side effects. I find it especially useful to suppOrt
modeling. Any metal marker will do; half of a vascular clip, the epiphysis after excavation of a large bar (351,385).
srainless sreel, or silver was commonly used in early cases. Trans- In a caviry that is graviry dependent, I pour the Cranioplasr
versely orienred Kirschner wires (K-wires) parallel wirh each in a liquid state. If rhe caviry is not in a dependent position, I
other and with rhe pl1ysis, one in the metaphysis and one in rhe place the Cranioplast in a syringe and push it inro the defect
epiphysis, allow accurate assessmenr of angular growrh (Fig. 5- through a shorr polyethylene tube (Fig. 5-43A). A1ternarively,
32). Tiranium Kirschner wires avoid arrifacr on subsequenr MRJ I may allow [he Cranioplast ro set parrially and rhen push ir
evaluarion. At presenr, lO-mm lengths of Titanium 0.062 K- into the defect like putry. As little CraniopJast as possible should
wires are used. be allowed ro remain in the metaphysis. After the Cranioplast
has set, the rest of the metaphyseal caviry is filled with previously
removed cancellous bone (Fig. 5-43B).
Preferred Interposition Material Misundersrandings concerning methylmethaClylate are re-
lated to terminology. Pure methylmethacrylate, or Cranioplast,
Next, I place the inrerposition marerial inro rhe caviry. The
was first produced in 1927. It has been used for over five decades
objecr is ro fill rhe caviry ro prevenr blood from occupying rhe
caviry, organizing, and re-forming a bone bar. by neurosurgeons to repair skull defects and has been found to
I prefer Cranioplast as an inrerposition material because of be an inerr and safe material. When used as an isolated subsrance,
irs sevet'al advanrages. It is easily available and inexpensive, rhere it has caused no rejection, infection, or neoplastic change (362).
is no Food and Drug Administration (FDA) conrrol (as for $i- Its thermogenic properties are minor, as evidenced by rhe neuro-
lastic), and no second incision is needed (as for fat). It is lighr, surgical practice of pouring ir in a semiliquid form directly on
easy ro handle and mold, rhermally nonconductive, and radiolu- dura and brain tissue before setting. It is also radiolucent.
When ini tial results from roral hip arrhroplasry revealed pros-
cenr. Borh the liquid (monomer) and the powder (polymer) are
thesis loosening, a search for a bone cement was underraken.
sterile as packaged and can be mixed in the operating room. It
is unnecessalY to take cultures. It provides hemosrasis because Cranioplasr was found to work well, but the radiolucenr properry
made subsequent loosening difficult ro derect. Barium was added
it occupies the emire desired ponion of rhe caviry; it is suong,
to the merhylmethacrylate. This achieved radiopaciry, but it de-
creased the sercing rime and increased the exothermic property
significantly. Thus, the material thar is now generally referred
to as merhylmethaclylare is, in fact, Cranioplasr wirh barium

B c
FIGURE 5-42. Metal markers. A: Metal markers are placed in cancel-
lous bone of the epiphysis and metaphysis, away from the interposition B
plug, longitudinally oriented to each other and as close to the center
of the bone as feasible. B: A plug that stayed with the epiphysis as the FIGURE 5-43. Insertion of Craniopiast. A: Only enough Cranioplast is
physis grew away from the proximal marker and the growth arrest line. inserted, here shown by use of a syringe and catheter, to bridge all
e: A plug that stayed with the metaphysis as the physis grew. The plug physeal surfaces. B: The remainder of the defect is filled with bone
has not migrated. (Redrawn from Peterson HA. Partial growth plate chips harvested at the time of exposure. (Redrawn from Peterson HA.
arrest and its treatment. J Pediatr Orthop 1984;4:246-258; with permis- Partial growth plate arrest and its treatment. J Pediatr Orthop 1984;4:
sion.) 246-258; with permission.)
added. This rype of methylmethacrylare is undesirable as an Postoperative Infection
inrerposirion material for bar excisions because of its radiopaciry
Postoperarive infecrion can occur, as in any orthopaedic surgery.
and possibly because of its exorhermic properry. The radiopaciry
However, in rhe author's experience, it has occurred only in rhree
obviates detection of recurrenr bar formation.
parienrs in whom rhe original cause of rhe bar was infection. This
infection is chronic and requires debridemcnr and antibiotics
like other bone infections. Once rhe infection is cleared, bar
Osteotomy management proceeds using any of rhe previously discussed
Mild angular deformiry secondaty ro peripheral bars may correcr methods.
sponraneously wirh growrh after excision of the bar. Angular
deformiries of more than 20 degrees will probably not correct Follow-Up
sponraneously and usually require osteoromy (212,336,337).
This can be done at the same rime as bar excision, or later. Reexcision May Be Necessary. Follow-up until maruriry is es-
sential. Reestablished physeal growrh may cease at any time.
Recurrent bar Formation has been successfully treated by reexcis-
Postoperative Care. Posroperatively, jf Cranioplast is inserted
ing rhe bar (Fig. 5-33) (331,364,367). If a bat re-forms near
and no osteotomy is performed, no cast or other immobilizarion
maturiry or if the entire physis ceases growing on rhe injured
is necessary. ]oinr motion and weight-bearing are encoutaged on
side earlier than its contralateral counterpart (a fairly common
the day of operation, or as soon as operative discomfort subsides.
finding), physeal arresr on the contralateral side may be consid-
ered.

COMPLICATIONS Scanograms
Bar Re-formation Scanograms (305,306,308) are the most precise way 1'0 measure
the increasing distance between the [wo metal markers (Fig. 5-
The major complication of bar excision is bar re-formation. Al-
33A,D,H). As the child grows, lengrh and circumFerence of the
though this may occur after excision of a bar of any size, in any
exrremity increase, allowing magnification of the distance be-
location, and at any sire, it is more likely ro occur wirh large
[Wecn the markers on regular roentgenograms, teleoroentgeno-
bars (those that occupy 50% or more of the entire physis). A
grams, and orrhoroelltgenograms. This magnification falsely en-
recurrenr bar may form at any rime, ea.r1y or late, after initial
hances the result. Scanograms have no magniflcarion. They can
excision. If it occurs soon after excision and significant growth
be measured and remeasurecl directly on the film by tape mea-
remains, the recurrent bar can be reexcised with some hope of
sure. They also show any deformiry or other abnorma.liry of the
success (Fig. 5-33F,G,H). More commonly, when bar formation
entire bone.
occurs, it occurs near the completion of growth, which under-
Tr is suspected rhat the physis on the opposite end of an
Scores the need for careful foHow-up (see the nexr section). Bar
injured or operated bone somerimes overgrows to compensare
re-formation signals a less-than-desirable outcome but does nor
for any damage at the other end (364). Alrhough the amount
preclude application of all orher rypes of bar management (see
of growth of bone attributable to each physis has been fairly
earlier) .
well established (for example, distal femur, 70%; proximal tibia,
60%; distal tibia, 40%), the only way to determine precisely the
amoul1f and percentage of growrh conttibuted by each physis
nhealthy Physis of a bone after bar excision, compared with its contralateral
In addition to the size of rhe bar and the adequacy of bar re- member, is to place a single metal marker in the diaphysis of
moval, other factors rhat may be associated with bar re-formation the normal conttalateral bone. This has been found valuable
are the patieJl['s health and the rare of growth of rhe physis ar in determining comparative growth, which aids in finding bar
rhe time of excision. A prorocol for using growth hormone afrer recurrence (Fig. 6-33D and H).
bar excision to enhance the short-term growrh acciviry was used
in one parient with equivocal results.
RESULTS

Technical Errors Assessing results is difflculr becausc so many facrars are involved.
When the procedure works well, it is most gratifying and may
Other complicarions of bar excision are primarily rechnical. be the onJy procedure needed. This renewed growrh may dimin-
Fracture of rhe medial portion of the disral tibial epiphysis has ish the angular deformity and the rate of progression of limb-
been noted after roo-generous removal of epiphyseal bone of a length inequaliry; occasionally, there may even be reduction of
medial distal tibial bar. A referral case, in which a large bar had the length inequaliry (e.g., the treated limb grows faster than
been complerely replaced wirh bone wax, resulted in recurrent rhe normal limh; Fig. 5-33A and H).
rranscutaneous extrusion of small bits of wax uncil rhe wax was Only patients followed to maturiry should be included in
entirely surgically removed. any reporred series. Some operated physes, aJthough growing
 Chapt{'/' 5. Phpl'fll Injuri"J find Growth Arr(."sr 129

well afrer rhe procedure, close earlier rhan rheir conrralareral grows more rhan rhe normal side) somerimes occurs, but parents
physes. Thus, in some parienrs, surgical arresr of rhe conrralareral should nor be led to believe rhat it will. There were 37 osreotO-
physis is performed roward rhe end of growrh ro negare addi- mies ro correct angular deformity, performed eirher concomi-
rional discrepancy. This approach favorably influences rhe resul r rantly wirh the bar excision or later. Forry parients had epiphysi-
expressed as a percenrage. odeses of rhe contralareral bone or of rhe adjacenr bone in rhe
case of rhe lower leg. Thirreen parients had lengrbenings of the
involved bone. Eighteen recurrenr bars were reexcised.
Fifty Percent Rule Of rhe 43 distal femoral lesions, 30 were in boys and l3 in
Excision of bars consriruring 50% or more of rhe enrire physis girls. The interval between injulY and bar excision was 2.8 years.
usually fail (Q resrore sarisfacrory longirudinal growrh. Bars more The average age ar rime of bar excision was 10.5 years. The area
rhan 50% of rhe physis may be excised in very young children of rhe bar was more rhan 45% in 11, less rhan 30% in 12, and
because rhe alrernarives are undesirable, because rhe procedure less rhan 30% in 20. The sire of the lesion was medial (13),
occasionally works, and because if rhe procedure is unsuccessful, lareral, cenrral (LO), posrerior (9), and anterior (6) (some lesions
all orher merhods of management can srill be used. occupied more rhan one locus). The opera red side grew 78%
as much as the normal side. Addirional procedures included
epiphysiodesis (23), osteoromy (11), and lengthening (9). There
The Mayo Clinic Experience were nine recurrenr bars and rwo infecrions (rhe cause of rhe
From 1968 through 1996, 178 patienrs were rreared by bar bar in rhese rwo was osteomyelitis).
excision at the Mayo Clinic (Table 5-3). Bar formarion was at Of the 18 proximal ribial lesions, nine were found in boys
rhe knee (disral femur and proximal ribia) in 50% of rhe cases, and nine were found in girls. The incerval berween injuly and
whereas these sires accounr for only 2.2% of all physeal injuries surgelY W;l,S 2.1 years. The average age ar rime of surgery was
(Table 5-2). This dispariry is explained by rhe anaromy of these 11.7 years. The area of the bar was more rhan 45% in rwo
physes. Their undulations and irregulariries in multiple planes parienrs, more rhan 30% in one parienr, and less than 30% in
insulare rhem from injury, bur when injury occurs, rbe same 15 parients. The site of arresr was cencral (6), lareral (5), medial
undularions predispose rhe patienr ro damage of rhe growth (4), anterior (4), and posterior (1) (some lesions occupied more
layer of rhe physis. All operarions were performed by four sraff rhan one locus). The average growth of the operared side was
pediarric orrhopaedisrs, wirh lirrle variarion in rechnique. Crani- 88% of the uninjured side. Additional procedures include oste-
oplasr was used for rhe inrerposirion marerial in 153 parienrs, oromy, epiphysiodesis (9), and lengrhening (3). There were rwo
far in 23, merhyl merhacrylare in 1, and sheer Silasric and Gel- recurrences and one infection (rhe cause of the bar in rhis case
foam in 1 (381). was osreomyelitis).
In 98 parienrs followed ro maruriry, rhe average growrh of Of rhe 37 distal ribial lesions, 26 were in boys and 11 were
rh.e opera red side was 84% of thar of the unoperated side. The in girls. The interval berween injury and surgery was 1.9 years.
average was 78% for rhe disral femur, 88% for rhe proximal The average age ar rime of surgery was l1.1 years. The area of
ribia, and 93% for the disral tibia (Table 5-4). the bar was more rhan 45% in rhree patients, more than 30%
Th.irreen of rhese 98 patients (13%) had no accompanying in four parients, and less rhan 30% in 30 parienrs. The site of
surgery. Adjuncrive surgelY in the remaining 85 parienrs (87%) the bar was medial (14), anrerior (0), central (5), posrerior (5),
was usually performed for lengrh discrepancy and angular defor- and lateral (3). The average growth was 93% of thar of the
miry exisring before rhe bar excision, which did nor correct even conrralateral nonoperared side. Addirional surgery included oste-
wi th a successful bar excision. Resumption of normal growrh oromy (15), physeal arrest (8), and lengthening (I). There were
thar StopS progression of angular deformiry and length discrep- 7 recurrent bars, 2 fractures, and no inrcctions.
ancy is a successful ourcome of bar excision. Improvement of From this dara, ir can be seen rhar rhe more disral the lesion,
angular deformiry and lengrh discrepancy (the operated side the better the result (Table 5-4). The overall resu]r, expressed

TABLE 5-4. RESULTS OF 98 MATURE CASES

Growth" Average Age Time Bar Area c Bar Area c Central

No. (%) (Vrs) Interval b (Vrs) >45% <45% Bars

Distal femur 43 78 10.45 3 11 (26) 32 (74) 10 (23)

Prox tibia 18 88 11.66 2.1 2 (11} 16 (89) 6 (33)
Dist Tibia 37 93 11.1 1.9 3 (8) 34 (92) 5 (14)

a Growth = % of growth of operated vs. contralateral non-operated physis

b Time lapse = interval between injury and bar excision
, Bar area = area of bar expressed as a percentage of entire area of physis. Number is number of cases. () = percentage of cases
130 General Principles

as a percentage of growth of the contralateral normal physis, Historical Review

improves as the site progresses distaJly and correlares direcrly 5. Foucher JT. De la divulsion des epiphyses. Cong of Med de France
with the percentage of lesions smaller than 45% of the physis. 1963 (Reprimed in English in Gin Orthop 1984; 188:3-9.); 1:63-72.
FactOrs favoring the distal tibia were the shorr rime interval 6. Poland J. Traumatic separation of the epiphpes. London: Smirh.
between injury and bar excision, the few larger lesions (8%), Elder & Company. 1898. (Portions reprinred in Clin Orthop 1965),:
7-18.
and the many smaller lesions (92%). FactOrs contriburing to rhe
less saris factOry resulrs in rhe disral femur include the long rime
inrerval, rhe greater number of large lesions (26%), rhe fewer
smali lesions (74%). Classification
There was no correlation of result with gender or locarion 7. Airken AP. The end result of rhe fracrured disraJ ribial epiphysis. j
of rhe bar within rhe physis. However, several specracular results Bone joint Surg 1936; 18:685-691.
were obrained in cenrral bars, and the presence of an inracr 8. Airken AP. Fracrures of rhe epiphysis. Clin Orthop 1965;41 :19-23.
9. Airken AP, Ingersoll RE. Fracrures of rhe proximal ribial epiphyseal
cartilage ring of Ranvier is believed to be beneficial. carrilage.] Bone ]oilll Stllg Am 1956;38:787-796.
10. Airken AP, MaGill Ht<. Fracrures involving rhe disral femoral epiphy-
seal cartilage. .J Bone joiul Surg Am 1952;34:96-108.
Interposition Material Removal II. Cass JR, Pererson HA. Salrer and Harris Type IV injuries of rhe disral
ribial epiphyseal growrh plare wirh emphasis on rhose involving rite
The criteria for the subsequent removal of il1terposirion marerial medial malleolus . .J Bone joint Surg 11m 1983;65: 1059-1 070.
or for bone grafring of defects left by fat have nor been escab- 12. Chadwick C]. Bendey G. The c1assillcarion ancl prognosis of epiphy-
lished. If the physis grows away from the inrerposirion material, seal injuries. Ii/jUlY 1987; 18: I 57.
rhe material becomes locared in rhe meraphysis or diaphysis. As 13. Chaclwick q, Bendel' G. Chadwick and Bendel' c1assillcarion ofdisral
the meraphysis remodels, rhe inrerposirion marerial, alrhough ribial growrh plaIt: injuries. In: Uhrhoff Nt<. Wiley H, eds. Behavior
ofthe growrh plLtte. New York: Raven Press. 1988;105-110.
remaining rhe same size, occupies a grearer proportion of rbe 14. Dias LS, Tachdjian MO. Physeal injuries of rhe ankJe in children:
transverse plane of the shafr of rhe bone (compare Figs. 5-33C c1assiflcarion. Gin Orrhop 1978; 136:230-233.
and E). This may predispose the bone 1'0 parhologic fracrure and 15. Johnson EW. Fahl Jc. Fracrures of rhe disral epiphysis of rhe ribia
has done so in one parienr afrer rhe Cranioplasr was removed. In and Ilbula in children. Am j Surg J 957;93:778-781.
16. Johnsron RM. Jones WW. Fracrures rhrough human growrh plares.
one parient, remodeling of the cortex allowed the Cranioplast
Or/hop Trans 1980;4:295.
to extrude and become exrraosseous. Patienrs should be advised 17. Kling TF. Managemenr or ph)'seaJ injuries. In: Chapman M\XI. ed.
that the interposition material may have to be removed in rhe Operative orthopaedics. 2nd ed. Philadelphia: ]B Lippincorr, 1993;
future. All Cranioplast plugs have been embedded firmly in the 3035-3049.
bone. There has been no loosening, such as occurs when methyJ- 18. Lerts RM. Compression injuries of the growth plate. In: UhrhofTHK,
Wiley H. cds. Behavior of the growth plLtte. New York: Raven Press.
methacrylare is used with a prosthesis. In the few that have been 1988;111-118.
removed, histOlogic evaluation revealed only a thin surrounding 19. Ogden JA. Injury to rhe growrh mechanism of the immarure skclclOn.
layer of fibrous tissue and no unroward reaction. The material Skeletal RadiolI981;6:237-253.
is not easily removed, and usuaJly a thin area of surrounding 20. Ogden JA. Skclcral growth mechanism injlny parterns . .J Pcdiatr 01'-
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22. Peterson HA. Disral tibial triplane fractures. In: Heckman JD. ed.
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ACKNOWLEDGMENTS 23. Pererson HA. Physeal ri'acrures: parr 2. Two previously unclassified
rypes . .J Pediatr Orthop 1994;14:431-438.
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273. Siffert RS. The effect of staples and longitudinal wires on epiph}'scal
growth. An experimental study.] Bone joint Surg Am 1956;38: 1077-
Developmental Physeal Abnormalities 1088.
274. Stcedman ]T, Peterson HA. Brachymetatarsia of th~ first m~tatarsal
246. Beck CL, Burke SW, Roberrs JM, Johnston CEo Physeal bridge resec- treated by surgical lengthening. ] Pediair Orthop 1992; 12:780-
tion in infantile Blount disease.] Pediatr Ouhop 1987;7:16l-163. 785.
247. Bradway JK, Klassen RA, Peterson HA. Blount discase: a review of
the English literature.] Pedit/IT Orrhop 1987;7:472-480.
24,'L Cook PA, Yu JS, Wiand W, et at. Madelung deformity in skeletally Physeal Arrest
immature patients: Morphologic assessment using radiography, CT,
Etiology
and MRl.] Comput Assist Tomogr 1996;20:505-511.
249. Takahara M, Sasaki I, Kimura T, et al. Second fr"crure of the distal 275. Barash ES, Siffert RS. The potcntial for growth of experimenrally
humerus afrer varus malunion of a supracondylar fracture in children. produced hemiepiphysis. ] Bone }oil1l Stlig Am 1966;48: I 548-
] Bone joint Slog Br 1998;80:79\-797. 1553.
136 General Principles

276. Caffey J. Traumatic cupping of the meraphysis of growing bones. Am 303. Park EA. The imprinting of nutritional disturbances on the growing
} Roentgenol 1970; 108:451-460. bone. Pediatrics 1964;33:815-862.
277. Friedenberg ZB. Reaction of the epiphysis to partial surgical resection. 304. Peterson HA. Magnetic resonance imaging of growth plates. In: de-
} Bone Joint Surg Am 1957;39:332-340. Pablos J, ed. Surgery of the growth plate. Madtid: Ediciones Ergon,
278. Friedenberg ZB, Brashear R. Bone growth following partial resection SA, 1998;22-28.
of epiphyseal cartilage. Am} Surg 1956;91 :362. 305. Peterson HA. Lerrer to rhe editors.} Pediatr Grthop 1994;14:823.
279. Key JA, Ford LT. A study ofexperimental trauma to rhe distal femoral 306. Peterson HA. Scanning the bridge. In: Uhrhoff HK, Wiley J], eds.
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280. Langenskiold A. Traumatic premature closure of the distal tibial epi- 258.
physeal plate. Acta Grthop Scand 1967;38:520. 307. Porat S, Nyska M, Nyska A, Fields S. Assessment of bony bridge by
281. Peterson CA, Peterson HA. Analysis of the incidence of injuries to computed tomography: experimental model in the rabbit and clinical
the epiphyseal growth plate.} Trauma 1972; 12:275-281. application.} Pediatr Grthop 1987;7: 155-160.
308. Pugh DG, Winkler NT. Scanography for leg-length measurement:
an easy, satisfactory method. Radiology 1966;87: 130-133.
309. Tanner JM, Whitehouse RH, Marshall WA. Assessment ofskeletal ma-
Assessment turity andprediction ofadult height (TW2 methods). London: Academic
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quality by microdose digiral radiographs. } Pediatr Grthop 1987;7: 310. Young JW, Bright RW, Whirley NO. Compured tomography in the
311--316. evaluation of partial growth plate arrest in children. Skeletal Radial
283. Borsa J], Peterson HA, Ehman RL. MR imaging of physeal bars. 1986; 15:530.
Radiology 1996; 199:683-687. 311. Young JW, Bright RW, Whirley NO. The value of CT in the assess-
284. Bright RW. Partial growth arresr: Identification, classification, and ment of partial growth arrests in children. Radiology 1984; 153:
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285. Bylander B, Aronson S, Egund N, et al. Growth disturbance after
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99m-Tc MOP. Acta Radial 1983;24:85-96. cular growth plare transfers. Part I: Investigation of vascularity.} Bone
287. Carlson WO, Wenger DR. A mapping method to prepare for surgical Joint Surg Br 1988;70:305-310.
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288. DeCampo JF, Boldt DW. Computed tomography of partial growth growth plate transfers. Part II: investigation offeasibility.} BoneJoint
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289. Gabel GT, Peterson HA, Berquist TH. Premarure partial physeal 315. Brown K, Marie P, Lyszakowski T, et al. Epiphyseal growth after free
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1968;61:10-15. 317. Connolly JF, Huurman WW, Lippiello L, Pankaj R. Epiphyseal trac-
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Surg Am 1991;73:1234-1241. 319. Cundy PJ, Jofe M, Zuleske OJ, et al. Physeal reconstruction using
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294. Howman-Giles R, Trochei M, Yeates K, et al. Partial growth plare 320. Eades JW, Peacock EE. Aurogenous transplantation ofan interphalan-
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5:109-111. follow-up. } Bone Joint Surg Am 1966;48A:775-778.
295. Hynes 0, O'Brien T. Growth disturbance lines after injury of the 321. Fjeld T, Steen H. Growth retardation after experimental limb length-
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Br 1988;70:231-233. 322. Harris WR, Martin R, Tile M. Transplantarion of epiphyseal plates.
296. Jaramillo 0, LaorT, Zaleske OS. Indirect trauma to the growth plate: } Bone Joint Surg Am 1965;47:897-914.
Results of MR imaging after epiphyseal and metaphyseal injury in 323. Heikel HV. Experimental epiphyseal transplantation. Part II: histo-
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297. Jaramillo 0, Shapiro F, Hoffer FA, et al. Posttraumatic growth plate 324. Hoffman S, Siffert RS, Simon BE. Experimental and clinical experi-
abnormalities: MR imaging of bony-bridge formation in rabbits. Ra- ences in epiphyseal transplantation. Plast Reconstr 5urg 1972;50:
diology 1990;175:767-773. 58.
298. Kumar R, Madewell JE, Swischuk LE. The normal and abnormal 325. Jones CB, Dewar ME. Aichroth PM, et al. Epiphyseal distraction
growrh plate. Radial Clin North Am 1987;25: 1133. monitored by srrain gauges. } Bone Joint Surg Br 1989;71 :651.
299. Loder RT, Swinford AE, Kuhns LR. The use of helical computed 326. Lalanandham T, Ehrlich MG, Zaleske OJ, et al. Viability and metabo-
tomographic scan to assess bony physeal btidges.} Pediatr Grthop lism of cartilage transplamed to physeal regions. } Pediatr Grrhop
1997; 17:356-359. 1990; 10:450-458.
300. Mayer V, Marchisello PJ. Traumatic partial arrest of tibial physis. 327. Nerrelblad H, Randolph MA, Weiland A]. Heterotopic microvascular
Clin Grthop 1984; 183:99. growrh plate transplantation of the proximal fibula: An experimemal
301. Murray K, Nixon GW. Epiphyseal growth plate: evaluation with canine model. Plast Reconstr 5urg 1986;77:814-820.
modified coronal CT. Radiology 1988; 166:263-265. 328. Nerrelblad H, Randolph MA, WeilandAJ. Free microvascularepiphy-
302. Ogden JA. Growth slowdown and artest lines.} Pediatr Grthop 1984; seal-plate transplantation. } Bone Joint Surg Am 1984;66:1421-
4:409-415. 1430.
 Chapter 5: PhyJeal Tnjuries and Growth Arrest 137

329. Olin AO, Creaseman C, Shapiro F. Free physeal rransplantation in using chondrocyte allograft transplants. ] Pediatr Grthop 1987;7:
the rabbit: an experimental approach to focal lesions. ] Bone Joint 381~388.
Surg Am 1984;66:7. 355. Osterman K. Operative elimination of partial premature closure: an
330. Peltonen JI, Karaharju EO, Alitalo I. Experimental epiphyseal distrac- experimental study. Acta Grrhop Scand 1972;147(Suppl):7-79.
tion producing and correcting angular deformities.] Bone Joint Surg 356. Sudmann E, Husby OS, Bang G. Inhibition of partial closure of
Br 1984;66:598. epiphyseal plate in rabbirs by indomethacin. Acta Orthop Scand 1982;
331. Peterson HA. Management of partial physeal arrest. In: Chapman 53:507-511.
MW, ed. Operative orthopaedics, 2nd ed. Philadelphia: JB Lippincott,
1993;3065-3075.
332. Peterson HA. Partial growth plate arrest and its treatment. In: Mor- Clinical Experience
rissy RT, ed. LOlJell and Winters pediatric orthopaedics, 3rd ed. Phila- 357. Alford BA, Oshman DG, Sussman MD. Radiographic appearances
delphia: JB Lippincott, 1990;1071-1089. following surgical correction of the partially fused epiphyseal plate.
333. Peterson HA. Review: partial growth plate arrest and its treatment. Skeletal Radial 1986; 15: 146.
J Pediatr Orthop 1984;4:246-258. 358. Birch JG, Herring JA, Wenger DR. Surgical anatomy of selected
334. Ray SK, Connolly JF, Huurman WW. Oistrarion treatment of de- physes. J Pedz,ltr Orthop 1984;4:224-231.
formities due to physeal fractures. Surg Forum 1978;29:543. 359. Bollini G, Tallet JM, Jacquermier M, Bouyala JM. Case report: new
335. Ring PA. Transplantation of epiphyseal cartilage: an experimental procedure to remove a centrally located bar. J Pediatr Grthop 1990;
study.] Bone Joint Surg Br 1955;37:642-657. 10:662-666.
336. Scheffer MM, Peterson HA. Opening-wedge osteotomy for angular 360. Botte MJ, Sutherland DH, Mubarak SJ. Treatment of partial epiphy-
deformities of long bones in children. Adv Grthop Surg 1995; 19: seal arrest by resection of the osseous bridge and interposition with
16-18. silicone rubber. Grthop Trans 1986;10:457.
337. Scheffer MM, Peterson HA. Opening-wedge osteowmy for angular 361. Broughton NS, Dickens DR, Cole WG, Menelaus BB. Epiphyseolysis
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325-334. ] Bone Joint Surg Br 1989;71:13-16.
338. Spira E, Farin I. Epiphyseal rransplantation: a case report.] Bone]oint 362. Cabanela ME, Coventry MB, MacCarry CS, Miller WE. The fate of
Surg Am 1964;46:1278-1282. patients with methylmethacrylate cranioplasry. j Bone Joint Surg Am
339. Tear L, Bosse Jp, Gilbert A, Tremblay GR. Pedicle graft epiphysis 1972;54A:278-28I.
transplantation. Clill Grthop 1983; 180:206-218. 363. Coleman 55. Physiolysis: resection of premature incomplete fusion
340. Tsai TM, Lugwig L, Tonkin M. Vascularized fibular epiphyseal trans- of the physis. Grthop Trans 1986;10:554-555.
fer. A clinical study. Clin Grthop 1986;210:228-234. 364. Heikel HV. Has epiphyseodesis in one end of a long bone a growlh-
341. Whitesides ES. Normal growth in transplanted epiphysis.] BoneJoint slilIlulating effect on the other end? An experimental study. Acta 01'-
Surg Am 1977;59:546-547. thop Scand 1961;31:18.
342. Wilson IN. Epiphyseal transplantation. A clinical study.] Bone Joint 365. Hume MC, Burstein SM. Silastic implantation after epiphyseal bar
Surg Am 1966;48:245. resection. Orthop Trans 1988;12:151.
343. Wolohan MJ, Zaleske OJ. Hemiepiphyseal reconstruction using tissue 366. Kasser JR. Physeal bar reseclions after growth arrest about the knee.
donated from fetal limbs in a murine model. ] Orthop Res 1990;9: Clin Grthop 1990;255:68-74.
180-185. 367. Klassen RA, Peterson HA. Excision of physeal bars: the Mayo Clinic
344. Zaleske OJ, Ehrlich MG, Piliero C, et al. Growth-plate behavior in experience 1968-1978. Grthop Trans 1982;6:65.
whole joint replantation in the rabbit. J Bone Joint Surg Am 1982; 368. Langenskiold A, Osterman K, Valle M. Growth of far grafts after
64:249-258. operation for partial bone growth arrest: demonstration by CT scan-
345. Zaleske OJ, Floyd WE, Hallet J, et al. Epiphyseal replacement using ning.] Pediatr Orthop 1987;7:389-394.
developing tissue donors in a murine model: A combined hiswlogic 369. Langenskiold A, Videman T, Nevalainen T. The fate oHat transplants
and radiographic study. J Grthop Res 1988;6:155~ 165. in operations for partial closure of the growth plate. Clinical examples
346. Zehntner MK, Jakob Rp, McGaniry PL. Growth disturbance of the and an expetimental study. J Bone Joint Surg Br 1986;68:234-238.
distal radius epiphysis after trauma: Operative treatment by corrective 370. Langenskiold A. Surgical treatment of partial closure of the growth
radial osteotomy. ] Pediatr Grthop 1990; I0:411-415. plate.] Pediatr Orthop 1981; 1:3-11.
371. Langenskiold A, Osterman K. Surgical treatment of partial closure of
the epiphyseal plate. Reconstr Surg Traumatol1979; 17:48.
Experimental Studies 372. Langenskiold A. Partial closure of epiphyseal plate: principles of treat-
ment. Int Grthop 1978;2:95.
347. Barr SJ, Zaleske OJ. Physeal reconstruction with blocks of cartilage 373. Langenskiold A. An operation fot partial closure of an epiphyseal
of varying development time. ] Pediatr Grthop 1992; 12:766-773. plate in children, and its experimental basis. j Bone Joint Surg Br
348. Bright RW. Further canine studies with medical elastomer X7-2320 1975;57:325-330.
after osseous bridge resection for partial physeal plate closure. Grthop 374. Langenskiold A. The possibilities of eliminating premature partial
Trans 1981 ;5:264. closure ofan epiphyseal plate caused by trauma ar disease. Acta Orthop
349. Bright RW. Surgical correction ofpartiaJ growth plate closure. Labora- Scand 1967;38:267-279.
tory and clinical experience. Orthop Rev 1978;8: 149. 375. Mallet J, Rey Jc. Treatment of traumatic partial epiphysiodesis in a
350. Bright RW. Operative correction of partial epiphyseal plare closure child by epiphysiolysis. Int Grthop 1978;1:309.
by osseous bridge resection and silicone rubber implant. J Bone Joint 376. Mallet J. Les epiphysiodeses partielles traumatiques de L'extremite
Surg Am 1974;56:655-664. inferieure du tibia chez l'enfant: leur traitement avec desepiphysiodese.
351. Bueche MJ, Phillips WA, Gordon J, et al. Effect of interposition Rev Chir Grthop 1975;61:5.
material on mechanical behavior in partial physeal resection: a canine 377. Peterson HA. Treatment of physeal bony bridges by means of bridge
model. J Pediatr Grthop 1990; I0:459-462. resection and interposition of cranioplast. In: dePablos J, ed. Surgery
352. Foster BK, Hansen AL, Gibson GJ, et aI. Reimplantatioll of growth ofthe growth plate. Madrid: Ediciones Ergon, S.A., 1998;299-307.
plate chondrocytes into growth plate defects in sheep. ] Grthop Res 378. Peterson HA. Treatment of physeal bony bridges of the distal femur
1990;8:555-564. and proximal tibia. In: dePablos J, ed. The immature knee. Barcelona:
353. Hanson AL, Foster BK, Gibson GJ, et at. Growth plate chondrocyte Masson, S.A., 1998;333-342.
cultures for reimplantation into growth plate defects in sheep. Charac- 379. Peterson HA. Growth plate injuries and physeal bridge resection. In:
terization in cultutes. Clin Grthop 1990;256:286-298. Buckwalter JA, Ehrlich MG, Sandell LJ, Trippel SB, eds. Skeletal
354. Kawabe:--l, Ehrlich MG, Mankin GH. Growth plate reconstruction growth and development: clinical issues and basic science advances. Amer-
138 General Principles

ican Academy of Orthopaedic Surgeons, Rosemont, Illinois, 1998; sion of partial physeal arrest: a rabbit model. J Pediatr Drthop 1992;
561-575. 12:736-760.
380. Peterson HA. Treatment of physeal bony bridges by means of bridge 383. Talbert RE, Wilkins KE. Physeal bar resection: factors contributing
resection and interposition of cranioplast. Mapfte Medicina 1993; to success. Drthop Trans 1987; 11 :549.
4(Suppl I1):226-230. 384. Versveld GA. Surgical management of partial closure of the growth
381. Peterson HA. Operative correction of postfracture arrest of the epi- plate (Abstract). J Bone Joint Surg Br 1984;66:460.
physeal plate: case report with 10-year follow-up. J Bone Joint Surg 385. Visser JD, Nielsen HK. Operative correction of abnormal central
Am 1980;62: 1018-1020. epiphyseal plate closure by transmetaphyseal bone bridge resection
382. Post WR, Jones ET. Tetracycline labeling as an aid to complete exci- and implantation offat. NethJ Surg 1981;33:140.
 PATHOLOGIC FRACTURES
ASSOCIATED WITH TUMORS AND
UNIQUE CONDITIONS OF THE
MUSCULOSKELETAL SYSTEM
JOHN P. DORMANS
JOHN M. FLYNN

FRACTURE ASSOCIATED WITH CYSTS, PA HOl GIC FRACTURES AFTER LIM B

TUMORS, OR TUMOR· IKE PROCESSES lENGTH IN
Unicameral Bone Cysts
Aneurysmal Bone Cysts FRACTURES r DlTION THAT WEAKEN
Tumors of Bone BONE
Osteogenesis Imperfena
BO ] -. A D FIBROU TISSUE DISEASES Osteopetrosis
Fibrous Dysplasia Pycnodysostosis
Osteofibrous Dysplasia of rhe Tibia and Fibula Rickets
Neurofibromatosis Idiopathic Osteoporosis
Iatrogenic Osteoporosis
CONGENITAL I SENSITIVITY TO PAl
Hyperparathyroidism
MARROW DfSEASE 0 BO. E Cushing's Syndrome
Gaucher's Disease Scurvy
Sickle Cell Disease Copper Deficiency and Scurvy-like Syndrome
Leukemias
I~RACTURES IN EUROMUSCULAR 01 EASE
Hemophilia
Cerebral Palsy
o TEOMYELITlS Myelomen ingocele
Definitions Muscular Dystrophy
Clinical Presentation Arthroglyposis and Poliomyelitis
Radiographic Evaluarion Spinal Cord Injury
Injuly
Trearment

As a child grows, the pattern of injUlY and the response to injLllY traumatic lI1)ury may reveal the underlying condition for the
and treatment change. One of the more difficulr situarions en- first time. This chapter describes the pertinent clinical and radio-
countered in caring for children occurs when the diagnosis and graphic features of the conditions of the pediatric musculoskele-
treatment of a complex injury are complicated by a preexisting tal system thar can predispose a child to pathologic fracture,
underlying disease process or condition of the skeleton. The including specific patterns of injury and special concerns of treat-
diagnosis of borh the injury and the underlying condition de- ment. For most orthopaedic surgeons, experience with these con-
pends on an accurate understanding of how these conditions ditions is limited, and diligence is needed to avoid pitfaJJs of
alter the presentation of the child, given that evaluation of the treatment. The physician must always be aware of the possibility
of a pathologic fracture, especiaJly when a patient presents with
a fracture foJJowing minimal trauma.
A pathologic fracture is defined as a fracture that occurs
John P. Dormans and John M. Flynn: University of Pennsylvania School
of Medicine; Division ofOrrhopaedic Surgery, The Children's Hospital of Phila- through abnormal bone. These fractures occur in bone that lacks
delphia, Philadelphia, Pennsylvania. normal biomechanical and viscoelastic properries. Pathologic
140 Ceneml Prillicple,

FIGURE 6-1. A fracture through the vascular foramina of this 9-year-old boy's left clavicle. The fracture
healed uneventfully.

fracrures may result from inrrinsic or extrinsic processes. EX:lIll- Biopsy is somerjmes needed [Q derermine the cause of a
pies of intrinsic processes include the osreopenia of osreogenesis pathologic Franure, especially wirh parhologic fracrures rhrough
imperfecra or replacement of bone wirh wmor. Wirh cxrrinsic rumors or [Umor-like proccsses. [n rhis situarion, rhe surgeon
processes, rhe weakness is caused by something rhat lessens rhe musr ensure rhat biopsy is performed on represencative areas of
inherent srrucrmaJ integrity of bone, such as radiation or a hoJe the bony lesion.
in bone from biopsy or internal fixarion. Addirionally, padlO- Pathologic fracrures differ from fractures in normal bone in
logic fracrures may result from localized (a bone cYSt, for eX:lI11- rhat rhe eriology, narural histoty, and rrearmenc of rhe underly-
pie) or generalized processes (such as osteopetrosis), and rhe ing abnormality of rhe bone musr be raken inco accounr. Accu-
fracture may be cOITectabJe (rickers) or noncorrecrable (meta- rarc and careful dererminarion of these unJerlying diagnoses
sraric cancer). A fracture similar co a pathologic fracture can is crirical for rhe appropriare care of rhese fracrures. Fracrure
occur rhrough anacomically normal bone rhat is weakened by management principles ofren are alrered for parhologic fraccmes
normal srrucrures such as a vascular foramina (Fig. 6-1). because of the abnormal condition responsible for rhe fracrure.
Parhologic fractures c:ln occur in children with generalized Tne rrearmcnr plan musr consider both the rrearment of rhe
bone condirions and in those wirh rumors or rumor-like pro- fracture and rrearmenr of rhe underlying cause of rhe fracrure.
cesses of bone. Although the presenring episode of a child with Once a fracrure occurs secondalY to a previously unrecog-
generalized bone disease (osteogenesis imperfecta, osteoperrosis, nized condirion, subsequent fractures ofren can be prevenred,
and rickers) may be a fracture, more commonly, the diagnosis usually rhrough parient education. Lmogenic parhologic fracture
has been made based on clinical findings such as hiscoty, physical ofren can be prevenred by rhe appropriare use of inrernal f]xarion
examin:lrion, radiographs, or laboratory findings. Ofren, rhe his- (avoidance of unnecessalY cortical pencrrarion with drills and
rory is mosr helpful. For example, pathologic fracrure secondary guide pins for exampJe), prorecrion of all exrremity wirh inrernal
to generalized osreopenia associared wirh chronic drug rherapy
(sreroids or anriconvulsanrs) may become evidem rhrough the
p:lrient's history. Some of the key poims in analysis of a pediarric
p:l(icm wirh a musculoskeleraJ rumor or rumor-like lesion :ue
shown in Table 6-1. TABLE 6-1. EVALUATION OF A PEDIATRIC
PATIENT WITH A
Hipp and colleagues proposed a way of quamifying the risk MUSCULOSKelETAL TUMOR OR
of pathologic fracrure in 1995 (3). They defined the Ii/ctor of TUMOR-LIKE LESION
ris/? as rhe load applied to rhe involved bone divided by tne load
required for bone failure. Orher atrempts have been made co 1. Age of patient (see Table 6-2)
2. Location of lesion (see Table 6-3)
measure rhe risk of pathologic fracrure in patienrs with underly-
Epiphysis, metaphysis, diaphysis?
ing condirions of bone (5,27,34). Unfonunatcly, retrospecrive Central or eccentric?
studies have failed co find any predictive merhods based on radio- 3. What is the lesion doing to the bone? (Pattern of
graphic findings that can accurately forecast fracrure in mosr involvement)
a. Zone of transition (narrow or wide; can measure)
siruations. New merhods thar apply engineering principles co
b. Geographic versus "moth eaten;' versus permeative
information from compmed tomography (CT) scans may pro- 4. What is the bone doing to the lesion?
vide bener noninvasive esrimares for rhe risk of parhologic frac- Periosteal response or "walling off"
rure (3). No response?
Wirh parhologic fracrures througn a rumor or rumor-like Early, immature?
Late, mature?
lesion, rhe age of rhe parienr can also be helpful in maklng rhe
5. Is there a characteristic appearance of the lesion, ie matrix?
diagnosis (Table 6-2). Mosr rumors and rumor-like processes Lytic, calcified, ossified, "Ground-glass"
are recognizable by radiographic appearance; rhe locarion of rhe
lesion can also be helpful (Table 6-3) (2).
 Cl.l7pter 6: PathoLogic Fractures 141

TABLE 6-2. PEAK AGE OF COMMON PEDIATRIC MUSCULOSKELETAL

CONDITIONS, (TUMORS AND TUMOR-LIKE LESIONS OF
~- . -- ~ BONE)

Age
(ye.ars) Benign Malignant

0-5 Langerhans cell histiocytosis Ewing's sarcoma

Osteomyel itis Leukemia
Neuroblastoma (metastasis)
Wilms' tumOr (metastasis)
Neuroblastoma (metastasis)
Unicameral bone cyst Ewing's sarcoma
Aneurysmalbone cyst Osteos~rcoma
Nnnossifying fibroma Rhabdomyosarcoma
Fibrous dysplasia
Osteoid osteoma
Langerhans' cell histiocytosis
Osteomyelitis
10-20 Unicameral bone cyst Osteosarcoma
Aneurysmal bone cyst Ewing's sarcoma
Osteoid osteoma (Chondrosarcoma)
Fibrous dysplasia
Chondroblastciim Rhabdomyosa'rcoma
Osteofibrous dysplasia Synovial cell sarcoma

TABLE 6-3. LOCATION OF TUMOR AND TUMOR-LIKE LESIONS OF BONE

Metaphyeai'-Any lesion Posterior elements spine

Epiphyseal Aneurysmal bone cyst
Chondroblastoma Osteoblastoma
Brodie's abscess of the epiphysis-subacute epiphyseal os- Osteoid osteoma
teomyel itis Metastatic (usually adult)
Giant cell tumor Pelvis
Fibrous dysplasia Ewing's sarcoma
Diaphyseal Oste'osarcoma
Fibrous dysplasia Osteochondroma
Osteofibrous dysplasia (child), adamantinoma (adult) Metastasis
Langerhans'cell histiocytosis '. Fibrous dysplasia
Ewing's sarcoma Chondrosarcoma (usually adult)
Leukemia, Iymphom~ Rib
Subacute osteomyelitis Fibrous dysplasia
(Occasionally osteoid osteoma and UBC) LCH
Multiple lesions. . Ewing's sarcoma
Histiocytosis. Metastatic lesions
Fibrous dysplasia (Albright's syndrome) Chondrosarcoma (usually adult)
Leukemia, metastasis Benign but locally aggressive tumors:
Enchondroma (allier's disease) Chondroblastoma
Multiple hereditary exostosis Aneurysmal bone cyst
. Hemangioma of bone Chondromyxoid fibroma
Anterior e.lements spine Giant cell tumor
Eosinophilic granuloma (Langerhans' cell histiocytosis) Osteoblastoma
Leukemia Chordoma
Hemangioma Adamantamona
Metastasis
Infection (end plate, unless tuberculosis)
Giant cell tumor·
Chondroma (usually adult)
142 General Pril1icples

fixation by cast or brace when appropriate, and the use of injury. In one series (8), 40 o;CJ of pathologic femoral neck frac-
rounded edges of bone biopsy sites (1). tures in children were due to UBCs. Pathologic fracture with
collapse of the arTicular surface of the femoral head and joint
incongruity also has been reported (17).
FRACTURES ASSOCIATED WITH CYSTS, Although the fracture commonly heals within 6 weeks of
TUMORS, OR TUMOR-LIKE PROCESSES injury, the UBC usually persists, often with further fracture.
Only abour 10% of CYStS heal after fracture. In a 1993 report
Benign tumors can be classified according to their aggressiveness of 52 pathologic fractures due to UBC, Ahn and Park (4) found
(Table 6-4). Stage 1, Ot latent benign lesions, are usuaJly asymp- that only 8% of cysts healed at an average of 5.5 years after
tomatic, discovered incidentally, and seldom associated with rnJury.
pathologic fracture. Stage 2 lesions are intermediate in behavior,
and stage 3, or aggressive benign lesions, are usuaJly symptOm- Radiographic Findings
atic, grow rapidly, and may be associated with pathologic frac-
ture. The classic appearance of a UBC is a centraJly located, radiolu-
cent, slightly expansile lesion of the metaphysis (Fig. 6-2) (38).
The width of the lesion seldom exceeds that of the adjacent
Unicameral Bone Cysts
physis [a feature characteristic of the more expansile aneurysmal
Unicameral bone CYStS (UBCs) are radiolucent expansile fluid- bone cyst (ABC)]. Occasionally, UBCs are located in the diaphy-
filled cystic lesions found most commonly in the metaphyses of sis when the physis has migrated away from the lesion with
long bones. The term unicameral suggests a single-chambered growth (Fig. 6-3) (23). The so-called f:1l1en fragment sign, de-
cyst, but often, especially after treatment or fracture, the lesions scribed by Reynolds (38) in 1969, is a fracture fragment seen
are multi loculated with radiolucent fibrous septa segregating the on plain radiographs at the bOttOm of a cYSt suggesting a hoHow
primary lesion intO multiple small chambers (11). The cysts caviry in the bone rather than a solid tumor (Fig. 6-4). A cortical
usually contain yellow serous fluid. In order of decreasing fre- fragment also may be tilted into the interior of the lesion. The
quency, the cysts most commonly occur in the proximal hume- differential diagnosis of UBC includes ABC, fibrous dysplasia,
rus, proximal femur, proximal tibia, distal tibia, distal femur, enchondroma, giant cell tumor, and eosinophilic granuloma.
calcaneus, distal humerus, radius, fibula, ilium, ulna, and rib
(34). Approximately 70% of these CYStS are found in either the Natural History-Predicting Fracture
proximal humerus or femur. Some authors have suggested that
UBCs evolve from an accumulation of interstitial fluid in the The natural history of UBCs is variable, but typically they gradu-
bone because of a defect in venous or lymphatic drainage (14, ally improve with growth. Most UBCs persist into adulthood,
15,24). but some disappear spontaneously at puberty (24). The cYStS are
Approximately 75% of patients who have UBCs present with tradirional I)' described as active if (hey are adjacent ro the physis
pathologic fractures (7,12,18,19.36,44). These cysts usually are
(24) or latent if more than 0.5 cm from the physis (35) (Table
diagnosed within the first twO decades of life (13,15,21), and 6-5). Ahn and Park (4) nOted that pathologic fracture occurred
the ratio of males to females is about 2: 1 (26). Fractures are
often incomplete or minimally displaced. Patients with patho-
logic fractures through UBCs present with mild to moderate
pain in the extremity after either mild trauma or no history of TABLE 6·5. STAGING OF UNICAMERAL BONE
I CYSTS

Inactive or
Active "Latent"

TABLE 6-4. CLASSIFICATION OF BENIGN Age of the 510-12 years >12 years
LESIONS ACCORDING TO THEIR patient
I AGGRESSIVENESS
Location Abutting the Sepa rated from
Stage 1, Latent Benign physis physis by a zone
Asymptomatic of normal
Often discovered incidentally cancellous bone
Seldom associated with pathologic fracture X-ray appearance Sing Ie cavity Multiloculated cavity
Stage 2, Active Benign
Majority Intralesional >30 em H2 0 6-10 cm H2 0
pressure
Tend to grow steadily
May be symptomatic Pathology Thin shiny Thick membrane,
Stage 3, Aggressive Benign membrane, frequent giant
Generally symptomatic few osteocytes, cells, cholesterol
Discomfort, usually tender little or no slits, hemosiderin,
May be associated with pathologic fracture hemosiderin, osteoblasts
Growth rapid osteoclasts
 Chapter 6: PathoLogic Fractures 143

A B

c D
FIGURE 6-2. A: A 14-year-old girl presented with right hip pain. X-ray study reveals a large lytic expansile
lesion of the proximal femur. B: A technetium scan was performed, and the anterior cortex was thin
with fluid within the lesion. C: MRI was performed, and signal intensity was equal to that within the
bladder, and a diagnosis of unicameral bone cyst was made. 0: It was treated with curettage and bone
graft.
144 Genera! Prinicp!e.i

A B

FIGURE 6-3. A 12-year-old boy sustained a pathologic fracture while

throwing a tennis ball. A: Radiographs at presentation revealed a lytic lesion
of the proximal humerus with pathologic fracture seen distal to the lesion.
There is also the suggestion of a pathologic fracture through the cyst. The
lesion was believed to represent a unicameral bone cyst, and the fracture
was treated in a hanging arm cast. B: At 8-weeks follow-up, fracture lines
were beginning to obliterate but the cyst persisted. A nondisplaced healing
fracture through the cyst is also well visualized. C: At 8-week follow-up, the
patient was believed likely to be prone to have a recurrent fracture and
was taken to surgery. With the patient under general anesthesia, the lesion
was injected with radiopaque dye and was found to be a cystic lesion. Ste-
c roid injection was done. (Figure continues.)
 C!Japter 6· PathoLogic Fraetul-es 145

D
FIGURE 6·3. (continued) D: At 12-week follow-up, the patient is
asymptomatic, with radiographic improvement of the lesion.

when the transverse diameter of the cyst was 85% or more,

whereas Nakamura et a!' (33) reponed that the chance offracture
was high if the CYSt wall was Jess than 5 mm in width.
Complications after fracture of the proximal femur include
malunion, growth arrest, and avascular necrosis of the femoral
head. Kay and Nason (30) noted growth disturbance in five of
their 21 patients (24%) with pathologic proximal humeral frac-
ture before treatment of the UBC. Moed and LaMont (31)
reponed three patients in whom premature closure of the medial
proximal humeral physis resulted in humeral shonening of 2 to
5 cm. Malunion may be a problem in fractures through cySts B
ofrhe proximal femur (15), and avascular necrosis of the femoral
FIGURE 6-4. A 13-year-old boy sustained a pathologic fracture. A: X-
head has been reponed after displaced femoral neck fracrures ray studies at presentation revealed a lytic lesion of the proximal humer-
(26) and after an undisplaced femoral neck fracture in an 8- us with pathologic fracture. A so-called fallen fragment sign is seen at
the bottom of a cyst suggesting a hollow cavity in the bone rather than
year-old boy (48). Infrequently, the cyst may extend from the a solid tumor. The lesion was believed to represent a USC, and the
metaphysis into the epiphysis (5,7,20) and collapse of the surface fracture was treated in a hanging arm cast. B: At 8-week follow-up,
of the femoral head has been reponed. fracture lines were beginning to obliterate. (Figure continues.)
146 Gmeral Pl'inicples

of success. Earlier interventions consisted primarily of curettage

and bone grafting. Lesions treated with this technique have a
recurrence rate varying from 18% to 40% (6,7,19,34,35,47).
Delaying the treatment until the cYSt converts from an activc
ro a latem stage has been advocated by some physicians, but a
2-year period of observation may be necessalY (7). Some data
suggest that the response ro treatmenr may be the same for latenr
as for acrive cystS (23). After fracture, mOSt authors advocate at
least a 6-week delay in treatmenr ro allow the fracture to heal
before curettage and bone grafting (15,39). There seems ro be
no substantial difference in the ratc of healing with the use of
either aurogenous bone graft or allograft.
Open curettage and bone grafting has fallen oue of favor for
the treatmenr of upper extremity and smaJler lower extremity
UBes due 1'0 the invasive nature of the operation and also rhe
still signiflcanr persistence and recurrence rates associated with
this option. Curettage and bone graft remains a popular method
of treatment for larger UBCs of the proximal femur, however;
the reponed recurrence rates range from 10% to 40% (6,7,19,
36). Although panial persistence or recurrence of the UBC may
occur, interim healing usually occurs such that the risk of patho-
logic fracture and displacement is lessened and subsequent per-
sistence or recurrence can be treated with corticosreroid injec-
tions (Fig. 6-5). Follow-up of the treated lesions with periodic
x-ray srudies is suggeSted.
The patient with a calcaneal UBC usually presents wi th pain
C due to microfracrure (22,32,37). UBCs in this location may not
FIGURE 6-4. (continued) C: At 6 month follow-up, the cyst has partially
respond as well co injections with methylprednisolone (22,32),
healed. and several amhors have recommended primary curettage and
bone grafting (22,32).
Because of the high rates of recurrence after curettage and
bone grafting, a number of approaches were developed, includ-
Treatment ing intentional fracrure of the cYSt (46), crushing of rhe lesion
Pathologic fractures through UBCs invariably heal with simple with onlay bone grafting (5), and packing of the defecr with
immobilization; the cyst, however, persists in nearly 85% of plasrer of Paris pellets (37). Radical excision of the lesion with
patients, and additional fractures are common. NeeI' et al. (34) or without grafting produced recurrence rates of9% or less (19,
observed an additional 2.5 fractures per patient during observa- 21,30), bur this procedure is a larger operation with greater risk,
tion periods after the initial injury, and Oppenheim and Galleno can be difficult technically, and requires subsrantia'! bone graft.
(36) emphasized that prolonged observation with inevitable re-
fracture may be Stressful ro patients and may adversely resn'ict Aspiration and Injection. In 1974, Scaglietri et al. began em-
children from normal childhood activities. piric injection of UBCs with methylprednisolone and in 1979
In the upper extremity, minimaJly displaced, stable patho- (43), reported healing rares (mostly radiographic improvement
logic fractures through UBCs are [l'eared with simple immobili- of the CYSt) of 96% in 72 p:ltients. Two needles were inserted
zation for 4 ro 6 weeks ro obtain healing. Usually, a sling is inro each cysr, and the initial corticosteroid dose varied from
adequate treatment for srable fractures of the proximal humerus, 40 to 200 mgs for Jarge cysts. Complete healing was initially
and once healed, the options for further treatmenr are discussed reponed in 55% of CYStS undergoing this treatment. Local recur-
with the patient and family (see later). rence in 45% of cases was treated with up to flve additional
\I!ith pathologic fracture rhrough UBC in the proximal injections of 40 to 80 mg of methylprednisolone at 2- to 3-
femur, prcliminaty traction before surgical intervenrion may be momh inrervals until healing occurred.
appropriate (49). Most authors recommend inrernal fixation if The mechanism for cyst healing after methylprednisolone
the fracture is unStable or displaced (7,26,29,34). Malunion is injection remains unknown. Scaglietti et al. (43) suggested chat
common in these fractures (15). Intertrochanteric osteotomies an antiinflammatory response initiated by the corticosteroids
may be necessary later ro correer alignment (25). promoted cysr healing. Shindell et al. (45) observed elevated
levels of prosraglandins in cysrs; after serial injections of cortico-
sreroid, levels decreased. Because prostaglandins stimulate osteo-
OPERATIVE TREATM NT clastic acriviry, rhese aurhors suggesred rhat a corticosteroid-in-
duced repression of prostaglandins may indirectly aid in cYSt
Curettage and Bone Grafting. Many surgical techniques have healing. In animal experimenrs, however, corticosteroids are rap-
been developed for the treatment of uscs, with va,ying rates idly cleared from the medullary canal of long bones after injec-
 Chapter 6: Pathologic Fractures 147

A,S

FIGURE 6-5. A 7-year-old boy was playing basketball and

felt a severe pain in his left hip and was unable to bear
weight on that side. A: X-ray studies revealed a comminuted
pathologic fracture through a large lytic lesion extending
from the base of the femoral neck to the subtrochanteric
region (comminuted type I-B hip). The appearance of the
lesion is believed to be most compatible with a UBC. B: The
fracture and cyst were approached laterally. Open reduction
and internal fixation were performed using a pediatric hip
screw and side plate. The cyst contents were consistent with
USC; it was curetted and packed with cancellous bone graft.
The patient was placed in a hip spica cast for 6 weeks with
healing of the fracture. C: At 4-month follow-up, the fracture
has healed and the cyst appears to be consolidating. (Figure
c continues.)
 148 GeneraL PrinicpLes

FIGURE 6-5. (continued) 0: At 2-year follow-up, x-ray studies

show a partial recurrence or persistence of the cyst. The cyst was
subsequently grafted again. E: At 4-year follow-up, x-ray studies
show no evidence of recurrence or persistence of the cyst. The
E patient has no discomfort and has returned to full activities.
 Chapter 6: Pathologic Fractures 149

tion (16). Others have suggested that cyst healing occurs through for small, stable UBCs of rhe lower extremity, but if the cyst is
decompression of cyst fluid pressure by multiple trephination potentially unstable and there is a risk of malunion (e.g., varus
(13,16,42). of the femoral neck), one should consider surgical fixation and
Methylprednisolone injection for UBCs became popular be- bone grafting.
cause of its relatively low morbidity and an apparent long-term
effectiveness approaching that of more invasive techniques. Complications
However, incomplete healing and recurrence are common after In addition to tecurrence of the cyst, complications that occur
the initial injection of corticosteroid, and multiple injections with corticosteroid treatment include recurrent pathologic frac-
of corticosteroid may be necessary in 50% to 92% of patients tures (12,20,36) and avascular necrosis of the femoral head (8,
(intervals ranging from 2 to 6 months) (11,36). 12). Nakamura et al. (33) measured the bone mineral content
In those cysts that respond to methylprednisolone treatment, of the corticosteroid injected cyst by densitometer and found
the cortical margins of the lesion usually thicken. By 6 months, that if there was no increase in density 2 months after injection,
the central portion of the cyst assumes a frosted-glass appearance, then the chance of refracture was high. In one series, growth
and by 12 months, the cyst may heal with dense sclerotic bone disturbance was a problem in 20% of 141 patients with bone
(12,40). cysts treated by corticosteroid injection (8). Systemic reactions
to the corticosteroid injection, such as corticosteroid flush or
Aspiration and Injection-Operative Technique. A fWo-needle increased appetite and temporary weight gain, are rare (16,36).
injection technique is most commonly used. Some authors (36)
recommend the use of fWO Craig-type needles or Jamshidi biopsy Newer Methods
needles so that a biopsy specimen can be obtained at the time Some authors believe that relieving the pressure of the interstitial
of injection. The initial dose of methylprednisolone vaties from fluid in the lesions can heal the cyst. Chigira et al. (13) treated
40 to 200 mgs (11,18,43), and the volume can be adjusted to six patients by puncturing the cysts with multiple Kirschner
match radiographic volume of the cyst. The injeerion can be wires, which were then left in place; cysts subsequently recurred
given under local anesthetic (10), but most prefer general anes- in 6 to 8 months in fWO patients. Santori et al. (42) decompressed
thesia. Several authors (11,36,37) have emphasized the impor- UBCs with Enders nails or Rush pins without curettage or graft-
tance of outlining the cyst with radiopaque dye injection before ing, and during short-lerm follow-up, they noted healing in all
placement of the methylprednisolone. With this technique, in- 11 patients. The effect of the fixation on the adjacent physes
tracystic fibrous septa were found in 92% of lesions in one series awaits long-term follow-up.
(11) and these may prevent complete filling of the cyst by cotti- New grafting materials also are becoming available. Deminer-
costeroids with later incomplete healing. This cystogram also alized bone matrix (DBM) or commercial product paste is com-
allows the surgeon to verifY that the cyst is indeed fluid filled. posed of demineralized bone particles ranging from 100 to 500
If it does not fill with contrast material, other diagnoses, such /Lm in a glycerol base. It has been used in the treatment of delayed
as fibrous dysplasia or enchondroma, should be considered. Ca- unions and nonunion, in some primary bone-healing situations,
panna et al. (11) recommend vigorous saline irrigation of the and more recently, for the treatment ofUBCs (27,28,41). Killian
cyst through fWO needles to lyse the fibrous septa, whereas Op- et al. (27) used DBM in 11 patients with UBCs, and nine CYStS
penheim and Galleno (36) simply reinject the areas of cyst that healed (within 4 to 5 months) after a single injection. At 2 years'
are not filled by contrast material in the initial injection. follow-up, no cysts were deemed active or recurrent (26).
Other materials also have been used. Packing of the defect
Aspiration and Injection- The Humerus. With fluoroscopic with plaster of Paris pellets (calcium sulfate) was described by
guidance, the humerus is rotated until an area of thin cortex is Peltier in 1978 (37). Osteoset pellets bone void filler is a new
identified, and fWO 20-gauge spinal needles are passed through material made of medical grade calcium sulfate. This radiopaque
this area into the cyst so that the needle tips are at opposite ends product can be used in an open grafting situation or can be
of the cyst cavity. A more stout, disposable biopsy needle can injected percutaneously. The biodegradable pellets are resorbed
be used for areas of thicker bone. The presence of serous fluid in 30 to 60 days when u~ed according to labeling. This product
with removal of the needle stylet is indicative of UBC. A cysto- is not intended to provide structural support during the healing
gram is then performed by injection ofseveral millilirers of Reno- process and therefore is contraindicared when structural supporr
grafin dye both to confirm the fluid-filled nature of the cyst and is required.
to ascertain whether the cyst is indeed unicameral or multilocu- Adjuvants such as liquid nitrogen have been used for the
lated. If the dye does not fill a cyst cavity, the diagnosis of UBC treatment of UBCs (46), but their efficacy or safety has not been
should be questioned. If the cyst is multiloculated, the needles established. Current research includes rhe use of aspirated bone
can be used to break up any septations that exist. Methylprednis- marrow injected into UBCs.
olone is then injected through one of the needles using a dose
ranging from 40 to 200 mgs (Fig. 6-6). To guard against recur- Internal Fixation of Proximal Femoral Pathologic
rent fracture, the arm is protected in a sling for 2 to 6 weeks Fractures
and x-ray studies are performed every 6 weeks initially to moni- If there is a significant loss of proximal femoral bone because
tor healing. Incomplete healing or persistence of the cyst can of the UBC, there is a high risk of a coxa vara deformity after
be treated with additional injections or with other techniques. treatment without internal fixation. Both the location of the
Aspiration, cystogram, and steroid injection can also be done UBC and the amount of bone loss dictate whether fixation can
150 General Prinicples

A B

FIGURE 6-6. A: A radiopaque dye injection of a

unicameral cyst of the proximal humerus. Note the
poor filling of the inferior portion ofthe cyst (large
arrow) and the proximal portion (small arrow).
This suggests that fibrous septa are present in the
cyst. B: More radiopaque dye was placed in the
distal portion of the cyst through a second needle,
and a venous drainage of the lesion is now visual-
ized (large arrow). The proximal portion of the cyst
is still poorly filled (swag arrow). C: With a third
needle superiorly, the proximal portion of the cyst
is now filled. The total dose of corticosteroid is di-
vided into equal portions and injected separately
through the three needles to ensure complete dis-
persal throughout the lesion. A single dose
through the first needle might not have saturated
c the entire cyst.
 hapter 6: Pathologic Frncturcs 151

IMMATURE l\1ATURE

A,B,CD Type I-A Type I-B Type II-A* Type II-B * E,F

+ Lat buttress - La t bu ttress + Lat buttress - Lat buttress Type III-A Type III-B
+ Bone in neck + Bone in neck - Bone in necl, - Bone in neck
+ Lat buttress - Lat buttress
* Tr'action & cast 01' pins as shown
For' all: Curettage (with biopsy) and bone g"afting with stabilization (as shown above) and spica cast

FIGURE 6-7. Our classification system for the treatment of pathologic fractures of the proximal femur
associated with bone cysts in children. A: In Type lA, a moderately-sized cyst is present in the middle of
the femoral neck. There is enough bone in the femoral neck and lateral proximal femur (lateral buttress)
to allow fixation with cannulated screws after curettage and bone grafting. B: In Type IB, a large cyst
is present at the base of the femoral neck. Although there is enough bone in the femoral neck, there
is loss of lateral buttress, so a pediatric hip screw and a side plate should be considered rather than
cannulated screws, after curettage and bone grafting. CD: In Type IIA-B, a large lesion is present in the
femoral neck, so there is not enough bone beneath the physis to accept screws. There are 2 options for
treatment of these bone cysts: (1) After curettage and bone grafting, parallel pins across the physis can
be used in combination with a spica cast. (2) The patient can be treated in traction until the fracture
heals (with subsequent spica cast) followed by curettage and bone grafting. E,F: In Type IIIA-B, the physis
is closing or closed. The lateral buttress is present in Type lilA hips, so cannulated screws can be used
to stabilize the fracture after curettage and bone grafting. In Type IIIB hips, the loss of lateral buttress
makes it necessary to use a pediatric hip screw and a side plate following curettage and bone grafting.
In all types, we recommend spica cast immobilization following surgery.

stabilize the ftacture after grafting and what type of fixation is \;lie recommend simple immobilization for most fractures
appropriate. We have classified pathologic fractures of the femo- occurring through UBCs. Spontaneous healing of the cyst can
ral neck in children into six types (Fig. 6-7) (9). occur, although infrequently. Once the fracture has healed, gen-
eralJy by 6 to 8 weeks, further ueatment of the cySt can be
rendered, if necessalY.
~ AUTHORS' PREFERRED METHOD Displaced pathologic fractures of the proximal femur are
,~ OF TREATMENT based on the location of the cyst. The amount of bone loss
dictaces whether fixation can stabilize the fracture after grafting
Overall, methylprednisolone injection has a favorable rate of and what type of fixation would be best to use. We use the
success compared with open surgical treatment; the ease of treat- classification of pathologic fractures of the proximal femur in
ment, relatively low operative morbidity, and the information children shown in figure 6-7.
obtained with aspiration and cystogram make it a favorable ini-
tial choice for treatment of UBCs in the LIpper extremity and
Aneurysmal Bone Cysts
smaller cYStS in the lower extremity. Because incomplete healing ABCs are eccentric or central, expansile osteolytic lesions usually
and recurrence are common after the initial injection of cortico- occurring in the metaphyseal ends of long bones or in [he poste-
steroid and because multiple injections of corricosteroid are nec- rior elements of the spine during adolescence. Nearly 75% of
essary in most patients, new grafting materials are being used ABCs are found in patients younger than 20 years old, and 50%
more commonly at our instj tution, especially if the first stetoid are seen in individuals between to and 20 years of age (50,
injection fails. Grafton demineralized bone matrix (Osteotech, 54). Girls are affected slightly more often than boys. ABCs are
Eatontown, N]) and Osteoset pellers (Wright Medica! Technol- relatively rare, accou1lting for approximately 1.5% of all primalY
ogy, Arlington, TN) are the twO most ofren used at present. bone tumors (50).
152 General PriilicpteJ

A B

c D
FIGURE 6-8. An 8-year-old girl presented with a 4-week history of back pain. A: Radiographs show
absence of the pedicle of T5 on the left. B: Close-up view of the same areas. C: The axial T2-weighted
image through the body of T5 shows multiple blood-fluid levels within the left sided expansile destruc-
tive mass. D: Sagittal proton density MRI of the thoracic spine shows a blood fluid level (arrow) within
an expansile mass. (Figure continues.)
 Chaprer 6: Pathologic Fmctu.res 153

E
FIGURE 6-8. (continued) E: Postoperative x-ray studies showing instrumentation and fusion after ex-
tended curettage and removal of tumor. The patient is pain free without recurrence or deformity at 4
years after surgery. (From Cohen RB, Dormans JP, Guttenberg ME, Hunter N. Back pain in an 8-year-
old girl. Clin Orthop 1997;343:249-252; with permis~ion.)

The long bones are involved in 65% of pariems. In order of mon, glVlng rise to the so-called soap bubble or honeycomb
decreasing frequency, the most commonly involved bones are "ppearance. Lesions in the short tubular bones, such as the meta-
the distal femur, proximal ribia, proximal humerus, and distal carpals and metatarsals, are commonly more cenrral. Spinal
radius. The vertebrae are involved in 12% to 27% of patients ABCs usually are located in the posrerior elements of the spine
(54,59), some of whom have symptoms of radicular pain. The but may also occur in rhe vertebral bodies and can be associated
lumbar vertebrae are most commonly affected. The primary sire with pathologic fracture and vertebral collapse (Fig. 6-8) (66,
of involvement is the posterior elements of the spine with fre- 79).
quent exrension into the vertebral body (58). The x-ray picture often evolves with time. Initially, there is
The lesions are nor true cystS bur rather sponge-like collec- frank osteolysis of the margins of the bone, and periosreal eleva-
tions of interconnected fibrous tissue and blood-filled spaces tion; with growrh of the lesion, there is progressive destruction
(59). They tend to be destructive lesions, which replace bone and of bone with poorly demarcated margins. A stabilization phase
thin the corrices of the host bone. The elevated viable periosreum follows, with formation of a bone shell wirh septa. Later, with
usually maintains a thin osseous shell. further ossification, a bony mass begins to form (59).
The eriology of ABCs is unknown. Some have considered Campanacci et al. (54) have classified the ABCs into three
them primary lesions of bone (79), whereas others have nared groups (Fig. 6-9). An aggressive CYSt has signs of reparative os-
a secondary associ arion with other lesions such as UBCs, nonos- teogenesis with ill-defined margins and no periosteal shell. An
sifying fibromas, fibrous dysplasia (52), and osteogenic sarcoma. active cyst has an incomplete periosteal shell and a defined mar-
They also can occur in association with fractures of the long gin between the lesion and the host bone. l\n inactive cyst has
bones (58,63). The most common presenting symptom is local- a complere periosteal she'll and a sclerotic margin berween the
ized pain of less than 6 months' duration (54,79). Patients with cyst and the long bone.
ABCs are three times more likely to have pain during exercise Angiography may aid diagnosis and trearmenr; abnormal pe-
rather than pain at resr (71). ripheral vascularization is often present (71). Percutaneous dye
injection has been used as an additional diagnostic technique
and in evaluarion of vertebral lesions (72). Technetium bone
Radiographic Findings
scan Llsually shows an increased uptake of the isotope in the
ABCs are eccentric or central lyric lesions of bone, sometimes periphery of [he lesion, but homogeneous uptal<e is also seen
wirh extension beyond the correx (50,52,79). Septarion is com- (68). Magnetic resonance imaging (MRl) often is helpful in
154 Gmerltl PrinicpleJ

II III IV V

FIGURE 6·9. Classification of morphologic types of ABC. (From Capanna R, Bettelli G, Biagini R, et al.
Aneurysmal cysts of long bones. Ital J Orthop Traumatal, 1985;XI:421-429; with permission.)

demonsrrating the characteristic seprations and fluid levels, but up of 3 years, there were no recurrences and no complicltions
these findings are not pathognomonic for ABC (Figs. 6-8 and relared to embolization.
6-10) (78). Treatment of ABCs by cryotherapy in conjunction wirh cu-
rettage has a recurrence rate of benveen 8% and 14% (5 1,73,
77). Dabezies et al. (58) obtained healing of ABCs associated
Natural History wirh fractures by collapsing the CYSt manually after curerrage.
Polymethylmethacrylate cementation also has been described as
ABCs are benign bur usually behave in a locally aggressive man-
an adjuvant to curettage for tbe treatment of ABCs. Ozaki er
ner. Pathologic fracrures occur in II % to 35% of patients with
al. (74) compared curettage and bone grafting in 30 patients
ABCs of tne long bones (67,71). The humerus and femur are
with curettage and cementation in 35 patients. At follow-up
tne most commonly fracrured long bones (57,71). Orher sires
ranging from 24 to 161 monrhs, the recurrence rate was 37%
of fracture occur, but rhese are rare. In one series, venebral body
for curettage and bone grafring compared with 17% for curettage
ABC was associared wirh fracture in 27% of patients (79).
and cementation.
Although rare, epiphyseal involvement by the lesion rhrough
Injection has been used by some physicians (61). Guibaud
metaphyseal extension has been reported (5 I ,60,(9). Capanna
et al. (65) reponed on the use of percutaneous embolization with
et al. (56) reponed nine patients with invasion of the physis
an alcoholic solution of Zein (Ethibloc; Ethnor Laboratories/
by large metaphyseal ABCs. In five of these patienrs, growth
Ethicon, Norderstedt, Germany) in 18 patients. In two patients,
disrurbance of the involved physis subsequently developed.
the cystOgram showed marked venous drainage and emboliza-
Conservative treatment with immobilization is inappropriate
tion was not attempted. Six patients underwent repeat emboliza-
as a definitive treatment for pathologic fractures of ABCs. AJ-
tion. Ar follow-up ranging from 18 months to 4 years, there
though the pathologic fracture will heal, the ABC will persist
were no recurrences.
and enlarge and a recurrem pathologic fracture wiJJ occur.
Complete en bloc resection is reserved for active or recurrent
ABCs (50,56,66,71) and is most feasible in the proximal fibula,
distal ulna, ribs, pubic rami, metatarsals (54), and metacarpals
Treatment
(53). Resection of metacarpal lesions with replacement by a fibu-
AJthough ABC healing after simple biopsy has been reporred lar auwgraft often results in soft tissue scarring with reduced
(54), this does nor occur often and obsetvation is not recom- joint motion (53). Campanacci et al. (54) recommended saucer-
mended because these lesions usually are locally aggressive. Sim- ization of peripheral acrive and aggressive cysts.
ple curettage and bone grafting have been associated with high Irradiation should be avoided. Its use has been associated
recurrence rates (51,54,59,66,79), ranging from 20% to 30% with the development of sarcoma (79). It has been used for
(54,59). There appears to be a higher rate of recurrence in pa- lesions that are surgically inaccessible (57), but it is contraindi-
tients younger than 15 years of age (79). Freiberg et al. (62) cated in the pelvis, where the reproductive organs may be af-
treated ABCs with curettage and bone grafting in seven patiems fected, and in areas of active gtO\Vth of the long bones (54).
younger rhan 10 years of age and noted recurrence in five of the ABCs of the spine can be difficulr to treat because of the
seven patienrs at an average of 8 months after the first procedure. relative inaccessibility of the lesion, proximiry of the lesion to
Selecrive arterial embolization is used most commonly in lo- the spinal cord and nerve roOtS, and the potential for spinal
cations where a tourniquet cannot be used a.nd control of bleed- instability (75,81). Papegelopoulos et al. (75) reported on 52
ing can be difficult (e.g., spine, pelvis, and the proximal portions consecutive patients with spinal ABCs treated over an 83-year
of rhe extremities). Green et al. (64) reported on eight patients period and recommended preoperative selective arterial emboli-
treated with selective arterial embolization. In seven patienrs, zation, intralesional excisional curettage, bone grafting, and fu-
embolization was performed in conjunction wirh open bone sion ofrhe affected area ifinstability is present (fig. 6-8). Turker
grafting and, in one patient, as definitive treatment. At a follow- et al. (81) described three patienrs with ABCs of rhe spine and
 Chflpter G: Pathologic Fraetrlres 155

B
FIGURE 6-10. A 14-year-old-girl presented with distal thigh pain from microfractures through the
thinned wall of an aneurysmal bone cyst ofthe distal femur. A: X-ray studies show an eccentric, expansile,
lytic lesion of the lateral aspect of the distal femoral metaphysis. There is a narrow zone of transition
with a sclerotic border. B: MRI shows septation of the lesion with the fluid-fluid levels, which are charac-
teristic of ABC. The patient was treated with extended curettage and bone grafting.
156 Cer!eml Prinilples

emphasizcd the need fot spinal stabilization and fusion in con- cells, and multinucleated giant cells (84). Most pathologic Frac-
junction with removal of the lesion. tures occur in boys (83), and age at presentation varies from 6
to 14 years (91).
FCDs are small metaphyseal lesions ranging from 1 to 2
cm in diameter and most commonly occur in the distal femur,
• AUTHORS' PREFERRED METHOD proximal tibia, and fibula. They are eccentric and usually are
,~ OF TREATMENT surrounded by the thinned cortex, with the medullary wall of
the lesion tending to be scleroric. FCDs are common and can
The first step in effective treatment of a patient with an ABC be seen on x-ray studies of the lower extremity in approximately
is to confirm the diagnosis with open biopsy and frozen seerion; 25% of pediatric patients (93). In view of their usually asymp-
this biopsy usually is done at the same surgical serring as the tOmatic nature, it is difficult to estimate the true incidence. They
definitive surgical procedure. [t is important to remember that usually require no treatment other than observation.
ABC can be secondary to other tumors such as nonossifying
fibroma, giant cell rumor, and chondroblasroma; telangiecratic
osreosarcoma may be difficult ro distinguish from ABC with an Radiographic Findings
inadequate biopsy specimen because the aplastic rumor cells are
NOFs also are eccentric Jesions of the metaphysis, bur they may
seen only ar the periphelY of the lesion (70,76).
achieve a length of 5 cm (90) or more and can extend across a
Once rhc diagnosis is made, treatment should be initiated as
substantial portion of the width of the long bone. They present
soon as possible because most ABCs are aggressive and often
at a similar age as FCDs, and follow a similar distribution of
grow and invade rapidly. Preoperarive planning is important ro bone involvement, and multiple lesions are present in approxi-
ensure adequate exposure, preparation for blood loss, internal mately one third of patients (83,87). On x-ray study, the lesions
fixarion, grafting material, and in selecred cases, preoperative are usually eccenrric, radiolucent cysdike areas that can be either
embolization. uniloculated or multiJoculated; in small bones such as the Fibula,
Achieving adequare exposure with a large conical window for they may occupy the entire width of the shaft (84). Sclerotic
thorough extended curettage is a key componenr for successful scalloping is often present along the endosteal margin (89). Usu-
trearmenr. The use of a high-speed burr allows systemaric intrale- ally, NOFs ate asymptOmatic unless a pathologic fracture is pres-
sional excisional curenage. Adjuvants phenol and alcohol, liquid ent (84). They become clinically significant when they present
nitrogen, and polymerhyl merhacrylate (PMMA) usually are re- with or predispose ro pathologic fracture.
served for large or recurrent ABCs bur may be considered in the
inirial management. Bone grafting is done for all lesions and
can consisr of aurograft, allograft, bone subsritutes, or a combi- Natural History
nation of rhese methods, depending on the circumsrances. Mosr
Arata et al. (82) Found that 43% of pathologic fractures through
patients with franures through ABCs have microfractures that
NOFs were in the distal tibia. Several previous reports suggested
do nor alter treatmenr. For those with more significant or un-
that these lesions regress spontaneously (83-85,87,90,92)
stable fractures, internal stabilization is used when appropriate,
Rjtschl et al. (92) described the radiomorphic course of NOFs,
particularly in the hip, femur, or tibia. The classification and
demonsttating that the defects become sclerotic and resolve.
recommendations in figure 6-7 are applicable for those with
Typically, this rumor remains asymptOmatic and is commonly
proximal fc:moral fractures associated with ABCs. A walking hip
an incidental radiographic finding. However, lesions with exten-
spica cast (i.e., a unilateral h.ip spica cast with the hip and knee
sive conical involvement can cause pathologic fracrures.
in 20 ro 30 degrees of flexion) is sometimes appropriate for
Previous repons suggest that the absolute size of the lesion
young children with stable fractures. Close follow-up is recom-
correlates directly with the risk of pathologic fracrure (82). Based
mended initially because recurrence can be rapid and aggressive.
on this factOr, prophylactic curetrage and bone grafting of larger
For ABC of the spine, we recommend preoperative selective
NOFs have been recommended. Arata et al. (82) noted that ail
arterial embolization, inrralesional extended excisional cutettage
pathologic Franures associated with NOFs in the lower extremity
and bone grafting. Instrumentation and fusion of the aFFected
occurred through lesions involving more than 50% ofthe trans-
area should be performed if instabiliry or the potential for insta-
verse cortical diameter. These large lesions were defined as exhibit-
bilityexists. Ifinstrull1entation is used, ritanium instrumentation ing more rhan 50% corticli involvemenr on anreroposrerior (AP)
allows follow-up MRI wirh less Iller:!l artifact compared with and lateral x-ray studies and a height measurement of more than
stainless sreel implants (Fig. 6-11) (80). 33 mm (82). Although the aurhors recommended careful obser-
vation of these large NOFs, they suggested that "prophylactic
curettage and bone grafting be considered if rhere is a reasonable
Tumors of Bone chance of franure." Their series does not include any large le-
sions meeting their size criteria that did not fracrure, and their
Fibrous Cortical Defects and Nonossifying Fibromas
hypothesis has never been tested in any published series. Dren-
Fibrous cortical defects (FCDs) and a larger varianr known as nan er al. (87) suggested that Iargc NOFs causing pain may
nonossifying fibroma (NOFs) may be associated with pathologic predispose to franure and recommended prophylanic curettage
fracrures in children. Both lesions contain Fibrous tissue, foam and bone grafting for selected larger lesions.
 Chllpter 6: Pllthologic Fractures 157

A B

c D
FIGURE 6-11. When dealing with pathologic fractures secondary to tumors or tumor-like processes of
the spine, if instrumentation is needed, titanium instrumentation allows much better postoperative
visualization with both CT and MRI for the detection of tumor recurrence as compared with standard
stainless steel instrumentation. A: Postoperative MRI of the spine with standard stainless steel instrumen-
tation showing a large degree of artifact that makes interpretation difficult. B: Preoperative CT scan of
a patient with an ABC of the spine. C: Postoperative (T scan of the same patient showing an adequate
view of the surgical area. D: Postoperative MRI of a patient with a previous spinal tumor again ade-
quately showing the surgical site to monitor for recurrence or persistent tumor.
 158 GeneraL PriTlicptes

A B

FIGURE 6-12. A: An 8-year-old boy was referred after being casted at an-
other institution for a pathologic fracture of the right femur. The x-ray
studies in the cast show a pathologic fracture of the right distal femur
through an NOF. B: At 14 weeks after the injury, the fracture has united
with some posterior displacement of the distal fragment. C: At 7 months
after fracture, there has been good remodeling at the fracture site with
persistence of the NOF. The patient returned to full activities and has had
c no further problems at 7-year follow-up.
 Chapter 6: Pathologic Fractures 159

and cast immobilization, and no refractures occurred. They sug-

gested rhat most parients with large NOFs can be monitored
without intervention, because previous studies support sponta-
neous resolution of most of rhese lesions (82,84,87). All frac-
tured NOFs in rheir series healed wirh closed reducrion and
immobilizarion. Ir may be reasonable ro resrricr rhe acriviry of
parients wirh large NOFs based on the nine parients in their
srudy wirh parhologic fractures caused by rrauma.
Fracrures usually are treared with immobilization until heal-
ing is obtained (83,86). Surgery is necessary only if the residual
lesion is of significant size to predispose rhe patienr to further
parhologic fractures or rhere is doubt about rhe identity of the
lesion (84). Displaced parhologic supracondylar fracrures of the
distal femur may require open reduction, bone grafting, and
inrramedullary fixation (87). Subperiosreal resection of a parho-
logic humeral shafr fracrure followed by bone grafting has re-
sulred in pseudoarthrosis (89).

• AUTHORS' PREFERRED METHOD

,~ OF TREATMENT

Trearmenr is based on rhe size and location of rhe lesion and

rhe type of pathologic fracrure. Small lesions without fracture
can be observed and may require 1 ro 3 years co spontaneously
resolve (83). SubstanriaJ lesions of the lower exrremiry iIi active
children, even if they are asymptomatic, should ei ther be fol-
A,B lowed carefully wirh serial x-ray studies or should undergo curer-
FIGURE 6-13. A 13-year-old athlete presented with a pathologic frac- tage and bone grafting to avoid pathologic fracture. AJrhough
ture through the distal tibia after a fallon the ice. A: The patient was
treated with a long-leg cast immobilization. After the fracture had absolute size parameters may be useful in predicting pathologic
healed, the patient underwent open currettage and bone grafting of fracture, they do nor imply a requiremenr for prophylactic curet-
the lesion. B: Follow-up x-ray studies show healing of both the fracture tage and bone grafring. Most patients wirh large NOFs can be
and the lesion, and the patient has returned to full activities.
monitored wirhollt surgical intervention, and fracrures can be
successfully managed with nonoperative rrearmenr. Our experi-
ence is that a considerable number of incidentally discovered
large NOFs do not fracrure. Although we cannor readily identi~'
Fracrures through NOFs exhibir excellent healing porentiaJ an accurate denominator, we infer thar many large NOFs remain
(82,84,87), but rhe lesion usually persists after heaJing of the unidentified and nonproblematic. Patient and family wishes and
fracrure (Figs. 6-12 and 6-13). Recurrent fracrures have been rhe individual's activiry demands also obviously influence the
reponed, bur the incidence of documented refracture is low (82, decision. Given the historic evidence for spontaneous resolurion
87). Fracrure union rakes place normally, bur often mulriple and favorable healing characteristics of NOFs, patienrs with le-
radiolucencies remain (84). Overall, fracture healing does nor sions larger than 50% of the widrh of the bone should be ap-
usually oblirerate the lesions so recurrent fracture can OCCl\[ (82, proached individually.
89).
Large lesions, defined as having a diamerer more than 50%
of the width of a Jong bone on both AP and lateral x-rays, are Giant Cell Tumors of Bone
believed ro be prone ro parhoJogic fracrure; most amhors have
recommended curertage and bone grafring for these large lesions Gianr cell tumors of bone are rare in the pediarric popularion;
(83,84,86,87,89,91). mosr occur in skeleralJy mature individuals. In a series of 22\
Easley and Kneisel er al. (88) reported rhat although absolute patients with gianr cell rumors of bone (%), only 20% of pa-
size parameters were helpful in predicting pathologic fracture, tients were younger rhan 20 years of age. In order of decreasing
rhey did not imply a requirement for prophylactic curertage and frequency, these tumors mosr commonly occur in rhe distal
bone grafting. In their series, 13 (59%) large NOFs had not had femur, proximal tibia, proximal humerus, and distal radius. The
pathologic fracture despite exceeding rhe previously established incidence of pathologic fracrures with these lesions is approxi-
size threshold. In the nine (41 %) patients in whom parhologic marely 16% (94-98).
fracrure occurred, healing was unevenrful after closed reducrion Radiographically, rhey are osteolyric, metaphyseal lesions rhar
 160 General Prinicples

A B

FIGURE 6-14. An 18-year-old girl presented

with left medial knee pain. A: X-ray studies
showed an eccentric, lytic, destructive lesion
involving the distal portion of the medial
metaphysis with extension into the epi-
physis. B: CT scan showed the destructive le-
sion with thinning of the cortex and no ex-
ternal soft tissue mass. Open biopsy and
frozen sections were consistent with giant
cell tumor of the distal femur. An extended
curettage was then performed with phenol
as an adjuvant and subsequent cementation
using methyl methacrylate bone cement. C:
Follow-up x-ray studies at 2 years after sur-
gery showing no evidence of recurrence. The
patient is asymptomatic and has full range
c of motion and function of the knee.
 Chapter 6: Pathologic Fractllres 161

can extend into the epiphysis, usually after physeal closure (Fig.
TABLE 6-6. TREATMENT OF GIANT CELL
6-14). They can be eccentric, but larger lesions can involve the TUMORS
full width of the bone. Little or no sclerosis usually is present
around the margin of the tumor. Although heavy trabeculation Scenario Treatment
may be present, new periosteal bone formation is uncommon.
1. FraCture undisplaced, No change in treatment plan
Giant cell tumors usually are treated by extended curettage structurally insignificant, (Usually extended
in combination with adjuvants, such as phenol or liquid nitro- non-articular curettage and cementation
gen, and filling with material such as PMMA (Fig. 6-14) with adjuvant such as
phenol)
(94-96). En bloc or wide resection is a more aggressive option.
2. Fracture simple, but Joint preserving options:
Simple curettage and bone grafting are associated with a high displaced
recurrence rate. In one series (96), simple curettage and bone a. Fracture can be a) closed reduction and
grafting had a 34% recurrence rate, whereas wide resection of reduced closed delayed extended
the lesion resulted in only a 7% recurrence rare. Wide resection curettagea
b. FraCture cannot be b) Open reduction,
is most appropriate for giant cell rumors involving expendable
reduced closed extended curettage,
bones and for aggressive lesions with significant involvemenr of simultaneous internal
the articular surface. The location and extent of the lesion and fixation and
the proximity of the rumor to articular cartilage and physis influ- cem'entation b
ence the treatment of giant cell tumors in children. 3. Fracture displaced, Resection or partial resection
intraarticular; Open of the joint
reduction, extended
curettage and internal
Pathologic Fractures Associated With Giant Cell fixation cannot be
achieved satisfactorily
Tumors of Bone
(uncommon in children)
Pathologic fracmres are associated with gianr cell tumors in 6%
to 30% of patients. The complexity of treatment is markedly a If a fracture can be reduced and held by closed methods, it may
be preferable to delay the definitive surgery until initial fracture
increased if a pathologic fracture is present. Managemenr de- healing has' occurred. Fracture healing is biologically faster than
pends on the type of fracmre and fracture displacement (Table the growth of the tumor; a delay of 4 to 6 weeks will have a
6-6). minimal effect on tumor progression,
b Atechnically demanding and difficult procedure: i.e,
A biopsy may be needed before fracmre treatment if the diag- mechanically removing all tumor (with curets and high-speed bur),
nosis is not certain. Most pathologic fractures are undisplaced, use of adjuvant s'uch as phenol, reduction and fixation of thin
"shell" of !;lone and cementation around the internal fixation
structurally insignificanr, or nonarticular, and require no change device.
in rhe rreatmenr plan. For more significant fractures, an attempt
at preserving rhe joint should be made. Overall, rhe presence of
a pathologic fracture itself does not seem to directly influence
the recurrence rate of giant cell tumor; it may influence the
reconstruction options and the overall functional result.

similar to solitary enchondroma, but usually with deformity and

Enchondroma shortening of the extremity due to growth disturbance (Fig. G-
16£). A unique x-ray finding that is believed to be pathogno-
Solitary enchondroma is a rare lesion in children. In one series
monic for enchondromatosis is the presence oflinear radiolucen-
of enchondromas (10 1), 57% of patients were between II and
cies extending from the metaphysis down the shaft of the long
30 years of age. The common presenring symptom is pain, usu-
bone.
ally associated with a pathologic fracture. Most common sites of When these lesions are associated with multiple hemangio-
involvement in decreasing order of frequency are the phalanges, mas, the general condition is known as Maffucci's syndrome
metacarpals, metatarsals, humerus, and femur. Pathologic frac- 000, I 02). ]n this syndrome, 30% of patients have one or more
ture is commonly the presenting symptom for enchondromas pathologic fractures (l 02). Approximately half of these fracrures
located in the phalanges of the hands or feet, but is rare for go on to delayed union or nonunion. Unilateral skeletal involve-
enchondromas in other locations. ment occurred in 48% of patients, with involvement in rhe order
On x-ray studies, the lesions can be central or eccentric and of frequency of the hand, foot, tibia, femur radius and ulna,
a stippled calcification of the cartilage tumor matrix may be humerus, and ribs. Skeletal deformities tend to stabilize at maru-
seen. ]n the long bones, lesions tend to be cenrral with only rity. Sarcomatous degeneration has been reported in approxi-
slight bulging of the cortex. The short tubular bones with en- marely 15% of parients.
chondromas show a cloudy radiolucency wirh bulging and thin- Asympcomatic lesions can be observed. Biopsy may be
ning of the cortex (Fig. 6-15) (01). necessary when the identity of rhe lesion is uncertain. Symp-
Children can also have multiple enchondromas or enchon- tomatic lesions respond well to curenage and bone grafting
dromatosis (Oilier's disease), which is commonly seen between (99,100). Trearmenr is individualized for displaced fracrures
2 and 10 years of age (Figs. 6-16). X-ray studies show lesions (Fig. 6-15).
162 General Prjnicples

A B

c
FIGURE 6-15. An 8-year-old boy presents with pain and swelling of the ulnar border of his right hand.
A: X-ray studies showed and expansile, lucent lesion of the diaphysis of the patient's right fifth metacar-
pal with microfractures. The patient had an open incisional biopsy with frozen section, which was consis-
tent with enchondroma with subsequent curettage and bone grafting. 8: Gross appearance of material
removed at the time of surgery, which is consistent with enchondroma. C: At 6-month follow-up, the
fracture is well healed, and there is no sign of recurrent tumor.
 Chapter 6: PathoLogic Fractures 163

A,a c

D E,F
FIGURE 6-16. Multiple enchondromatosis. A: A 10-year-old girl with multiple enchondromas sustained
a spontaneous pathologic fracture of the femur while running. Nine months before the injury, she had
sustained a fracture of the same femur, which had been treated with a one-and-a-half hip spica cast
for 3 months. B: The lateral x-ray study shows overriding of the fracture. C: The fracture was treated
with 3 weeks of skeletal traction, and then the extremity was placed in a cast brace for 9 weeks. On x-
ray, the excessive anterior bow of the femur has been somewhat corrected by deliberate posterior
angulation of the fracture. D: At 3-year follow-up, the fracture is well healed. E: The anteroposterior
x-ray study of the hand in this patient demonstrated multiple expansile enchondromas of the small
bones. F: An x-ray study of the humerus shows the streaked-mud appearance of the lateral humerus
(arrow).
164 G'mernl Prinil'ples

• AUTHORS' PREFERRED METHOD Eosinophilic Granuloma (Langerhans' Cell

,~ OF TREATMENT Histiocytosis)
Eosinophilic granuloma of bone is a henign condition with
Solitary enchondromas often require biopsy ro establish the diag-
either solitary or multiple lytic bone lesions. It is considered pan
nosis. For asympromatic patiems with small lesions with classic
of a general family of diseases collectively known as Langerhans'
x-ray findings, biopsy usually is nor necessary. Curetrage and
cell hisriocyrosis (LCH) or histiocyrosis X, which also includes
bone grafting is necessary for those lesions with acme or impend-
Hand-Schi.i1ler-Christian and Letterer-Siwe diseases (111,115).
ing pathologic fractute. Fixation is not necessary for those lesions
Bone lesions contain large coffee bean-shaped histiocyres, eosin-
of the short tubular bones but may be necessalY for lesions of the
ophils, and multinucleated gial1t cells (117).
proximal femur or long bone of rhe lower cxtremiry. Standard
Nearly 75% of patiems with eosinophilic granuloma of bone
fracture care is adequate to treat most injuries.
are younger than 20 years old, and 34% are younger than 4
years old. The ratio of male ro female is approximately 3: 2
(117). Nearly 50% of patients present with localized pain and
Osteochondromas tenderness (t08, 117); the duration of symptoms ranges from 2
Osteochondromas are one of the most common rumors of bone weeks to 2 months, wirh occasional associated trauma. Swelling
in children, and clinical symptoms usually are related ro in'ita- may be presem over superficial bones such as rhe skull, clavicle,
tion of the surrounding soft tissue structures. Peroneal nerve and tibia (l08). In order of decreasing frequency, rhe sites of
palsy may occur in association with osteochondroma of the prox- involvement are the skull, femur, pelvis, ribs, humerus, spine,
imal fibula (103). Radiation induced osteochondromas also can clavicle, mandible, tibia, radius, scapula, and fibula. In one series
occur (104). (113), 14% of patients with solitary eosinophilic granuloma of
Although they are rare, fractures may occur through the base bone had additional lesions within 2 years of diagnosis, whereas
or stalk of a pedunculated osteochondroma (105); conservative 85% of patients with multiple lesions at rhe time of initial diag-
trearmem is adequare (Fig. 6-(7). Fractures through solitary os- nosis had additional bone involvement. The incidence of patho-
logic fracture in patients with LCH is approximately 14% (J08,
teochondromas should be observed, and excision should be re-
served for those pariems wirh persistent symproms after healing.
117). Laboratory tests usually are not very helpful; eosinophilia
is infrequent (117)
Patients with vertebral body involvement present with back
pain and may have neurologic signs or symptoms. Although the
thoracic spine is the most commonly involved pan of the spine,
both cervical and lumbar lesions have been reported (113).

Radiographic Findings
In children, long bone lesions may occur in both the diaphysis
and metaphysis, with destructive osteolysis that erodes the cortex
and overlying expansion by periosteal layering (108,113,114).
Epiphyseal involvement is rare. Defects in bone may be lobu-
lated, and aggressive subperiosteal bone formation may suggest
malignancy. The size of the lytic area may vary from 1 to 4 cm
(tll) .
Classic vertebral plana is uncommon with eosinophilic granu-
loma of the spine in a child. When present, however, usually
only one vertebra is involved, and it assumes a coin-on-end ap-
pearance with intact adjacent disk spaces. X-ray studies of pa-
tients with skull involvement show characteristic punched-out
round lytic lesions that are beveled on rangenrial views.
The lesion may mimic osteomyelitis, Ewing's sarcoma, Bro-
die's abscess, metastatic disease, and osteogenic sarcoma (t 08).
Bone scans tend to be unpredictable, with the incidence oHalse-
negative scans ranging from 28% ro 35% (106). In one series
(106), the increased uprake of isotope was seen in 60% of pa-
FIGURE 6-17. A 10-year-old-boy with pain over the right medial tibia tients, and there was an II % incidence of cold lesions found
after a direct blow. An exostosis is present, and the transverse radiolu- only in the venebraJ column and rhe ribs. Although bone scans
cency at its base may represent a fracture. The patient continued to
have symptoms after healing of the fracture and the osteochondroma may be useful in identifyi ng recurrent lesions (l 06), the skeletal
was excised. survey is most valuable in identifying the lesions. A bone scan
 CI)apter 6: f'athologic PmctureJ 165

should be used only when the x-ray studies are normal or equiv- al. (119) described a percutaneous needle biopsy technique for
ocaL diagnosis with subsequent methylprednisolone injection for pa-
tients with localized LCH; 34 of35 lesions injected with methyl-
Treatment prednisolone healed, and there were no complications. Other
Biopsy usually is needed for diagnosis because of the lesion's investigarors (107) have had similar results. Radiation therapy
tendency to mimic more serious conditions. Once the diagnosis has been recommended for some inaccessible lesions (108), bur
is established, treatment options may include curettage, curet- one series suggesred an associarion of rhis rreatment wi rh subse-
tage and bone grafting, irradiation, chemotherapy (J 08, 117), quent lymphosarcoma (08). Chemorherapy, usually consisring
and corticosteroid injection (115). All of rhese forms of rreat- of oral merhotrexate and prednisone, is used in patients with
ment result in healing of the lesions (08). For small lesions and severe, painful, or progressive lesions or visceral involvement
an established diagnosis, observation may be the best option; (115).
marginal sclerosis about the lyric area suggests healing. Fracture bracing is useful for both acme fracrures and prophy-
Sbarbaro and Francis (117) reponed an average healing time lactic use for impending fracture or after biopsy of lower extrem-
of 16 monrhs after curettage without grafting. McCollough iry lesions (109). Surgery may be necessalY fOf unstable fractures
(113) noted thar if a lesion increased in size afrer surgery, then (Fig. 6-18). The diagnosis of vertebral lesions usually is besr
additional bone or soft tissue lesions usually appeared. Yasko et established by biopsy, especially if there are any arypical radio-

FIGURE 6-18. Eosinophilic granuloma. A: A 4-year-old boy

with a pathologic fracture of the right femoral neck sec-
ondary to eosinophilic granuloma (arrow). B: The pins were
removed, and at 3-month follow-up, the fracture was
B healed with acceptable alignment.
166 C{'}/fra/ Pl'ilJirplf.\

A B

c
FIGURE 6-19. Eosinophilic granuloma. A: A 5-year-old boy presented with mild back pain and normal
results of physical examination. A lateral x-ray study showed equivocal posterior wedging of L4 (arrow).
Bone scan was read as normal. B: Nineteen days later on follow-up, he had marked spasm of the lower
back. The lateral x-ray study now shows vertebral plana of L4 (arrow). C: CTscan shows marked expansion
and erosion of the pedicle (arrow) and vertebral body. (Figure continues.)
 Chapter 6: Pathologic Fractures 167

o ',(. - • .. I-.- E
FIGURE 6-19. (continued) D: MRI shows marked collapse of L4 with thickening of the adjacent interver-
tebral disks. Soh tissue mass is also seen adjacent to L4 (arrow). Eosinophilic granuloma was diagnosed
by Craig needle biopsy guided by CT scan, and the patient was treated with a spinal orthosis. Radiation
treatment was also recommended, and a total of 600 rads was given in three divided doses. E: At 2-
month follow-up, the compressed vertebra was beginning to regain density (arrow). The patient was
asymptomatic. Bracing was continued for a total of 6 months.

graphic fearure of a lesion such as a sofr tissue mass. After diagno- Careful staging (124,130) and subsequent biopsy (121,131,
sis, they usually are [I'eated with activity modification and a 132,135) are critical in the evaluation of children with malignant
spinal orthosis (Fig. 6-19) (110,112). Seimon (118) tecom- bone rumors. To avoid pathologic fraerure from biopsy of bone,
mended biopsy "only if rhere is any uncertainty in diagnosis," an oval hole with smooth edges should be used and should be
and irradiation only fot progressive disease. Surgery may be nec- filled with PMMA (130). Many malignant tumors have a large
essalY when there are associated neurologic deficits (113). Re- soft rissue mass that can be biopsied, obviating the need ro make
modeling is seen with some spinal lesions but does not seem [Q a hole in the bone. There has been a great deal of progress in the
cortelare with patient age (110,112,116). understanding of the moleculat biology and genetics of cancer
(125-128). These advances have already led ro bener diagnostic
analysis of these rumots. Immunohisrochemical, molecular ge-
~ AUTHORS' PREFERRED METHOD netic, and cytogenetic rests often are critical in establishing the
,~ OF TREATMENT correct diagnosis, especially small round blue cell tumors. The
evaluation and biopsy of these children should preferably be
Pathologic fractute is uncommon in patienrs wirh LCH. The done at a center where these rechniques are known and available
correer diagnosis should be established with biopsy for mosr (121,129,131,132).
lesions, and the use of newer diagnostic merhods such as immu- One of the major advances in the care of children with iso-
nohisrochemisrries (such as CDIA) can be helpful in confirming lared exnemity sarcoma has been the development of limb-spar-
rhe diagnosis of these lesions. The !1arural hisrory is one of grad- ing sutgical techniques for local control of the rumors. Patho-
ual regression and healing. Standard fracrure care is usually suff!- logic fracture has been cited as a contraindication ro this
ciem for parhologic fracrures. procedure because of concerns about rumor dissemination by
fracture hemawma (Fig. 6-20). Until recently, there has been
little clinical data in the literature on which to base the treatment
Malignant Bone Tumors and Metastasis
of these patients. A number of recent srudies, however, have
The two most common primary sarcomas of the long bones shown that pathologic fractures heal with neoadjuvanr chemo-
in children are Ewing's sarcoma and osteosarcoma. Destrucrive therapy and do not affect survival rates (123,133,137). Abudu
lesions also can be caused by metastatic cancer to bone. et al. (120) reviewed the surgical treatment and outcome of
168 Cmeral Prillicples

B
FIGURE 6-20. A 15-year-old girl was referred with a pathologic fracture of the femoral shaft after a
fall while going down stairs. On close questioning, she stated that she had had pain in her thigh for
several weeks before the fall and that the fall occurred after her leg gave way while going down the
stairs. As an infant, she had already been treated with a cast for 2 months. A: The patient had been
casted at another hospital, and x-ray studies in the cast show a transverse fracture of the mid-femoral
shaft with destructive changes and worrisome periosteal elevation. B: MRI showed destructive changes
of the mid-shaft of the femur with a soft tissue mass and bleeding from the fracture. An open biopsy
established the diagnosis of Ewing's sarcoma of the femur, which was treated with neoadjuvant chemo-
therapy.
 Chapter 6' Pathologic Fractllres 169

pathologic fractures in 40 patients with localized osteosarcomas and deformity. Three forms exist: monostotic fibrous dysplasia,
and found that limb-sparing surgery with adequate margins of polyostotic Fibrous dysplasia, and McCune-Albright syndrome
excision could be achieved in many patients without compromis- (MAS). In 1937, McCune and Bruch (154) and Albright et al.
ing survival, but that 19% of those treated with limb-sparing (138) described patients with these osseous lesions in association
surgery had local recurrences. Scully et al. (134) reviewed the with cutaneous pigmentation and endocrine dysfunction. Later,
surgical treatment of 18 patients with osteosarcomas pathologic Lichtenstein and Jaffe 052,153) coined the term fibrous dyspla-
fractures. Of the 10 patients who had limb-sparing surgery, three sia and further divided the entity into monostotic and polyos-
had local recurrences and six had distant recurrences. Although totic fotms without endocrine disorder. The common factor is
the distant recurrence rate for patients undergoing amputation expansile fibrous tissue lesions of the bone, which contain woven
was no different from the rate for those undergoing limb salvage, bone formed by metaplasia with poorly oriented bone trabec-
the difference in local tumor control approached statistical sig- ulae.
nificance. All patients who developed local recurrence died. The Studies have demonstrated that MAS is caused by activating
authors stated that surgical treatment should be individualized mutations in the gene for the alpha subunit of the heterottimeric
(134). Limb-sparing surgery is possible and appropriate in care- stimulatolY G protein of adenylate cyclase (GNASl gene), lo-
fully selected patients as long as wide margins can be safely cated on the long arm of chromosome 20 at locus 20q 13.2-
achieved and the function of the child will be betrer than that q13.3 (139,155). The mutation in this gene likely occurs in
achieved with an ampmation and a well-fitting prosthesis. emblyonic development and is expressed in a mosaic pattern,
Pathologic fracture after limb-sparing surgery is a major com- resulting in the often lateralized pattern of skin and bone in-
plication, occurring most commonly after allograft reconstruc- volvement in patients with MAS. This mutation is not present
tion (122,136). Berrey et al. (122) teviewed 43 patients in whom in tissue from patients with aggressive fibromatosis involving
allografts used in reconstruction after resection of tumors had bone or osteofibrous dysplasia (139).
subsequently fractured. Four fractures healed with immobiliza-
tion alone, and the remainder of patients attained satisfactory
results with open reduction and grafting, replacement of the Monostotic Fibrous Dysplasia
internal fixation device, or total joint replacement (122). San-
Julian and Canadell (136) repotted on 12 patients with 14 frac- Clinical Presentation
tures (10.2% of 137 patients with allografts for limb-sparing The diagnosis usually is made between the ages of 10 to 15 years
surgery in their seties). They recommended intramedullary fixa- of age, although neonatal fibrous dysplasia of the fibula has been
tion whenever possible co reduce the incidence of allograft ftac- reponed. The lesions usually are asymptomatic until a fracture
ture. occurs, then patients may have pain and swelling (146). Incom-
Pathologic fractures also can occur in children with metastatic plete fractures are most common. The sites of fracture in order
disease but are less common in children than in adults. Most are of decreasing frequency are the proximal femur, tibia, ribs, and
microfractures and can be managed with conservative fracture bones of the face (146). Cutaneous lesions usually are not present
management techniques. in monostotic fibrous dysplasia. Although ptegnancy may stimu-
late the lesions (I76), overall progression is rare after initial pre-
sentation. Sarcomatous degeneration has an incidence of approx-
• AUTHORS' PREFERRED METHOD
imately 0.5% and generally occurs approximately 15 years after
\..~ OF TREATMENT
initial diagnosis.
The central dilemma in monostotic fibrous dysplasia is distin-
In all suspicious lesions, careful staging and biopsy are the appro-
priate treatments by individuals who have experience in the man- guishing the lesion from other benign disorders. The differential
agement of children with musculoskeletal sarcomas. Further- diagnosis usually includes eosinophilic granuloma, VBe, giant
more, access to special diagnostic modalities, such as cell tumor, enchondroma, solitary fibroma, and osteomyelitis.
immunohistochemistry and cytogenetics, will lessen the chances MRl can be helpful in evaluating these lesions, but biopsy is
of misdiagnosis. The decision for or against limb-sparing surgery sometimes necessary to establish the correct diagnosis.
in patients with pathologic fractures should be individualized
based on factors such as the fracture displacement, fracture sta- Radiographic Findings
bility, histologic and radiologic response to chemotherapy, and Radiogtaphically, lesions of monostotic fibrous dysplasia usually
most important, the ability to achieve wide margins for local are elliptical, central lesions in the mid-diaphysis. The borders
tumor control. Pathologic fractures that occur after reconstruc- of the lesion are commonly sclerotic; trabeculation is more com-
tion through allograft or endoprosthetic reconstruction often mon than a ground-glass appearance. There often is a slight
can be successfully treated with bone grafting or exchange of bowing of the tibia, but bowing of the femur is uncommon.
allograft or endoprosthesis. With evaluation by CT scan, the extent of conical thinning
can be studied and relative central densities measuted. Eosino-
BONE AND FIBROUS TISSUE DISEASES philic granuloma, neoplasm, and osteomyelitis have a density
on CT scan ranging from 20 to 40 Hounsfield units, whereas
Fibrous Dysplasia fibrous dysplasia has a higher density, ranging from 70 to 130
Fibrous dysplasia, a developmental abnormality of bone present- Hounsfield units. MRl may be useful to differentiate fibrous
ing as expansile fibrous lesions, can result in pathologic fracture dysplasia from other lesions, especially VBe.
170 General Prinicples

Injury comas also have been reported. The warning signs for sarcoma
Pathologic fractures occur in nearly 45% of patients. Fractures in existing lesions of fibrous dysplasia are pain and rapid enlarge-
of the long bones are generally not displaced; many are micro- ment of the lesion.
fractures. Although the fractures heal rapidly, endosteal callus is
poorly formed and periosteal callus is normal (148). With mild Radiographic Findings
deformiry, the cortex thickens on the concave side of the long Polyostotic fibrous dysplasia appears as multiple expansile lesions
bone. Nonunion is rare. with cortical erosion. Most have a multilocular appearance asso-
ciated with a scalloped pattern of endosteal erosion (175). A
Treatment ground-glass appearance on x-ray study is caused by the meta-
Conservative treatment with immobilization is indicated for plastic woven bone comprising the lesion. A radiolucent cystic
most fractures that occur in conjunction with monostotic fibrous appearance also is common. Cartilage may be present in approxi-
dysplasia. Traction with subsequent casting can be used for fem- mately 10% of lesions, and radiographic stippling may be seen
oral shaft fractures in young children; casts or cast-bracing for (153). In contrast to those in monostotic fibrous dysplasia, the
upper and other lower extremity fractures is often appropriate lesions in the polyostotic form have little increased peripheral
(146). density, and they usually form a characteristic fusiform expan-
Operative intervention is indicated for fractures of severely sion of the bone (Fig. 6-21). Bowing of the long bones is com-
deformed long bones and those through large cystic areas. Bone mon, and normal tubulation may not occur with growth (148).
graft can be resorbed, but total obliteration of the lesion often Distinguishing polyostotic from monostotic fibrous dysplasia
can be accomplished with grafting. Deformiry can occur, and may be difficult. Plain x-ray skeletal surveys usually are done;
internal fixation may be required for stabilization. Complete en technetium bone scans are helpful in identifYing multiple lesions
bloc extraperiosteal excision with grafting has been shown to be that may not be present on plain x-ray studies (143,149). Harris
successful for severe lesions bur is seldom needed. Both painful et al. (148) suggested that the hallmarks of polyostotic fibrous
lesions without fracture and impending pathologic fractures can dysplasia is the chatacteristic long bone lesions with extension
be treated with bone grafting. from epiphysis to epiphysis and increased density at the base of
Proximal femoral lesions with pathologic fracture are espe- the skull. They suggest that a survey of the pelvis and femurs is
cially troublesome because of the propensity for malunion with most helpful in noting multiple lesions. Epiphyseal lesions can
coxa vara. For fractutes through small lesions, either cast immo- also occur (148).
bilization or curettage with grafting can be used; osteotomy can
be done for residual deformity (145). For larger lesions, internal
fixation is necessary. Proximal femoral pathologic fractures have Injury
been stabilized with lag screws, blade plates (146), intramedul- In one series of 37 patients with polyostotic fibrous dysplasia,
lary nails, and Enders nails. Cast immobilization and protected nearly 85% had at least one fracture and 40% had an average of
weight bearing are necessary after these procedures to protect three fractures (148). Fractures are most common in the femur,
the reduction. Spine fractures are rare but can be tteated with humerus, radius. and wtist (152,153). Like fractures in monos-
bed rest followed by immobilization with an orthosis (146). totic fibrous dysplasia, fractures in the polyostotic form generally
are nor displaced and healing is not delayed; nonunion can
occur, however (148). Rib fractures are rare, and generally rib
Polyostotic Fibrous Dysplasia lesions are asymptomatic. A shepherd's crook deformity of the
Clinical Presentation humerus associated wirh polyostotic fibrous dysplasia has been
Most patients with polyostotic fibrous dysplasia present before reported (143,157). Compression of the spinal cord by fibrous
age 10 years with pain, limp, deformity, or pathologic fracture tissue also has been reported.
(146,152). The bones most commonly affected are the femur,
tibia, humerus, radius, facial bones, pelvis, ribs, and phalanges Treatment
(152). Involvement is often unilateral, usually affecting a single The fractures of polyostotic fibrous dysplasia usually occur
extremity. In one series, 50% of patients had facial involvement through very diseased bone and are associated with marked de-
(I 46). Spine involvement occurs with polyostotic fibrous dyspla- formity. They often require more aggressive treatment than frac-
sia, and limb-length discrepancy is common (146,148). Al- tures seen in the monostotic form. Conservative immobilization
though most laboratory studies are normal, serum alkaline phos- techniques usually are appropriate for most shaft fractures in
phatase levels may be elevated (I48). Some authors believe that children before puberty. Fractures of the femur can be treated
polyostotic fibrous dysplasia does not usually progress signifI- with traction and subsequent casting in young patients. After
cantly after adulthood (I 46,158), but others (148) believe that adolescence, however, the recurrence of deformity after surgery
puberry does not affect the bone lesions. is less, and curettage and grafting should be considered for frac-
Both intramuscular myxoma and myositis ossificans tures, especially for large lesions with associated deformity (148,
progressiva have been associated with polyostotic fibrous dyspla- 153). Stephenson et al. (156) found that in patients younger
sia. \Y/hen it occurs, sarcomatous degeneration of the lesions than 18 years of age, closed treatment or curettage and bone
occurs 10 to 12 years after the initial diagnosis of fibrous dyspla- grafting of lower extremity fractures gave unsatisfactory results,
sia; osteogenic sarcomas, chondrosarcomas, and giant cell sar- but internal fixation produced more satisfactory outcomes. A
 Chapter 6: Pathologic Fractures 171

A,B c
FIGURE 6-21. Polyostotic fibrous dysplasia in a IO-year-old girl. A: A fusiform expansile lesion is present
in the mid-shaft of the humerus. B: A more eccentric expansile lesion is seen in the tibial shaft. There
is scalloping due to endosteal erosion with a central ground-glass appearance. The lesion was painful
and was treated with curettage and bone graft. (Courtesy of Jack Henry, M.D., San Antonio, Texas.) c:
Polyostotic fibrous dysplasia in a 26-year-old woman. A large erosive lesion is present in the inferior
neck of the femur. This lesion was treated by curettage with both fibula and iliac crest bone graft.
(Courtesy of Gregorio Canales, M.D., San Antonio, Texas.)

So field procedure (osteotomy and intramedullary nailing) can McCune-A/bright Syndrome

be used for tibial deformity.
Clinical Presentation
The gteatest challenge in polyostotic fibrous dysplasia is rreat-
McCune-Albright syndrome is a rare variant of fibrous dysplasia
ment of fractures of the proximal femur. Wirh recurrenr fracture
associated with endocrine dysfunction (such as precocious pu-
and deformiry, a severe coxa vara resembling a shepherd's crook
berry in females), characteristic bone lesions (osteitis fibrosa dis-
develops. Curenage of the lesion with abundant bone grafting
seminata), and areas of cutaneous pigmentation (138,154). It
has been recommended for mild deformities (149,153), and fixa-
affects both women and men and has been associated with pirui-
tion usually is needed for large lesions. Femoral neck fracmre
taty adenoma, gigantism, hyperthyroidism, and Cushing's syn-
or osteotomy for deformiry can be stabilized with inrernal fixa-
drome (150). The skin lesions generally are flat, multiple mela-
tion. For severe shepherd's crook deformiry, medial displace-
notic areas that stop at the midline and parallel the distribution
ment valgus osteowmies with plate fixations are needed to re-
of bone lesions (146). The irregular margins have been compared
store the biomechanical stabiliry of the hip (147). For severe
to the coast of Maine in contrast to the smoother lesions found
lesions, Funk and Wells (145) recommended complete excision
in neurofibromatosis, which are likened to the coast of Califor-
of the intertrochanteric area and advancement of the psoas and
nia. Skin lesions may also be absent.
gluteus medius tendons. Breck (140) recommended securing the
On x-ray smdies, a polyostotic presentation is seen. With
side plate of the femoral nail with bolts and washers rather than
precocious sexual development, there is rapid bone maturation
with screws w obtain bener stability. Massive auwgenous bone
with early physeal closure and short stamre (146). Pathologic
grafring is believed to be superior w donor bone graft (148),
fractures in childhood occur with a pattern and appearance simi-
but it may be impractical because the iliac crests of a young
lar co those in polyoscotic fibrous dysplasia.
child may be small and the pelvis may have coexisting disease.
The use of bisphosphonates may offer hope for a medical Treatment
rreatment for patienrs with severe fibmus dysplasia. Radiation The lirerature is limited regarding specific treatment of
therapy is not recommended (152). McCune-Albright syndrome, but both conservative treatment
172 Gl'I7era! Prin;cples

A B

C,D E
FIGURE 6-22. A: A 7-year-old girl presented with McCune-Albright syndrome. Skull radiographs show
multiple lesions consistent with this condition. B: Expansile rarefied lesions are present throughout the
humerus and the radius. C and D: Both proximal femurs have areas of rarefaction with expansile lesions
(arrows). E: Both tibiae and fibulae show areas of expansile fibrous dysplasia (arrows).
 Chapter 6: Pathologic Fral'tures 173

and aggressive surgical intervention have been used wirh appar- fu] preoperative evaluation in preparation for anesthesia and sur-
ent success. lnrernal fixarion may be necessary in severe cases gery. The reader is referred ro an excellent review by Langer et
(Fig. 6-22). Wirh [he recenr progress in undersranding rhe ge- al. (151) for further information.
neric basis of rhis disorder, newer rrearmenr aJrernatives may
become available. Osteofibrous Dysplasia of the Tibia and
Fibula
• AUTHORS' PREFERRED METHOD Clinical Presentation
,~ OF TREATMENT The term osteofibrous dysplasia of the tibia and fibula is advo-
cated to describe specific, uncommon fibrous lesions of the tibia
Conservarive trearmenr with immobiJizarion is indicared for and fibula in young children (160). These lesions superficially
mosr fracrures in children wirh monosroric fibrous dysplasia. ]n resemble monostotic fibrous dysplasia but exhibit unique natural
younger children, immediare casring, or rraction and subsequenr histoIY, response to treatment, and specific histology.
casring are used for most femoral sh.afr fractures. Because frac- Most patients present before the age of 5 years, but the range
tures in parienrs wirh polyoswric fibrous dysplasia usually occur varies from 5 weeks ro 15 years of age (160,163). There usually
through velY abnormal bone and can resulr in marked deformi ry, is painless enlargemenr of the tibia with slight to moderate ante-
they ofren require more aggressive trearmenr (e.g. inrernal fixa- rior or anterolateral bowing. The disease process is almost always
tion). confined to one tibia, but the ipsilateral fibula can also be in-
Mrer adolescence, rhe occurrence of deformiry after surgelY volved. SolitalY involvement of the fibula is infrequent, and bi-
is less frequenr. Nonoperative trearmenr of fracrures and curer- lateral involvement of both tibias is rare. Barh distal and proxi-
tage and cancellous bone grafring do nor generally produce saris- mal lesions can occur, and with fibular involvement, the lesion
facrolY results in children with fibrous dysplasia of the lower is locared distally.
extremiry. Curettage and grafting are indicated for fractures of Biopsy specimens distinguish this entiry from fibrous dyspla-
severely deformed long bones and those through large cystic sia or adamantinoma. The fibrous tissue present is less cellular
areas, with internal fixarion appropriate for the location and age. than in fibrous dysplasia. Woven bone is at rhe center of the
Bone graft can be resorbed after placemenr in extensive lesions, lesion, with newly formed bone trabeculae bordered by active
and proximal deformiry can occur after corrective osteowmy. osteoblasts and lamellar srrucrure near the periphelY of the le-
sion. This parrern is unusual in fibrous dysplasia. A particular
Proximal Femoral Lesions zonal architecture is present in large biopsy specimens and shows
increasing size and maruriry of the bone trabeculae toward the
One of the most common sites of fracrure and deformiry is edge of the lesion. Some authors believe rhat osteofibrous dyspla-
the proximal femur. Proximal femoral lesions with pathologic sia may be related to adamantinoma (164,165).
fracture are especially difficult because of the tendency for varus
deformiry and repeated fracture. Stable fractures through small
lesions can be treated with cast immobilization, but one must be Radiographic Findings
vigilant and ready to inrervene at any sign of varus displacemenr. An eccentric intracortical lesion of osteolysis usually is present
Femoral neck fractures can be stabilized in situ with a cannu- in the middle third of the tibia, with extension proximally or
lated screw, or compression screw and side plate, depending on distally (Fig. 6-23) (163). The cortex overlying the lesion is
the extenr of involvemenr and the nature and location of the expanded and thinned, and in the medullaty canal, a dense band
fracture. Fixation can be combined with valgus osteotomy if of sclerosis borders the lesion with narrowing of the medullaty
there is preexisting deformiry or with curettage and grafting if canal. A single area of radiolucency may be presenr and has
there is a large area of bone loss. Postoperative cast immobiliza- a ground-glass appearance, but often there are several areas of
tion and protected weight bearing usually are necessary. Varus involvement with a bubble-like appearance.
deformity is best treated with valgus osteotomy of the subtro- The differential diagnosis usually includes borh monostotic
chanreric region and incernal fixation early in the course of the fibrous dysplasia and adamantinoma, but some authors (160)
disease w resrore the normal neck shaft angle and mechanical believe that the characteristic x-ray appearance and the early
axis. ]nrramedullaty load-sharing fixation (such as flexible inrra- onset of the disease effectively exclude these two disorders and
medullary nails) can be used for juvenile patients with femoral that biopsy is not necessalY. Others support the need for biopsy
shaft fracrures. to establish diagnosis. Bracing with orthotics is advisable after
For larger lesions with more severe deformiry, and in older open biopsy for diagnostic purposes.
patienrs, rigid fixation often is necessary. Depending on the situ-
ation, intramedullary load-sharing fixation devices that suppOrt
Injury
not only the femoral neck but also the shaft of the femur (such
as custom intrameduLlary reconstruction nails) are better and Pathologic fractures are present in nearly one third of patients
should be used when possible. For severe shepherd's crook defor- (160). These fractures are either incomplete or minimally dis-
miry, medial displacemenr osteotomies are needed ro resrore the placed and heal well with both closed and open methods (160),
biomechanical stabiliry of the hip. although delayed union may be a problem. Pseudarthrosis is
Patients with McCune-Albright syndrome should have care- rare.
174 General Prinilples

FIGURE 6-23. Osteofibrous dysplasia of the tibia. A: An 8-year-

old girl presented with slight bowing of the left leg. X-ray study
showed a circumscribed sclerotic and lytic lesion of the diaphysis
of the tibia. Lateral radiographs show bowing of the tibia with
a disphyseal intracorticallesion. The patientwasthoughtto have
osteofibrous dysplasia. and was braced and followed yearly. B:
Eight years later. the lesion has become slightly more extensive
and is associated with slight progression of anterior bowing of
the tibia. The patient underwent open biopsy. and pathologic
diagnosis was consistent with adamantinoma. Chest CT showed
no sign of lung involvement. The patient was treated with wide
excision of the entire lesion and free vascular fibula bone graft
reconstruction. C: The patient has had no evidence of further
A recurrence at 16-month follow-up.

B c
 Chapter 6: Pathologic Fractures 175

Treatment hypemophy of rhe limbs is presenr in 37% of adulcs with neuro-

fibromatosis (1%), whereas children have an 11 % incidence of
The natural history of this disorder in untreated patiems is vari-
limb-length discrepancy and only a 3% incidence of soft rissue
able. Most lesions show slight or moderate progression in lare
enlargement of the exuemities (177).
childhood, but others may show aggressive expansion with bow-
A diagnostic biopsy of a dermaJ neurofibroma is considered
ing of the tibia in patiems up to 15 years of age. Rarely, the
a valuable criterion for the diagnosis of neurofibromacosis. These
lesions may even regress or remain stationary over 3 to 4 years.
rumors, however, tend not ro be clinically apparenr unril the
Mosr lesions stop expanding afrer completion of skeletal growrh.
child is older rhan 12 years of age (177). Plain x-ray srudies are
Whar appears to be osteofibrous dysplasia may actually be early
nor helpful in idenrifying these sofr tissue rumors. MRI can be
adamanrinoma (164). MRJ showing a sofr tissue extension is
helpful in identifying the sofr tissue masses. Technetium
indicative of adamanrinoma. Open biopsy also may be needed
99m-Iabeled dierhyleneuiaminepenraaceric acid (DTPA) accu-
to establish the biphasic histology of adamanrinoma.
mulates in the soft tissue rumors of neurofibromacosis (191,
Curetrage and grafting were associated wi th a local recurrence
192). Routine isocopic imaging wirh this rechnique can idenrify
rate of up to 64% in children 14 years old or younger in one
lesions as small as 1.5 cm. Lesions as small as 0.8 cm were seen
series (160). Others reponed a lower local recurrence rate. Ozaki
through a more advanced rechnique known as single prown
et al. (162) showed rhe course of six ribial lesions in five patienrs
emission computed romography. Such techniques may be useful
with osteofibrous dysplasia who were followed longer rhan 10
in idenrifying occult neurofibromarosis and pseudarrhrosis of
years (average: 16.8 years). Curertage and autogenic bone graft-
the long bones.
ing were perFormed on fWO lesions, which rhen healed. Of four
lesions on which curettage and autogeneic bone grafts were per-
Injury
Formed, three healed and one recurred. The recurrenr lesion
healed after curenage and xenogeneic bone graFting. Three le- Pseudarthrosis of the long bones in patienrs with neurofibro-
sions healed wirhout surgical rreatment. Dming long-term Fol- marosis can be a therapeutic dilemma. The appearance of pseud-
low-up, this disease showed a clear tendency for healing (162). arrhroses and their resistance co rreatmenr has been postulated
Wide exrraperiosreal resection can be performed, bur grafr re- to be due ro a deficiency of bone formation secondary co meso-
sorprion can srill occur (160). Some authors (159,161) believe dermal dysplasia. More recenrly, the abnormal soft cissue associ-
rhar bracing unril skeleral maruriry is preferable to surgely. ated with rhese pseudarrhroses has been postulated to be the
Pathologic fracrures in this disorder should heal with casr im- major associated facror in causing pseudarthrosis (216). Wright
mobilizarion in plasrer casrs. If fracrures recur, or if rhe lesion is et a1. (216) developed a rabbit tibia congenital pseudarrhrosis
rapidly progressive, wide exrraperiosteal resection with grafting is model and suggested that a possible underlying abnormality in
necessary (160). Open reducrion wirh bone grafting and internal congenital pseudarthrosis might acrually be the abnormal soft
fixation is recommended for fractllres with angular deFormity. tissue surrounding the bone rarher than the bone itself (216).
Early osreotomy is recommended For severe bowing deFormity. Approximately 5% of patients with neurofibromarosis are
rhought eventually ro have pseudarthrosis of the long bones.
Neurofibromatosis The tibia is rhe bone mosr often affected, but only 55% of the
cases of congeniral pseudarthroses of rhe tibia are thought to be
Neurofibromatosis, also known as von ReckJinghausen's disease, associated with neurofibromatosis (176).
is an autosomal dominant condirion with variable penerrance The term congeniral pseudarthrosis in neurofibromarosis is
rhat occurs in 1 in 2,500 to 3,000 live births (177). Ir affects misleading because a substanrialmunber of patients do not have
neural rissue, vascular S£ructllres, skin, and the skeletOn. The a pseudarthrosis ar birth but rarher develop it larer after a patho-
diagnosis of neurofibromatosis can be based on the presence of logic fracrure (199). Brown er al. (175) found chat in six children
fWO of the four following criteria, according to Crawford and
wirh neurofibromacosis, anterior bowing of rhe leg developed at
Bagamery (177): an average age of 8 monrhs and then went on to fracrure and
1. Mulriple cafe-au-Iait spors pseudarrhrosis an average of 4.5 monrhs afrer the initial clinical
2. Positive family history for neurofibromacosis observation of deformity.
3. Diagnosric biopsy of a neurofibroma The focus of the recenr onhopaedic literamre has been treat-
4. Presence of pseudarthrosis of the tlbia, hemihypertrophy, or menr of congeniral pseudarthrosis of the ribia (199), but pseud-
a shon, angular scoliosis arthroses in other locations in children with neurofibromacosis
also occur and can be a challenge. Pseudarrhroses have been
Crowe and Schull (178) poinred our that adult patienrs with
reponed in the radius (171,175,184,185-194,195), ulna (166,
neurofibromatosis usually had more rhan five cafe-au-lair spors
167,170, III ,189,200,201), both the radius and the ulna (167,
wirh a diameter of more rhan 1.5 cm. The presence of cafe-au-
170,193,195,205,207), femur, clavicle, and humerus. Most pa-
lair spors, however, is nor pathognomonic for neurofibromacosis.
rienrs had associared neurofibromatosis, but some with pseud-
Whitehouse (214) nored that 23% of normal children have one
arthroses in each of the above-mentioned locations did nor.
or two cafe-au-Iait spots with a diameter of more than 0.5 cm,
and the presence of five or more cafe-au-Iait spors is needed to
Radiographic Findings
suggest the diagnosis of neurofibromatosis. Although cafe-au-
lair spars may be presenr ar birrh, usually rhey are nor seen unril Amerolareral bowing of rhe tibia wirh loss of the medullaty canal
the patienr is 5 or 6 years old (177). Generalized sofr rissue usually is presenr before fracture (Fig. 6-24) (175). Another x-
176 Get/eral Prillicplf:S

A B

c D

FIGURE 6-24. A: A 2-year-old boy with neurofibromatosis presented

with anterolateral bowing, sclerosis, and partial obliteration of the
medullary canal of the tibia without fracture. B: A modified McFarland
technique for prophylactic bypass grafting was performed as shown.
C: Immediate postsurgical x-ray studies of the tibia after prophylactic
bypass grafting. 0: Three years later, x-ray studies show continued
growth of the tibia without fracture but some absorption of the allo-
graft and relative loss of structural support by the allograft related to
continued growth. E: X-ray studies after a second prophylactic bypass
E grafting. (Figure continues.)
 Chnpter 6: Pathologic Fractures 177

FIGURE 6-24. (continued) F: Clinical photographs of patient's lower ex-

tremities. G: Current x-ray study 5 years after the initial presentation. The
patient has had no fractures and is functioning well without pain. (From
Dormans JP. Modified Sequential McFarland Bypass Procedure for pre-
G pseudarthrosis of the tibia. J Orthop Tech 1995;3: 176-180.)
 178 Genera! Prinicples

A B

FIGURE 6·25. A and B: Two examples of untreated congenital pseudarthrosis of

the tibia in children with neurofibromatosis. C: After resection and reconstruction
c with a vascularized free fibula interposition.
 Chapter 6: Pathologic Fractures 179

compression of the pseudarthrosis with callotastic lengthening

of rhe prox.imal ribia. All of rhese merhods may be complicated
by furrher pathologic fracture.
In contrast to pseudarthrosis of the upper extremity, rhere is
substantial experience with trearment of pseudarthrosis of rhe
tibia, but results are also disappointing. Bracing has proved inef-
fectual in the rrearmem of an esrablished pseudarthrosis. Surgical
procedures have included bypass grafts (197), onlay grafts (173),
grafring wirh small bone chips, intramedullary nailing proce-
dures (168,169), and inrramedullary rod fixation afrer segmental
osteotomies (209). The rate of union with these procedures
ranges from 7% to 90%, and eventual amputarion has been
common. Electrical stimulation has been used with some success,
but most series reporting its use have short patient follow-up
and the electrical stimulation was used in combination wirh
other surgical techniques. In one series, a 20% success rate was
FIGURE 6-26. Pseudarthrosis of the fibula is associated with valgus achieved using direct-current srimulation (174). In another se-
deformity of the ankle. ries, union was achieved in 10 of 12 patients wirh pseudarthrosis
of rhe ribia rhrough rigid intramedullary rod fixarion and elecrri-
cal srimulation through implamed electrodes (202). The Farmer
procedure, a skin and bone pedicle from the contralareralleg, has
ray characteristic is a prefracture cystic lesion of the tibia with a reported union rate approaching 53% (198). Free vascularized
anterolateral bowing (176). Biopsy specimens of these pseud- fibular grafts also have been used for reconsrrucrion after excision
arthroses invariably reveal fibrous tissue, but there are reports of the involved tibia (198). In one series, 11 of 12 parients with
of (167,194) found evidence of neural tissue in biopsy speci- neurofibromatosis and pseudarthrosis of the tibia were success-
mens. None of these findings, however, has been confirmed by fully treared with free vascularized fibular grafrs. Union of the
elecrron microscopy to document the presence of Schwann cells. pseudarthrosis occurred between 3 to 8 months afrer surgery
X-ray findings in patients with established pseudarthroses of the (172,179,213). A free vascularized iliac graft has been used in
ribia include narrowing or obliteration of rhe medullary canal one patienr with neurofibromarosis, resulting in union wirhin
ar the pseudarthrosis site, wirh sclerosis and anterolateral angula- 10 weeks (188). Fabry et aJ. (181) obtained union of pseud-
rion (Fig. 6-25). Pseudarthrosis of the fibula is associared wirh arthrosis of the tibia in two patienrs with compression through
valgus deformity of the ankle (Fig. 6-26). an I1izarov fixaror. In anorher series (204), the fractures in tnree
In upper exrremity pseudarthroses of neuroflbromawsis, rhe of five patieors healed in 4.5 months. The other two patients
x-ray signs of the bone at risk are narrowing of the diaphysis needed supplementary iliac grafts, and eventually, the bone
(201), sclerosis and hypoplasia with associated absent medullary united. It is important to stress that treatment cannot be consid-
canal (193), and the presence of a cystic lesion in rhe bone. ered successful until skeletal maturity has been reached; many
Once a fracture has occurred, a pseudarthrosis is likely when of these series included patients with short follow-up, and few
rne fracture line persists for more than 7 weeks afrer injury (194). included follow-up ro skeletal maturity.
The ends of rhe fracrure gradually become capered, there is lirde A prophylacric bypass grafting of rhe prepseudarrhrotic ribia
callus, and rhe cortex of rhe healing bone thickens wirn a de- in neurofibromatOsis has been performed wirh some success.
creased diameter of the medullary canal. The cause of these This modificarion of the original McFarland bypass procedure,
radiographic changes is unclear. Biopsy specimens from upper which was originally done for established pseudarthrosis, was
exrremity pseudarthrosis have consistently shown the presence successful in a series of parients from several ceorers reviewed
of dense fibrous tissue without evidence of neurofibroma. Pseud- by Srrong and Wong-Chung (211). A modified sequential
arrhroses have developed in children with neurofibromatosis McFarland bypass procedure for pre-pseudarthrosis of the tibia
after fracture through normal-appearing forearm bones (185, also has been described (Fig. 6-24) (180).
186). Amputarion should be considered and discussed with the
family early when previous operative interventions have been
unsuccessful. Amputarion usually is at the Syme level, with pros-
Treatment
thetic flrring around the pseudarrhrosi,. In a gair analysis srudy,
A tibia with an anterolateral bow in an infant or child will even- Karol et al. (187) compared 12 patients wirh previously opera red
tually fracture; corrective osteotomy ro correer angular deformity and healed congenital pseudarthroses of rhe tibia wirh four chil-
will only accelerate the progression w pseudarthrosis and should dren with amputations for final treatment of congenital pseud-
not be done. Once the fracture occurs, there is no indication arthroses of the tibia. They found marked disturbance of gair
for closed treatment. In conjunerion wirh excision of rhe hypo- and muscle strength in patients wirh healed congeniral pseud-
trophic bone ends, merhods of treatment of this congeniral arthroses of the tibia. They concluded that parients with early
pseudarthrosis include imramedullary fixation wirh iliac bone onset of disease, early surgery, and transankle fixation nad more
grafr, fixation with vascularized fibular grafr, and Ilizarov's inefficient gaits rhan amputees. Parieors with forearm pseud-
180 G'me)'{iL Pri/'licpLfS

anhroses can be pain Free and funcrion may be sarisFacrory wirh children witb neurofibromawsis because 16% of children with
observarion or splinting. However, persisrence of an ulnar pseud- neuroflbromarosis had hyperrension in one series (212).
anhrosis in a growing child oFren leads ro bowing of rhe radius
and posrcrior lareral subluxarion or dislocarion of the radial head Injuries of the Spine in Neurofibromatosis
(166,167,189,201). Healing after 6 months of casting has been Spinal deformiry is rbe most common musculoskeletal abnor-
reponed in a 2-monrh-old infant wirh a congeniral pseud- maliry seen in individuals with neuroflbromarosis. Althougb sco-
arthrosis of the radius. There was no clinical evidence of neurofl- liosis was presenr in 64% of patients with neurofibromarosis in
bromarosis at the time ofnearmenr ofrhis parient (183). Union one series (177), kyphoscoliosis may be rhe primary conrriburor
afrer conventional bone grafring and f1xarion has been reponed ro the devclopmenr of paraplegia (215) Patienrs younger than
in only a small number of parients with congeniral pseud- 19 years of age may have paraplegia secondary ro venebral deFor-
arrhrosis of the forearm (J70,171,185,186,193,208). Man)' of miry, whereas rhose patients older than 19 are more likely ro
rhese parients require mulriple conventional bone graFting proce- have neurologic deficits secondary ro a neurofibroma. Complere
dures and often years of immobilization. There are more repom dislocarion of rhe spine wirh neuroJogic defect has been reporced
of parients (and probably many more parients) wirh pseud- in rwo patients with neurofibromatosis (206). Rib penetrarion
arrhroses of the forearm bones who did nor respond ro multiple of the enlarged neural foramen with spinal cord compression in
grafring procedures (166,171,175, I 94,20 1). The resu Its of rrear- neuroflbromarosis has also been reponed in four patienrs (182,
ment of congenital pseudanhrosis of rhe forearm in neuroflbro- 190). CT scan and MRl are useful For evaluaring rhese patients.
marosis by free vascularized fibular grafrs are encouraging. Allieu Resecrion through eirher an anrerior or a posterior appro~ch
er al. (167) treared one patient with radial and ulnar pseud- seems sarlsFactory (I90).
arrhroses and another wirh ulnar pseudarrhrosis with Free vascu-
larized fibular grafrs. They obtained union in rhe parienr wirh
radial and ulnar pseudarrhroses in 6 weeks and in the parienr
wirh ulnar pseudanhroses in 3 months. Earlier convenrional
If' AUTHORS' PREFERRED METHOD
,~ OF TREATMENT
gr:lfring rechniques had failed in borh. Two addirional patients
wirh pseudarrhroses of rhe radius wirhour evidence of neurofl-
The rrearment of congeniral pseudarthrosis of the ribia remains
bromarosis were rreared wirh free vascularized fibular grafrs, re-
conrroversial. When a child presenrs wirb prepseudarrhrosis, (an-
sulring union wirhin 6 weeks (207,216). Mathlin er al. (195)
gulation withoL\( Fracrure), either bypass graFting wirh fibular
reponed six pseudarrhroses of the forearm bones neared with
allograFt or bracing ar'e reasonable oprions. Once pseudarrhrosis
vascularized fibular grafting wirh union in five ranging from 6
has developed, our preFerence is inserting an intramedullary rod
to 18 monrhs aFter surgery. Orher surgical options include exci-
and bone graFting of borh the tibia and fibula when possible. If
sion of the u"nar pseudarthrosis ro avoid a later rethering eFfecr
these procedures Fail, Free vascularized fibula transfer or resecrion
on the growing radius (J 66) and Fusion. of the disral radius and
and bone rransporr wirh circular frame rcchniques can be consid-
ulnar joinr (201). Crearion of a one-bone forearm is often rech-
ered. Ampurarion and prosthetic fining should be considered
nically successful, bur borh lengrh and rOtarion of the Forearm
early in parients with failure of rhe above-menrioned techniques
arc sacrificed with this procedure (189,201).
and severe shortening and a stiff ankle and fOOL Conservative
Exrreme care should be taken in surgical treatmenr of chil-
options sucb as bracing or observation for upper exrremiry
dren wirh neurofibromatosis, in whom rhe periOSteum of rhe
pseudarchroses may be jusrifled in a parient with a nonprogres-
long bones is bcJieved ro be Jess adherenr ro the bone rhan
sive deformiry and a sarisFacrOlY Functional use of rhe exrrcmiry.
normal [)eriosteum.
Conventional bone graFting and fixation procedures for trear-
ment of pseudarthrosis of the upper exrremiry have very limired
success, and orher approaches should be considered. Free vascu-
Complications larized fibular graFts seem rbe rreatment of choice for upper
Exrensive subperiosteal hemorrhage wirh subsequenr ossification exrremiry pseudarthrosis associated with neurofibromarosis.
was reported in a 9-year-old parient who underwent surgical
epiphysiodesis of rhe proximal ribia and fibula (217). Massive
subperiosrcal hemorrhage due to minor rrauma in cbildren wirh CONGENITAL INSENSITIVITY TO PAIN
neuroflbromarosis occurred in rhe ribi" and Femur (217). The
amount of blood loss in subperiosreal hemorrhages can be liFe- Congeniral insensitiviry ro pain is a rare disorder characrerized
rhreatening. Yaghmai and Tafazoli (2 J7) evacu~ted a subperios- by rhe absence of normal subjecrive and objective responses (()
teal hemorrhage of a femur in an 11-yeu-old boy wi th neurofl- noxious srimuli in parients with intacr ccnrral and peripheral
bromarosis who presenred wirb a rapid Iy growing mass of the nervous systems. The cause is unknown, bur sporadic repons
thigh aFter a minor Fall. An eggshell calciflcarion was visible have appeared in the orrhopaedic lirerarure (219-222).
around rhe Femur within weeks of rhe rrauma. The cysr held Orthopaedic maniFcsrarions of congenital insensiriviry to
2,100 mL of serous fluid and well( on w complete ossiGc~rion pain include recurrent fractures, osreomycliris, and neuropathic
wirhin 12 weeks of surgery with marked rhickening and disror- joinrs (Fig. 6-27). Limb-Iengrh discrepancy may occur From phy-
tion of rhe involved Femur. seal damage. Lack of pain perception is associated with rhe devel-
Ir is important preoperarively ro rule out hyperrension in opment oFCharcot's joinrs, which may lead wiater neuroparhic
 Cl1apter 6: Pathologic Fractures 181

A,B

FIGURE 6-27. A: This 6-year-old child with anhydrosis,

congenital insensitivity to pain and attention deficit disor-
der presented with a history of swollen ankles and knees.
This AP radiograph and (8) this lateral radiograph shows
Charcot changes in the subtalar joint with calcaneous and
distal fibula fracture. C: This AP radiograph of the right
knee and (0) this lateral radiograph of the right knee show
large, loose osteochondral fragments, medial subluxation
of the femur on the tibia and extensive periosteal new
bone formation in the distal femur. Soft tissue shadows
are consistent with her huge knee hemiarthrosis. More
than 100 mL of sterile serosanguineous fluid was aspirated
from the knee at her initial visit. The effusion quickly re-
turned in the days following the aspiration. Because man-
agement with casts at another hospital resulted in signifi-
cant skin breakdown. we stabilized the knees with
removable hinged braces. The effusions improved but did
C,D not resolve.
182 General Pri1'licples

arrhropathy. The weight-bearing joints usually are affected, espe- Clinical Presentation
cially the knees and ankles.
Most patients with Gaucher's disease are diagnosed before age
The differential diagnosis includes a spectrum of closely re-
10 years (236). Common clinical findings include hepacospleno-
lated sensory disorders including congenital sensory neuropathy,
megaly, yellowish pigmentation of the skin, pingueculae of the
hereditary sensory radicular neuropathy, familial sensory neu-
eyes (235,237), and bone lesions in 50% to 75% of patients
ropathy with anhydrosis, and familial dysautonomia (Riley-Day
(235). Bone pain, presenting as dull extremity ache, is present
syndrome). Acquired conditions with pain insensitivity include
in most patients, and joint pain is equally common (228). He-
syringomyelia, diabetes mellitus, tabes dorsalis, alcoholism, and
molytic anemia, leukopenia, and thrombocytOpenia result from
leprosy. Loss of protective sensation promotes self-mutilation,
both hypersplenism and marrow replacement. These factOrs,
burns, bruises, and fractures. The disease comes to light when
along with abnormal liver funnion, tend to make these patients
the child develops teeth and then bites his or her tongue, lips,
susceptible to infection and abnormal bleeding (224-228). Pa-
and fingers.
tients often have an increased serum acid phosphatase level and
Management should aim at education and prevention of in-
may have a decreased level of activity of glucocerebrosidase en-
jury. Prevention of joint disease is the best early option (219,
zyme in whire cells.
222). Joint injury should be recognized and treated early to
Bone lesions are most common in the femur, but they also
prevent progression to gross arthropathy. Early diagnosis of in-
occur in the pelvis, vertebra, humerus, and other locations (235).
jury is important, with signs of instability, swelling, and local
Infiltration of bone by Gaucher's cells leads to vessel thrombosis;
warmth prompting early investigation and rreatment. Most frac-
compromise of the medullary vascular supply leads to localized
tures are treated nonoperatively, when appropriate. Immobiliza-
osteonecrosis of the long bones (237), and avascular necrosis of
tion, bed rest, or appropriate bracing usually is indicated (219, the femoral head occurs in most patients in whom the disease
221). is diagnosed in childhood (238).
In a severely unstable, degenerated joint, arrhrodesis may Bone crisis and osteomyelitis in patients with Gaucher's dis-
eventually be appropriate; however, poor healing, nonunion, and ease demonstrate similar symptoms. Nearly half of patiellts with
pseudarthrosis are common in neuropathic joints. The condition Gaucher's disease have episodes of bone crisis, also [mown as
appears to improve with time with the gradual recovery of pain pseudo-osteomyelitis, in which they present with acute shatp
sensatlon. pains of the extremity with associated local warmth, redness,
and tenderness (239). Distinguishing this problem from osteo-
myelitis can be difficult. With bone crisis, a patient may have
severe pain in the back or extremities, rubor, fever, and an ele-
MARROW DISEASE OF BONE vated white blood cell count (239). Radiogtaphs may show peri-
Gaucher's Disease osteal reaction or lytic lesions that are difflculr to differentiare
from osteomyelitis. Blood cultures are sterile, and aspiration of
Gaucher's disease is a hereditary disorder of lipid metabolism
the affected bone is often necessary to provide conecr diagnosis
caused by a deficiency of the lysosomal enzyme glucocerebrosi- (224).
dase resulring in an abnormal accumulation of glucocerebroside Osteomyelitis is present in a significant number of patients
(glucosylceramide) in macrophages of the reticuloendothelial with Gaucher's disease. Hematogenous osteomyelitis was found
system. It is the mOSt common sphingolipidosis and is inherited in 10% of 49 patients in one series (224). Acute osteolTI)'elitis
as an autosomal recessive trait (232). It is very rare, with most is best managed conservatively when possible. Open irrigation
cases noted in Ashkenazic Jews of eastern European origin (228). and debridement of the bone may result in chronic osteomyelitis.
It has three forms of presentation. Type I is a chronic non- Noyes and Smith (237) reviewed 18 patients with bone crisis
neuroparhic form (i.e., without neurologic problems) with vis- who underwent biopsy to rule out osteomyelitis, and 61 % of
ceral (spleen and liver) and osseous involvement. This is the them went on to have postoperative osteomyelitis.
most common form (more than 90% of cases) and the type Plain x-ray studies usually are not helpful in differentiaring
most commonly seen by orthopaedic surgeons. This type is also ctisis from infection (224). Technetium 99 bone scanning often
lmown as the adult form, but commonly, patients present during demonstrates no increased uptake with a crisis (224) and shows
childhood (238). Type II is an acute, neuropathic type with decreased uptake in the area of osteonecrosis secondary to bone
centr;),l nervous system involvement and early infantile death. crisis, usually within I to 3 days after onset (225). Gallium 67
Type III is a subacute non-neuropathic type with chronic central scintigraphy may be useful in differentiating crisis from infection
nervous system involvement. These later twO types, characterized by showing a lack of uptake in osteonecrosis and bone crisis,
as either infantile or juvenile, are notable for severe progressive which may prove useful in excluding the presence of osteomyeli-
neurologic disease and usually are fatal. tis (236). Bell et al. (224) recommended the use of CT scans to
Lipid-laden histiocytes, known as Gaucher's cells, provoke document the presence of purulent exudate in osteomyelitis in
clinical symptoms by their accumulation in the liver, spleen, and patients with Gaucher's disease. Recently, some authors have
bone marrow. Osseous lesions result from marrow accumulation found MRJ useful for excluding osteomyelitis in patients with
and include Erlenmeyer's flask appearance, osteonecrosis (partic- Gaucher disease (237), but others (225) believe that MRl can nor
ularly of the femoral head), and pathologic fractures, especially distinguish between osteomyelitis and pseudo-osteomyelitis of
of the spine and femoral neck. bone crisis.
 Chapter 6: Pathologic Fractures 183

Radiographic Findings Karz er al. (232) reponed 23 pathologic fractures in 9 children

with Gaucher disease; 7 had multiple fractures. In decreasing
Radiographically, rhree paccerns of bone involvement have been
order of frequency, the site of involvement included rhe distal
described. (a) Generalized infilrrarion of rhe bone marrow of
femur, basilar neck of rhe femur, spine, and proximal ribia. Frac-
long bones by Gaucher cells causes a decreased densiry and corti-
rures also occurred infrequendy in rhe disral ribia, proximal hu-
cal rhinning. There is a general tendency for failure of rubularion
merus, rib, and acetabulum. Fracrures of (he long bones were
(229), and this problem is most pronounced in rhe distal femur,
rransverse and usually in the metaphysis. Fracrures of (he spine
where it produces an Erlenmeyer's flask appearance (Fig. 6-28).
were eirher wedge shaped or cenrrally depressed a( rhe end pla(e.
(b) The bone is moth-eaten with occasional osreosclerosis, and
The facrors predisposing rhese children co franure included sig-
a cenrrally locared curvilinear or verrical radiolucent srrcak is
niftcanr medullary space inftlrrarion, corrical bone erosion, os-
seen in the distal femur. (c) Dense collections of Gaucher cells
teonecrosis, and associared disuse osteoporosis (232).
form localized bubbly expansile lytic lesions in rhe bone, and
In anorher repon of 53 parienrs wirh Gaucher's disease aged
associared areas of asepric necrosis with medullary infarction
9 ro I8 years (234), II had vertebral fractures, usually ar rwo or
form diaphyseal lyric lesions with repararive periosreal reacrion
rhree sites in each patienr, wirh either anrerior wedging, central
surrounding rhem (229).
vertebral collapse, or total rectangular collapse. Mosr parienrs
Avascular necrosis of rhe femoral head is similar ro thar seen
had relief of rheir pain afrer 1 to 4 monrhs of conservarive treat-
in Legg-Calve-Perrhes disease, and verrebral plana may be pres-
menr; two required decompression laminectomies, and one had
enr wirh lesions of the spine (229). MRI is more sensirive dun
a posterior lareral fusion to srabilize the spine.
radiographs or CT in demonstrating marrow involvemenr.
K;],tz et al. (233) found rhat fractures of the upper exrremities
in Gaucher's disease were prone ro occur in areas of prior crisis.
Injury
AJthough exrernal callus formed in 6 ro 8 weeks in mOSt patienrs,
Parhologic fracrures, especially of rhe femoral neck or shafr after complete healing with internal callus rook almosr 2 years in
biopsy and of rhe spine, usually are besr managed conservarively. some. Other authors have found fracrure union to be rapid
(229). Both delayed union and nonunion (237) have been re-
ported in older patients with Gaucher's diseasc.
Pathologic femoral neck fracrures wirh minimal associared
trauma in children with Gaucher's disease ofren heal wirh a
varus malunion and minimal subsequenr remodeling; avascular
necrosis of the femoral head also can be associared wirh femora.!
neck fractures (229,235). Goldman and Jacobs (229) stared rhat
the presence of a mixed densiry of bone of the femoral neck on
x-ray wirh narrowing of rhe medial cortex was a risk factor for
fracture.

Treatment
In the past, there was no specific treatmenr for Gaucher's disease.
Splenectomy was often performed ro help correcr thrombocyto-
penia (228), but some authors believed that splenecromy wors-
ened the orthopaedic com plications of Gaucher's disease and
recommended that it should be delayed as long as possible (332).
Enzyme replacemenr rherapy for the deficit found in Gaucher's
disease has been developed (230). It is known as alglucerase
(Ceredase) and is given in inrravenous infusions every 2 weeks,
with most patienrs having a decrease in the size of their livers
and spleens, and improvemenr in their anemia. With the recom-
mended dosage of 60 units of algJucerase per kilogram, a 30-kg
child requires a yearly amounr of enzyme costing $I63,800
(227). Low-dose imiglucerase (Cerezyme, Genxyme), a placcntal
recombinant human-derived beta-glucocerebrosidase enzyme re-
placement. is also being used to uear patienrs with rype I
Gaucher's disease (244). Studies have shown that either a re-
duced dose or a low-dose-high-frequency regimen can achieve
similar clinical effects wirh less cosr (227,243). Less cosdy home
intravenous enzyme replacemenr rreatment is possible (245).
FIGURE 6-28. A 2-year-old child with Gaucher's disease. Early flaring After 1 year of rreatment wirh replacement enzyme, parienrs
of the distal femur is already present and will likely develop into a
classic Erlenmeyer's flask deformity. Note the moth-eaten appearance with Gaucher's disease seem to have a decreased tendency for
of the metaphysis (arrow). infecrion (243). The eft'eCts of the enzyme on the bone disease
184 Gmerfll Prinitples

are unclear. Zevin et al. (242) found no change in bone appear- S, is a homozygous recessive condition in which individuals in-
ance after 1 year of replacement therapy, whereas Hill et al. (231) herit the beta S globin gene from each parent. SCD has systemic
noted improved appearance of the long bones and involved spine effeers particularly on splenic function and on the cemral ner-
after 16 momhs of enzyme replacemem therapy. Bone marrow vous, renal, hepatic, and musculoskeletal systems. SCD aHccts
transplamation also has been shown to be helpful in reversing approximately 1 in 400 African-Americans. Sickle cell trait
the medical effects of Gaucher disease (241), but the mortality affects 8% to 10% of the African-American population and other
rate of patiems undergoing allogenic marrow transplantation is groups less frequently (267). With sickle cell trait, each individ-
greater than 15% (227). ual has inherited a beta-S globin gene and a beta-A globin gene.
Clinical manifestations of sickle cell trait usually are not appar-
Fracture Management ent. The presence of these abnormal hemoglobins in red blood
Pathologic fractures of the upper extremities and the spine re- cells causes them to be mechanically fragile, and when they are
spond well ro conservative immobilization techniques. For frac- deoxygenated, the cells assume a sickle shape, which maJ<es them
tures of the lower extremity, prolonged bed rest is to be avoided prone to clumping with blockage of the small vessels of the
because of the additional complicarion of disuse osteoporosis. spleen, kidneys, and bones (262,263). Chronic hemolytic ane-
Early mobilization with non-weight bearing casts is necessary mia is presem in most severely affeered patients, and marrow
ro avoid angulation of the fractures. Complete healing as defined hyperplasia is found in both the long bones and the short tubular
by the appearance of imernal callus may require from 10 to 32 bones. These disorders are diagnosed by hemoglobin electropho-
weeks of immobilization. Correerive osteotomy may be necessary resis (252).
for residual angulation. Some authors have recommended con-
servative treatmem with non-weight bearing for minimally an- Clinical Presentation
guhted femoral neck fractures (228,232), with imernal fixation
reserved for unstable femoral fractures with progressive or Musculoskeletal involvement results from small vessel occlusion
marked displacement (232,235). by clumped sickle cells wirh bone infarction, avascular necrosis,
All pariems with Gaucher's disease considered for a surgical and increased suscepribility to infeerion. These problems are
procedure should undergo extensive preoperative evaluation of most commonly seen in sickle cell anemia and sickle cell disease.
their abnormal clotting function. Excessive bleeding may even Bone infarction is caused by blockage of marrow vascular chan-
occur when clotting tests are normal (224). It is importam for nels by sickled erythrocytes. It is seen in patiems as young as 6
the anesrhesiologist to recognize that patiems with Gaucher's to 12 momhs of age. Ultimate infarction occurs in as many as
disease may be prone to upper airway obstruerion because of 74% of patients. Patiems with acute long bone infarctions pres-
infiltration of the upper airway with glycolipids and commonly em with pain and swelling of the affected extremity and a low-
may have an airway up to 50% smaller than predicted for age grade fever. The long bone usually is tender, and infrequently,
(240). These patients are prone to infection, likely due to abnor- both erythema and warmth also are present (257). Acute symp-
mal neutrophil chemotaxis (223), and needle biopsy under oper- toms usually resolve within a week. One presenting sign of sickle
ating room conditions is preferable to open biopsy (237). cell disease in an adolescent is an indolent ulcer over the lateral
malleolus of the ankle with surrounding areas of patchy hyper-
pigmentation (260). Sickle cell dactylitis, or infarction of the
small bones of the hands and feet, may resemble infection and
• AUTHORS' PREFERRED METHOD is common in infancy and childhood (259). Young children
,~ 0 F TREATMENT getting their feet wet or walking in the snow can initiate episodes
(253). Pain and swelling may last for 1 to 2 weeks. X-ray studies
Conservative immobilization with non-weight bearing is sug- may show osteolysis and periosteal new bone formation.
gested for long bone fractures when appropriate. Stable fractures Acute bone infarct in patiems with SCD may be difficult to
of the femoral neck should be treated by guarded immobilization distinguish from osteomyelitis. Osteomyelitis occurs in fewer
with frequent follow-up x-ray studies. Internal fixation should than 1% of affected patiems. Acute long bone infarctions are
be used in femoral fractures that show signs of or potential for 50 times more common than bacterial osteomyelitis in patients
displacement. Preoperative planning is imporram, with careful with sickle cell disease (257), but in Africa, osteomyelitis is 200
evaluation of clotting function and preoperative consultation times more common in patiems with SCD than in normal indi-
by the anesthesiologist. Femoral head osteonecrosis is managed viduals (256). Osteoarricular bacterial infection was diagnosed
symptomatically, at first with osteotomy or joim replacement in 1.6% of 247 admissions in one series of children with sickle
later when necessary. cell disease admitted to the hospital for musculoskeletal com-
plaints (261). These authors recommended aspiration as the di-
agnostic procedure of choice for infection. CIIinicall and x-ray
Sickle Cell Disease presemations in both of these conditions are quite similar, except
The term sickle cell disease (SCD) characterizes conditions that high fevers are more common in osteomyelitis. Patienrs
caused by the presence of sickle cell hemoglobin (HbS). Variants present with a warm, swollen, painful extremity. Multifocal bone
of these conditions include sickle ceJJ anemia (HbS-S), the less involvement was reported in 73% of patients with osteomyelitis
severe sickle cell disease (HbS-C), and the often asymptomatic in one series (265), and the most common si,tes in decreasing
sickle cell trait (HbA-S). The mosr common type ofSCD, HbS- order of frequency were the humerus, metatarsals, tibia, femur,
 Chapter 6: Pathologic Fractures 185

radius, metacarpals, and ulna. Routine evaluation should include actually become narrowed with thickening of the cortex. Larg
blood cultures and needle aspiration of the affected area. Typical bone infarctions may not be visible on plain x-ray studies becaus
causative organisms in osteomyelitis include Staphylococcus au- of limited circulation, but commonly within 2 weeks of onse
reus, Salmonella, and Streptococcus pneumoniae. Bennett et al. of symptoms, areas of involvement appear moth-eaten, with ir-
(247) reviewed bone and joint manifestations in 57 patients with regularly distributed translucent areas commonly bound by ele-
sickle cell anemia and found that osteomyelitis occurred in 61% vated periosteum with new bone formation (252). Widesprea
and rhat Salmonella was rhe causative organism in 71 % of these involvement may form a "bone within a bone" appearance
pariems. Others have also found that Salmonella is a common (253). Nearly 85% oflong bone infarcts are found at the junc-
organism seen in osteomyelitis in SCD (256,265), but Epps tion between the metaphysis and diaphysis, and 10% are cen-
and co-workers (255) found that Staphylococcus was the most trally located (248). Plain x-ray studies cannor distinguish be-
common organism in their patients with SCD osteomyelitis. AI- tween osteomyelitis and bone infarction in these patients.
Salem (246) also found that Staphylococcus was the most com- Although Keeley and Buchanan (257) believe that bone scans
mon organism in osteomyelitis in those patients with sickle cell are not helpful in the diagnosis of bone infarction, Koren et at.
trait. Both the metaphysis and diaphysis are common locations (258) noted that in the first 48 hours of symptoms, there was
of infection (250,265). Septic arthritis is rare in patients with decreased uptake in the affecred area of bone infarct by techne-
SCD. Surgical drainage of septic joints, osteomyelitis, and subp- tium bone scan. Normal isotope uptake developed approxi-
eriosteal abscesses is indicated. mately 1 week later. They found that increased isotope uptake
Other common problems in SCD include avascular necrosis was common 2 to 4 weeks after the onset of symptoms. Gallium
of both the femoral head and proximal humerus. Wedging or bone scan was thought to be a helpful adjunct to this technique
flattening of the vertebral bodies is also seen in older patiems when osreomyelitis was suspected. MRI has not been found
(253). Fat emboli, secondary to marrow infarcts, can occur in useful in distinguishing osteomyelitis from acute infarcts (251),
patients with less severe SCD (HbS-C) and less frequently in but contrast material-enhanced CT scan can aid in diagnosis
patients with sickle cell anemia. Pneumococcal sepsis is the lead- of osteomyelitis in these patients by its ability to visualize subper-
ing cause of death in young children with SCD. iosteal abscess (266). Differentiation from infarction can be
aided by aspiration and by comparing the results of technetium
Radiographic Findings 99 scans with those of a bone marrow scan. Both partial and
full femoral head involvement can occur in avascular necrosis
In young patients, marrow hyperplasia results in a generalized
of the capital femoral epiphysis in SCD (253), and coxa vara
osteoporosis with widening of the medullary canal and thinning
also has been reported (259).
of the cortex. As the patients become older, endosteal bone appo-
sition causes sclerosis (Fig. 6-29) and the medullary canal may
Injury
Pathologic fractures of the long bones in SCD frequently may
be rhe first symptom of the disorder (262), and many authors
report pathologic fractures in their series (247,250,252,254,259,
264). In a series of 81 patients with 198 long bone infarcts
with occasional concurrent osteomyelitis, Bohrer (248) found
evidence of fracture in 25% of femoral lesions, 20% of humeral
lesions, and a significant percentage also in tibial bone infarcts.
Ebong (254) reported pathologic fractures in 20% of patients
with SCD and osteomyelitis. The most common site of fracture
was the femur. The fractures are transverse and commonly lo-
cated in the shaft of the long bone (253), and although minimal
trauma is needed to cause them (259), they often have significant
displacement (248,249). The exact mechanism for pathologic
fracture in these patients is unclear; although it is often associated
with bone infarct, the fracture itself is seldom through the area
of infarction (259). Marrow hyperplasia may be a major contrib-
uting factor; not only does the hypercellular bone marrow ex-
pand the medullary canal with thinning of both trabecular and
cortical bone, but it also extends into widened haversian and
Volkmann canals (253). This process probably weakens the bone
sufficiently so that fractures occur. The healing process seems
unaffected, and union usually occurs normally (262).

FIGURE 6-29. A young man with sickle cell disease. The lateral x-ray Treatment
of the femur shows evidence of past avascular necrosis, and scalloping
and radiolucencies of the shaft with sclerosis are seen posteriorly Vaso-occlusive episodes are managed with nonsteroidal antiin-
(arrow). This x-ray appearance can mimic osteomyelitis. flammatory medications, oxygen, and hydration. Sym tomatic
186 General Prillicplej'

bone infarccion should be creaced wich bed resc, analgesics, and in leukemic children chan in adulrs because a child's small mar-
incravenous or oral adminisrrarion of fluids (257). If osceomyeli- row reserve can be repJaced quickly by leukemic cells. Approxi-
cis is suspecced, idenriricarion of che organism should be ar- marely 50% ro 75% of children wirh acure leukemia develop
cempced by borh blood culrures and aspiration of subperiosceal racLographic skeleral manifesrarions during rhe course of rheir
fluid (265). The choice of ancibiorics is based on Gram's srain. disease (277,280). Rogalsky er al. (282) reported a 12% InCI-
For Gram-posicive organisms, eicher cephalochin or nafcillin is dence of fracrure associared wirh acme leukemic lesions.
used inirially, and for Gram-negarive organisms, eicher ampicil-
lin or chloramphenicol is used. Changes in anribiocics are based
on lacer culrure resulrs and sensitivities. The parienr is monicored Clinical Presentation
by C-reactive prorein or sedimentacion rare, and incravenous
anribiotics usually are conrinued for ar leasr 6 weeks. Operative Parienrs presenr wirh farigue, pallor, purpura, fever, heparosple-
rreatmenr of patienrs wirh SCD is porenrially hazardous. Ex- nomegaly, or bone and joint pain; 20% w 60% of patienrs
rreme care must be raken to oxygenare the parienr's rissues ade- presenr wich musculoskeleral signs or sympwms (275). ]n one
quatcly during rhe procedul'e, and ideally, elective procedures series, bone pain was a presenring symprom in 59% of pariems
should be preceded by mulriple rransfusions to reduce hemoglo- (284,285). Rogalsky er al. (282) reponed a 20.6% incidence of
bin (5) (0 Ic:ss than 30% of total hemoglobin levels. A random- repons of problems wirh rhe skeleral sysrem ar inirial presenra-
ized Illulricenrer srudy found rhac a simple conservarive cransfu- rion. Migrarory arrhriris may be presenr in some pacienrs; poinr
sion regimen to i'aise Hb levels to 10 g/dL was as cffecrive as pain is believed ro be secondary ro leukemic cell infllrrare of rhe
an aggressive exchange rransfusion regimen (to reduce HgS to meraphyseal periosreum (285). Leukemia may mimic osreomye-
less rhan 30%) in prevenring perioperarive complicarions. The liris, rheumaric fever, sepric arrhriris, and ruberculosis (283).
conservarive approach resulred in only half as many rransfusion- Eirher leukocyrosis or leukopenia is presenr, and rhe presence
associared complicarions (268). Inrravenous hydrarion also is of immarure leukocyres in rhe peripheral blood smear should
imporranr, wirh one and a half ro fWO cimes rhe daily fluid suggesr a diagnosis of leukemia. In che early phase of rhe disease,
requiremerirs needed in addirion to rourine replacemenr of fluid anemia, neurropenia, and rhrombocyropenia occur in 80% of
losses. The use of a courniquer in surgery for parienrs wich SCD pacienrs; 10% of children have normal peripheral blood counrs.
is somewhar conrroversial. Some aurhors believe rhac ir is noc Bone marrow aspirare usually is diagnosric.
indicared because ir is porenrially dangerous (253,255); orhers
found no increased risks associared wirh irs lise in rhese pariencs
(259,267). Radiographic Findings
No pachognomonic osseous manifesrarions occur in acme leuke-
mia. Skeletal invoJvemenr occurs in approximately 50% of pa-
cienrs, and diffuse osceopenia is che mosc frequem manifesrarion .
• AUTHORS' PREFERRED METHOD Lucencies and periosticis may mimic osreomyelicis.
,~ OF TREATMENT
Nonspecific juxraepiphyseallucenc lines are a resulc of gener-
alized merabolic dysfuncrion. Scleroric bands of bone trabeculae
Pachologic fracrures in parienrs wirh SCD usually heal well wirh
are more typical in older children. A characrcriscic lesion seen
conservarive immobilizacion cechniques (253). Cusromary pre-
wirhin a monrh of onser of symproms is a radiolucenr meraphy-
caurions should be followed in rhose pacients who require open
seal band adjacenr 1'0 rhe physis. These are usually bilaceral and
surgical procedures for dispbced or unsrable fraccures. Os-
vary from 2 ro 15 mm in widrh (285). Similar radiolucenr bands
reonecrosis of che femoral head is an especially difflculc problem
al'e seen borh in infams wirh scurvy and in older children wirh
in pariencs wirh SCD. Treacmenr oprions include conservacive
neuroblasroma.
measures and core decompression (a mulcicenrer rrial is under
Osreolycic lesions wirh puncrace areas of radiolucency are
way). Tocal joinr replacemenr is occasionally indicaced in young
found in rhe meraphyses and can eirher appear morh-earen or
adulcs. Before general anesrhesia, che pacienr's hemarocric should
as a conAuenc radiolucency. Similar lesions can be presenr in
be raised to 2::30 Hb (Q 2::10 g/dL
rhe diaphysis (273), rhe skull, pelvis, ribs, and bones of rhe hands
and feer. Large geographic lesions also may be seen. Periosreal
reacrion ofren is presenr wirh osreolycic lesions and is mosr com-
Leukemias mon in rhe poscerior cortex of che disral femoral metaphysis,
Leukemia accounrs for over 30% of cases of childhood cancer. che medial neck of rhe femur, and rhe diaphyses of rhe cibia and
Acuce lymphocycic leukemia (ALL) is one of rhe mosr common fibula (286).
malignanr diseases in child hood and accounrs for 80% of pediar- Medical managemenc prorocols usually include vincrisrine,
ric leukemias. There is an increased occurrence of lymphoid prednisone, and L-asparaginase (VPL) or merhouexare, vincris-
leukemias in pacienrs wirh Down syndrome, immunodefi- cine, L-asparaginase, and dexamerhasone (MOAD) (272). Re-
ciencies, and acaxic cebngieccasia. The peak incidence is ar 4 mission rares are now up ro 98%, wirh cure rares approaching
years of age. 80% (272).
Leukemic involvemenr of bones and joinrs occurs freqllenrly The complicarion seen mosr commonly by orrhopaedic sur-
in parienrs wirh leukemia. Skeleral lesions occur more freqllenrJy geons is avascular necrosis (AVN) of rhe femoral head (278,
 Chapter 6: Pathologic Fractures 187

287). This may occur after chemotherapy, after chemotherapy outcome in childhood leukemia. Heinrich et al. (277) concluded
and allogenic bone marrow transplantation (BMT), or after that children withom radiographic skeletal abnormalities have
graft-versus-host disease (GVH) related to BMT. (270) Al- an aggressive form of acute leukemia that results in a worse
though most AVN is attributed to glucocorticoid therapy, L- prognosis.
asparaginase can contribute to thrombophilia and has been im-
plicated in the production ofAVN. The risk ofAVN is especially
Injury
high after BMT in boys older than 16 years who are treated for
GVH with steroids or irradiation. MRl is best for the early Pathologic lesions predisposing children to a fracture usually
detection of AVN. Treatment modalities include weight relief, resolve during treatment. Fracture is most commonly associated
symptomatic treatmenr, core decompression, and total hip re- with osteoporosis of the spine, resulting in vertebrae plana. Frac-
placement. Bizot et aI. (271) described the results in 27 patienrs tures occasionally occur at other locations and usually after
treated with total hip arthroplasty for AVN after allogenic BMT. minor trauma.
Most bone lesions in leukemia improve during remission after Vertebral compression fractures are the most commonly re-
treatmenr and tend to progress with worsening of the disease. ported fractures associated with leukemia. The thoracic vertebrae
The radiolucenr metaphyseal bands usually are not affected by are the most commonly involved; uniform spinal osteoporosis
rreatmenr, however, and further demineralization of the skeleton often is present (278,281). A bone scan may aid in identifying
may occur with both corticosteroid use and methotrexate ther- clinically silent areas but may not correlate with areas of obvious
apy. Diffuse demineralization of the skeleton occurs in almost destruction on radiographs. Spastic paraparesis has been reported
all patienrs with widening of the medullary canal and thinning in one patienr with vertebral fracture due to leukemia (278).
of the cortex (285). Although increased uptake of isotope is seen
on technetium bone scan in 80% of patienrs, positive areas of
Treatment
isotope uptake correlate poorly with both sites of clinical bone
pain and the presence of lesions on x-ray study (274). Most fractures are treated using standard methods (Fig. 6-30).
Several authors (269,276,277,279) have arrempted to evalu- Newman and Melhorn (281) noted a prompt decrease in pain
ate the prognostic signifIcance of the extenr of bone involvemenr in fout patients with vertebral fractures due to leukemia once
in childhood leukemia. Hughes et aI. (278) reponed that major chemotherapy was initiated. No bracing was used in these pa-
skeletal involvemenr, in fact, may correlate with a better overall tients, and full activity was encouraged. In one of their patients

FIGURE 6-30. A: A 13-year-old girl with acute

lymphocytic leukemia presented with a pathologic
fracture of the right hip. Note the destructive
changes associated with the displaced femoral
A neck fracture. (Figure continues.)
188 General Prinilples

B C
FIGURE 6·30. (continued) B: The patient subsequently underwent in situ screw fixation of the hip
fracture with postoperative hip spica cast immobilization and subsequent continuation of chemother-
apy. C: Follow-up x-ray studies 1 year after surgery shows healing with slight varus and without evidence
of avascular necrosis. At present, the patient is alive and well, has no hip pain and walks with a very
slight Trendelenburg gait.

observed for more than 5 years, there was no evidence of heaJing Classic hemophilia, or hemophilia A, (factor VIII deficiency) is
of the fractured venebra on x-ray study. There are no specific an inherited sex-linked recessive disorder. The incidence is 1 per
treatmenr recommendations for any other associated pathologic 10,000 live male births in the United States (291). Christmas
fractures of leukemia in the literature. disease, or hemophilia B, is a sex-linked recessive factOr IX defi-
ciency and occurs in 1 per 40,000 live binhs.
\Xlhen hemophil ia is suspccrcd, screening tests should be per-
formed, including platelet coum, bleeding time, prothrombin
~ AUTHORS' PREFERR D METHOD time, and partial thromboplasrin rime. Deficiency of factor VII,
\...j! OF TREATMENT the most common form of hcmophilia, causes a marked prolon-
gation in the paniaJ thromboplastin time (337). Once the disease
Prompt diagnosis and initiation of chemotherapy is the first step is suspected, specific factor assays can document the type of
in thc trearmem of pathologic fractures associated with leukemia. hemophilia.
Most fractures are srable microfraerures and can be treated with Musculoskeletal complications in a child wirh hemophilia
conservative immobilizarion rechniques with emphasis on carly include acute hemarthroses (knee, elbow, and ankle, in decreas-
ambulation to avoid further problems with disuse osteoporosis. ing order of frequency), soft tissue and muscle bleeds, acute
Most vertebral fractures can be treated nonoperatively with close compalTment syndrome, carpal wnnel syndrome, and femoral
observation. nerve neuropraxia. The severity of the deficiency often is corre-
lared with circulating levels of factor vnr or IX (Table 6-7).
The disease is classified as severe when clotting activity is less
Hemophilia than 1%, moderate when clotting activity is 1% to 5%, and
mild when clotting activity is more than 5%. By definition, each
Hemophilia is a sex-linked recessive disorder of clotting mecha- milliliter of normal human plasma contains one unit of factor
nism that presents most commonly as a functional deficiency of activity, and the clinical severity of hemophilia correlates with
either factor VIIl (hemophilia A) or factor IX (hemophilia B). the parienr's percenrage of normallcvels of plasma factor activity
 Chapter 6: PathoLogic Fmetures 189

Complications
TABLE 6-7. SEVERITY OF HEMOPHILIA
Significant complications are caused by the use of replacement
CORRELATED WITH PLASMA
FACTOR ACTIVITY LEVELS therapy in hemophiliacs. Antibodies ro replacement facror,
known as facror inhibitors, develop in 15% ro 25% of patiems
Degree of Percentage Clinical with severe facror VIII deficiency (up ro 50% if transient or
Hemophilia of Factor Characteristics
insignificant inhibitors are included) (291,331). When inhibi-
Mild 20%-60% Usually clinically occult, tors are present in quantities higher than 5 Bethesda units, very
excessive bleeding after high doses of factor may be necessary ro achieve significant activ-
major trauma or surgery ity levels. Many children with high titer factor VIII inhibirors
Moderate 5%-20% Excessive bl'eeding during
are treated with daily high doses of factor VIII (immune roler-
surgery and after mi nor
trauma ance) to reduce or eliminate the inhibiror. The level of inhibirors
Moderately 1%-5% 'Excessive bleeding with rises sharply 6 ro 10 days after ini rial treatmen t (30 I), and the
severe mild injury and effectiveness of replacement therapy gradually deteriorates. In
infrequent spontaneous parients with hemophilia A with inhibiror levels greater than 20
hemarthrosis
Bethesda units, factor VIII replacemem is ineffective. There has
Severe Less than 1% Frequent excessive
bleeding with trauma been some success in treating these patients with alternative ther-
and spontaneous apy such as nonactivated factor IX concentrates, activated facror
bleeding into the soft IX, porcine factor VIII (340), and activated prothrombin com-
tissue and joints plex concentrate (Auroplex T) (288). Desmopressin (L-deamino-
8D-arginine vasopressin) is becoming a creatment of choice in
patients with mild hemophilia A and also has an effect on pa-
tients with von Willebrand's disease as well as platelet disorders
(40 l,404). Patients can have an approximate threefold increase
in facror VIII. Studies have shown effectiveness of this medica-
(Table 6-7). Eady diagnosis and aggressive management are the tion through administration by intravenous route or subcutane-
keys ro lessening complications. ous injections, as well as intranasal administration by spray.
A large percenrage of the adult hemophiliac population
treated with concentrated plasma-derived factor before 1985 be-
Treatment-Bleeding Episodes came human immunodeficiency virus (HIV) positive. Because
replacement therapy for 1 year (or one surgery episode) may
During bleeding episodes, the primary therapy is intravenous expose hemophiliacs to the equivalent of 3,200 units of donor
replacement of the deficient facror. Several different treatment
blood (291), these patients have been panicularly susceptible to
plans exist: On-demand therapy is the traditional method of both hepatitis and HIV infection. The annual rate of hepatitis
hemophilia management; facror replacement is given at the first in hemophiliacs is estimated to be 5% (294). In a study of 181
sign of a bleeding episode. Primary prophylaxis involves initia- patients with either hemophilia A or B, Ragni et al. (332) found
tion of regular facror replacement therapy soon afeer the diagno- that 45% were HIV seropositive, and 82% of patients treated
sis of severe hemophilia (usually when rhe child is 1 ro 2 years with facror VIII concentrate were HIV positive. In this study,
of age) with the intention of preventing joint bleeds. Secondary the peak of seroconversion occurred in 1982, with declining
prophylaxis is used after a child has established a pattern of rates in the ensuing years, presumably owing to HIV antibody
frequent bleeding but before frequent joint bleeds occur. donor screening and heat inactivation of blood products. The
Empirically, one unit of facror VIII per kilogram of body overall incidence of acquired immunodeficiency syndrome
weight will raise plasma activity by 2%, and a similar dose of (AIDS) for all these patients was 5.5%, but in patients who were
facror IX will elevate the plasma level of that factor by 1.5% HIV seropositive for more than 5 years, the incidence of AIDS
(291). The usual half-life of facror VIIJ varies from 6 to 12 hours approached 32%. All hemophilia patients are monirored for de-
and that of factor IX varies from 8 ro 18 hours. Routinely in velopment of treatment-related viral infection; the incidence of
the nonbleeding patient, factor VIII must be given every 8 hours infection today is extremely low. Serial examinations of T4
and facror IX must be given every 12 hours ro maintain a stable COunts are performed for patients at risk. Medical therapies are
facror level. Higher than usual dosages given more frequently still evolving for AIDS patients with hemophilia. Current gene
are necessary in patients with active bleeding. In the past, facror therapy efforts are focused on developing a vecror that is safe
replacement was accomplished through plasma rransfusion, but and gives long-rerm expression of the missing facror at levels
the quantities necessary for adequate facror levels may result in that will significantly change the phenotype (289).
circularory overload and pulmonary edema (331). This problem
was eventually solved through the use of Clyoprecipitate, protein Surgery in Hemophilia
prepared from plasma that is rich in factor VIII and fibrinogen. In preparing a patient with hemophilia for surgery, the orthopae-
More concentrated forms of both facror VIII and facror IX (Ko- dist and the hematologist shouJd work closely rogether. Preoper-
nyne 80) have become available. The reader is referred ro an ative]y, the patient should be tested for the presence of inhibiror
excellent review by Connelly and Kaleko (298) for a current srate and a test dose of facror replacement should be given to deter-
of rhe an review of gene rherapy for patients with hemophilia A. mine the biologic half-life of that facror for that particular patienr
190 General Prinicples

(291). Elective surgery usually is contraindicated in the presence Treatment. Most fractures in hemophiliac patients are treated
of inhibitor. Most authors recommend a level of factor activity conservatively with immobilization. Factor replacement is im-
during surgery ranging from 70% to 100% (291,317,331), al- portant for about the first week after the fracture, and levels of
though others believe that approximately 50% is adequate (328, factor activity recommended vary from 20% to 50% (290,291,
330). The initial dose is usually 40 units/kg (331), and it should 295,301,308,317). Circumferential plaster casts are extremely
be given 1 to 2 hours before surgery (308,317). In prolonged hazardous in the treatment of these fractures because of the risk
procedures with aerive bleeding, the factor level should be of swelling from bleeding as well as subsequent compartment
checked as often as every 3 hours and appropriate factor supple- syndrome and skin necrosis (338). A Robert Jones dressing may
mencation given as necessary (331). Tourniquets are recom- be preferable for fracture immobilization immediately after in-
mended for extremity surgery. Although some aurhors believe jury, and a cast should be applied once active swelling has
electrocaurery is adequate for obtaining hemostasis (308,317), stopped (308). All casts applied should be well padded and split,
others consider ligation of vessels preferable (291,331). The use and the patient should be monitored carefully for swelling. Frac-
of routine drains is not advised, bur 24 hours of suction drainage tures of the femur can be treated with traction and subsequent
is favored by some (291,317,331). Factor levels are checked im- spica casting (295). Some authors consider skeletal traction to
mediately after surgery and then at least daily. Factor VIII is
be hazardous because of the risk of infection or bleeding (291,
given every 6 hours, and factor IX is given every 8 hours. It is
308), but Boardman and English (295) believe that with proper
useful to check a trough level factor activity immediately before
replacement therapy, skeletal pins can be used in the hemophil-
the next dose oHactor supplemencation. In the immediate post-
iac. In the presence of inhibitor, a large blood loss owing to
operative period, factor levels are maintained at 30% to 40%
fracture should be treated with transfusion with saline-washed
(291,317), and these levels should be maintained uncil surures
packed red blood cells (313). Replacement therapy is advisable
are removed (317). During the rehabilitative period, mainte-
while fractures are manipulated and casts are changed. Most
nance levels of factor ranging from 20% to 50% immediately
authors think that open reduction and internal fixation should
before sessions of physical therapy should be maincained (291,
be performed in hemophiliac patients for fractures that would
317,328,331). Intramuscular injections of analgesics should ob-
viously be avoided, as should aspirin compounds and nonsteroi- customarily be treated with such methods (291,295,317).
dal antiinflammatory medications that affect platelet function.
Both acetaminophen (Tylenol) and codeine medications are safe Muscle Hematoma
otal analgesics (312). In [he past, hemophiliac patients had an Clinical Presentation. Hematomas of the soft tissues in hemo-
increased risk ofoperative infections and delayed wound healing, philiacs occur in superficial tissues but are more of a clinical
but aggressive replacement therapy has minimized those prob- ptoblem when they develop in muscle (317). Although most are
lems (331). spontaneous, a history of trauma was noted in 24% of 178
episodes of muscle hematoma in one series (292). In order of
Injury frequency, the most common sites of involvement in that series
were the quadriceps, calf, anterior compartment of the leg, thigh
Fractures and Dislocations adductors, hamstrings, and sartorius muscle. The first clinical
Clinical Presentation. Most, bur not all authors, believe that symptoms are tenderness, stiffness, and swelling of the involved
hemophiliac patients have an increased incidence of fracture muscle group with pain on motion (292). Early volar compart-
(290,301,308). These patients have been predisposed to fracture
ment syndrome of the forearm, which responded to factor re-
because of poor muscle function, limitation of joinc movemenc,
placement, has been reported in a young child (322), and before
and osteopenia secondary to recurrenc joinc hemarthrosis. Most
the advent of replacement therapy, Volkmann ischemic con-
authors have noted that healing of fractures proceeds primarily
tracture of the forearm could evolve from this injury (291). A
with endosteal callus and very little periosteal callus (301,313,
hematoma in the iliacus muscle can present as severe groin pain,
339), but Lancourt et al. (317) observed signitlcant periosteal
flexion deformity of the hip, and a tender mass palpable along
calcification in these fractures with a normal rate of healing.
the iliac crest. Passive extension of the hip increases pain, and
Fractures occur in both the upper and lower extremities (290,
significant swelling of the muscle can cause compression of the
295,301,313,333). Joinc dislocations are rare in hemophiliac
femoral nerve (with subsequent femoral nerve palsy and quadri-
patients. Floman and Niska (302) reported on a 6-year-old boy
who sustained a posterior dislocation of the hip with mild trauma ceps muscle paralysis) by the inguinal ligamenc superiorly and
that required a closed reduerion under general anesthesia and the iliopectinelligament medially. X-ray studies usually are not
immobilization in a hip spica cast. The joint was found to be helpful in the diagnosis of intramuscular hemorrhage in the he-
ankylosed at 6-year follow-up. Ackroyd and Dinley (289) re- mophilic. Ultrasound (316), CT scan (336), and MRl are useful
ported on two patients who had their patellas locked into the in documenting the presence of muscle hematoma. Wilson et
intercondylar notch of the distal femur after sustaining hyper- al. (341) noted that in early hemorrhage of the muscle, the
flexion injuries of the knees, which had limited range of motion ultrasound shows increased echogenieity, bur in established mus-
owing to arthropathy. These injuries were treated by flexion of cle hematoma, the echogenicity is decreased. This may be helpful
the knee under general anesthesia, depression of the inferior pole in recurrence, because fresh hemorrhage into an organizing he-
of the patella to unlock it, and then extension of the knee fol- matoma can be distinguished by this technique. One should not
lowed by splinting. assume that all groin pain in hemophilia is due to an iliacus
 Chapter 6: Pathologic Fractures 191

muscle hematoma. Although rare, hip hemarrhrosis can occur, the small bones in the hands and feet are the most common
and septic arthritis ofthe hip has also been reported in hemophil- sites; the prognosis is better with these sites than with more
iac patients. In this clinical siruation, a hip ultrasound and aspira- centrally located pseudotumors (290). Large pseudorumors may
tion can help make the correct diagnosis (341). develop calcific deposits that are visible on plain x-ray studies.
An established cyst may be associated with semilunar struts of
Treahnent. The most important consideration in the treatment bone projecting from the adjacent bone at the proximal and
of a patient with muscle hematoma is early initiation of replace- distal ends of the pseudocyst (296). With involvement of the
ment therapy. Aronstam et al. (293) found that if teplacement small bones of hands and feet, interosseous expansile lesions with
therapy was initiated within 2 hours of onset of symptoms, then surrounding periosteal elevation are seen (317). The CT scan is
excellent recovery ensued. The only exception to this finding useful in delineating the extent of pseudorumor (329).
was hematomas of the calf muscles, which responded equally
well to replacement therapy if it was treated within 3 hours of Treatment. Aspiration is contraindicated in treatment of pseu-
the onset of symptoms. Most authors recommend raising factor docysts because not only does the needle track fail to heal but
levels to between 20% and 50% (291,292,308,320,325) and hematoma soon recurs, with the possibility of infection and
continuing treatment for 24 hours (292) to 5 days (317). The
bleeding from the needle wound (291,296,325,339). Very early
patient should not bear weight on the extremiry (292), and the
treatment of small pseudorumors with replacement therapy,
affected joints should be placed in a position of comforr, with
compression dressings, and prolonged immobilization may ar-
a compression dressing and ice packs applied to the swollen
rest their development (290,308,315,317). Factor levels of 50%
muscle (292,308). Serial casting may be useful in regaining joint
were used in one series (290). Radiation therapy has been used
motion after active bleeding has ceased (308), and light traction
to treat pseudorumors of hands and feet successfully but should
may be useful for regaining hip motion in patients with iliacus
be discouraged in children (368,375,376,400). Surgical excision
hematoma. Quadriceps muscle function usually rerurns with re-
of the pseudotumor may be necessary if the diagnosis is in ques-
covery from quadriceps hematoma. Infrequently, ectopic bone
tion or if the lesion is enlarging with danger of skin perforation
may form in the soft tissues after hematoma (309). In severe
(291,297). Malignant degeneration is unlikely, and only one
cases of muscle hemorrhage that do not respond to conservative
treatment, fasciotomy and neurolysis (with proper replacement case of fibrous sarcoma has been associated with a pseudorumor
therapy) may be necessary (317). of the chest wall (319). Surgical removal of a pseudorumor is
quite demanding, and often residual cyst must be left behind
when it is connected with vital structures. Amputation may be
Neurapraxia necessary if the lesion is complicated by infection (317).
In addition to the compression of the femoral nerve seen in
iliacus hematoma, neurapraxia in hemophiliacs can occur in the
peroneal, sciatic, median, and ulnar nerves (291). Carpal runnel Hemarthrosis
syndrome due to hemorrhagic compression of the median nerve Clinical Presentation. Patients with severe hemophilia have a
has been reported (317,326). Facror levels for these patients high rate of hemarthrosis. The joints most commonly involved
should be raised to 80% to 100% of normal for 2 days and in decreasing order of frequency include the knees, elbows, an-
then maintained at 40% of factor levels for another 7 days with kles, hips, and shoulders (291). There usually is a prodrome of
splinting of the extremity (291). Another neurologic complica- stiffness and pain before clinical swelling, and trauma usually is
tion in patients with hemophilia is significant intracranial bleed- absent. The joint is held in a position of flexion that is most
ing from minor head trauma. This has been reported in 2% to comfortable, and eventually, the joint becomes tense and swollen
13% of children who have hemophilia and von Willebrand's with decreased range of motion. A subacute hemarthrosis of the
disease (299). knee is said to be present when twO or more episodes of acute
hemarthrosis have preceded it. On clinical examination, the sy-
Pseudotumor of Hemophilia novium is very thick and boggy with decreased range of motion
Clinical Presentation. The pseudorumor of hemophilia is a of the joint. Pain is uncommon. In chronic hemarthrosis, gener-
cystic swelling of the muscle due to hematoma. Adjacent bone ally a subacute arrhrosis has been present for at least 6 months,
erosion is often evident on plain x-ray study and is seen most and destructive changes are present on the x-ray srudies of the
frequently in the ilium and femur (335). In children, a patho- knee with osteoporosis, overgrowth of the epiphysis with sub-
logic fracture can occur after a destructive pseudorumor of the chondral cysts, and eventual narrowing of the joint space (Fig.
femoral shaft. Pseudotumors can also evolve after fracture of the 6-31) (291). MRI was found to be llseful in examining both
femur (296). These lesions may develop through subperiosteal the hypertrophied synovium in hemophilia arthropathy as well
hemorrhage, which causes pressure necrosis of the overlying as subchondral cysts (311,327). Various systems of classifIcation
muscle and underlying bone (339). Progressive enlargement can of joint arthropathy of the knee in hemophilia have been pro-
compress surrounding vital soft tissue structures, and extreme posed (291,306). The chronic phase of articular involvement
enlargement may eventually result in skin perforation, with in- for patients with hemophilia can lead to articular cartilage degen-
fection and possible death (296). In children, the peripheral eration from recurrent bleeds and effusions. Initially, synovial
skeleton is mosr commonly affected by pseudotumor (308), and hypertrophy and chronic hyperemia occur, followed by epiphy-
192 Ceneral PrinicpleJ

to be successful, a large needle such as a 16-gauge needle must

be used (317), and aspiration must be accomplished within 24
hours of the onset of swelling because the dO[ begins to loculate
after rhat time (308). Facror replacemenr must not be given
before the aspiration because tl1is will promote clotting of the
hemarthrosis fluid and prevent removal; ideally, therapy is initi-
ated at the same time as aspirarion (320). The value of aspiration
is uncertain because there was no difference in rhe range of
motion berween aspirated and unaspirated knees at 5-day follow-
up in one conrroJled trial (310). In addirion to factor replace-
ment, splinting, ice packs, and compression bandages are helpful
(317).
lntraarricular dexamethasone and nonsteroidal antiinflam-
matol)' drugs (NSAIDs) are used by some. A short course of
corticosteroids seems to reduce the need for ]ong-tcnn replace-
ment therapy (3l4). In subacute hemarthrosis, aspiration is not
necessary, and factor replacement with levels from 20% to 30%
is used three times weekly to protect the patient from further
bleeding during physical therapy sessions (300). Mobilization
FIGURE 6-31. A 22-year-old man with hemophilia had frequent he· should conrinue for 3 to 4 weeks, and if there is no response to
marthrosis of the knee. Moderately severe arthropathy is present, with therapy, synovectomy may be indicated (317). A ta..rget joint is
joint space narrowing. spurring, and subchondral cyst (arrow).
defined as one with four bleeding episodes in a 6-month period.
Treatment involves regular replacemenr therapy for at least 6 to
12 weeks co interrupt bleeding cycles. Replacement therapy can
include recombinant or pbsma-derived factor; most patients use
seal overgrowrh. Arricular involvemenr may be graded as shown
recombinant factor. In general, 1 unit per kg of body weight of
in Table 6-8. A diagnosric dilemma rhar can occur is sepric
factor V1II concenrrate provides a 2% increase in the facror VlIl
arrhriris in HIV-positive hemophiliacs wirh exisring joinr effu-
plasma activity. Today, acute joint bleeds are treated with a more
sion. Merchan et a!. (324) reported four patienrs with this com-
intensive therapy than was used previously (334,337).
plication, of which one was a l5-year-old boy wirh a sepric elbow
Managemenr of the patient with chronic articular involve-
due ro StreptococCltS pileumoniae rhar was [I'eared wirh 3 weeks
ment is aimed at sropping this phase with a prophylactic facror
of penicillin G rherapy.
replacemenr regimen (334,387). Greene et al. (304) reviewed
their experience with prophylactic transfusions for hypertrophic
Treatment. The first step in the rreatmenr ofjoint hemarthrosis synovitis in 19 children wirh severe hemophilia and found mixed
is prompr factor replacemenr with levels ranging from 30% to results. Persistent, painful, or progressive synovitis can be man-
50% (291,307334,337), and these levels may need to be main- aged with open or arthroscopic synovectomy, especially for the
tained for up to 4 days for severe cases (307). Home care factor knee and elbow of those with breakthrough bleeds. Greene (305)
replacement provides a means of rapid iniriation of therapy reported good results in five children who underwenr synovec-
(291). Wirh effecrive matmenr, usually prompt pain relief is romy of the ankle with a decreased rate of hemarthrosis episodes.
achieved in minutes after iniriation of replacement therapy, and Chemical (Rifampicin) or radioactive (Au-l98) synovectomy
the extremity should be splinted and ice should be applied to has also been used. Erken (300) reported 35 patients who under-
the joint (291). In acute hemarthrosis of the knee with a vel)' went medical synovectomy by intraarticular injection with the
tense, swollen joinr that is not responding well 1'0 replacement radiocolloid yttrium-90 silicate. Of these patients, 21 were
rherapy, early aspirarion may be of some value. For aspiration
younger rhan 10 years, and at a mean follow-up of 7 years, 47
joints were pain free and l3 joints had not experienced another
hemorrhagic episode. There was no change in the radiographic
appearance of the joints at follow-up. Erken suggested that this
GRADES OF ARTICULAR form of treatment is for patients who have failed to respond to
TABLE 6-8.
INVOLVEMENT intensive physical therapy as well as tnose patients who have
inhibitors to factor replacement. Fixed joint contractures can be
Grade 1 Transitory synovitis; no bleeding sequelae, and
with no more than three episodes in 3 monthS treated with reversed dynamic slings (308,338) or a turnbuckle-
Grade 2 Permanent synovitis with increased joint size, type cast (291). Slow continuous passive motion may be usefuJ
synovial thickening, and limitation of movement after surgelY of the knee in hemophiliacs (303). Joinr con-
Grade 3 Chronic arthropathy with axial deformity and tractures resistant to these conservative therapies can be treated
muscular atrophy
with either soft tissue procedures, osteotomies, arthrodesis, or
Grade 4 Ankylosis
joint replacement (291). Total joint arthroplasty may be helpful
in selected candidates.
 ChI/firer 6: Parhologic Fractures 193

• AUTHORS PREFERRED METHOD possible presence of both hepatitis and HIV, and the utmost
,~ OF TREATMENT care should be used in any SOrt of invasive ptocedure with these
patients.
Collaboration between the orthopaedist and the hematologist is
important in providing care for children with hemophilia. Most
fractures in children with hemophilia can be treated with either OSTEOMYELITI
rraction or cast techniques. Cate must be taken to avoid compli-
cations related to compression in these patients, and a mono- The character of pediatric acme hemarogenous osteomyelitis in
valved, well-padded plaster cast provides a safe means of treat- Notth America has changed somewhat during the past several
ment. A fiberglass cast is not as desirable because a simple decades. AJthough the typical clinical picture of acute osteomye-
monovalve will fail ro expand the cast completely. Operative litis in children is still seen, more subtle presentations are more
rreatment shouid be reserved for fracrures that normally require frequent. This may be due to a variery of reasons, including
surgery, and the usual precautions for hemophiliac patients for modification of the clinical course by antibiotics given before
surgery are observed. Muscle hemaromas are treated wirh a com- admission (351) and, possibly, increased awareness and an earlier
bination of replacement therapy, ice packs, bed rest, and a partic- presentation ro a medical Faciliry resulting in earlier diagnosis.
ular emphasis on rehabilitation. CT scans are extremely helpful Children oFten present with subacute osteomyelitis (Fig. 6-32,
in following the course of an iliopsoas muscle hematoma. Pseu- Table 6-9). Less common variants include Brodie's abscess, sub-
dorumors of the small bones of the hands and feet can be treated acute epiphyseal osteomyelitis, viral osteomyelitis (365), and
with excision and bone grafting. Hemarthrosis of the knee re- chronic recurrent multifocal osteomyelitis (354). Some patients
sponds well ro prompt facror replacement therapy and immobili- present with a bone lesion that may be confused with other
zation; aspiration is seldom needed. The orthopaedic surgeon disease entities, including neoplasm (345). AJj can masquerade
caring for patients with hemophilia must be ever mindful of the as osteomyelitis with fever and tenderness over areas of focal

1a 1b 2 3

4 5 6
FIGURE 6-32. Classification of subacute osteomyelitis. (From Dormans JP, Drummond DS. Pediatric he-
matogenous osteomyelitis: new trends in presentation, diagnosis, and treatment. J Am Acad Orthop
Surg 1994;2:333-341.)
194 meral Prinicples

Tn order of decreasing frequency, the most commonly involved

TABLE 6-9. COMPARISON OF ACUTE TO
SUBACUTE OSTEOMYELITIS
bones include the femur, tibia, humerus, fibula, radius, ph:llan-
ges, calcaneus, ulna, ischium, metatJrsals, and vertebral bodies.
Presentation Subacute Acute Although the etythrocyte sedimentation rate is commonly ele-
Pain Mild Severe vated in osreomyelitis, the white blood count is normal in 40%
Fever Few patients Majority ro 75% of patients (353). Blood cultures are positive for the
Loss of function Minimal Marked infecting organism in 40% to 50% of patients (364), and direct
Prior antibiotics Often (30%-40%) Occasional cultures of the site of infection are positive in no more than
Elevated WBC Few Majority
ESR Majority Majority 70% (353). The most common organism in hemarogenous os-
'Blood cultures Few positive 50% positive teomyelitis is Staphylococcus aureus. In velY young children, both
Bone cultures 60% positive 85% positive Haemophilus influenzae type b and Streptococcus pneu/nor/iae have
Initial x-ray study Frequently abnormall Often normal a significant prevalence (353), but Haemophilus influeIlzae has
Site Any location (may Usually
cross physis) metaphysis virtually been eliminated as a musculoskeletal padlOgen by im-
munization. Table 6-10 shows rhe mosr common organisms
From Dormans JP, Drummond, DS: Pediatric hematogenous affective ind ivid uals by age.
osteomyelitis: New trends in presentation, diagnosis, and
treatment. J Am Acad Ortho Surg, 2:333-341, 1994.

Radiographic Evaluation
Only 20% of patiems have plain x-ray findings of osreomyelitis
wirhin 10 ro 14 days after onset of symptoms; the earliest flndi ng
leukemic bone destruction (366). Biopsy often is needed ro clar- is loss of defined deep soft tissue planes (353). Because of this
ifY the diagnosis. Even with appropriate antibiotic therapy, somc early insensitivity of plain x-ray studies, isotope scanning tech-
patients have recurrent infection, growth disturbance, or patho- niques have been used [Q aid in diagnosis with valying rates of
logic fractures. success. In proven osreomye1itis, abnormal tech netium scans are
seen in 63% to 90% of patiems (352,358). In onc srudy (358),
Definitions gallium scans were abnormal in aU patients with osreolllyelitis,
but they were also abnormal in 30% of parients without a hone
Acute hem.ltogenous osteomyelitis can be classified by age (neo- infection. In neonares with osteomyeliris, only 31.5% had ab-
n:ltal, childhood, and adult osteomyelitis), organism (pyogenic normal technetium bone scans in one series (342). Although
:lnd granulomarous infections), onset (acuce, subacute, and somewhat technically difftculr, indium-labeled leukocyre scan:;
chronic ostcomyelitis), and routes of infection (hematogenous
are usually abnormal at sitcs of osteomyelitis. CT scans have
and direct inoculation). Chronic osteomyelitis is defined by mOSt
proved to be helpful in rhe evaluation of primary epirhyscal
authors as ostcomyelitis with symproms that have been present
bone abscess (343). MRJ is becoming the study of choice for
for longer than 1 month.
defining the stage and extent of osteomyelitis, after plain x-ray
studies (350). Bone infection can be idcIltified by soft tissue
Clinical Presentation changes through MR[ techniques in 92% of patieIlts, but the
Most patiencs with acute hematogeilous osteomyclitis present presence of prior surgery or coexisting fracrures affecrs rhe accu-
with fever, pain, and localized tenderness at the site of infection. racy of this study (344).

TABLE 6-10. INITIAL ANTIBIOTIC THERAPY FOR OSTEOMYELITIS

Patient Type Probable Organism Initial Antibiotic.

Neonate Grp. BStrep, s. aureus, Cefotaxime (100-120 mg/k/24 h) or

Gram-negative rods oxacilli,n and gentamidn (5-7.5 mg/kg/24
(H. influenza) h)
Infants & children S. aureus (90%) Oxacillin (150 mg/kg/24 h)
if allergic to penicillin a Cefazolin (100 mg/kg/24 h)
if allergic to penicillin and C1indamycin (25-40 mg/kg/24 h) or
cephalosporins" Vancomycin (40 mg/kg/24 h)
Sickle cell disease S. aureus or Oxacillin and ampicillin or chloramphenicol
Salmonella or cefotaxime (100-120 mg/kg/24 h)

a OveraLl 80% due to S. aureus

 Chapter 6: Pathologic Fractures 195

Injury isolated by culture, then longer term parenteral antibiotics must

be considered. Total length of therapy is based on the type of
In 1932, Capener and Pierce (347) reviewed 1,068 parients with
organism isolated and the patient's response to treatment. Un-
osteomyelitis and found only 18 pathologic fractures, 13 of
kila-Kallio et al. (370) found that in acute hematogenous osteo-
which occurred in the femur. They thought these fractures were
myelitis in children, the serum C-reactive protein correlated
due to delayed recognition of the infection or inadequate treat-
more closely than erythrocyte sedimentation rate to the clinical
ment. Other factors were disuse osteopenia, presence of a weak
course of osteomyelitis, with rapid elevation at the onset of dis-
involucrum, and excessive surgical removal of involved bone. In
ease and a significantly faster decline with effective treatment
this preantibiotic era, most of these fractures were sustained after
than the erythrocyte sedimentation rate.
surgical treatment of the osteomyelitis, and the authors believed
that conservation of the involucrum and proper immobilization
could have prevented these injuries. White and Dennison (371)
noted that before antibiotics, pathologic fractures of osteomyeli- Fracture Management
tis were common, but union occurred with certainty in the pres- Fractures associated with osteomyelitis may be difficult to treat
ence of dense involucrum. Daoud and Saighi-Bouaouina (348) and may be associated with complications such as malunion and
reported 'on 34 patients with hematogenous osteomyelitis com- growth disturbance (359). Pathologic fractures associated with
plicated by pathologic fracture, pseudarthrosis, or significant seg- osteomyelitis are rare in North America and usually are associ-
mental bone loss. The tibia was affected in 24 cases, the femur ated with neglected or chronic osteomyelitis, neonatal osteomye-
was affected in 8 cases, and the humerus was affected in 2 cases. litis, or septic arthritis. In children with chronic osteomyelitis,
A pathologic proximal femoral fracture has been reported in the purulent material elevates the periosteum and a supportive
neonatal osteomyelitis (342). Although the condition is tare, involucrum develops. Sequestrectomy of a portion of the ne-
hematogenous osteomyelitis can also evolve at the site of a closed crotic diaphysis while leaving the supportive involucrum is often
fracture from 1 to 6 weeks aftet injury (346,355,363). Canale needed to bring the infection under control, but the timing
et al. (346) reported three children with osteomyelitis after closed of this procedure is controversial. Langenskiold (356) delayed
fracture. They pointed out that progressive pain and swelling at sequestrectomy of a necrotic femoral shaft for 10 months in a
a fracture site during healing are suggestive of possible osteomye- 6-year-old patient to allow the involucrum to develop, but
litis. Daoud et al. (349) reported 35 children with upper femoral Daoud and Saighi-Bouaouina (348) recommended much earlier
osteomyelitis with associated septic arthritis. The incidence of debridement. In patients with active infection, they performed
AVN of the femoral head was approximately 50% both in the sequestrectomy with debridement, followed by antibiotic ther-
group that was treated with arthrotomy and in the group in apy for up to 6 months. Prolonged cast immobilization was
which no surgery had been done. They postulated that AVN of necessary. They obtained healing in 33 of 34 patients with
the femoral head may be due to compression by abscess of the pathologic fractures or pseudarthroses due to osteomyelitis. The
vessels lying on the posterior superior femoral neck. The compli- mean healing time of fractures was 5 months in patients with
cations of fracture, dislocation, and displacement of the capital involucrum. Patients with active infection without involucrum
femoral epiphysis occurred in two thirds of their patients, and required debridement, antibiotics, and subsequent treatment
these usually were patients who presented long after an acute with corticocancellous iliac grafr. The mean healing time was
phase of the disease. They recommended surgical drainage of 8.7 months. Their patients without active infection and no invo-
septic hips, and reduction and stabilization of hips with AVN lucrum were treated with prolonged immobilization and cancel-
using skin traction and plaster immobilization for 40 to 60 days. lous bone graft supplemented by fixation. Angular deformities
Lewallen and Peterson (357) documented osteomyelitis in 40% were treated with cast manipulation. Tudisco et al. (369) re-
of 20 non unions of diaphyseal open fractures in children. They ported on 26 patients with chronic osteomyelitis with average
believed that the presence of infection was a significant factor
follow-up of 23 years. Approximately 15% had shortening and
in their failure to heal. Long bone lesions also may be present angular deformity of the affected limb. Newer techniques for
in congenital rubella (361), and pathologic fractures have been
difficult cases have also been developed (Fig. 6-33).
reported in congenital cytomegalic inclusion disease (367).
Pathologic fractures also can occur in association with ad-
vanced or neglected septic arthritis in older children and in asso-
ciation with neonatal osteomyelitis and septic arthritis. Infants
Treatment with septic arthritis, especially of the shoulder or hip, present
Once osteomyelitis is clinically suspected, needle aspiration of with pseudoparalysis of the extremity. In the upper extremity,
the area of maximal tenderness of the long bone is recommended this can be confused with Erb's palsy. Plain x-ray studies may
to obtain the causative organism either from subperiosteal fluid show only soft tissue swelling and equivocal widening of the
or from the metaphysis directly. If gross purulent material is joint (362); technetium bone scans often are unreliable in neo-
obtained, surgical drainage should follow (353). Ultrasound or nates (362,368). Ultrasound and MRI can both be helpful; aspi-
MRI may be helpful in evaluating equivocal cases. With the ration should be done if clinical suspicion exists. Schmidt et al.
increased concern about medical economics, recent trends to (362) found that more than half of their patients with septic
decrease the duration ofintravenous antibiotic treatment of these arthritis of the shoulder also had osteomyelitis, and they recom-
infections appear to be appropriate as long as certain criteria are mended arthrotomy of the shoulder with drilling of the proximal
mer. If oral antibiotics are inappropriate or the organism is not humeral metaphysis if aspiration of the joint was positive.
196 emeral Prinicples

A,B c

D,E F
FIGURE 6-33. A 20-year-old patient presented with recalcitrant chronic draining osteomyelitis of the
left tibia 4 years after a grade 3A open tibia fracture treated with an intramedullary nail. A, B: X-ray
studies at presentation show healing of the fracture but changes consistent with chronic osteomyelitis.
c: X-ray studies after resection of the involved segment of bone and sequestrum, with early bone trans-
port from above and below a corticotomy. D: Early regenerate is seen at the time of docking of the
transported segment and the distal tibia. E: Healing at the docking site is seen after posterolateral bone
grafting. F: X-ray studies 6 years after the resection and bone transport showing healing and remodeling
of the tibia. The patient has returned to work, is free of pain, and has no signs of active infection.
 Chapter 6: Pathologic Fractures 197

~ AUTHORS' PREFERRED METHOD teopenia, many surgeons reapply a fixator, correct any malalign-
\...~ OF TREATMENT ment caused by the fracture, and compress at the fracture site
until healing. To ensure that the regenerate bone can bear the
With early recognition and appropriate rreatment, osteomyelitis forces of normal activity, a variety of imaging methods have
leading to pathologic fracture is uncommon. When osteomyeli- been used (372,376). When the regenerate bone attains the den-
tis is associated with pathologic fracture, it usually is neglected sity and ultrastructural appearance (developmem of the cortex
chronic osteomyelitis, or rarely, neonatal osteomyelitis or septic and the medullary canal) of the adjacent bone, fixator removal
arthritis. The most important step in the treatment of fracture is generally safe.
associated with osteomyelitis is to control the underlying infec- Pathologic fracture also can be caused by the osteopenia and
tion. At a minimum, this requires drainage and debridement of joint contractLlres that can occur after months in an external
the infection with immobilization in association with antibiotic fixation device. Some children, because of pain or anxiety, are
therapy. In advanced infections, sequestrectomy may be neces- reluctant to bear sufficient weight on their fixator devices, put-
sary. MRl is useful in identifying the sequestrum; an attempt ting them at risk for disuse osteoporosis. Joint contractures can
should be made to leave as much supporting involucrum as be related to either the lengrhening itself or insufficient rehabili-
possible at the time of sequestrectomy. Bone teansport and tation during and after lengthening. Many of the fractures due
lengthening also are occasionally useful. Prolonged immobiliza- to these causes are avoidable; when they do occur, appropriate
tion with either plaster casts or external fixation devices may be immobilization or internal fixation is used.
needed, and segmental bone loss can be treated with bone ttans-
POrt or grafting.
FRACTURES IN CONDITIONS THAT
WEAKEN BONE
PATHOLOGIC FRACTURES AFTER LIMB
Osteogenesis Imperfecta
LENGTHENING
Osteogenesis imperfecta (Ol) is a heterogenous group of inher-
Limb lengthening has evolved dramatically over the past several ited disorders in which the structure and function of type I
decades. Surgeons experienced with lengthening techniques can collagen is altered. The fragile bone is susceptible to frequent
now correct problems that previously had no satisfactory solu- fractures and progressive deformity (390,405). 01 is identifiable
tion. The very high complication rate that has come with these in 1 in 20,000 total births, with an overall prevalence of approxi-
advances has decreased with newer rechniques and more exten- mately 16 cases per million index patients (405,423). The wide
sive surgical experience. Complications with the Wagner spectrum of clinical severity-from perinatal lethal forms to
method, popular 20 to 30 years ago, were as high as 92% (375, clinically silent forms-reAects the tremendous genotypic heter-
377). Newer rechniques, using gradual lengthening with either ogeneity (more than 150 different mutations of the type 1 pro-
monolateral fixators or fine wire fixators such as the Ilizarov collagen genes COLlAl and COLIA2 have been described).
fixa to r, have decreased the complication rate. As the molecular basis of this continuum of severity is further
Fractures that occur in association with limb lengthening fall elucidated, the phenotypic groupings of the various classifica-
into three general categories: (a) fractures through pin tracks, tions and subclassifications may seem arbitrary. However, these
(b) fractures through regenerate bone, or (c) fractures through classifications facilitate communication, prediC[ natural history,
bone weakened by disuse osreoporosis. Fractures that occur and help the clinician plan management strategies (405). From
rhrough holes left after removal of screws or fine wires generally a practical viewpoint of orthopaedic care, patients with or can
occur a few weeks after device removal. The incidence of these be divided into two groups. One group of patients with severe
fractures can be minimized by prorective weight bearing after disease develops long-bone deformity through repetitive frac-
removal of the device and using the smallest possible screw diam- tures, eventually requiring open treatment with intramedullary
eter that is appropriate for the fixation device needed. fixation. Another group of patients has mild disease with fre-
Fracrures through regenerate bone are true pathologic frac- quent fractures, but their injuries usually respond well to closed
tures. The bone that is formed by distraction callotasis must be merhods of treatment and there is less residual deformity.
subjected to normal weight-bearing forces over a period of time
before normal bony architecture is established. Fractures rhat
Clinical Presentation
occur through the lengthening gap can occur soon after removal
of the fixator or years later. Various repons describe fractures Children wirh severe 01 may present with a short trunk, marked
through regenerative bone occurring as late as 2 ro 8 years after deformity of the weight-bearing lower extremities, prominence
lengthening (376-378). The incidence of fractures has been of the sternum, triangular facies, rhin s1Gn, muscle atrophy, and
reported to be as high as 18% for Wagner lengthenings bur only ligamentous laxity; some develop kyphoscoliosis (386,397,410),
3% for newer techniques (373-375,378-380). At present, most basilar impression (408,417), and deafness (due to otosclerosis)
lengthenings are performed through the metaphysis, which has a (398). Despite this multitude of physical problems, children
larger bone diameter and better blood supply than the diaphysis, with 01 usually have normal intelligence. Blue sclera, a classic
where Wagner lengthenings were done. When fractures occur finding in certain forms of 01, can also be present in normal
in regenerate bone, they can be treated with simple cast immobi- infants, as well as in children with hypophosphatasia, os-
lization. However, because this method further promotes os- reoperrosis, Marfan's syndrome, and Ehlers-Danlos syndrome
198 Ceneral Prinicptes

FIGURE 6-34. A: This 10-month-old boy with a history of

osteogenesis imperfecta presented with a right thigh
pain and swelling and refusal to bear weight. This AP
radiograph and (8) this lateral radiograph of the right
femur show the extraordinarily abundant, hyperplastic
callus-with the characteristic butterfly shape-that can
occur in osteogenesis imperfecta. This appearance may
A,S be mistaken for an infection or a neoplastic process.

(402). Hisrologic findings in severe cases reveal a predominance The diagnosis of 01 is based on clinical and radiographic
of woven bone, an absence of lamellar bone, and thinning of findings. There is no specific laborarory diagnostic test, alrhough
the corrical bone with osteopenia. fibroblast celJ culture can detect the collagen abnormality in
Patiems with 01 may present with swelling of the extremity, 85% of or patiems (389). In the absence of multiple fractures,
pain, and low-grade fever and a radiograph showing exuberam, the initial radiographic diagnosis can be difficult. Ir is crucial,
hyperplastic, callus formation (Fig. 6-34). The callus may occur but often difficult, ro distinguish 01 from nonaccidenral injury
without fracture and can have a distinct bunerfJy shape (402), (404,409). Unexplained fractures in mild, undiagnosed 01 can
as opposed ro the usuaJ fusiform callus of most healing fraccures. drag a family through unnecessary legal proceedings; conversely,
The femur is most commonly involved, but cases noting involve- a child with 01 may be abused but not exhibit classic ftacrure
mem of the tibia and humerus have been reported (416). The patterns (e.g., corner fracrures) owing to the fragility of theit
sedimemation rate and serum alkaline phosphatase may be ele- bones. Although no test or finding is specific, skin biopsy plays
vated. Because osteosarcoma has been associated with 01 (401, an important role (414,421).
403), aggressive-appearing lesions may occasionalJy require bi-
opsy ro confirm their benign nature. Treatment
The multiple fractures in 01 usuaJly are transverse, diaphyseal,
Radiographic Findings
and seldom displaced, and they usually heal at a relatively normal
Radiographic findings vary. In severe involvement, there is rate in most patients (402,417). Most fractures in patients with
marked osteoporosis, thin cortical bone and evidence of past or occur before skeletal maturity. In a series of 3\ parienrs,
fracture with angular malunion (Fig. 6-35). Both anterior and Moorefield and Miller (4\ 0) noted 951 fracrurcs, 91 % of which
lateral bowing of the femur and anterior bowing of the tibia are occurred before skeletal marurity. Fractures of the femur and
common. The long bones may be gracile with multiple cystic ribia predominare. The humerus is the most commonly fractured
areas. Spinal radiographs may show compression of the vertebrae bone in the upper extremity. Multiple long bone fractures may
between the carti laginous disk spaces (so-called codfish vertebra). result in coxa vara, genu valgum, and leg-length discrepancy.
The presence ofwormian bones on a skull radiograph is relatively Lateral dislocation of rhe radial head has been noted in some
specific for OJ. Subsequent development of multiple pathologic patienrs (402). Olecranon fractures, which are rare in unaffected
fractures with callus and deformity firmly establishes the diagno- children, are more common in parienrs with 01, especially the
sis (Fig. 6-36). tarda form (391,422). Oi Cesare et al. (391) reponed an infanr
 Chapter 6: Pathologic Fractures 199

FIGURE 6-35. A: X-ray study of a nondisplaced trans-

verse femoral shaft fracture (arrow) in a 6-year-old boy
with osteogenesis imperfecta. Mild anterior bowing of
the femoral shaft is already present, and with further
fractures, this deformity will worsen. B: X-ray study of
a 5-year-old ambulatory girl with osteogenesis imper-
fecta. Note the marked osteopenia of the proximal fe-
murs. C: Thirteen months later, the patient sustained
bilateral proximal femoral stress fractures, which even-
A tually required treatment with Bailey-Dubow rods.

B c

wll0se presentarion with bilateral isolated olecranon fractures led unions. Orte patient evemually required an amputation for a
to the diagnosis of OJ. painful nonunion of a distal femoral supracondylar fracture.
Nonunion is more common in 01 than in similar fractures
in unaffected children. Although nonunion was mentioned in Prevention
several series (410), Gamble et al. (393) emphasized the problem The role of medical therapy to limit the fracrure frequency in
with a report of 12 nonunions in 10 patients. Almost all had or should be considered investigational but promising (396,
type III or (419) and presented with nonpainful clinical defor- 413). The tremendous genorypic and phenotypic variations in
mity and decreased functional abiliry. A history of inadequate or must be considered as the results of these trials are analyzed:
treatment of the initial fracture was seen in 50% of these non- A drug that works well for children with certain forms of or
200 General Printcples

FIGURE 6-36. A: This 6-week old girl presented with

multiple fractures in different stages of healing. She
was evaluated for osteogenesis imperfecta and nonac-
cidental injury. She had a strong family history of os-
teogenesis imperfecta. An AP radiograph of the left
upper extremity shows marked osteopenia and a non-
displaced spiral fracture of the left proximal humerus.
B: An AP radiograph ofthe right lower extremity show-
ing osteopenia and healing fractures of both the femur
and the tibia. There is already some varus angulation
B and bowing to the mid-shaft of the right femur.

may be ineffective for others. Sodium fluoride, growth hor- immobilization, weakness and osteopenia, then refracture (381,
mones, and anabolic steroids have all been shown to be indlec- 405,410). Plaster splints and casts, braces, and air splines have
tjve. CaJcironin, whicll limits osteoclasts, has had variable suc- all been used (387,388,392,410,417).
cess. Nishi et al. (413) reponed that the fracture rate decreased Protected weight bearing is thought to reduce the incidence
in 10 patients with or treated with either calcjronin injection of lower extremity fractures (395). Customized splints and
or nasal spray. braces can add support to limbs weakened by fragile and de-
At prcscnr the most promising agenrs are the bisphosphonates formed bone. Letts et a!. (406) encouraged weight bearing in
(385,396). Pamidronate, like other bisphosphonates, is a potent patients by protecting them with vacuum pants. The splinting
inhibitor otbone resorption. In a trial of 30 children with severe system is a two-layer set of panes with Styrofoam beads between
Or, Glorieux et al. (396) showed that cyclic intravenous admin- the layers. By evacuating the ineerval betwcen the layers, a form-
istration of pamidronate every 4 ro 6 months resulted in a 41. 9% rltting orthosis results, much like the bean bag seating systcms.
increase per year in bone mineral densiry, an increase in metacar- Borh decreased frequency of fracture and increased bone density
pal cortical width, and a decrease in fracrure incidence of 1.7 were reported after use of this support system.
fractures per year. Mobiliry improved in 16 of the 30 children,
and :111 reported substanrial relief of chronic pain.

Closed Methods OPERATIVE TR ATME NT

The orthopaedisr caring for children with or must balance good,
standard fractme care (sarisfacrory reduction and casting) with Load-sharing devices (such as intrameduHary rods) are used for
the goal of minimizing immobilization to avoid a vicious circle: internal fixation oElong bone fractures or osteotomies in children
 hapter 6: Pathologic Fractures 201

with 01. Plates and screws should be avoided. In parients with

01, most internal fixation is used for stabilization after corrective
osteotomies. The goals of these osteotomies are to improve func-
tion and reduce fractures in weight-bearing bones by correcting
angulation. Porat et al. (415) found that the percentage of ambu-
latory patients in their series went from 45% to 75% after intra-
medullary rodding. The amount of bowing that requires osteot-
omy has not been defined. In one series (411), the average
preoperative bowing was 71 degrees for the femur and 40 degrees
for the tibia, but many patients had much less angulation.
Tradirionally, multiple osteotomy and rodding procedures
(So field technique) involved extensive incisions with signifIcant
soft tissue stripping and blood loss. Sijbrandij (418) reporred a
percutaneous technique in which the deformity is straightened
by closed osteoclasis and Rush pins are inserted along the proxi-
maJ axis of the long bones, partially transfixing them to stabilize
them in a new alignment. Most centers now use limited inci-
sions, thus minimizing blood loss and periosteal stripping, while
ensuring optimally placed osteotomies and efficient, controlled
instrumentation. The choice of fixation device should be based
on the age of the patient and the width of the medullary canal of
the bone. Both fixed-length rods (402,415,420) and extensible
Bailey-Dubow rods (382-384,393,394,411,412,415) are used. A
Skeletally mature patients and patients with very small medullary
canals are best treated with nonelongating rods, whereas skele-
tally immature patients with adequate width of the medullary
canal are best treated with extensible rods (394). Luhmann et
al. (407) reported a 20-year experience with extensible nails:
both overlapping Rush rods and Bailey-Dubow rods. They first
implanted the rods at an average age of7 yeats old and averaged
more than 5 years before the first revision. They recommended a
posterior position in the canal and using the stronger overlapping
Rush rods technique in the femur whenever the canal diameter
permitted; they advised against using overlapping Rush rods in
the tibia.
Displaced fractures of the apophysis of tbe olecranon in pa-
tients with 01 can be treated with open reduction and stabiliza-
tion by resorbable suture in infants and with open reduction
and inrernal fixation with two Kirschner wires and tension band
technique by figure-of-eight absorbable suture in older children
(422) (Fig. 6-37). Tibial tubercle avulsion injuries should be
treated by surgical stabilization if displaced. B
FIGURE 6-37. This 10-year-old girl with osteogenesis imperfecta pre-
Complications sented with a displaced olecranon sleeve fracture of the left elbow.
Complication rates are high (Fig. 6-38). Problems include frac- This was her first fracture. A: This lateral radiograph shows a widely
ture at the rod tip (Fig. 6-39), migration of the fixation device, displaced fracture involving the posterior portion of the articular sur-
face. B: She was treated with open reduction and internal fixation with
joint penetration, loosening of components of extensible rods, two K-wires and tension band construct using #2 Vicryl suture. She was
and fractures through the area of uncoupled rods (Fig. 6-40). maintained in a cast for 3 weeks and then started on range-of-motion
Harrison and Rankin (399) compared the complications of 23 exercises.

extensible rods with those of 27 fixed length rods. They found

that the refracture rate was higher in the fixed length rods and
fewer surgical interventions were necessary when extensible rods
were used. Gamble et al. (394) reported that, although the com- sleeve and burying it slightly under the bone of the greater no-
plication rate approached 69% for Bailey-Dubow rods (mostly chanter to prevent displacement. Jerosch (400) found a similar
due to loosening of the T-piece), the fixed lengrh rods had a 63.5% complication rate for Bailey-Dubow rods but also
complication rate of 55%; however, the replacement rate for thought that they were the best device available. Porat et aI.
nonelongating rods was 24% bur only 12% for the Bailey- (415) found that the compJication rate was 75% for Bailey-
Dubow rods. They recommended crimping the T-piece to the Dubow rods and 50% for noneJongating rods, with a similar
202 General Prinicples

B
FIGURE 6-38. A: The lower extremity deformities of this 14-year-
old girl with severe osteogenesis imperfecta were managed
throughout childhood with Bailey-Dubow rods. This AP radio-
graph of both legs shows successful lengthening and maintenance
of alignment of the lett tibia but failure of rod lengthening with
valgus angulation of the right tibia. B: The AP radiograph of both
femurs, also taken at age 14, shows signs of several of the prob-
lems in the management of the femoral deformities throughout
childhood. The right Bailey-Dubow rod protrudes into the soft
tissues distally. There is femoral bowing with a fracture and bend-
ing of the Bailey-Dubow rod at the junction of the male and fe-
male ends. In the lett femur, part of the Bailey-Dubow rod has
been removed because it was protruding into the sott tissues.
There is a pathologic fracture through the bowing of the proximal
A femur. C: Deformities of both femurs were treated by osteotomy
and exchange of the Bailey-Dubow rods for a Rush nail. D: One
year after the exchange, the osteotomy has healed. The femoral
alignment is good, but the proximal portion of the Rush rod is
prominent in the soft tissues.

c D
 Chapter 6: Pathologic Fractures 203

A B
FIGURE 6-39. A: An 11-year-old boy with osteogenesis imperfecta fell and sustained a right subcapital
femoral neck fracture (arrow). B: The fracture was reduced with gentle traction by a fracture table
under general anesthesia and was stabilized with a cannulated screw, which was placed with difficulty
through an open approach, just anterior to the Bailey-Dubow intramedullary rod.

FIGURE 6-40. A: This 1O-year-old with severe osteogenesis imperfecta

presented several years after Bailey-Dubow rod treatment for fractures
and deformity of the right femur. This lateral femoral radiograph
shows osteopenia, good position of the Bailey-Dubow rod, and signs
that the rod has allowed significant lengthening of the femur without
deformity. B: This lateral radiograph of the right femur, taken 2 years
later at age 12, shows that the rod has separated. There is now a
fracture in the gap between the male and female ends of the Bailey-
Dubow rod. (Courtesy of Brian Grottkau M.D. and Michael Goldberg,
A,B M.D., Boston, Mass.)
204 G'mera/ Prini.ples

Severe bowing of the extremities after recurrenr fractures is an

indication for osteotomy and inrramedullary rodding. Whenever
possible, surgery is delayed umil the child is 6 or 7 years old.
We recommend extensible rods in skeletally immature patienrs
and nonelongating rods both in older patients and in younger
patients whose canal is not wide enough for insertion of Bailey-
Dubow rods. When possible, we use limited incisions for inser-
tion of Bailey-Dubow rods to minimize blood loss and to avoid
devascularization of the long bones, which occurs commonly in
the so-called open shish-kabob technique.

Operative Technique-Bailey-Dubow Rod

Multiple small skin incisions are made at the point of maximal
deformity of the long bones, and a small periosteal incision is
made to permit introduction of a drill bit. After the cortex is
drilled repeatedly, manual osteoclasis completes the osteotomy
and the long bone is straightened. A guide pin is drilled in to
the medial edge of the tip of the greater trochanter, and down
inro the inrertrochanreric femur, and then is tapped distally
through the intramedullary canal through the knee. If caHus
FIGURE 6-41. An 8-year-old girl with osteogenesis imperfecta with from old fraerure halts progress, the guide pin can be drilled
limb-length discrepancy. Lateral tomograms of the knee show a central through the obstruerion and then tapped farther distally into
physeal arrest of the proximal tibia and early physeal arrest ofthe distal the middle of the distal flexed knee joint. Next, the reamer is
femur (arrows). Such complications are not infrequent with the use of
Bailey-Dubow rods. advanced over the guide pin and the female portion of the Bailey-
Dubow rod is threaded over the guide pin and driven down the
canal. The guide pin is pulled out of the knee joint through a
small atthrotomy incision, and the T -piece is attached to the
Bailey-Dubow sleeve. The T-piece is tapped down into the
percemage requiring reoperation for both types of nails. Zionts
greater trochanter. The male portion is then slid into the sleeve
ct al. (424) reported 40 complications in 40 extensible nailings
to complete assembly of the expandable rod.
of 15 children, finding a much higher complication rate when
The patient is immobilized for approximately 4 weeks in a
insertion of the rods was initiated before 5 years of age. Compli-
hip spica cast and then in a brace for 3 to 6 months. When
cations were also higher for tibial nailings.
there are fractures associated with intramedullary rods, these are
Postoperative bracing is suggested for lower extremity frac-
treated with either rod revision or immobilization. Every effort
tures (411). Upper extremity fractures should also undergo pro-
should be made to keep patients ambulatory early after fractures
longed splinting after removal of fracture fixation. Immobiliza-
occur to minimize disuse osteoporosis.
tion also may be adequate to treat stable, minimally displaced
fractures just distal or proximal to the intramedullary rods (394).
Nonunions, after fracture or surgical intervemion, may cause Osteopetrosis
difficulry in both ambulation and transfer. In one series of non-
Osteopetrosis, also known as Albers-Schonberg disease, is a con-
unions (393), the average age at diagnosis was close to 10 years
dition in which excessive density of bone occurs as a result of
and most patients tesponded to [['eatment with intrameduJlalY
abnormal funerion of osteoclasts (425,442). The resultant bone
rods and bone grafting, with healing in approximately 9 weeks.
of these children is dense, brittle, and highly susceptible to
Nonunion can occur after insertion of rods for upper extremity
pathologic fracture. The incidence of osteopetrosis is approxi-
fractures. Growth arrest also can follow the use ofintramedullaty
mately 1 per 200,000 births. The inherent problem is a failure of
rods in the lower extremities (Fig. 6-41).
bone resorption with continuing bone fotmation and persistent
primary spongiosa. The disorder classically has been divided into
a severe infantile malignam rype and a milder form that presents
~ AUTHORS' PREFERRED METHOD later in life. Intermediate forms have been idenrified in which
\...~ OF TREATMENT osteopetrosis presents as renal tubular acidosis (448). Although
the number of osteoclasts present in the affeered bone is variable
Protected weight bearing is the goal for patienrs with severe Or. (408,435), in the severe form of this disease, the osteoclasts may
Close follow-up is nccessaIY in the first few years of life, with be increased but funerion poorly (446).
protective posterior plaster spliming for fractures. Orthoses are Radiographically, the bones have a dense, chalkJike appear-
construered for bracing of the lower extremities to aid in both ance (Fig. 6-42). The spinal column may have a sandwich or
standing and ambulation. Standing frames also are used. Once rugger jersey appearance because of dense, sclerotic bone at each
he or she is am bulatory, the patienr is advanced to the use of a end plate of the vertebrae and less involvement of the central
walker or independent ambulation. portion. The long bones tend to have a dense, marble-like ap-
 Chapter 6: Pathologic Fracture,. 205

endobones of the pelvis (type II) are six times more likely to
have fractures than patients with only sclerosis of the cranial
vault (type 1) (427).
Patients with the severe, congenital disease have transverse
or short oblique fractures of the diaphysis, particularly the femur
(Fig. 6-43). Distal physeal fractures with exuberant callus may
be confused with osteomyelitis (441). Common locations for
fractures include the inferior neck of the femur, the proximal
third of the femoral shaft, and the proximal tibia (425,441).
Although most fractures involve the long bones of the lower
extremities, upper extremity fractures also occur frequenrJy (425,
432). The onset of callus formation after fracture in osteopetrosis
is variable (425,432,435). Although many studies state that frac-
tures in osteopetrosis heal at a normal rate (435,442), others
report delayed union and nonunion (425). In a rat model of
osteopetrosis, Marks and Schmidt (439) found delayed fracture
healing and remodeling. HasenhutrJ (432) observed that in one
patient with recurrent fractures of the forearm, each succeeding
fracture took longer to heal, with the last fracture taleing nearly
5 months to unite.
The orthopaedist n'eating fractures in children with os-
teopetrosis should follow the principles of standard pediatric
fracture care, with additional vigilance for possible delayed union
and associated rickets (432,445). Immobilization is prolonged
when delayed union is recognized. Armstrong et al. (425) sur-
veyed the membership of the Pediatric Orthopaedic Society of
North America and compiled the combined experience of 58
pediatric orthopaedic surgeons with experience treating patho-
logic fractures in osteopetrosis. In this comprehensive review,
they concluded that nonoperative treatment should be strongly
considered for most diaphyseal fractures of the upper and lower
limbs in children, but surgical management is recommended for
FIGURE 6·42. This 2-year-old with osteopetrosis presented with fore-
arm pain. An AP radiograph shows the characteristic increased bone femoral neck fractures and coxa vara.
density and absence of a medullary canal, especially in the distal radius Open treatment of these fractures with fixation is technically
and ulna. There is a typical transverse, non displaced fracture (arrow) difficult. One author (431) described inseruon of fixation into
in the distal ulnar diaphysis.
this bone like "drilling into a rock." In intramedullary fixation
of femoral fractures, extensive reaming may be required because
the intramedullary canal can be completely obliterated by scler-
otic bone (428). Other authors have found fixation of hip frac-
pearance and may have an Erlenmeyer's flask shape ar their ends
tures with fixation to be a formidable task (425,441), with dam-
owing to deficienr cutback remodeling. Radiolucenr transverse
age occurring co the fixation devices on insertion. The bone is
bands may be presenr in the metaphysis of the long bones, and
hard enough ro break the edges off boch chisels and drill bits.
these may represenr a variable improvemenr in rhe resorption
Armstrong et al. (425) cautioned that "the surgeon should expect
defect during growth of the child (441). There may be bowing
to use several drill bits and possibly more than one power driver."
of the bones due to multiple fractures (432), spondylolysis (440),
In addirion to these technical difficulties, patients with os-
or coxa vara (442). The small bones of the hands and feet may
teopetrosis are at risk for excessive bleeding and infeccion, proba-
show a bone-within-bone appeatance with increased density
bly related co the hemacopoetic dysfunction caused by oblitera-
around the periphery. The unusal radiographic appearance may
tion of the marrow cavity (445). Procedures should not be
initially obscure occult, nondisplaced fractures.
performed unless the plateler count is greater than 50,000 mm 3 ,
and preoperative platelec transfusions may be necessary (445).
Prophylactic antibiotic coverage is advised. Minor procedures
Treatment
should be performed percutaneously whenever possible (445).
Pathologic fractures are quite common In patienrs with os- In the past, primary medical treatment for osteopetrosis in-
teopetrosis (408,427,432,436,438,445,448). Patienrs with a se- cluded transfusions, splenectomy, calcitriol, and adrenal cortico-
vere form of the disease have more fractures than rhose with steroids, bm these cechniques have proved ineffectual (444,447).
presentation later in childhood. Concurrent blindness can make Bone marrow transplantation for infant malignant osteopecrosis
patients more susceptible to accidental trauma. Patiems with has proved co be an effective means of treatment for some pa-
aurosomal dominant osteopetrosis with rugger jersey spine and cients, bur it is noc possible in alJ patients, it does not guarantee
 206 General Prinicples

A,B c

FIGURE 6-43. A: This 9-year-old with osteopetrosis sus-

tained similar bilateral subtrochanteric fractures of the
femur over a 2-year period. This AP femoral radiograph
and (B) this lateral femoral radiograph shows a healing
transverse subtrochanteric fracture of the left femur. C:
One year later, at age 10, she sustained a similar right
transverse minimally displaced subtrochanteric femur
fracture, which was treated with reduction and a spica
cast. D: This AP radiograph taken at age 14 years shows
that both proximal femur fractures have healed and there
D is mild residual coxa vara, especially on the right side.

survival, and it may be complicated by hypercalcemia (425,429, Radiographs show a sclerotic pattern very similar to that of
430,443). osteopetrosis. In pyknodysosrosis, however, the medullalY ca-
nals, although poorly formed, are present and a faint trabecular
Pyknodysostosis pattern is seen (Fig. 6-44). Such sclerotic bone is also seen in
Engelmann's disease, but clinically those patients are tall and
Pyknodysostosis is a rare syndrome of shorr stature and general- eventually develop muscle weakness. The distal femur in a pa-
ized sclerosis of the enrire skeleton. The dense britde bones of tient with pyknodysostosis usually has an Erlenmeyer's flask de-
affected chi ldren are highJy susceptible to parhologic fractures. formity similar to that found in patients with Gaucher's disease
Henri Toulouse-Lautrec was thought to be afflicted by this dis- (449).
order (452). Pyknodysostosis is inherited as an autosomal reces-
sive trait, with an incidence estimated as 1.7 per 1 million births.
Treatment
The long bones are sclerotic, with poorly formed medullalY ca-
nals; histologic section show attenuated haversian canal systems. Although pathologic fractures are thought to be less common
Patients with pyknodysostosis have shorr stature, a hypoplas- in pyknodysostosis than in 0 I, almost all patients wi th pycnody-
tic face, a nose with a parrot-like appearance, and both fro nra I sostosis reported in the literature have had pathologic fractures.
and occipital bossing. Bulbous distal phalanges of the fingers By age 22 years, one patien t had sustained more than 100 frac-
and toes with spooning of the nails are common. Coxa vara, tures (450). The fractures are usually transverse and diaphyseal,
coxa valgum, genu valgum, kyphosis, and scoliosis may be pres- and heal with scanty callus (453). The fracture line can persist
ent. Failure of segmentation of the lower lumbar spine has been for nearly 3 years after clinical union, with an appearance similar
reporred. Results of laboratory studies usually are normal. ro a Looser line. Lower extremity fractures are the most common
 Chapter 6: Pathologic Fractures 207

did well, although immobilization was prematurely discontinued

(450).

Ric;kets
Rickets is a disease of growing children caused by eirher a defi-
ciency of vitamin 0 or an abnormaliry of irs merabolism. The
osteoid of rhe bone is not mineralized, and broad unossified
osteoid seams form on the trabeculae. With failure of physeal
mineralization, the zone of provisional calcification widens and
the ingrowth of blood vessels into the zone is disrupted. In the
rickets of renal failure, rhe effects of secondary hyperparathyroid-
ism (bone erosion and cySt formation) also are present. Before
widespread fortificarion of common foods, vitamin 0 deficiency
was a common cause of rickers, but other diseases affecting the
metabolism of vitamin 0 have become a more common cause.
Regardless of the underlying cause, the various rypes of rickets
share similar clinical and radiographic features. Although many
of the metabolic findings are the same, there are some differences
(Table 6-11).
Both pathologic fractures (435,457,464,466,468) and epi-
physeal displacement (458,465) can occur in rickets with associ-
ated renal disease. The treatment of rickets with associated
FIGURE 6-44. A young boy with pyknodysostosis. Although bone den- pathologic fractures depends on identification of the underlying
sity is increased overall, a medullary canal is present in the proximal
humerus with faint trabecular lines (arrow) in contrast to osteopetrosis, cause. In addition to nutritional rickets, many diseases of the
in which the medullary canal is usually completely obliterated. (Cour- various organ systems can affect vitamin 0 metabolism, and
tesy of John D. McKeever, M.D., Corpus Christi, Texas) their treatment is necessary before the clinical rickets can be
resolved.

Nutritional Rickets
(450), and clinical deformity of both the femur and ribia is
frequem. Inadequate dietary vitamin 0 and lack of exposure to sunlighr
Fracture healing has been described as both normal (455) can lead to a vitamin 0 deficiency (Fig. 6-45). Pathologic trac-
and delayed (450). Nonunion is reponed in the ulna, clavicle, tures from vitamin 0 deficiency rickets also occur in children
and tibia (453). One series (453) with long-term follow-up sug- on certain diets: unsupplemented breast milk (463), diets re-
gem dut fractures tend to heal readily in childhood, but non- striCted by religious beliefs (457), and fad diets (460).
union can be a problem in adulthood. Edelson et al. (451) re- Fractures are treared with both cast immobilization and cor-
ported 14 new cases ofpyknodysoswsis from a small Arab village. rection of rhe vitamin deficiency by oral vitamin 0 supplementa-
They described a hangman's fracture of C2 in a 2-year-old child tion. Oral calcium supplements also may be necessalY, and pa-
that went on w asympwmatic nonunion. There was 100% inci- tients should consume a vitamin O-fortified milk source (457).
dence of spondylolysis in their patjenrs aged 9 years or older,
with most located at L4-L5. None of the spondylolytic lesions
showed uptake on technetium 99m bone scan. Treatment was Rickets in Malabsorption Diseases
conservarive, with one parient with sympwmatic spondylolysis Celiac disease caused by gluten-sensitive enteropathy affects in-
responding to bed rest. testinal absorption of fat-soluble vitamins (such as vitamin D),
Cast immobilization is successful in the treatment of most resulting in rickets. Biopsy of rhe small intestine shows character-
of these fractures. Taylor et al. (456) [l'eated a femoraJ fracture istic atrophy of the villi. Trearmenr is oral vitamin 0 and a
in an II-year-old boy with skin traction and a one-and-a-halfhip gluren-free diet. Infants with short gut syndrome may have vita-
spica cast. At 6-momh follow-up, clinical union with persistenr min O-deficiency rickers. This syndrome may develop afrer
fracrure line was seen. In adulrs, both plates and screws and intestinal resection in infancy for volvulus or necrotizing entero-
hip screws have been used for proximal femoral fracrures (454). colitis, in intesrinal atresia, or after resecrion of the terminal
Delayed union of tibial ftactures has been treated with both ileum and rhe ileocecal valve (471). Pathologic fractures have
com pression plating and bone grafting (453)' and in uamedullary been reported, and treatmenr is immobilization and adminisrra-
nailing with cast immobilization. Roth (454) noted that treat- tion of vitamin O 2 with supplemental calcium gluconate.
ment of a hip fracrure with fixation was technically difficult. Hepatobiliary disease also is associated wirh rickets (459,462)
Cervical immobilization through a Minerva cast and soft cervical (Fig. 6-46) With congenital biliary atresia, rhe bile acids, essen-
collar has been used for a C2 fracture in a child, and the patient tial for the inrestinal absorption of viramin 0, are inadequate.
208 General Prinicples

TABLE 6-11. RICKETS: METABOLIC ABNORMALITIES

1.25(OHh Alk
Disorder Cause Vitamin D PTH Ca z+ P Phos

Vitamin Ddeficiency rickets Lack of vitamin D in the diet L L or~· 1

Gastrointestinal rickets Decreased gastrointestinal absorption of vitamin·.D Ldr~ ! !
or Ca 2+ .

Vitamin D-dependent rickets Reduced l,:25(OHh vitamin D Production II I !

Vitamin D-resistant rickets- Intestinal cell insensitivity to vitamin D causing I or~ I !
end-organ insensitivity decreased Ca 2 + absorption
Renal osteodystrophy Renal failure causing decreased vitamin D II n I
synthesis, phosphate "retention, hypocalcemia
and secondary hyperparathyroidism

By age 3 months, nearly 60% of patients with biliary atresia min 0 prophylaxis (467). In a study of20 children with epilepsy,
may have rickets (461). Intravenous vitamin 0 often is needed there was no difference in the bone mineral density of the femo-
for effective treatment of these patients. After appropriate surgi- ral neck in patients on either phenobarbitaJ or phenytoin com-
cal correction of the hepatic syndrome, the bone disease gradu- pared with control subjects (470).
aJly improves. The pathologic fractures that develop in these Ifosamide, a chemotherapeutic agent used for treatment of
disorders (459) can be treated with immobilization. Ewing's sarcoma, can cause hypophosphatemic rickets in chil-
Anticonvulsant therapy can interfere with the hepatic metab- dren. The onset of rickets may occur anywhere from 2 to 14
olism of vitamin 0 and result in rickets and pathologic ftactures. months after chemotherapy and can be corrected with the ad-
Fewer fractures occur in institutionalized patients teceiving vita- ministration of oral phosphates (469). Other mineral deflcie~-

A B
FIGURE 6-45. A: This 3-year-old girl presented with extremely severe nutritional rickets. An AP radio-
graph of the pelvis and both femora shows severe coxa vara, widening of all physes, and osteopenia
of the distal femora, with flaring of the distal femoral methaphysis. B: Standing lower extremity radio-
graph shows further deformity of the distal tibia with Looser lines visible on the concavity of the defor-
mity of the right distal fibula.
 Chapter 6: PathoLogic Fractum 209

cies such as magnesium (a cofactor for parathyroid hormone)

can cause rare forms of rickets (Fig. 6-47).

Rickets and Very-Low-Birth-Weight Infants

Very-low-birth-weight infants 0,500 g or less) can have patho-
logic fractures. In one study of 12 vely-Iow-birth-weight in-
fants, the incidence of pathologic fracture was 2.1 %, nearly twice
the rate of other premature infants with a birth weight of more
than 1,500 g (472). The fractures are likely caused by a nutri-
tional osteomalacia that may evolve into frank rickets in nearly
30% of vely-Iow-birth-weight infants (472,474,476,478) (Fig.
6-48). During the last trimester of pregnancy, intrauterine
growth rate is exponential and almost two thirds of the birth
weight is gained at that time (480). Eighry percent of both cal-
cium and phosphorus is acquired then (475). Bone loss can be
graded by either loss of cortical bone of the humerus (479) or
loss of bone of the distal tadius (476). Other than craniotabes
(thinning and softening of the skull bone, with widening of the
sutures and fontanelles), the clinical signs of rickets are generally
lacking in these patients (574). The risk factors predisposing
these patients to both rickets and fractures include hepatobiliary
disease (461,462,472), prolonged total parenteral nutrition
(472), chronic lung disease (472), necrotizing enterocolitis
(471), patent ductus arteriosus (473), and physical therapy with
A passive range-of-motion exercises (474,477). In a prospective
study of 78 low-birth-weight infants, Koo et aJ. (477) observed
a 73% incidence of rickets with associated pathologic fractures
in patients with a birth weight of 800 g or less and only a 15%
incidence of rickets with fractures in patients with a birth weight
ranging from 1,000 to 1,500 g.

Treatment
In most cases, pathologic fractures in very-low-birth-weight
infants are found incidentally on chest x-ray or gastrointestinal
studies. The fractures may be suspected when physical examina-
tion reveals swelling and decreased movement of an extremity.
The differential diagnosis of these fractures is limited bur impor-
tant: Or, copper deficiency syndrome, child abuse, and patho-
logic fracture from overzealous physical therapy (474). Recurrent
fractures, physical findings, and a positive family history are the
hallmarks of 01; serum copper levels are useful in establishing
copper deficiency syndrome. Neonatal osteomyelitis may also
present a similar x-ray appearance. If risk factors for infection
are ptesent, the bone lesion should be aspirated and cultured
(472).
In the series reponed by Arnir et al. (472), 120.2%) of973
preterm infants had fractures; 11 of 12 had more than 1 fracture.
B Radiographically, osteopenia is first seen at the fourth week of
,FIGURE 6-46. A: This 18-year-old boy with sclerosing cholangitis and life. Typically, rib fractures are next seen at 6 ro 8 weeks of life,
a history of steroid use presented with several months of worsening then fractures of the long bones at 11 to 12 weeks (480). In
low back pain. This lateral radiograph of his lumbar spine shows marked
osteopenia, collapsed codfish vertebra with sclerotic end plates and one study, 54% of fractures were in the upper extremities, 18%
widened disc spaces and Schmorl's nodes. B: This MRI shows flattened in the lower extremities, 22% in the ribs, and approximately
concave vertebra that are smaller in most locations than the adjacent 6% in either the scapula or the clavicle (477). Most long bone
intervertebral disc. He was successfully treated with 3 months in a thor-
aco-Iumbar-sacral-orthosis (TLSO) brace, followed by weaning from the fractures are metaphyseal and may be transverse or greenstick
brace and conditioning exercises. with either angulation or complete displacement (472). Callus
is seen at the fracture site in less than a week, and complete
remodeling occurs in 6 to 12 months (472,477). Passive range-
210 General Prinicples

A B
FIGURE 6-47. A: A 13-year-old girl presented with rickets caused by magnesium deficiency. She had
back and hip pain aher a seizure; the x-ray study shows compression fractures of the thoracic vertebrae
(arrow). B: Displaced femoral neck fractures are also present with periarticular calcification (arrows).
(Figure continued.)

of-motion exercises for these infants, by both physical therapists 50 children (490). Typically developing about 1.4 years after
and parents, should be avoided unless it is absolutely necessary diagnosis of the kidney disease (490), the clinical syndrome is
(474). Rib fractures have been associated with vigorous chest a combination of rickets and secondary hyperparathyroidism
physiotherapy (477,478). Care also should be taken even with with marked osteoporosis. These children presem with short
routine manipulation of the extremities during nursing care, and stature, bone pain, muscle weakness, delayed sexual develop-
special care should be taken in restraining the extremities during ment, and bowing of the long bones (483). The underlying renal
surgical procedures (477). disease may be chronic nephritis, pyelonephritis, congenitally
Splinting is the treatment of choice for pathologic !l-actures small kidneys, or cystinosis (468). Identification of the renal
of the long bones in very-Iow-birth-weight infants (Fig. 6-49). disorder is important because patients presenting with rickets
Hip spica casts are contraindicated because they may compro- due to obstructive uropathy may respond to surgical treatment
mise cardiopulmonary support and hamper nursing care (477). of the renal disease.
Regardless of the means of immobilization, the prognosis is ex- Specific clinical deformities include genu valgum (most com-
cellent for most of these fractures because they go on to complete mon), genu varum, coxa vara, and varus deformities of the anlde
remodeling within 12 months; prolonged follow-up is advised. (482,483,485). These deformities are most common in patiems
Preventive measures are important to minimize the risk of frac- diagnosed before 3 years of age. Davids et aJ. (485) showed
(LIre in low-birth-weight infants. Their nurritional need for high that periods of metabolic insrabiliry, characterized as an alkaline
levels of calcium, phosphorus, and vitamin D should be recog- phosphatase of 500 U for at least 10 momhs, were associated
nized. Alternating high levels of calcium with low levels of phos- with progression of deformiry. With the adolescent growth
phorus in hyperalimentation solutions can help meet these spurt, osseous deformities can accelerate rapidly over a matter
needs. Because growth arrest is possible after fractures, follow- of weeks (485).
up over the first 2 to 3 years of life is advised. Radiographs show rickets and osteopenia with osteitis fibrosa
cystica (482). Osteoclastic cySts (brown tumors) may form. Me-
taphyseal cortical erosions occur in the law'a] clavicle, disral ulna
Rickets and Renal Osteodystrophy
and radius, neck of the humerus, medial femoral neck, medial
Renal osteodystrophy is common in patients with end-stage proximal tibia, and middle phalanges of the second and third
renal failure; it was diagnosed in 79% of patients in a series of fingers (490). The proximal femut may become so eroded with
 Chapter 6: Pathologic Fractures 211

FIGURE 6-47. (continued) C: The fractures were openly re-

duced with fixation by multiple cannulated screws. She was
placed in a hip spica cast to protect the fixation. D: At 12-
month follow-up, the femoral neck fractures have united,
with no evidence of avascular necrosis of the femoral heads.
With medical treatment of the rickets, new bone has been
D added to the pelvis (arrows.)

tapering and thinning that it has been likened to a rotting fence Preoperative tests needed for these patients before surgery in-
post (502). In renal osteodystrophy, the Looser zone may repre- clude electrolytes, calcium, phosphorus, and alkaline phospha-
sent a true stress fracture and, with minor trauma, may extend tase. Before surgery, these patients may need dialysis, phosphate
across the fuJl thickness of the bone with development of a true adjustment, either medical or surgical correction of hyperpara-
fractLlre. Callus may be scanty in patients with fractures who thyroidism, or chelation therapy for aluminum toxification. Sup-
have untreated renal disease, but in patients on hemodialysis, plemental vitamin D should be discontinued or the dose halved
abundant callus may form at the fracture site (466). 2 to 4 weeks before any procedure that may require immobiliza-
tion (483). It is important [Q rule out dental abscess, which
Treaunent may be present in as many as 25% of patients with vitamin
In renal osteodystrophy, pathologic fractures of the long bones, D-resistanr rickets (494). Postoperative infection may be more
as well as rib fractures, vertebral compression fractures, and dis- common in parients who are on corticosteroid therapy after renal
placement of the epiphyses, occur frequently. Fractures occur tra..nsplantarion (496). Prophylactic antibiorics are highly recom-
in areas of metaphyseal erosion or through cysts. Immobilization mended for surgery of all patients wirh renal osteodystrophy
is used [Q treat pathologic fractures through both generalized (487).
weakened bone and brown tumors. Osreonecrosis may occur in weight-bearing bones, with the
Once the underlying bone disease is under control, open femora! head most often symptomatic (501). Other sites of in-
procedures such as curettage of CYStS with bone grafting and volvement include the disral femoral condyles and the talus (482,
open reduction of fractures may be considered when appropriate 499). Osteonecrosis may result from the use of immunosuppres-
(466). Internal fixation is preferable to external fixation (484). sive corticosteroids, because there is less osteonecrosis when the
212 General Prinicples

extremities are performed to place them in the optimal position

for function. Osteonecrosis in renal osteodystrophy can be
treated with repeated joint aspiration, crutch ambulation, and
physical therapy (485),

Rickets and Renal Osteodystrophy-Slipped Capital

Femoral Epiphysis
The incidence of epiphyseal displacement in children with renal
osteodystrophy ranges from 20% to 30% (465,491). Sites of
involvement include the distal femur, proximal femur, and prox-
imal humerus, the heads of both the metatarsals and metacarpals,
and the distal radial and ulnaI' epiphyses, which tend to displace
in an ulnar direction (491). In the proximal femur, both femoral
neck fractures (458) and slipped capital femoral epiphysis occur
(Fig, 6-50),
Possible explanations for displacement of the proximal femo-
ral epiphysis include metaphyseal erosion with subsequent frac-
ture (458,491), and a layer of fibrous tissue that forms between
the physis and the metaphysis because of the destructive effects
FIGURE 6-48. A 4-month-old premature infant of low birth weight
with healing rickets, New periosteal bone is cloaking the humerus of the renal osteodystrophy (492). The warning signs and risk
(arrow). factors for slipped capital femoral epiphysis in renal osteodystro-
phy include subperiosteal erosion of the medial femoral neck,
increasing width of the physis, bilateral coxa vara, male gender,
and an age between 10 and 20 years (458). Wirh erosion of rhe
conicosteroid dose is decreased (486). Ferris et al. (488) de- conex of the inferior medial femoral neck, rhe femoral head
scribed osteochondritis dissecans lesions of the medial femoral collapses, decreasing rhe neck shaft angle, and subjecting the
condyles in young adults with hypophosphatemic rickets. Both physis to shear forces as it assumes a vertical orientation.
loose bodies and so-called trap-door lesions were seen in these The aggressive medical treatment of renal osteodystrophy,
patients, Older patients developed calcification of the ligaments including administrarion of vitamin 0 (493), calcitriol, hemo-
abom the hip, knees, and spine. Lesions of bilateral osteochon- dialysis, renal transplantation, and pararhyroidectOmy, has
dritis dissecans may require repeated arthroscopic irrigations and improved rhe long-term survival and quality of life for rhese
removal of loose bodies (488). Joint stiffness in older patients parients. Temporary limitation of weight bearing is recom-
due to ligamentous calcification about the knees, hips, and spine mended if there is little metaphyseal erosion, minimal coxa vara,
can be minimized if early corrective osteotomies of the lower and fusion of the physis is expected within 1 to 2 years (466),
Goldman et al, (458) recommended prophylactic hip pinning
or close follow-up if risk factOrs are present for slipped capital
femoral epiphysis in parients with renal osteodystrophy. With
continuing slippage after medical treatment, most authors rec-
ommend in situ fixation (458,483,497), Continuing displace-
ment of the proximal femoral epiphysis may occur even after
pinning. Fixation holds poorly, possibly because the wide radio-
lucent zone of the femoral neck in this disorder is nor true physis
bur rather poorly mineralized woven bone and fibrous tissue
(465). In a very young child, threaded pin fixation of rhe proxi-
mal femoral epiphysis may resulr in growth abnormality with
trochan teric overgrowth,
Smooth pins can be used to stabilize rhe epiphysis remporarily
until medical treatment resolves the underlying bone disease,
For patients younger than 5 years, Hanjen and Koman (489)
recommended treatment of slipped capital femoral epiphysis
with reduction through Buck's tracrion and fixation with a single
specially fabricated 4.5-mm conical screw. The distal threads of
rhe screw were machined off so [hat only the smooch shank of
FIGURE 6-49. A tibia splint has been constructed for this premature the screw extended across rhe physis. Subtrochanteric osreotomy
infant by wrapping a tongue blade in a heavy layer of Webril and then
fractufi,ng the tongue depressor so that it assumes a sugar tong appear- with fixation or total hip arrhroplasty may be necessary in older
ance, Tape is gently wound around the splint to hold it in place, patients with severe coxa vara after slipped capital femoral epi-
 Chapter 6: Pathologic Fractures 213

FIGURE 6-50. A: This 13-year-old boy with renal osteodystrophy

presented with bilateral hip and thigh pain. This AP pelvis radio-
graph shows widening of the proximal femoral physes with scle-
rosis. Slipped capital femoral epiphyses were diagnosed. B: This
AP pelvis radiograph taken 9 months after surgery shows narrow-
ing of the physis and no evidence of further displacement of the
B capital femoral epiphyses.

physis (458,483). Medical management of the underlying renal phosphate binder (481). Aluminum intoxication causes defective
disease and of hyperparathyroidism is mandatory. Pinning of mineralization. Multiple pathologic fractures may occur with
the proximal femur may not be necessary. poor healing. Serum aluminum levels are not diagnostic, but
the use of deferoxamine, a chelation agent, in an infusion rest
may provide the diagnosis (495). A bone biopsy often is neces-
Renal Osteodystrophy Complicated by Aluminum
sary.
Toxicity
After treatment of the renal disease with correction of the
Oppenheim et al. (498) noted the contribution of aluminum aluminum toxicity by chelation agents, acute fractures will heal.
toxicity to the development of fractures in renal osteodystrophy. Severe bowing of the long bones due to fractures can be treated
Because phosphorus restriction is important in children with with multiple osteotomies with intramedullary Rush rod or plate
renal disease, aluminum hydroxide has been commonly used as a fixation (498). Recurrence of the syndrome is prevented by use
214 General Prinicpies

of aluminum-free phosphate-binding agents such as calcium car- be stabiJized wirh in situ screw fixacion in older children if pro-
bonate (500). gression is noted despite medical rreatmenr. Multiple screws
should be considered because the underlying metaphyseal bone
is quite soft. For treatment of progressive slipped capital femoral
~ AUTHORS' PREFERRED METHOD epiphysis in very young children, some form of umhteaded fixa-
\..~ OF TREATMENT tion seems most logical.
Most fractures of the long bones respond readily ro caSt or
Recognition of the underlying metabolic abnormalities is the splim immobilization with concurrent aggressive medical treat-
most important aspect in the care of all of these injuries. Slipped mem of the underlying metabolic disease. Femoral neck fractures
capital femoral epiphysis may be the first preseIlting sign of are (L·eated with anatomic reducrion and imernal fixation. The
renal failure (458). A slipped capital femoral epiphysis should underlying bone disease should be medically treated to ensure

A B

c D
FIGURE 6-51. A: This case demonstrates multiple pathologic fractures in a previously healthy teenage
boy who developed idiopathic osteoporosis. This AP radiograph of the right knee and (8) this Ilateral
radiograph demonstrates a displaced distal femoral metaphyseal fracture with apex posterior angula-
tion. C: This was treated with closed reduction and percutaneous pinning and application of a cast. D:
This lateral radiograph shows satisfactory alignment with the pins in place. (Figure continues.)
 Chapter 6: Pathologic Fractures 215

E F
FIGURE 6-51. (continued) E: A few months later, he sustained a left proximal femur fracture, which
was treated with a spica cast. F: This AP pelvis radiograph taken 3 years later shows healed proximal
femoral fractures with varus angulation. and severe osteopenia of the pelvis and femora with profrusio
of both acetabuli.

success of open procedures. Significant cYStS should be rreared observed that 87% had vertebral fracrures and 42% had metaphy-
with curenage and bone grafting. Angular deformities of the seal fractures. Symptoms of back or extremity pain can predate
long bones should be corrected when the patient is dose ro fracrures by 6 months (503). Generally, 30% of bone mass must
maturity. be absent before osteoporosis is detected on radiographs (511).
Serum calcium, phosphorus, and alkaline phosphatase levels are
usually normal (509). Low plasma calcirriol, a vitamin 0 metab-
Idiopathic Osteoporosis
olite that aids calcium absorption in the gut, has been observed
Osteoporosis in a child generally is associated with either con- in juvenile osteoporosis (512).
genital disease such as osteogenesis imperfecta or metabolic dis- Radiographs of the spine show decreased density in rhe cen-
orders such as Cushing's syndrome. Rarely, children develop tral areas of the vertebral bodies, and dari ty of the dense vertebral
idiopathic osteoporosis with pathologic fractures (Fig. 6-51). end plates is increased. The long bones lose trabecular anatomy
Idiopathic osteoporosis is chatacteristically seen 2 years before and show thinning of the cortex (509,514). Once symptOms
puberty, but age at presentation may tange from 4 ro 16 years begin, a mildly lucent area of newly formed bone, a so-called
(515). Unique metaphyseal impaction fractures are a hallmark neo-osseous porosis, is observable in the metaphysis. This is con-
of this disorder (509). Biopsy specimens show a quanrirative sidered weaker than the surrounding bone, which formed before
decrease in the amount of bone that has been linked to borh onset of the disease (515).
increased resorption (510) and primary failure bone formation
(515). Osteoblasts in this disorder seem to function normally
Treatment
when stimulated by oral 1,25-hydroxyvitamin 0 3 (504). Symp-
toms can persist for 1 ro 4 years after diagnosis, with spontaneous Lowet extremity and vertebral ftactures (513) ate common, al-
resolution in most patients after the onset of puberty. The only though fracrures of the proximal humerus, radius, ulna, and ribs
consistent metabolic abnormality is a negative calcium balance are frequent (509). Nonunions of rhe tibia, radius, and ulna
with high rates of fecal excretion of calcium (509). This finding have been reponed (507,509). Spinal cord compression has also
supporrs the hypothesis that idiopathic juvenile osteoporosis re- been reponed with verrebral fractures of OSteoporosis in a child
sults from intestinal malabsorption of calcium (507). (505). Metaphyseal fractures can starr as hairline cracks thar
Although many children present with back pain as the only gradually exrend across the width of the shaft, and with further
complaint, the most severely affected present with generalized collapse in the femoral shaft, the cracks may telescope inro the
skeletal pain (503,506-510,515). Patients have difficulty walk- distal femur, with later distortion of the femoral condyles (509).
ing, and their symproms may be initiated by mild trauma. In a Tibia and femoral shaft fractures may heal with bowing. Long
review of 40 patients with idiopathic osteoporosis, Smith (515) bone shafr Fractures are either transverse or oblique (509), and
216 General Prinicptes

the callus fotmed seems to be normal (509,512). A technetium Hyperparathyroidism

bone scan may be useful in showing healing fractures that are
Primary hyperparathyroidism in childhood results from either
not obvious on plain x-ray studies (512). No clear-cut effective
hyperplasia of the parathyroid gland in very young children or
medical treatment has been found for idiopathic juvenile osteo-
parathyroid adenoma in older children (525). Increased parathy-
porosis (508-510). Many patients have been neated by both
roid hormone increases osteoclastic activity, leading ro general
vitamin 0 and calcium supplements with equivocal benefit, and
demineralization of the skeleton. In severely affected patients,
usually mineralization of the skeleton does not improve until
osteitis fibrosa cystica may develop with fibrous tissue replace-
puberty, when the disease spontaneously resolves.
ment of bone and formation of cysts (531). Hypercalcemia is
Dent and Friedman (507) summarized the treatment of frac-
commOn.
tures in juvenile osteoporosis when they stated that these frac-
A particularly severe form of primary hyperparathyroidism
tures should undergo anatomic reduction with immobilization
seen in infants is congenital primary hyperparathyroidism, which
"as little as practical." They noted both severe deformity of the
results from an autosomal recessive u'ait (529) and is lethal with-
long bones and pseudarthrosis when the fractures could nor be
Oll( parathyroidectomy. These patients present with respiratory
immobilized. The bones usually are so soft that they are thought
difficulty, hypotonia, poor feeding with constipation, and failure
to be unsuitable for the usual forms of fixation, but femoral
to thrive (536). Serum calcium is markedly increased in most
neck fractures in this disorder have been treated with internal
patients, but a gradual rise above normal serum levels may occur
fixation (509).
in some infants with serial measurements (535). Radiographs
reveal demineralization of the skeleton. Marked resorption is
present in the femoral necks and distal tibiae, with decreased
Iatrogenic Osteoporosis trabeculae and poorly defined cortices (529). Periosteal elevation
Osteoporosis of Chemotherapy is common, and when it is severe, the long bones may acrualJy
look cloaked with new bone (Fig. 6-52). Periosteal resorption
Osteoporosis is common in association with chemotherapeutic of the bone of the middle phalanges is believed to be characteris-
agents. Methotrexate, for example, is believed to inhibit os- tic of this disease. Brown tumors are rare in infancy.
teogenesis, causing both delayed union and nonunion of frac- In older children and adolescents, the clinical presentation is
tures (520). The incidence of pathologic fractures after metho- more subtle. Weakness, anorexia, and irritability are present in
trexate use ranges from 19% to 57% (518,520,522). Generalized 50% of patients, and constipation is present in 28% (525). Renal
demineralization of the skeleton is seen with marked tadiolu- calculi also are present in 25% of patients, and polyuria, excessive
cency of the metaphyseal regions of the long bones. Radiographic thirst, bone pain, abdominal distention, pancreatitis, and swelJ-
changes in the metaphysis and epiphysis resemble those seen in ing of the knees are occasionally present (524,525,528). Approx-
scurvy (520). Minimally displaced transverse fractures occur in imately 50% of older patients have osteopenia and other osseous
the long bones of both the upper and lower extremities, and the signs of hyperparathyroidism (525). The serum calcium is only
small bones of the feet (520,522). Schwartz and Leonidas (521) moderately elevated in many patients, but 24-hour urine calcium
caution that stress fractures of the long bones that can occur excretion is abnormally high (525,534). If the diagnosis is uncer-
after methotrexate therapy can be mistaken for recurrence of tain, selective venous catheterization for parathyroid hormone
leukemia. If feasible from an oncologic viewpoint, methotrexate can be done, localizing the gland by either ultrasound, CT scan,
should be discontinued ro aIlow these fractures to heal in a cast. or MRJ (526).
The cast immobilization itself may result in additional osreope-
nia and fractures even though methotrexate is discontinued Treatment
(521). Persistent non unions require open reduction and internal
Pathologic fractures of the long bones are common in patients
fixation with bone grafr (522). Patients with severe osteoporosis
with hyperparathyroidism (523,534), especially in infancy. Ver-
and bone pain without fracture also respond to a hair in metho-
tebral fractures, which occur in 4.4% of adult patients (527),
trexate therapy (520).
are rare in infancy. Increased levels of parathyroid hormone re-
sults in decreased function and numbers of osteoblasts, and
hence delayed union of pathologic fractures (533), bur this prob-
Immobilization Osteoporosis lem has only been reponed in adults; healing occurred after
Immobilization of an extremity for fracrure treatment can result parathyroidecromy (532).
in loss of as much as a 44% of mineralization of trabecular bone. Most fracrures are successfully treated with simple immobili-
In some patients, osteoporosis may persist for 6 months after zation. Occasionally, a fracture through a cyst requires curettage
injury (516). Immobilization leads to bone resorption, especially and bone grafting after a period of initial healing (537). Partial
in unstressed areas (517). In one study (516), bone density of or total parathyroidectomy is the primary treatment for hyper-
pararhyroidism (526,530). Solitary bone cysts often heal after
the distal radius returned to normal in all patients at I-year fol-
parathyroidecromy.
low-up. Nilsson and Wesdin (519) found a residual decrease in
bone mineralization of the distal femur of7% at nearly 11 years
of follow-up in a study of 30 patients. It is likely thar persistent
Cushing's Syndrome
osteoporosis after cast immobilization for fracture can contribute Cushing's syndrome results from excessive production of cortisol
ro refracture. and its related compounds. If the hyperactivity of the adrenal
 Chapter 6: PathoLogic Fractures 217

A B
FIGURE 6-52. A: Newborn with hyperparathyroidism. There is marked demineralization of bone, and
marked resorption is present in the proximal femora (arrows). B: Periosteal elevation is present along
the ulna (arrows). (Courtesy of Bruce Mewborne, M.D., San Antonio, Texas.)

conex is due to pituitaly gland stimulation, the syndrome is Treatment

most precisely known as Cushing's disease (541). In children,
The primary rreatmem of Cushing's syndrome of childhood is
hyperconisolism is most often caused by carcinoma, adenoma,
total adrenalectomy (548). The associated fractures usually can
hyperplasia of the adrenal cortex (540,543,547), Ewing's sar-
be treated with standard immobilization techniques, but care
coma (549), or exogenous conicosteroid therapy (538,550,551).
should be taken not to increase the extent of osteopenia through
The elevated adrenal corticosteroids inhibit the formation of
excessive immobilization. In patients on corticosteroid therapy,
osteoblasts (544), resulting in increased resorption of the bone
the dose should be reduced, convened to an alternate-day sched-
matrix and decreased bone formation (546).
ule, or discontinued, if possible (538,549-551).
Tn infancy, carcinoma and adenoma are the primary causes
of Cushing's syndrome; the remaining cases are secondary to
hyperplasia of the adtenal cortex (543). Presenting symptoms Scurvy
include failure to thrive, shon stature with excessive weight gain,
moon facies, presence of a buffalo hump, hirsutism, weakness, The rariry of scurvy makes its diagnosis difficult. In children,
and hypertension (543,547). Cutaneous srriae are rare, and the scurvy may follow 6 to 12 months of a vitamin C-deficient
genitalia are of normal size. Mortaliry is well over 50% (547). In dier (556). Because vitamin C is essenrial for normal collagen
older children, the clinical picture is somewhat different: truncal formation, deficiency of the vitamin results in defective os-
obesiry, short stature, a lowered hairline, acne, weakness, emo- teogenesis, vascular breakdown, delayed healing, and wound de-
tionallabiliry, hirsutism, cutaneous striae, hypenension, and ec- hiscence (553). With abnormal crosslinking, the defective colla-
chymosis (538). Patienrs with Cushing's syndrome due to adre- gen formed inhibits formation of osteoid matrix. Meanwhile, the
noconical neoplasm may have a paJpable abdominal mass at an chondroid tissue continues to be mineralized and can become
average age of approximately 5 years (540). Diagnosis usually is completely calcified (559). Increased resorption and decreased
made by elevation of plasma 17 hydroxy steroids or increased formation of bone lead to generalized skeletal demineralization.
24-hour urinary excretion of 17-keto steroids (543). Cushing's The ends of the long bones resorb, leaving only a cuff of thick-
syndrome also has been associated with hemihypertrophy (539). ened periosteum to stabilize the epiphysis (552). Although
Corticosteroid therapy in children, both oral and inhaled (538, scurvy is often due to a dietary defIciency of vitamin C (553,559,
550,551), can also cause Cushing's syndrome, as well as the 560), both aspirin and phenytoin are associated with decreased
development of cataracts, ulcers, pancreatitis, myopathy, and plasma levels of ascorbic acid. Vitamin C deficiency also is pres-
hepatomegaly (542). ent in patients with myelomeningocele (558), although its con-
Radiographic findings may include severe osteopenia and a tributions to fracture in that population is unclear.
retarded bone age (543). Fractures of the ribs, vertebrae, and Infants with scurvy present wirh irrirabiliry, renderness of
long bones have been reported in child.ren with Cushing's syn- the lower extremities, wealrness, pseudoparalysis, and possibly
drome (545,548). bleeding gums (if teeth have erupted). Subperiosreal hemor-
 218 Genera! PrinicpJes

rhages may exist as well as hemorrhage into the subcutaneous ground-glass appearance and extreme thinning of rhe cortex.
tissues, muscles, urinary system, and gastrointestinal rract (555). Calcium accumulates in rhe zone of provisional calcification ad-
Anemia also is a common finding. In older children, tenderness jacent to the physis and becomes densely white (Frankel's line).
and swelling of the extremities are the most common findings. Fractures generally occur in the scurvy line (Trummerfeld zo-
Fever was noted at the time of presentation in 70% of 52 patients ne)-the radiolucent juxtaepiphyseal area above Frankel's line
in one series (557). Therefore, both osteomyelitis and septic where the matrix is not convened to bone. Dense lateral spurs,
arthritis must be initia.lly considered in tne differential diagnosis. known as Pelken's sign, may be seen (553). A characreristic
In developing countties, older children with scmvy presenting finding of scurvy is the corner sign, in which a peripheral me-
with inabiliry to walk may be misdiagnosed as having poliomye- taphyseal defect exists where fibrous tissue replaces absorbed cor-
litis (562). tex and cartilage (552). Cupping of the metaphysis is common
Radiographs show ptofound demineralization. In advanced in both scurvy and rickets; in rickets, the metaphysis is ragged,
disease, the long bones become almost transparent with a whereas in scurvy, the metaphysis is sharply outlined (553). The

A B

FIGURE 6-53. Scurvy. A: A 10-month-old boy presented with a 2-

week history of refusal to walk with tenderness of the lower extremi-
ties. He had a history of milk and cereal intake only. There are signs
of scurvy in the metaphysis (large arrow). The dense white line in the
zone of the provisional calcification of the distal femur is known as
Frankel's line. The radiolucent juxtaepiphyseal line above the white
line is known as the scurvy line. The peripheral metaphyseal defect,
where fibrous tissue replaces absorbed cortex in cartilage, is known
as the corner sign. Wimberger's sign is a thin, dense line surrounding
the epiphysis (small arrow). B: This is a child with healing scurvy. There
is marked periosteal calcification around the distal tibia (arrows). C:
A newborn with scurvy. Periosteal hemorrhage has become calcified
in the bones of the lower extremity (arrows). (Courtesy of Bruce
c Mewborne, M.D., San Antonio, Texas.)
 Chapter 6: Pathologic Fractures 219

epiphysis becomes ringed with a thin, dense line (Wimberger's syndrome. Cordano er al. (567) noted prompt healing of a distal
sign). The periosteal elevation caused by hemorrhage calcifies femoral fracture in an infant, but the fracture recurred before
within 10 days of treatmenc with vitamin C (Fig. 6-53). treatment of the copper deficiency. Such injuries could be treated
like those in scurvy, with simple immobilization and concurrent
correction of rhe copper deficiency.
Treatment
Fractures and epiphyseal displacemenr occur in both infancs and
older children with scurvy (552,556,557,563,564). The most FRACTURES IN NEUROMUSCULAR
common sites of fracture, in otder of frequency, are the distal DISEASE
femur, proximal humerus, cosrochondral junction of the ribs,
and distal tibia (553). Fractures of the long bones generally are
Cerebral Palsy
nondisplaced metaphyseal buckle fractures with mild angula- Fractllres of the extremities in parients with severe cerebral palsy
tion. In conrrast, marked epiphyseal displacement occurs with are relatively rare, but their treatment can prove challenging. In
a moderate amount of callus presenc even in umreated patients. a review of 1,232 institutionalized patients with cerebral palsy,
Exuberanc callus forms once vitamin C is administered. Standard McIvor and Samilson (575) documented 134 extremity frac-
immobilization, with administration of vitamin C, is adequate cures, primarily in quadriplegics. When the mechanism of injUlY
for most fractures. Remodeling potenrial is high in these patients was known, most of these fractures were the consequence of a
(563). Even healed fractures that appear ro have undergone faJI, often associated with seizure activity. Approximately 46%
growth arrest should JUSt be observed, because the potential for of these fractures involved the femoral shaft, 6% were fractures
continued growth with medical treatment of the vitamin C defi- of the head or neck of the femur, 15% involved the tibia and
ciency can be nearly normal (565). For infants who are older fibula, and 13% were humeral fractures. These authors believed
than 12 months of age and have begun weight bearing, spine that contracture or paralytic dislocation of the hip joint predis-
films are recommended co rule out vertebral fractures (556). posed these parients co femoral fractures (Fig. 6-54).
The literature of fracture trearmenr in scurvy consists primar- Miller and Glazer (578) emphasized that spontaneous frac-
ily of case teports. Hoeffel et al. (554) reponed on a 14-monch- tures can occur in patienrs wirh cerebral palsy without episodes
old girl with scurvy with bilateral distal femoral epiphysis dis- of trauma, and factOrs such as disuse atrophy, nutritional defi-
placement. This condition resolved after treatment with vitamin ciencies, and preexisting joint contractures contributed ro these
C, but limb-length discrepancy developed on one side (561). In injuries. Nearly 50% of the full-time bedridden patients they
two patients with distal femoral fractures, healing went on co studied developed spontaneous fractures. The diagnosis usually
cupping of the metaphysis with an appearance similar to that was delayed because the patients were noncommunicative. Anti-
in central growth arrest (557,564). convulsant therapy may contribute to osteoporosis in patienrs
with multiple fractures-low levels of serum vitamin 0 were
seen in 42% of patients in one series (573). Fractures through
Copper Deficiency and Scurvy-like osteoporotic bone can occur both above and below fixation de-
Syndrome vices.
Copper is a vital trace element needed in the production of Although long bone fractures in patients with cerebral palsy
collagen. Copper deficiency results in a decreased number of heal quickly with abundant callus (578), their treatment through
collagen crosslinks, with adverse effects on both bone and blood either dosed or open methods can be quite difficult. In a large
vessels (568). Copper deficiency can occur by 3 months in low- series of patients, McIvor and Samilson (575) recommended
birth-weight infants (569) and after prolonged total parenteral closed treatment through skeletal traction, hip spica cast, or
nutrition. Copper deficiency can also develop as a result of exces- long-leg cast. Approximately 65% of rhe femoral shafr fractures
sive supplemental zinc ingestion (566). and 86% of distal femoral fractures went on co malunion. De-
Infants at risk for this syndrome are those who are primarily spite malunion, most patients regained their prefracture func-
milk fed and are on semistarvation diets with concurrenr vomit- tion. Nearly 21 % of their patients had refractures, and the au-
ing and diarrhea (567). Both rib and wrist enlargemenr are fre- thors believed thar this was due to disuse osteopenia, inadequate
quent, (568) and neutropenia is common (569). The diagnosis reduction, or joint conrracrures. Closed treatment of these frac-
is commonly based on clinical presentation and decreased levels rures can be complicated by the developmenr of decubitus ulcers.
of serum copper. Closed fractures, especially those of the femur, can become open
Radiographic findings in copper deficiency syndrome are very injuries during treatment owing to spasricity or inadequate im-
similar to those in rickets, including metaphyseal cupping, flar- mobilizarion (575,578). Hip spica casts are difficult to use in
ing, demineralization of the skeleton, and subperiosteal elevation patients with severe flexion contractures or dislocation of the
with calcification (501). There are some tadiographic differences hip. The healing time of femoral fractures treated through im-
between scurvy and copper deficiency syndrome (568). The cor- mobilization varies from 1 co 3.5 months (575,578). Fractures
ner sign is frequently absent in copper deficiency, the metaphy- of the humerus have been treated with light hanging-arm casts
seal spurs are not strictly lateral but sickle shaped, and radiolu- or sling-and-swath bandages (578). Hip nails with side plates,
cent bands of the metaphysis are absent. Bone age also is compression plates, and intramedullary fixation also have been
frequently retarded. used for femoral shaft fractures in patients with cerebral palsy.
Pathologic fractures have been reponed in copper deficiency The mean healing time has been 5.3 monrhs (575).
220 Genera! Prinicp!es

A B
FIGURE 6-54. A: This 11-year-old boy with quadriplegic cerebral palsy had a varus derotatior osteotomy
followed by spica casting. Two weeks after cast removal, he sustained this distal femoral fracture during
physical therapy. An AP radiograph of the right knee and (B) a lateral radiograph of the right knee
show a distal femoral metaphyseal fracture in a location typical for insufficiency fractures in children
with neuromuscular disease. The fracture was minimally displaced and was treated with closed reduction
and a carefully applied, well-padded spica cast. Note the osteopenia and the typical changes around
the knee associated with long-standing knee flexion contracture.

Numerous repons note success in treating fractures of neuro-

logically impaired children wirh imernaJ or external flxarion
(570,571). Heinrich et al. (571) treared four femoral fraccures
in young patients wirh cerebral palsy with flexible intramedullary
nails wirh good outcomes. Femoral neck fracrures may require in
situ pinning, bur observation may be adequate in asympcomatic
bedridden patienes. Although he advocared open fixarion of
some lower extremiry fraccures in parienes with meneal retarda-
tion, Sherk (580) caurioned rhar some patients may have inade-
quare morivarion co resume ambularion even with successful
healing of rheir injuries. Medical managemem of rhese patients
must also be emphasized. In parienes with cerebral palsy and
multiple fracrures, Lee and Lyne (573) recommended metabolic
supplememation, aJong with tradirional fracrure care.
r ractures of the distaJ pole of the patella have been reponed
in children wirh cerebraJ palsy due ro spasriciry of rhe extensor
mechanism of the knee in the presence of established knee flex-
ion coneracrure (572,574,579). Lloyd-Roberts et al. (574) re-
poned on eight patienes with this injury who preseneed with
deterioration in walking and decreased endurance. AJI had knee
flexion coneracrures. Seven of the eight patienes complained of
pain and local tenderness ar the distal pole of the patella. In a
series of 88 patienes, fragmenration was seen in only 8% (579).
Patella alta and elongation of the patella are frequem in affected
FIGURE 6-55. A 1O-year-old girl with cerebral palsy had a healing stress
patients (Fig. 6-55) (572,579). Children predisposed co distal fracture of an elongated patella (arrow). Patella alta is also present.
pole patellar fractures are spastic ambulacors with flexion con- The injury responded to conservative treatment.
 Chapter 6: Pathologic Fractures 221

tractures of the knees, patella aha, and a history of falls (572). Myelomeningocele
Extension casting may be helpful in symptomatic patients (579).
Insufficiency Fractures
If conservative treatment is unsatisfactory, then hamstring
lengthening with correction of the knee flexion contracture can Children with myelomeningocele sustain fractures of the lower
result in both healing of the fracture and relief of symptoms extremities through bone weakened by either disuse or immobi-
(574,579). Some authors (572,574) also have excised the avulsed lization after reconstructive sutgical procedures. The incidence
distal pole of the patella to relieve chronic symptoms. of fractures in several series of patients with myelomeningocele
ranges from 12% co 31 % (586,588,592,594,592,603). The lo-
cations of these fractures, in order of decreasing frequency, are
mid-shaft of the femur, distal femur, mid-shaft of the tibia,
~ AUTHORS' PREFERRED METHOD proximal femur, femoral neck, distal femoral physis, and proxi-
,~ OF TREATMENT mal tibia (586). Fractures of the distal tibia also have been re-
poned in numerous series (590,594,595,602,603). Both me-
The goal of fracture treatment in cerebral palsy is to restore the taphyseal and diaphyseal fractures, usually resulting from minor
child to his or her prefracture level of function. If the patient trauma, are often either incomplete or impacted with intact peri-
is ambulatory, conventional forms of fracture treatment should osteum (597). They tend ro heal rapidly-nonunion is rare
be used. In nonambulatory children with cerebral palsy, a goal (586). Physeal fractures, however, may take 3 to 33 months to
of fracture care should be to preserve the ability to transfer. heal (603).
Special precaurions should be used in closed treatment of frac- Numerous factors predispose these patients ro fracture. Chil-
tures in these patients. The patients' spasticity and inability to dren with flail limbs tend to pick up one leg and drop it our of
communicate mal<e them prone to skin problems, so casts should the way when they roll over in bed or twist around while in a
be properly applied and well padded, usually with felt and poly- sitting position, and this may be enough force to cause a fracture
urethane foam. Extra padding should be placed over the patella, (594). Because protective sensation is absent, the child can nei-
anterior ankle, and heel, and a snug cast mold should be placed rher anticipate impending injUlY nor be aware of injury once it
above the calcaneus to prevent proximal migration of the heel has occurred. The level of neurologic involvement also affects
(Fig. 6-56). When indicated, operative fracture fixation should the incidence of fractures. In a series of 76 fractures, Lock and
be used in ambulatory patients. Elastic intramedullary nails can Aronson (597) found that 41 % occurred with neurologic deficit
be a very effective way ro treat femoral fractures in children with at the thoracic level, 36% occurred with deficit at the upper
spasticiry (Fig. 6-57). lumbar level, and only 13% occurred in patients with lower
Prevention should be an imporrant parr of managing fractures lumbar or sacral deficits. Nearly 86% of these fractures occurred
in children with cerebral palsy. Traditionally, long-leg casts or before 9 years of age, and 76% were associated with cast immobi-
lization. Most fractures after immobilization occur within 4
spica casts were used after multiple muscle lengthenings or hip
weeks of caSt removal (588), and in one series (597), 30% of
osteotomies, then after several weeks, the cast was removed and
patients with casts had multiple cluster fraerures of either the
therapy begun. After cast treatment, however, the osteopenia
casted extremity or the partially casted contralateral extremity.
was worse, the joints were stiff, and fractures-especially in the
In addition to the inhetent disuse osteoporosis from immobiliza-
distal femoral metaphysis-occurred during therapy or transfers.
tion, casting causes stiffness ofjoints, with concentration offorce
We and others (576,577) use foam abduction pillows and knee
on the osteoporotic bone adjacent to the joints (597). Boytim
immobilizers and an intensive therapy program in the immediate
et al. (583) reponed neonatal fractures in 6 infants with myelo-
postoperative period to avoid the deconditioning, osteopenia,
meningocele and concluded that the risk of fracture was 17%
and joint stiffness that develop aftet prolonged cast immobiliza-
for patients with thoracic or high lumbar level deficits with sig-
tion. In ambulatory children who need hip osteotomies, use of
nificant contracture of the lower extremities. The authors cau-
rigid internal fixation allows standing and gait uaining within tioned that particular care must be used to avoid fractures in
2 weeks, preventing not only osteopenia but also the risk that these patients during physical therapy, x-ray positioning, or sur-
the child may never regain the full level of preoperative function gical procedures.
after a prolonged period of caSt immobilization. Stable fracrures of the long bones may not require complete
In nonambulatory children with severe cerebral palsy, some immobilization (588). Femoral shaft fractures have been treated
degree of both malunion and shortening may be accepted. Well- with padding and sandbags (591). Skin traction of anesthetic
padded splints or castS are adequate treatment for many dis- limbs may cause massive skin necrosis (586,591). Skeletal rrac-
placed fractures. Acute femoral shaft fractures can be treated tion usually is inadvisable because of problems with decubitus
with a heavily padded hip spica cast and distal fractures of the ulcers and poor fixation in atrophic bone (586,591). However,
femur by a long-leg cast. Distal femoral buckle fractures in non- Drummond et at. (588) rreated 9 of 18 patients with skeletal
ambulatolY children are safely treated with a knee immobilizer. traction without mention of failure or fixation.
If a long-leg cast is used for a fracture of the lower extremity Preventive measures include limiting CaSt immobilization
and the joint of the involved side is dislocated, the rigid cast after reconstructive surgelY (587,588). Solid side cushions may
may function as a lever arm, with the posterior fracture of the prevent fractutes that occur when patients catch their lower ex-
proximal femur beyond rhe casr. tremities in bed rails (600). The most important consideration
 222 General Prinicples

A B

FIGURE 6-56. Casting in neuromuscular fractures. A: A poly-

urethane foam short-leg cast is being placed on a patient. Two
long rectangular sheets of foam (arrows) are placed anteriorly
and posteriorly over the stockinette. and Webril padding is
wrapped around the foam. B: A long toe plate is needed to
prevent injury to the foot of the patient. C: A thick, protective
cuff of foam is formed by folding the polyurethane toward
the center of the cast with the stockinette (arrow). D: The We-
bril must be wrapped quite snugly to compress the foam
against the underlying extremity evenly (black arrow). Extra
foam is placed over the anterior ankle and over the Achilles
tendon to prevent proximal migration of the foot in the cast.
A plaster cast is usually applied and covered with a layer of
fiberglass for strength. A lateral x-ray verifies the position of
C,D the heel in the cast (white arrow).
 Chapter 6: Pathologic Fractures 223

A.,S

FIGURE 6-57. A: This 6-year-old boy sustained a severe closed head

injury and left femur fracture when he was struck by a car. His femur
was shortened 4.cm. His involuntary movements made management in
traction very difficult. He was treated with retrograde titanium elastic
nailing. B: At 13 days, early callus is seen. He was standing with a brace.
C: At 3 months, AP and (0) lateral radiographs show a healed femur
fracture in anatomic alignment. Nails were removed 6 months later.
(From Flynn JM: Current treatment options for pediatric femur fractures.
CD U Penn Orthop J 1998; 11: 27-35; with permission.)
224 Genet/I! Prinicples

was noted by Norton and Foley (599) in 1959, wben rhey stated
"the quality of bone developed by activity appears CO be the best
protection against pathologic fractures," and the orthopaedist
should assist these patients in maintaining the highest activity
level possible.

Physeal Fractures
Fractures of the physes in patients with myelomeningocele are
relatively uncommon, bur for the unwary, the diagnosis can be
difficult. The clinical presentation may mimic infection, with
elevated temperature and swelling, redness, and local warmth at
the fracture site (601,602). Fractures of the proximal tibia may
be confused with septic arthritis of the knee, with swelling up
to the mid-thigh and limited knee nexion. Both the white blood
cell count and erythrocyte sedimentation rate are often elevated.
Immobilization of these injuties usually results in a dramatic
decrease in swelling and redness of the extremity within 2 co 3
days of casting. With healing, the x-ray picture can be alarming,
with epiphyseal plate widening, metaphyseal fracture, and peri-
osteal elevation (593). The radiographic differential diagnosis
should include osteomyelitis, sarcoma, leukemia, and Charcot's
joinc (601-603).
Recurrent trauma to the physis, from either continued walk-
ing or passive joint motion after injury, results in an exuberant
healing reaction (Fig. 6-58) (590). Repetitive trauma delays re-
sumption of normal endochondral ossification, resulting in ab-
normal thickening of the cartilage in the zone of hypertrophy
and the physeal widening seen on radiographs (Fig. 6-59) (603).
In a study of 19 chronic physeal fractures, Rodgers et a1. (601)
compared MRI with histology and found that adjacent to this
thickened, disorganized zone of hypertrophy is juxtametaphyseal
f1brovascular tissue that enhances gadolinium on MRI. Delayed
union is common, and premature growth arrest occurs in 29%
A,
co 55% of paticnts (597,603). Anschuetz et al. (582) reported
a unique syndrome in three patients with myelomeningocele FIGURE 6·58. A: This 7-year-old boy with spina bifida presented with
a increasing swelling of the distal tibia. This lateral radiograph of the
and fracrure. These children sustained fractures of the lower entire tibia shows slight widening of the distal tibial physis with subtle
extremities during long-term immobilization and with cast re- signs of posterior displacement of the distal tibial physis. There was a
high suspicion of a fracture, so the leg was treated with a well-padded
moval went on co dramatic cardiopulmonary distress with in- cast. B: This lateral radiograph, taken 2 months later, shows slight phy-
creased pulse rate, hypotension, and increased respitatory rate. seal widening with extraordinary periosteal new bone formation.
Fever also developed with decreased hematocrit levels. They sug-
gestcd that the etiology of this problem was loss of intravascular
volume imo the fracture sites and recommended intravenous
replacement ofAuid losses, along with careful splinting of associ- Cast Technique
ated fractures. Immediate cas(ing (588) and bivalved casting (591) have been
Physeal injuries in patients with myelomeningocele are more used for long-bone frac(Ures in children wi(h myelomeningocele.
difficulr to treat than metaphyseal or diaphyseal long bone frac- A bilateral hip spica cast is suggested for supracondylar fracrures
tures and require lengthy immobilization with strict avoidance of (he femur, because use of a one-and-a-half hip spica cast may
of weight bearing to avoid destructive repetitive trauma to the predispose (he uninjured side ro fracture (586). A bulky Webril
physis (590). Either a plaster cast or a snug-firring total-concact dressing approximately 1.5 cm thick wrapped with an elas(ic
orthosis is suggested for immobilization, and union can be deter- bandage can be used instead of a plas(er or fiberglass cast. Lock
mined by return of the physis to normal width on x-ray study and Aronson (597) used Webril immobilization for an average
(603). Kumar et al. (595) emphasized that applicarion of a long- of I co 3 weeks in (heir patients with fractures and discominued
leg cast for 8 ro 12 weeks is necess<Uy to obtain satisfacrory immobilization when callus was visible. They found similar ou(-
healing of physeal. fractures of the tibia, and weight bearing is comes in patiems (feared wi(h Webril dressings and those created
to be avoided uncil union occurs. wich casts; however, there was much less difficulty wirh pressure
 Chaptel' 6: Pathologic Fractures 225

FIGURE 6-59. This 11-year-old boy with L4 myelomeningocele presented with a warm, swollen right
ankle and no clear history of trauma. This AP radiograph of both ankles shows right distal tibial physeal
widening with adjacent sclerosis, consistent with a chronic physeal injury. The child was treated in a
well-padded, non-weight-bearing short-leg cast. He had complete resolution of symptoms when the
cast was removed 6 weeks later.

sores in the group treated with Webril dressings. Kumar et aJ. et al. (603) reported that most patients with proximal femoral
(595) used a polyurethane padded long-leg posterior plaster epiphyseal displacement can be treated with hip spica casts. Re-
splint for metaphyseal and diaphyseal fractures for 3 weeks, fol- duction and pinning with subtrochanteric osteotomy may be
lowed by bracing. necessary in certain patients. Bailey-Dubow rods may be valuable
Drennan and Freehafer (586) recommend a well-padded cast in multiple recurrent pathologic fractures of the femoral or tibial
for 2 to 3 weeks for infants with fracture and braces or Webril shaft (5%). If operative treatment is necessary, it should be noted
immobilization for incomplete fractures that followed surgery. that the incidence of malignant hyperthermia seems to be higher
Injuries with deformiry were placed in a cast. Mobilization was in patients with myelomeningocele than in other children (581).
begun as soon as practical to prevent further osteopenia-pa-
tients with shaft fractures began ambulation 2 weeks after injUlY.
Shortening was not a problem in their series. Lock and Aronson Latex Allergy
(597) cautioned that brace treatment of acute fractures may
cause pressure sores. Drummond el al. (588) reponed on 18 Life-threatening anaphylactic reactions due to latex allergy in
fractures treated by closed techniques that resulted in three mal- children with myelomeningocele have been reported with in-
unions, two shortenings, and twO episodes of pressure sores; one creasing frequency (584,597). Minor allergic reactions, such as
patient had four refracrures. Drabu and Walker (585) nOled a rash, edema, hives, and respiratory symptoms are common when
mean loss of knee movement of 58 degrees in 67% of fractures children with myelodysplasia are exposed to latex products such
about the knee. The stiffness began 2 months after fracture and as gloves, cathetets, and balloons. Between 18% and 40% of
was well established by 6 months but resolved almost completely children with myelodysplasia are allergic to latex (589). Meero-
in all patients 3 years after injUlY. They suggested that aggressive pol et al. (598) emphasized that evelY child with myelomeningo-
physical therapy to restore knee motion is probably not necessary cele should be screened for latex allergy, and those with a positive
in these injuries. history should be evaluated individually by the anesthesiologist
for preoperative prophylaxis. Current preoperative prophylaxis
begins 24 hours before surgery and is continued for 24 hours

a OPERATIVE TREATMENT
after surgery. Medications used include diphenhydramine, I mg/
kg every 6 hours (maximum 50 mg); methylprednisolone, I mg/
kg every 6 hours (maximum 125 mg); and cimetidine, 5 mg/
Operative fixation of fractures in children with myelomeningo- kg every 6 hours (maximum 300 mg). A latex-free environment
cele is associated with a high rate of infection (591). Wenger must also be provided rhroughour the hospitalization.
 226 Genera! Prinicp!es

~ AUTHORS' PREFERRED METHOD Muscular Dystrophy

,~ OF TREATMENT Fractures of the lowet extremity in children with Duchenne
muscular dystrophy must be managed so as not to cause prema-
In nonambulatory patients, mild malunion and shortening can
ture loss of the ability to walk (609) or transfer (606). In patients
be tolerated, and stable or minimally angulated fractures can
9 to 10 years old, increasing muscle weakness and joint con-
be treated with either polyurethane splints or Webril dressings.
tractures contribute to falls, and a loss of normal muscle bulk
Fractures with significant deformity may require reduction and
and fat limit the cushioning on impact (608). Patients in lower
immobilization in a cast heavily padded with polyurerhane foam.
extremity braces seem to sustain few fractures in falls (609),
In children who walk, fractures should be carefully aligned with probably because the overlying orthoses provide some protection
heavily padded casts that allow continued protective weight bear- (608). Patients confined to a wheelchair can fall because they
ing, if possible. Hip spica caStS may be necessary for femoral have poor sitting balance, and fractures are frequent because
shaft fractures. Fractures of the proximal femur should be n·eated these patients are more osteoporotic than ambularory individuals
by immobilization and any later deformity corrected byosteot- (608).
omy. Any patient considered for operative intervention should Concentric "osseous arrophy" occurs in the long bones of
be screened for latex allergy, and if needed, given appropriate patients with Duchenne muscular dystrophy; osteoporosis is also
prophylaxis. Physeal fractures are treated with padded long-leg common (604,607). Fractures are seldom displaced and are fre-
cam and non-weight bearing. Long-term follow-up is encour- quently minimally painful because there is minimal muscle
aged for physeal injuries because of the risk of growth arrest. spasm (608). Fractures tend to heal rapidly. The most commonly
Significant discrepancies can be addressed through conrralateral fractured bone is the femur (Fig. 6-60) (605,606,608), followed
epiphysiodesis or bridge resection. by the proximal humerus (608).

FIGURE 6-60. A: This 14-year-old nonambulatory boy with Du-

chenne muscular dystrophy crashed his wheelchair into the bumper
of a stationary car, sustaining a displaced subcapital femoral frac-
ture. This AP pelvis radiograph at the time of injury shows a dis-
placed fracture and marked osteopenia of the pelvis and proximal
femur. B: The fracture was treated by reduction and internal fixa-
B tion with two cannulated screws.
 Chapter 6: Pathologic Fractures 227

There are rwo goals offracture care in children wirh muscular with slipped capital femoral epiphysis was treated successfully
dystrophy: limb stability and maintenance of maximal function with pinning in situ.
during fracture healing. In ambulatory patients, trearment meth-
ods should allow children to maintain the ability ro walk as rhe
fracture heals. When ambularory ability is tenuous, even minor
~ AUTHORS' PREFERRED METHOD
bruises or ankle sprains (609) may end walking ability. As little
,~ OF TREATMENT
as 1 week in a wheelchair can prematurely end ambulation (609);
patients at bed rest for more than 2 weeks will likely lose the
The first goal of fracture treatment in children with muscular
ability to ambulate (606). Hsu (605) reported that 25% of am-
dystrophy is to avoid making matterS worse. The patient should
bularory patients with muscular dystrophy lost the ability to
be mobilized as soon as possible in a lighrweight cast or orthosis.
walk after sustaining fractures. 1n one of these patienrs, the ankle
Aggressive physical thetapy should be used to maintain func-
was casted in 20 degrees of plantar flexion, and the resulting
tional starus. In a very young child, mid-shaft femoral fractures
contracrure prevented ambulation at the end of treatmenL
can be treated by traerion and hip spica techniques, but in an
Treatment of specific fractures should be individualized.
older patient, ambularory caSt bracing might be a better choice.
Upper extremity fraerures can be treated with Iighrweight slings
(608). Lower extremity fractures can be treated with eirher light
walking casts or long-leg double upright braces (608,609).
Arthrogryposis and Poliomyelitis
Splints also can be used until the patients are pain free. Routine
activities are begun as soon as possible (605). Protected standing Arthrogryposis is a rare disorder with an incidence of3 in 10,000
and ambulation with physical therapy are crucial in maintaining live births (614). In this disease, muscle fiber is lost in utero,
independent ambulation (609). joint motion is limited during development, and taut ligaments
Hsu and Garcia-Ariz (606) reported on 20 femoral fractures and capsular tightness result in joint stiffness. Dislocations can
in 16 patients with muscular dystrophy. Six of the seven ambula- occur with severe shortening of the involved muscles. Fractures
tory patients were able to walk after treatmenL In the nonambu- may occur in 25% of infants with arthrogryposis multiplex con-
latory patients in this series, most had supracondylar femoral genita (610). Both difftcult delivery and forceful manipulation
fractures (Fig. 6-61), which were splinted for 2 to 3 weeks, with of the extremities in these children can lead to fracture (610).
emphasis on physical therapy to maimain functional abilities. Diamond and Alegado (610) reported on 16 fractures in 9 in-
Although union was achieved rapidly, hip and knee flexion con- fants with artluoglyposis; an ipsilateral dislocated hip was pres-
tractures often increased in these patients, and up to 20 degtees ent in 35% of patients. Most fracrures involved the femur, with
of angulation of the fracture was routinely accepted. One patient the remainder mostly tibial fractures, one humeral fracture, and
one clavicular fracture. Epiphyseal separations occurred in the
proximal tibia, distal femur, and proximal humerus. Clinical
symptoms included poor feeding, irritability, and fussiness when
handled. The involved extremity was thickened, and there was
often an increased white blood cell count. Plain radiographs after
acute injlllY, especially with epiphyseal separations, were nor
helpful, and arthrography was used in one patient to evaluate a
distal femoral epiphyseal separation. With healing, these frac-
tures develop exuberant callus with rapid union, and ready re-
modeling of angulated mid-shaft fractures.
Short-term immobilization is adequate to treat undispJaced
fractures in tbese patients. Heavy plaster splints are nOt necessary
(612). Some authors (611) recommend closed reduction of
acmely displaced epiphyseal fractures and fractures with rotatory
malalignment. Postnatal fractures are most common in parients
with either knee cOntracture or dislocation of rhe hip, and post-
natal injury could possibly be reduced by avoidance of forceful
manipulation of these extremities. Older patients with lower
extremity conuactures do not seem to have difficulty with patho-
logic fracrures (613).
Acute poliomyelitis has become a relatively rate disease in
most Western countries but occasionally occurs in children who
live in less developed countries. There are few reports in the
literature concerning fractures in patients with poliomyelitis.
Robin (612) reponed 62 fractures in parienrs with poliomyelitis.
FIGURE 6·61. This 13-year-old nonambulatory boy with Duchenne More than half were fractures of the femur, and 90% of rhose
muscular dystrophy sustained this typical impacted, minimally displaced
distal femoral metaphyseal fracture when he fell from his wheelchair. injuries were supracondylar fracrures. More than half of rhe frac-
Note the marked periarticular osteopenia. rures occurred after cast immobilizarion, and joint stiffness also
228 General Prinicples

was associared wirh a significant number of franures. There were ruming to ambularion wirh pwtecrion by walking braces is per-
no epiphyseal injuries in this series. mirred once callus and joinr morion are adequare. Every effort
Treatment of rhese fracrures is simple immobilization. Be- should be made ro resrore rhe child's prefracrure funnion. Mod-
cause mosr fractures have very lirrle displacemenr, reducrion is erare malunion and shonening are acceprable in parienrs who
seldom necessary; if rhere is preexisring deformity, manual os- are nonambularory. Operarive rrearmenr ofsuch fracrures should
teoclasis rhrough rhe fracwre sire can be used ro correcr defol'mi- be reserved for selecred parients whose funcrion would be signifi-
ties. Robin (612) stressed rhat joint mobility must be obtained candy compromised by less rhan anaromic reduction.
before general mobilization of the patient ro reduce the incidence
offracture aFter plaster immobilization. He also emphasized that
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557. McLean S, Mcintosh R. Healing in infantile scurvy as shown by x- ture complications in myelodysplasia.] Pedian' Or/hop 1984;4:22-24.
ray. Am] Dis Child 1928;36:875-930. 583. Boyrim MJ, Davidson RS, Charney E, Melchionni JB. Neonaral frac-
558. McKibbin B, Porter RW. The incidence of vitamin C defldency in rures in myelomeningocele patients.] Pediatr Orthop 1991; 11 :28-30.
meningomyelocele. Dev Med Child Neurol ] 967;9:338-344. 584. DOl'mans JP, Templeton], Schreiner MS, Delflco AJ. Inrraoperative
559. Nerubay J, Pilderwasser D. Spontaneous bilateral disral femoral phys- latex anaphylaxis in children: classification and prophylaxis of patienr
iolysis due to scurvy. Acta Orthop Seand 1984;55: 18-20. ar risk. J Pediatr Othop 1997; 17:622-625.
560. Ossofsky HJ. Infamile scurvy. Am) Dis Child 1965;109:173-176. 585. Drabu KJ, Walker G. Stiffness afrel" fracrures around the knee in spina
561. Quiles M, Sanz TA. Epiphyseal separation in scurv}'.] PcdialT Orthop biflda. J Bone Joint Surg Br 1985:67:266-267.
1')88;8:223-225. 586. Drennan ]C, Freehafer AA. Fracture of rhe lower extremiries in para-
562. Ramar 5, Sivaramakrishnan V, Manoharan K. Scurvy-a forgonen plegic children. Clin Orthop 1971;77:211-217.
disease. Arch Phys Med RehabilI993;74:92-95, 587. Drummond DS, Moreau N, Cruss RL. The results and complications
563. SCO(( W. Epiphyseal dislocarions in scurvy. J Bone Joint Surg Am of surgery for rhe paralytic hip and spine in myelomeningocek. J Bone
1941;23:314-322. Joint Surg Br 1980;62:49-53.
564. Silverman FM. Recovery from epiphyseal invaginarion sequel to an 588. Drummond DS, Moreau N, Cruss RL. Post-operarive neuropathic
unusual complicarion of scurvy. ] Bone Joint Surg Am 1970;52: fracrures in parienrs with myelomenjngocele. Dev Med Child Net/rol
384-390. 1981;23:147-150.
565. Silverman FM. An unusual osseous sequel to infantile scurvy. J Bone 589. FDA AJlergic Reacrions [0 Larex Comaining Medical Devices: FDA
Joint Surg Am 1953;35:215-220. Medical Alert, 1991.
240 General Prinicples

590. Edvardsen P. Physeo-epiphyseal injuries of tbe lower extremities in 605. HSll JD. Exnemiry fracwres in children wirh neuromuscular disease.
myelomeningocele. Acta Orthop Smud 1972;43:550-557. }ohns Hopkins Med j 1979; 145:89-93.
591. Eichenboltz SN. Mal13gemenr of long-bone fractures in paraplegic 606. HSllJ 0, Carda-Ariz M. Fracture of the femur in Duchenne's muscular
patienrs. j Bone joint Surg Am 1963;45:299-310. dyStrophy patient. j Pediat!' Orthap 1981;1:203-207.
592. Feiwell E, Sakai D, I3lart T. The effect of hip reduction on funcrion 607. Maybarduk PK, Levine M. Osseous atrophy associated wirh progres-
in patiems with myelomeningocele. j Bone joint Surg Am 1978; 60: sive muscular dystrophy. Am} Dis Child 1941;61 :565- 576.
169-173. 608. Siegel 1M. Fracrures of long bones in Duchenne's muscular dystrophy.
593. Gyepes MT, Newbern DH, Neuhauser EBD. Metaphyseal and phy- .I Trauma 1977;17:219-222.
seal injuries in children with spina birJda and myelomeningoceles. Am 609. Vignos PJ Jr, Archibald KC. Maintenance of ambulation in childhood
j Romtgf!i1oI1965;95: 168-177. mnscular dysuophy. j Chronic Dis 1960; 12:273-290.
594. James CCM. Fractures of the lower limbs in spina birJda cystica: a
survey of 44 fractures in 122 children. Dev Med Child Neum/1970;
22:88-93. Arthrogryposis and Poliomyelitis
595. Kumar Sj, Cowell HR, Townsend P. Physcal, metaphyseal, and dia-
physeal injuties of the lower exrremiries in children wirh myelomenin- 610. Diamond LS, Alegado R. Petinatal fracrures in arrhrogryposis mulri-
gocele. j Pet/iat!' Orrhop 1984;4:25-27. plex congenita. j Pecliat!' Ol'thap 1981; I: 189-192.
596. Laidl'lw AT, Loder RT, Hen,inget RN. Telescoping intramedullary 6 II. Nenhauser EBD. Arrhrogryposis multiplex congenita: susceptibiliry
rodding wirh Bailey-Dubow nails for recurrent parhologic fractures to injury. Postgrad Med 1969;46:61-63.
in children wiU10ut osteogenesis imperfccta. j Pediiltr Ol'thop 1998; 612. Robin CC Fractures in poliomyelitis in childten.} Bone }oint SlIrg
18:4-8. Am 1966;48: 1048-1054.
597. Lock TR, Aronson DO. Fractures in patients who have myelomenin- 613. Sodergard J, Ryoppy S. The knee in ardHogryposis multiplex con-
gocelc.} Bone joint Surg Am 1989;71:1153-1157. genita. j Pedil/n· Orthap 1990;10:177-182.
598. Meeropol E, Frost j, Pugh L, et al. Latex allergy in children wirh 614. Williams P. The management of arthrogryposis. Orthop Clin North
myelodysplasia: a survey of Shriners Hospitals.} Pediat!' Orrhap 1993; Am 1978;9:67-88.
13:1-4.
599. Norron PL, Foley jj. Paraplegia ill children. j Bone }aint SUl'g Am
1959;41: 1291-1309. Spinal Cord Injury
600. Quili" AN. Fractures in children wirh myelomeningocele: a reporr of 615. Abramson AS. Bone disturbances in injuries to the spinal cord and
15 cases and a review of rhe lirerarure. Acta Orthap Smud 1974;45: calida equina (paraplegia): their prevention by ambularion . .I Bone
883-897. }ohll SUlg Am 1948;30:982-987.
60 I. Rodgers WB, Schwend RM, Jaramillo D, et a1. Chronic physeal frac- 61G. Coman AE, Hurchinson RH, Bors E. Extremity fractures of patients
rures in myelodysplasia: magnctic resomnce analysis, hisrologic de- with spinal cord injuries. Am j SUl'g 1962; 103:732-739.
scriprion, trearmem, and outcome. .I Pee/iilt!' Ol'thop 1997; 17: 617. Drennan je. Freehafer AA. Fractures of the lower extremities in para-
615-621 plegic childten. Clin Orthop 1971;77:211-217.
602. Townsend PF, Cowell HR, SregfNL. Lower exttemity li·;lcwres simu- 618. Eichenholtz SN. Management of long-bone fractures in paraplegic
lating infection of myelomeningocele. Clin Orthop 1979; 144: parients . .! Bone joint SlIl'g Am 196.,;45:299-310.
255-259. 6[9. Freehafer AA, Masr WA. Lower extremiry fractures in patients with
603. Wenget DR, Jeffcoat BT, HerringJA. The guarded prognosis of phy- spinal-cord injury. j Bone joint SlIrg Am 1965;47:683-694.
seal injury in paraplegic children . .I Bone joint SUl'g Am 1980;62: 620. Hulth A, Olerud S. The healing in ftaCUlres in denervated limbs: an
241-246. experimental srudy using sensory and motor rhizotomy and peripheral
denervation. j Trauma 1965;5:571-579.
621. Karz JF. Spontaneous fracrures in paraplegic children. j Bom' }oint
Muscular Dystrophy Surg Am 1953;35:220-226.
G22. Robin CC Fracture in childhood paraplegia. Paraplegia 3: 165-170,
G04. Epstein BS, Abramson JL. Roentgenological changes in the bones in 1965.
cases ofpseudohypenrophic muscular dysrrophy. Arch Neurol f'sychia- 623. Schneider R, Goldman AB, Bohne WHO. Neuropathic injuries ro
ny 1941 ;46:868-876. rhe lower extremities in children. Radiology 1978;128:713-718.
 CHILD ABUSE
ROBERT M. CAMPBELL. JR.

EPIDEMIOLOGY ADDITIONAL IMAGING STUDIES

HISTORICAL OVERVI EW INTERPRETING IMAGING STUDIES J CHILD
ABUSE
THE HOMES AT RISK
The Corner Fracture in Child Abuse
THE CHILDR AT RISK
DATI NG FRACTURES
SEXUAL ABU E
LABORATORY STUDIES AND CONSULTATIO S
08'" AI ING THE HISTORY
The Investigative Interview THE DIFFERENTIAL DlAG osrs
Documentation OSTEOGENESI IMPERFECTA
PHYSI AL EXAMINATlO Temporary Brittle Bone Disease
Neurologic Injuries Sudden Infant Death Syndrome
Soft Tissue Injuries Accidental Trauma
Burns TREATME T AND LEGAL REPORTI G
Abdominal Injuries REQUIREMENTS
Genital Injuries
THE COURTROOM
FRACTURES IN CHILD ABUSE Disposition Following Custody Hearings
Rib FractLIres
Spinal FractLIres PREVENTION F CHILD ABUSE

EPIDEMIOLOGY abuse are impossible to estimare: one third of the victims of

child abuse grow up to be seriously inept, neglectful, or abusive
Child abuse is maltreatment of the child by either parents or parents; one third are at high risk for eventually becoming abu-
caretakers, and includes physical, sexual, and emotional abuse, sive parents; and only one third do not repeat the destructive
as well as emotional and physical neglect. The epidemic of child patterns they were exposed to as children (120). The orthopae-
abuse continues to worsen in the United States, with approxi- dist becomes involved in the care of 30% to 50% of abused
mately 2.9 million reportS now filed annually compared with children (2). Early recognition of these abused patients by rhe
1.2 million in 1982 (151). The incidence of physical abuse na- orthopaedist is critical, because the children who are returned
tionally is estimated to be 4.9 children per thousand, and one to their homes after an unrecognized episode of child abuse have
of every 1,000 abused children die (76). In Texas alone, 50,746 a 25% risk of seriolls reinjury and a 5% risk of death (32).
children were confirmed victims of child abuse or neglect in
fiscal year 1995, wi th 101 deaths recorded (152). The types of
abuse these children were subjected to included physical abuse
in 31.5%, sexual abuse in 15.6%, emotional abuse in 6.8%, HISTORICAL OVERVIEW
abandonment in 2%, medical neglect in 4.7%, physical neglect
in 15.4%, and neglectful supervision in 40.3%. The minimal In 1946, Caffey (28) described six infants with long bone frac-
annual cosr of child abuse in the United States is estimated to tures, chronic subdural hematOmas, and intraocular bleeding
be 9 biilion dollars (15l). The long-term social costs of child wirhout a histoly of trauma to explain the injuries. Although
his work is often cited as the first report in the English lirerature
of child abuse, Caffey did not speculate about the eriology of
Robert M. Campbell, Jr.: The University of Texas Healrh Science Ccnrcr the children's injuries. In 1953, Silverman (139) characterized
ar San Anronio. San Antonio. Texas. the unique metaphyseal fractures found in abused children in
242 Ceneml Principles

the pediacric literature and clearly emphasized that these were way obstrucrion. First-born children (18), premarure infants,
due to nonaccidental trauma. Altman and Smith (8) in 1960 stepchildren, and handicapped children are at a greater risk for
published the first series in the orthopaedic literature of injuries child abuse (2). Benedict et a1. (19), in a longitudinal study of
caused by child abuse. General public awareness of child abuse 500 handicapped children followed from birrh to age 10 years,
increascd with the 1962 publication of a report by Kempe et al. documented a 4.6% incidence of physical abuse. Surprisingly,
(79) characterizing rhe prob'lem as the battered child syndrome. they found that the mosr severely involved children were less
In 1')74, Caffey introduccd the term whiplash-shaken infimt .1)1}l- likely to be abused, whereas the marginally funcrioning children
drol11(, to the literature to emphasize the eriology of subdural were at greater risk, with parental frusrrarion possibly being a
hemaromas in infants caused by shaking episodes (29). In 1974, facror.
Congress acknowledged rhe national importance of rhe preven- Children who are persistently presenreJ by parenrs for medi-
tion of child abuse by the passage of rhe Child Abuse Prevention cal assessmem of vague illness and have a history of multiple
and Tre:ltmen tAct. diagnosric or therapeutic procedures with unclear outcome are
ar risk for having a form ot child abuse known as Munchausen's
syndrome by proxy (14,1 11). Munchausen's syndrome is named
THE HOMES AT RISK for Baron von Munchausen, an 18rh century mercenary whose
exaggerated tales of advenrure were viewed with great suspicion.
In assessing where abuse of children may occur, households in Asher, in 1951, described Munchausen's syndrome in adults
turmoil from marital separation, job loss, divotce, family death, who presented wirh apparent acure illness accompanied by dra-
housing difficulties, or money problems are more likely to have matic, unrruthful medical histories to gain attention (14). In
abusive episodes (49). Families with cwo unplanned births are Munchausen's syndrome by proxy, children become the victims
2.8 times more likely to have an episode of child abuse than of this adulr behavior when parenrs with a misguided sense of
families with no unplanned births (164). In these homes at risk, purpose fabricare a wide range of childhood illnesses for their
stepparents, babysiners, boyfriends, relatives, and even larger children, often subjecting them to needless diagnostic work-ups
siblings frequcntly are abusers (1,69,121). The parents of bat- aJ1d treannenr (111). Symptoms ofrhe child's "illness" are based
tered children Illay themselves have been abused when they were on an imaginary medical histOry given by rhe parenr, with signs
children (63). Parental substance abuse, whether alcohol or other of the illness eirher simulated or induced by the parent. For
drugs, makes child abuse more likely (67). The risk of physical example, a child may be brought into rhe emergency room by
child abuse is fivefold more likely with maternal cocaine use a parent wirh a complaint of vomiting. In MuncllJusen's syn-
(1')8). Young, unmarried mothers are more likely to have their drome by proxy, rhis complaint may eirher be a rotal fabrication
infanrs die from intentional injury, with a peak incidence of by the parent or the parent may simulare the complaint by pro-
10.5 inrentional deaths per I 0,000 live births in one study (J 36). ducing "vomirus" from some source as proof of the illness. In
Violence in the home is not directed solely toward the child; in the most abusive of siruations, the parent induces vomiting in
one study (30) of families with substantiated child abuse, 30% the child by the administrarion of salt (110) or ipecac. Over half
of the morhers had been barrered. Although the youngest, poo- of reponed cases of Munchausen's syndrome by proxy involve
rest, most socially isolated and economically frustrated caretakers induced symptoms, whereas another 25% involve a combi nation
are the most likely to aet violently toward their children (161), of borh simulation and induction of symptoms (21 ).The bio-
any adult from any social or economic level may be guilty of logic mother is almost always rhe perpetrator of this pattern of
abusing a child (1). abuse and often has a medical background: 35% to 45% are
nurses, 5% are medical office workers, 3% are social workers,
and 1% are orderlies (129). Exrreme examples of this syndrome
THE CHILDREN AT RISK include a rodenticide-induced coagulopathy in a cwo-year-old
child (16), a deliberate self-induced pretcrm delivery (62), and
Certain children of all ages are more likely to experience abuse, chronic illicir insul in administration to a I-year-old child by
and younger children are particularly ar risk. Most reponed cases rhe caretaker (Ill). The perperrator of the child's illness denies
of child abuse involve children younger than age 3 years (61). knowledge of its eriology, bur the acute signs and symptoms of
In one repolt (18) of child abuse 78% of all fractures reponed the child's illness in Munchausen's syndrome by proxy will re-
were in children less than 3 years of age and 50% of all fractures solve if the syndrome is recognized and the child is separated
occLlrred in children younger rhan 1 year of age. Infants younger from the parent (129). Failure to diagnose rhis condition places
rhan 1 year are t:specially at risk for the mosr severe form of child a child at risk for eirher serious long-term sequel:le or dearh in
abuse: infant homicide (44,86). Wirh severe shaking injuries by approximarely 9% of cases.
caretakers, 30% of infants are disabled and anOther 30% die Bizarre forms of child abuse may cause a confusing illness or
(25). The problem probably is more widespread rhan suspecred. injury. There are reporrs of young children forced ro aspirare
There is evidence to suggest rhat in rhe United Kingdom, 10% pepper, of intentional burns of infants by placing them in micro-
to 20% of children diagnosed as having sudden infant dearh wave ovens (7), of children denied water who developed hyper-
syndrome may be intentional infant homicides (56). In one re- natremic dehydration, and of infants poisoned with cocaine
pOlt (131), coven video recordings of adulrs attending their given ro them by carerakers (126). A high index of suspicion is
children who were hospitalized for suspicious illness docu- needed to avoid missing the diagnosis of non:lceidcntal trauma
memed 14 separate instances of caretaker arrempts ar upper air- in rhese siruarions.
 Chapter 7: Child Abuse 243

SEXUAL ABUSE they should be interviewed sepatately from the parents and other
members of rhe family.
AJrhough rhe onhopaedisr usually considers child abuse in rhe
contexr of fracrures and orher obvious injuries, an increasingly
The Investigative Interview
imponant aspecr of child abuse ro recognize is sexual abuse. Ie
is esrimated that 25% of abused or neglected children have been Once a full injury physical and radiographic assessment of the
sexually abused (96). Physically abused children have a 1: 6 child is complete, the investigative interview is begun by asking
chance of being sexually abused, whereas sexually abused chil- the primalY caregiver in a nonjudgmental way how the child
dren have a 1: 7 risk of being physically abuse (70). Children was acutely injured. To avoid provoking emotions, any addi-
Jiving with non biologic parenrs or with caretakers who are sub- tional soft tissue or skeletal trauma discovered should be brought
srance abusers are mosr at risk. The child usually discloses sexual up at the end of rhe interview for explanation once the presenta-
abuse under three types of circumstances: The child may have tion injury has been tnoroughly discussed. Each investigative
jusr experienced an argument with the abuser and may "acciden- interview should follow a systematic review of symptoms: what
tally" reveal the existence of the abusive relationship, the child happened, who was there, wnen was the injury recognized, and
is permanently separared from the abuser, or the abusive adulr how long before medical treatment was sought. Inconsistencies
is shifting auention to a younger sibling (160). The incidence are not challenged. Leading questions are avoided in favor of
of sexual abuse of handicapped parients has been esrimated as open-end questions. Medical rerms should be explained in plain
ranging from 25% to 83%, with handicapped males being more English, with care raken to avoid medical jargon. More plausible
likely to be sexually abused than nonhandicapped males in rhe explanations for the injury are not volunteered. The place where
general population (148). Both sexual and physical abuse may be the injury occurred and which individuals who were aC[l\ally
associared with cults, which may be identified by their symbols. present is determined. Leading quesrions should be avoided:
Satanic cults may use a pentagram (an encircled f1ve-poinred Never ask who caused the injury, bur rather ask what they saw
star with an inverred apex), the eye of Horus (an eye within a or what they think happened. Exactly who discovered the injury
triangle), or various symbols that modifY a cross, and the middle and how soon the child received medical care after onset of
or little finger of the left hand may be painted black (76). Sadistic symptoms are established. Delays in seeking medical care for an
ritual abuse has been reported in preschool and elementalY injured child are very suggestive of child abuse (49). The crucial
school children (162). questions co be answered are nOt only whether the given history
of trauma is sufficieur to explain the severity of injury but what
other possible scenarios could explain the injury if the volun-
teered expJanation is not plausible. This requires acquiring a
OBTAINING THE HISTORY working knowledge of the child's environment, which can be
obtained by asking specific, detailed questions (Table 7-1).
The hisrory is critical in the diagnosis of child abuse. It usually When interviewing injured children, it is essential to be as
is taken in the chaotic environment of a busy emergency room, gentle as possible, asking how rhey got hurt rather than who
so it is important ro find a quiet area for the interview where nurt them. Any question asked should be appropriate for the
tempers can cool and distracrions can be minimized. In addition child's age. The child's account of what he or she was doing ar
to taking a thorough hisrory with regard ro the mechanism of time of in jUly should be compared with rhe accounts of tne adult
injuly, the orthopaedist must question the patienr and the family witnesses. If possible, tne siblings of the injured child should be
in an investigative fashion to establish accurately the circum- interviewed because tney also are at risk for child abuse. Nonvi-
stances of the injury and the environment in which the child sual clues during the interview also may be helpful (Table 7-1).
lives. These skills are seldom taught in residency training. In a To make the diagnosis of child abuse, [he orrhopaedist musr
survey of pediatric residents (48), 42% of them had 1 hour or mal<e one crucial decision: Is tne histOly of trauma adequate to
less in training for detection of child abuse and most orthopaedic explain the severiry of injuly' That decision should be based
residents likely have even less training in this area. The extensive on experience in the care of fractures with knowledge of rheir
histoly needed ro derect child abuse is rermed the investigative mechanisms of injury and special insight into the types of trauma
il1terview. It begins with documenting the history (or the lack of most likely to cause significant injury. In addition, it is also
history) of the injury and, more importantly, goes on to uncover exrremely important to have knowledge of the developmental
enough details about tne child's life so that plausible scenarios abilities of a child when a caretaker states the child's injuries are
can be cteated to explain the injury. A full physical examination self-inflicted (76). It is patently absurd for the parents to explain
and skeletal survey should precede this interview ro search for that an infant's femoral fracture occurred in a fall while rhe
any possible evidence of additional undocumented child abuse. infant was standing alone when the infant is too young to even
The orthopaedist must become both social worker and detective, roll over. Details of the accident given as the reason of tbe injury
calmly and methodically establishing how the injured child lives; should be carefully considered. Ahhough it is not unusual for
finding out which family members, friends, or other caretakers a young child to sustain an accidental fall, it is unusual to sustain
have access to the child; and how likely it is that they mignt a serious injury from that fall alone. Infants fall from a bed or
have col1tributed to the child's injuries. A detailed history of a raised surface during a diaper change fairly frequently. In a
injury is obtained individually from each adult family member study of 536 normal infants (95), nearly 50% of them had fallen
in a private setring. If the patienr and siblings can communicate, accidentally from an elevated surface, usuaJjy after the first 5
244 General Principles

about the head. There was only one nondisplaced skull fracture
TABLE 7-1. CHILD ABUSE: INVESTIGATIVE
and one long bone fracture in a patient with osteogenesis imper-
INTERVIEW
fecta.
Environmental Issues Additional important information about rhe child and the
• Primary caretakers family may be obtained by a review of past medical records or
Unsupervised by contacting sociaJ workers who may have been involved with
Responsible for feeding, discipline, toilet training
rhe family. Conferring with rhe family's primary heaJth care
Easy or difficult child
• Home environment provider also may be extremely helpful. A medical release from
Place of residence rhe family is necessalY before these sources of infotmation can
living conditions be explored (49). The physician or social worker should be asked
Adults employed or unemployed if rhere have been prior concerns regarding abuse or neglect;
Sleeping arrangements
whether rhere has been a suspicious parrern of injury, illness,
Marital status of parents
Boyfriend or girlfriend of single parent ingestion of objecrs, or medications or noncompliance with
Substance abuse health care recommendations; wherher the family is receiving
• Home stress level counseling or other SUppOH from any communiry groups; and
Recent job loss whether rhe family has any previous involvemenr with child
Marital problems (separation or divorce)
protective services or the police (49).
Death in the family
Housing problems
Inadequate funds for food Documentation
Parental or Caregiver Responses and Attitudes
Careful documenration is criricaJ. Chan notes may later be
• Evasive, not readily responsive to questions
needed in coun as evidence for eirher custodial hearings or crimi-
• Irritated by questioning
• Contradictory in responses nal rrial (10 I ), and defending inaccurare or paHiaJ charr notes
• Hostile and critical toward child in coun can be extremely embarrassing. Each account should
• Fearful of losing child or criminal prosecution, or both be recorded in as much detail as possible, using quotarion marks
• Unconcerned about child's injuries for exact quores and specifying who is giving the history. Particu-
• Disinterested in treatment and prognosis
larly with cruciaJ answers, the exact quesrion preceding rhe re-
• Intermittently unavailable for interview (without valid reason)
• Unwilling to give medical information sponse should be documented. In addition, the general emo-
• Unwilling to give consent for tests rional state of the individual providing the account, as well as the
• Indifferent to child'ssuffedng (seldom touches or looks at individual's reaction to emotionally charged questions should be
child) documented to assisr in later evaJuation of the credibiliry of the
account. If rhe family wishes [Q change theit story after the initial
(Select data from Akbarnia BA. The role of the orthopaedic account, no changes should be made [Q rhe earlier record, bur
surgeon in child abuse. In: Morrissy PM, (ed.) Lowell and Winter's
pediatric orthopaedic. Philadelphia: JB Lippincott, 1990; and Green an addendum should be placed derailing the new account. The
FC: Child abuse and neglect: a pr.iority problem for the private completed record should include several specific items (Table
physician. Pediatr Clin North Am 1975;22:329-'-339; with
permission.) : 7 -2). If child protective services recommends emergency rransfer
of cusrody of rhe child [Q a foster home or a shelter, then the
orrhopaedisr should summarize chart documentation in a sepa-
rate norarized narrarive, which is preferred by most couns.

months of life, when the children were able to rollover and pull
rhemselves up. Significam injury after such falls is, however, DOCUMENTATION OF CHILD
TABLE 7-2.
exuemely rare. Combining rwo srudies (68,94) of782 children ABUSE
younger rhan 5 years of age who accidentally fell off an elevated
• Mechanism of injury
surface, such as bedor sofa, injuries were limited to three clavicu-
• Family social history
lar ftactures, six skull fractures, one humetal fracture, and one • Past medical history
subdural hematoma. More injuries occur in falls from greater • Family history of diseases such as osteogenesis imperfecta or
heights. In a report (75) of 363 stairway injuries, 10 were in other metabolic disease
infants who fell with their caretaJ<er while being carried on stair- • Physical examination findings (positive and nega1:ive)
• X"ray findings
ways, and four of those sustained skull fractures. In patients aged
• Laboratory results
6 momhs ro 1 year, 60% were using walkers at time of injury. .' Photographs of soft tissue injuries
Only 4% of patients had extremiry fractures, and 1% had skull • Results of consultations
fractures. Abr;lsions and contusions were presenr in 55% of pa- • Diagnosis of child abuse
tients, whereas 26% had lacerations. In another study (116) of • Teatment recommendations
Acute injuri es
76 children who had faJlen from a bed, a crib, or a chair (esri-
Investigation by child protective services
mated height 1 to 3 feet), while in the hospital for other illness,
18% had scalp or facial hemaromas and 12% had lacerations
 Chapm 7: Child AbuSE' 245

PHYSICAL EXAMINATION head is slammed onto a soft surface such as a mattress. On

impact, deceleration forces approaching 400 Gs may be seen,
After the initial musculoskeletal evaluation for acute fracture tearing the bridging vessels between the skuli and the brain, and
assessment, an extremely thorough physical examination of the producing intracranial hemorrhage and cerebral edema. Skull
patient should follow, systematically going from the head to the fractures, though, are rare unless the child is thrown onto a hard
toes, to detect any signs of additional acute or chronic injury. object. Simple linear skull fractures usually are due to a fall of
Additional acute fractures may cause local tenderness and swell- less that 4 feet and may be accidental, but complex skull fractures
ing, whereas chronic fractures may produce swelling from the without a history of significant trauma, including comminuced,
presence of callus and clinical deformity from malunion. Specific diastatic (separated sutures), displaced fractures, and fractures
radiographs should deteer clinical fractures, with skeletal surveys crossing suture lines, are suspicious for abuse (21). Children
showing most occult fractures. Othet body areas commonly in- with head injuties caused by direct impact trauma are described
volved in child abuse include the central nervous system, the as having shakerr impact syndrome (50). Children with head
skin, the abdomen, and the genitalia. These areas should be injuries have fevers, bulging fontanelles, and sometimes enlarge-
carefully evaluated for signs of acute and especially chronic in- ment of the head. A pattern of paresis may be present, and
jury, because 50% of verified abuse cases show evidence of prior reflexes may be increased (29). Skull fractures generally are un-
abuse (63). common, and either ultrasound or computed tomography (CT)
scans are used to diagnose subdural hematomas. Cerebral edema
may be lethal (37), and emergency neurosurgical consultation
Neurologic Injul"ies is needed. Funduscopic examination by an ophthalmologist is
Head injuries are the leading cause of death in child abuse (21). indicated because concurrent retinal hemorrhage is common
When an infant with musculoskeletal injury presents with al- (29). The examiner should be aware, however, that retinal hem-
tered mental status, whiplash-shaken infant syndrome should orrhages due to normal vaginal birth are present in 40% of
be suspected. Violent shaking of a small child whiplashes the newborns, but these injuries resolve by 3 to 4 weeks of age (53).
relatively large head back and forth over the thorax with possible Shal<en baby syndrome has a high mortality rate: Thiry percent
development of subdural hematomas (Fig. 7-1). Some authors of infants die of their injuries (25).
(50) believe these head injuries actually occur when the child's Fatal cerebral injury also occurs in the abusive tin ear syn-
drome: a clinical triad of unilateral ear bruising, CT scan evi-
dence of ipsilateral cerebral edema, and hemorrhagic retinopa-
thy, with a 100% mortality ['ate in one series (66).
Spinal fractures occur in child abuse when a child is forcibly
slammed onto a countertop with hyperflexion of the spine (I).
Although neurologic deficit wi(h this type of injury is uncom-
mon (41), children should be carefully evaluated for signs of
spinal cord injury secondary to spinal fracrure when abuse is
suspected.

Soft Tissue Injuries

In addi(ion to examination of the soft (issue around (he acute
fracture si(e for swelling and bruising, the patient's entire body
should be carefully and systematically evaluated to detect acure
and chronic soft tissue trauma. Deliberate soft tissue injuries are
present in 81 % [Q 92% of abused patients (61,109). The types
of skin lesions commonly encountered in child abuse include
ecchymosis, welts, abrasions, lacerations, scars, and burns.
The typical roddler often has multiple bruises over bony
prominences such as the chin, brow, knees, and the shins (l,
132). Bruises on (he back of the head, neck (l), burtOcks, abdo-
men, legs, anns, cheeks, or genitalia may be suspicious for abuse,
although accidental bruises can occur in all (hese locations (]32).
Accidental bruising of the head or face, though, is much less
common. In a study of 400 nonabused children, RobertSon
(128) found an overall incidence of juS( 7% for accidental soft
tissue injuries of the face and head, with the peak incidence of
17% seen in toddlers. Soft tissue injuries were present on the
FIGURE 7-1. Violent shaking of a small child held by the chest whi- lower extremities and buttocks in only 31 % of children and on
plashes the head back and forth over the thorax, with the possible
development of subdural hematomas as well as rib fractures. Infants the upper extremities of only 9%. The configura(ion of the
held by the extremities are also at risk for long bone fracture. bruise due to abuse may resemble the implement used to inflicr
246 Geneml Principlej·

Belt buckle Board or Spatula Belt

{
,
Bite

.... ,- /
Coat hanger 11II \

,.
Fly swatter
Paddles

Looped cord
I .••
~.

~':~
•
Spoon Hand

Hair brush
SticklWhip Sauce pan Knuckles

••••
FIGURE 7-2. Healing soft tissue injuries may
resemble the instrument used to inflict the
lesion.

rhe injury (Fig. 7-2), bur usually rhe sofr rissue injuries of abuse in which swelling accompanies bruising from injury rhrough
are "weapon" specific in fewer rhan 10% of parienrs (109). AI- lashing or whipping.
rhough bruises ofren are concenrrared on rhe rrunk and bu[[ocks, The rype of sofr rissue injuries in chiJd abuse may depend
rhey also can be presenr on rhe head and proximal exrremiries. on rhe age of rhe child (Table 7-3). In rhe pediarric denrisrf)'
The weapons used ro abuse children can be almosr any common lirerarure, in a series of 266 children suspecred of being abused,
objecr, bur rhey ofren include belr buckles, sraplers, ropes, Jessee and Rieger (74) also found rhar bruises were rhe masr
swirches, coar hangers, ironing cords, and rhe open or closed common sofr rissue injury, wirh rhe mosr common facial injury
human hand (77,149). Bruises inflicred by an open hand may ecchymosis of rhe cheek, forehead, periorbitaJ area, or rhe lip.
appear on rhe face or a flar area of skin from a slap and gmsp The age of a curaneous comusion reporredly can be esrimared
marks may appear as ovoid lesions when rhe fingerrips are deeply by a change in its color over 2 ro 4 weeks afrer injury, wirh fading
embedded in rhe exrremiries or rhe shoulders of the child during of rhe lesions beginning ar rhe periphery. An acure conrusion is
exrreme shaking (72). The injury partern and rhe severity of the blue or reddish purple; ir gradually changes ro green, rhen ro
ecchymosis depends on rhe amounr of force used, how direcrly yellow, wirh final resolurion as a brownish srain as rhe hemoglo-
rhe insrrumenr made conracr, and rhe specific type ofimplemenr bin is finally broken down (159). Langlois and Gresham (97)
used ro srrike rhe child (72). Weirs are more complex skin lesions nored rhar a yellowish bruise musr be older rhan 18 hours; a

TABLE 7-3. DISTRIBUTION OF SOFT TISSUE INJURIES IN 371 ABUSED CHILDREN

Head/neck
Age Bruises Abrasions Lacerations Scars Burns injury

:59 mas 71% 8% 16% 50%

10-35 mas 64% 13% 6% 6% 12% 38%
236 mas 61% 21% 4% 11% 3% 24%

Data from McMahon P, Grossman W, Gaffney M, and Stanitski C. Soft tissue injury as an indication of child abuse. J Bone Joint Surgery Am 77:
11'79-1183.
 Chapter 7: Child Abuse 247

red, purple, blue, or black coloration of the bruise may be present areas from burn (Fig. 7-3). The average child abused by scalding
from 1 hour after injury to resolution; red is always present in burns is an undernourished 2-year-old child with burns involv-
bruises regardless of the age; and bruises of identical age and ing 15% to 20% of the body, usually the bunocks; these children
etiology on the same person may be of different appearances and have a 10% to 15% mortality rate from burn owing to sepsis
may change at different rates. AJthough the age of a superficial (127).
conrusion may be approximately dated by itS appearance, a deep Burns also can be inflicted by many objects commonly found
conrusion may take some time [Q rise [Q the skin surface because in the household. Sometimes the objen can be identified by the
of fascial planes and thus delay visible ecchymosis. configuration of the burn. Intentional burns by cigarettes are
Narural skin lesions should not be mistaken for bruises. Mon- circular, deeply excavated, and sometimes repetitive, usually
golian spots are naturally occurring deep-blue pigmented areas about 8 mm in diameter (72). Isolated cigaretre burns may be
thar are presenr on the lower back at birth, usually just proximal accidental, and in such cases, rhey are usually superficial, point-
[Q the bunocks. They occur more commonly in black and Asian ing downward, and often appearing triangular. Lesions of impe-
infants than in white infants (15). Unlike rraumatic bruises, they tigo resemble those of cigarette burns, bLl[ they are much more
do not change in color but gradually resolve as the child matures superficial.
(72). Cui rural differences should always be considered when Contan with heated objects may cause burns of unique shape
unusual skin lesions are noted. Vietnamese children may be sub- that allow identification of their etiology (Fig. 7-4). Children
jected to a folklore medical practice known as cao-gio, which accidentally grasping curling irons sustain burns of the palms,
causes suspicious scratches and bruises on the back and may be whereas burns on the dorsum of the hands are more suspicious
mistaken for child abuse (13). for abuse (76). Hair dlyers can be used to inflict burns on chil-
dren, and full-thickness skin burns can result from contact with
Acute lacerations in various stages of healing and chronic
the grill of a dryer up to 2 minutes after it has been turned off
scarring may be present in an abused child. Like bruises, the
(124). Such burns can tesemble those caused by hot water or
configuration of the injury can resemble the weapon used [Q
could have a grill pattern caused by direct contan with the dryer.
inflict the injury on the child. Although minor lacetations
Abuse burns have also been inflicted by stun guns (59). These
around the eye are fairly common, multiple scars due [Q either
devices deliver a high-voltage impulse of up to 100,000 volts at
lacerations or burns (125) are suspicious for abuse.
3 co 4 rnA, incapacitating the individual and leaving hypopig-
mented burn scars on the skin 0.5 cm apart. Rope burns, sus-
tained when children are restrained about the wrists for beatings,
Burns may be seen as circular scars abour the wrists (76). FuJi-thickness
Burns are found in approximately 20% of abused patients (61) skin burns have been reponed in small children who were placed
and are most likely to be found in patients younger than 3 years in microwave ovens (7).
of age (109). Burn evaluation should include configuration, ap- Certain folklore practices may cause lesions simulating abu-
proximate pet'centage of body surface area, location, distribution, sive burns. Round burns on the abdomen, buttock, or berween
uniformity, length of time the child was in contaCt with the the thumb and forefinger of Southeast Asian children may be
due to a variant on the Chinese medical praCtice of moxibustion.
burning agent, temperature of the burning agent, and ptesence
Folk medical practitioners burn balls of the moxa herb on the
or absence of splash marks when hot liquids are involved (72).
surface of the skin for therapeutic purposes, and borh cigarettes
Most self-infliCted accidental pour or spill burns occur anteriorly
and yarn have been similarly used in refugee camps. The knowl-
on the child, bur accidental burns can also occur on the back.
edge of these practices may help co avoid inappropriate accusa-
In accidental burns, the injury usually has an arrowhead configu-
tions of child abuse (57). Infants may sustain second-degree
ration in which the burn becomes shallower and more narrow
burns when they accidentally come in conract with the hot vinyl
as it moves downward, and there may be splash marks surround-
upholstery of a car (I33).
ing the lesion (72). Abuse should be suspected when deep sec-
ond- or third-degree burns are seen well demarcated with cir-
cumferential definition. In accidental hot water immersion, an Abdominal Injuries
indistinct stocking or glove configuration may be seen with vary- Trauma to the abdomen is the second most common reason for
ing burn depths and indistinct margins. In deliberate immersion death from child abuse (21). Careful evaluation is needed co
burns, the burn demarcation shows uniform depth and a well- rule out occult abdominal injury in the abused child. These are
demarcated water line (72). Particularly severe burns occur when injuries due to beatings with the hand or fist and also can occur
a child's buttocks are immersed in hot tap water as abusive pun- when rhe child is thrown into a fixed object. External abdominaJ
ishment. The central aspect of the buttocks may be spated, giving bruising is present in only 12% to 15% ofcases of major abdomi-
a doughnut-like appearance to the burn. Galleno and Oppen- nal injuries (72). Patients with abdominal injury due to child
heim (61) noted that in accidental hot water immersion, the abuse may have fever, vomiting, and anemia, with abdominal
child is uniformly scalded about the lower extremities as the legs distention, localized involul1[ary spasm, and absent bowel
are quickly extended by the child to climb out of the water, bur sounds (I2l). One of the most common abdominal injuries is
in deliberate, abusive immersion the children are lowered into a ruprured liver or spleen, and the hypovolemic shock from
the water, so they instinctively pull up their legs to avoid the blood loss can be fatal (I56). Blunt trauma co the abdomen
scalding hot water, and knee flexion may protect the popliteal also may cause intestinal perforation, usually involving the large
248 Grneral Principles

/'

J'

j'

A B
FIGURE 7-3. A: In accidental hot water immersion, the child is uniformly scalded about the lower
extremities as the legs are extended quickly by the child to climb out of the water, with burns occurring
behind the knee (curved arrow), B: In nonaccidental immersion, the child instinctively pulls up the legs
to avoid the hot water, and knee flexion may protect the popliteal areas from burn (curved arrow),

Hot plate Knife Grid

0 Light bulb Steam iron

• Forks

e
Car cigarette lighter Immersion

(f)

-•.
Cigarette Curling iron

FIGURE 7-4. Contact burns by heated objects may

cause burns of unique shape that allow identifica-
tion of their cause,
 Chapter 7: Child Abuse 249

intestine, and the physical examination suggests petitonitis with even when there has been penetration, because hymenal cissue
free air seen on abdominal radiograph. Intramural duodenal he- is elastic and there can be rapid healing of trauma. There also
matoma may cause obstruction and projectile vomiting (72). is a wide variability of appearance of normal female genitalia
More severe trauma may cause duodenal avulsion or transection (31,55), bur posterior hymen disruption is rare and is suspicious
with nausea, vomiting, and clinical acure abdomen (155). Severe for abuse (20). If the sexual assault occurred within 72 hours of
blunt trauma to the abdomen or a blow to the back may cause evaluation, then a rape kit must be used by the evaluating physi-
renal or bladder contusion with hematuria. Blunt trauma to the cian or nurse examiner to provide medical evidence of the artack
abdomen also may result in shearing of the mesenteric vessels, (96).
leading to hypovolemic shock due to blood loss. Pancreatic tran- The physical signs of sexual abuse, including genital trauma,
section can occur where the pancreas overlies the vertebral col- sexuaHy transmiued diseases, or presence of sperm are preseO[
umn, and a pseudocyst may form (72). in only 3% to 16% of verified sexual assaultS (17,140), but even
Liver function tests are useful in detecting abdominal injUlY this minority of patients will be undiagnosed if sexual abuse is
due to occult liver injury in child abuse. In one study (39), not considered when a child presents with musculoskeleral injury
elevated aspartate aminotransferase, alanine aminotransferase, due to abuse. The orthopaedist or a consultant such as a pediatri-
and lactic dehydrogenase enzyme levels were useful markers for cian Ot a gynecologist must perform and document the genital
occult liver lacerations in abused children who had false-negative examination in children with physical abuse.
abdominal examinations. A CT scan is used to define liver in-
jury. If a bone scan is obtained to diagnose occult fracture, there
may be abnormal pauerns of isotope uptake in the abdomen FRACTURES IN CHILD ABUSE
due to intestinal injury, renal contusion, or muscle trauma of
the abdominal waH (71). Fractures documented on plain x-ray studies are present in 11 %
When abdominal injury is suspected in an abused child, the to 55% of abused children and are most common in children
hematocrit and hemoglobin levels are checked, the child is typed younger than 3 years of age (1,43,63). Fractures due to abuse
and crossmatched for blood, and an intravenous line is placed should be suspected in a young child if the caretaker brings in
to provide replacement fluids. Emergency general surgery con- the child for evaluation, reporting no accident, but does report
sultation should be obtained. The overall mortality rate associ- a change in the child such as extremity swelling or decreased
ated with visceral injUlY in child abuse is 40% to 50% (39). movement of the limb (99). Infants in the first year of life with
a fracture of the skull or the extremities have an equal risk of
the etiology being either accident or abuse (l07). Femoral frac-
Genital Injuries
tures are especially suspicious for child abuse in younger chil-
Sexual abuse should always be considered when evaluating a dren. One study (12) found that 79% of patients younger than
physically abused child. Children who have been sexually abused 2 years of age with femoral fractures were bauered, and of those,
can have symptoms of bed weuing, fecal incontinence, painful two thirds had femoral fractures as their only sign of abuse.
defecation, pelvic pain, abdominal pain, vaginal itching and Accidental femoral fractures can occur in children old enough
bleeding, sexually transmitted diseases, and pregnancy in POs[- to stand Ot run who fall with a twisting injuty to the lower
menarchal women. Types of sexually uansmitted diseases found extremities, but femoral fractures in children younger than 1
in abused children include gonorrhea, syphilis, chlamydiasis, year of age ate mOSt likely due to abuse (154). Fractures of both
trichomoniasis, and lymphogranuloma venereum. AJthough the the lateral clavicle and the scapula are suggestive of abuse in
percentage of sexually assaulted children with obvious physical young children (94). Infants may normally have a separate ossifi-
trauma to the genitalia is low, failure to document such findings cation center adjacent to the tip of the acromion, simulating a
is a serious mauer because sexual abuse is always a criminal fracture (92), but a true fracture has sharp, demarcated edges;
offense and must be reponed to legal authorities. may be positive on bone scan; and will show callus on healing
The genitalia should always be examined in a chaperoned (Fig. 7-5). Fractures of the hands and feet are most commonly
setting. Infant and toddler girls are placed in a supine frog-leg due to accidental trauma in older children (113) but are suspi-
position, and boys are placed in either a prone knee-chest posi- cious for abuse in infants. Nimkin et al. (117) reviewed 11 hand
tion or in a lateral decubitus position (140). Patterns of injury and foot fractures in abused children younger than 10 months
that suggest sexually motivated assault include bruises, scratches, of age and found mostly torus fractures either of the metacarpals
and burns around the lower trunk, genitalia, thighs, buuocks, or the proximal phalanges of the hand and similar fractures of
and upper legs, including the knees. Pinch or grip marks may the first metatarsals of the feet. Clinical signs of fracture wete
be found where the child was held. Attempted or achieved pene- present in only one patient, and bones scans were insensitive to
tration may involve the mouth, vagina, or anus (70). Sexually the presence of the fractures in all patients.
abused boys may have poor rectal sphincter tone, perianal scar- A1J types of fractures have been reported in the child abuse
ring, or urethral discharge. Female genital examination findings literature. In one of the largest series, King et al. (80) reported
that are consistent with, but not diagnostic of, sexual abuse in- 429 fractures in 189 abused children. Fifty percent of these
clude chafing, abrasion, or bruising of the inner thighs or genita- patients had a single fracture, and 17% had more than three
lia; distortion of the hymen; decreased or absent hymen; scarring fractures. Approximately 60% of fractures were found in roughly
of the external genitalia; and enlargemeO[ of the hymenal open- equal numbers in the humerus, femur, and tibia. Fractures also
ing (l 0). The examination of the female genitalia can be normal occurred in the radius, skull, spine, ribs, ulna, and fibula in order
250 General Principles

' ..

A B

FIGURE 7-5. A: A 7-week-old girl was seen in the emergency

department with swelling of the left shoulder. History re-
vealed her being roughly grabbed by the shoulder by one of
her parents. The anteroposterior x-ray study shows a trans-
verse lucency of the acromion, which was thought to repre-
sent either a congenital lesion or a traumatic fradure
(arrow). B: A technetium bone scan was obtained. Although
the delayed anterior image was normal, the posterior view
showed increased uptake in the left shoulder in the area of
the acromion (arrow) and a fracture was diagnosed. The inci-
dent was investigated. C: A follow-up x-ray study 9 days later
showed callus bridging the fracture site of the acromion
c (arrow).

of decreasing frequency. Another srudy (121) found a similar reporred fracture in one series (109), but only 10% of rheir
incidence of fractures of the humerus, femur, and tibia in abused patiencs underwent x-ray evaluacion.
children, with skull fractures seen in 14% of patiencs (Fig. 7-
6). [n contrast, Akbarnia et al. (3) found thac rib fraccures in
Rib Fractures
abused pacients were twice as prevalenc as fraccures of anyone
long bone; rhe next most frequently fractured bone was che Rib fractures are uncommon in childhood accidents, so their
humerus, followed by the femur and the tibia. Nearly a chird presence is veJY suspicious for child abuse, especially when ocher
of their patients had skull fractures. Loder and Bookout (102) long bone fractures are present (147). Abusive rib fracrures may
found che tibia co be che bone mosc commonly fraccured in cheir be caused by squeezing of che chesc by a carecaker (29), hitcing
series of abused children, followed by che humerus, che femur, che child from behind, or scepping on the chesc (90,143).
[he radius, and che ulna. Skull fraccures were [he mosc commonly Kleinman ec al. (90) postulaced chat severe shaking of an infanc
 Chapter 7: Child Abuse 251

A B
FIGURE 7-6. A: A 4-month-old male without history of trauma was brought into the emergency depart-
ment by his parents with a history of decreased use of the arm. This distal humeral shaft fracture was
seen on x-ray study. B: Skeletal survey disclosed a posterior skull fracture (arrow), and the injuries were
investigated.

( e Fig. 7-1) can cause from-to-back chesr compression, which

levers the posterior rib over the transverse process of the vertebral
body, causing fractures of the posterior rib shah at the transverse
process and of the rib head adjacent co the vertebra (Fig. 7-7).
These posterior rib fractures are diHicult co diagnose acutely
because of a lack of displacement. Even with healing, the caUus
on x-ray study may he obscured by the overlying transverse pro-
cess (86), and a bone scan may be needed co make the diagnosis
(Fig. 7-8). Posterior rib fractures are believed co be most com-
mon in child abuse, but fractures may occur anywhere along the
arc of the rib, including disruption of the anterior coscochondral
junceion. Posterior paraspinal rib fractures tend co occur betwecn
T4 and T9, rib fraceures in the axillary line occur mostly in rhe
lower rib cage, and disruption of the anterior coscochondral
junction usually OCCllrs from the sec nd co the nimh ribs (40).
Latcral rib fracturcs, both acute and chronic, may be difficult
[0 see on standard anteroposterior (AP) x-rays, so oblique views

may be necessary. Healing fractures show ea.rly ca.llus, but healed

fracrures may be subrle, with only a fusiform thickening of the
rib (see Fig. 7-8). Old fractures of the ribs in child abuse may
form lytic, expansilelesions that mimic a tumor (104). Fractures FIGURE 7-7. With anterior compression of the chest, the posterior rib is
levered over the transverse process of the vertebral body (open arrow),
along the lateral arc of the rib are likely due co AP compression causing fractures of the rib head adjacent to the vertebra (shaded
of the chest (Fig. 7-9A), while lateral compression of the chest arrow) as well as avulsion fractures of the rib at the transverse process.
252 Cmeral Principles

A B

FIGURE 7-8. A: This 5-week-old infant was presented by her parents with a com-
plaint of irritability when her left leg was handled. Her mother stated the infant's
18-month-old sibling may have "kicked" her in the leg. X-ray studies showed an
acute fracture of the proximal tibia. B: Skeletal survey showed a healing fracture
of the left distal clavicle (arrow), a healed fracture of the anterior left 5th rib
(arrow), and question of healing posterior right 6th, 7th, 8th, and 9th ribs (arrows).
(: The posterior image of the delayed phase of the bone scan confirmed the
c presence of healing posterior rib fractures (arrows).
 Chapter 7: Child Abuse 253

A B
FIGURE 7-9. A: Anteroposterior compression of the infant chest causes fractures both at the rib head
and adjacent to the transverse processes (open arrow), but fractures along the lateral arc of the rib are
also possible because of the acute bending of the ribs at this point by compression (shaded arrow). B:
Lateral compression of the chest likely causes fractures of the rib along its posterior arc lateral to the
transverse process, as well as possible disruption of the costochondral junction (open arrows).

likely causes fracrures of the rib along its posterior arc lateral to mity, 30% had pure compression fractures, and 20% had frac-
the transverse process as well as disruptions of the costochondral tures of rhe superior end plate without significant compression.
junction (Fig. 7-9B). In another study of fracrures of the cervical spine, prevetebral
Acute anteriot costochondral separations of the ribs may be soft rissue edema on x-ray study was the only sign of cervical
difficult to see on x-ray srudy, but ultrasound can show COSto- injury, because spontaneous reduction of the cervical vertebrae
chondral dislocation (141) and, wi th healing, the anterior end after dislocation was common (150). Thomas et al. (153) re-
of the osseous rib becomes widened and clubbed on x-ray study ported a 9-week-old boy with spinal cord injulY due to cervical
(94,121). spine fracrure who presented as a floppy infant. Although rourine
In rhe rare instances when rib ftactures are discovered in cervical radiographs were normal, magnetic resonance imaging
abused infants undergoing resuscitation for cardiac arrest, there (MRl) studies showed retropulsion of a fragment of the primarily
may be confusion about the etiology of the fractures (42), but cartilaginous C3 vertebrae into the spinal canal. Carrion er al.
the elasticity of the infant chest seems to enable it to tolerate (32) reported circumferential physeal fracrures of the spine asso-
compressions, with only 2% of 94 nonabused infants resusci- ciated with child abuse that required open reduction. Bone scans
tated having rib fracrutes in one series (23). In addition to rib using single photon emission computed tomography can be
fractures, abused infants can sustain severe lung contusion and helpful for diagnosing occult compression fractures of rhe tho-
respiratory distress from chest wall trauma (108), with fatal fat racic spine (40). Although neurologic injury in spinal fractures
embolus reported (lIS). Necklace calcifications may be present due to child abuse is uncommon (41), any patienr with abusive
in strangulacion cases (33). spinal injury should undergo complere neurologic examination.
In the case of infant fatalities of suspicious origin, postmor-
tem high-detail skeletal surveys and specimen radiography can
be helpful in diagnosing child abuse (83). In a postmortem study
ADDITIONAL IMAGING STUDIES
of 31 infants who died of inflicted skeletal injury, Kleinman et
al. (88) found a total of 165 fractures (51 % rib fractures, 39%
In addition to standard x-ray studies of the acute injury, a skeletal
metaphyseal long bone fractures, 5% long bone shaft fractures,
survey is used to detect the presence of additional fractures in
4% fractures of the hands and feet, 1% clavicula.r fractures, and
battered children. The skeletal survey should include separate
less thar 1% spinal fracrures). It is important to obrain skeletal
AP and lateral views of the skull and rhe entire spine, and an
radiography before autopsy to avoid artifacr (P. Kleinman, Per-
AP view of rhe chesr and exrremities rhar includes rhe shoulders,
sonal communication, 1998).
pelvis, extremities, feet and hands (98). Oblique x-ray srudies
of the hand are recommended to detect subtle rorus fractures
of rhe metacarpals and rhe phalanges (117). A single AP x-ray
Spinal Fractures
study of an enrire infant, the so-ca.lIed baby gram, is not adequate
Spinal fractures in child abuse are rare but can occur when a because rhe obliquity of the angle ar which rhe x-ray transverses
child is forcibly slammed onto a flat sutface wirh hyperflexion rhe skeleton may obscure subtle fracrures (40). The indications
of the spine (1). Based on autopsy findings (84), spinal fractures for skeleral survey are nor completely clear. Merten er al. (ll2)
of fatally abused children generally involved 25% or less recommended skeleral survey in infants 1 year of age or younger
compression of the vertebrae. Half of the fracrures involved the when rhere is evidence of neglect and in children age 2 years or
anterosuperior end plate associared wirh a compression defor- younger when clinical abuse is evident. The American Academy
254 General Prim'ipler

of PeJiacrics Section on Radiology (11) considered a skeletal dren and found that 56% were transverse, 36% oblique, and
survey mandatory in all cases of suspected physical abuse in only 8% spiral. In another study of 429 fractures (80), 48% of
children younger than 2 years of age, but the sensitivity of skele- Fracrures were transverse and 26% were spiral. Most of rhese
tal surveys was unclear in older patients. The cost-effectiveness long bone fracrures were in either the middle or disraJ third of
of such skeletal surveys appears to be low because in one study the shaft. Transverse fractures are most commonly associared
of 331 children, only eight patients without oven physical signs with either a violeor bending force or a direcr blow to the extrem-
of child abuse had occult fractures revealed by the survey (54), ity, whereas spiral or oblique fracrures of the long bones are
but the usc of the skeletal survey in these eight patients possibly due to rwisting injuries or a fall. Significant rotational force is
prevelHcd both reinjulY and death. Perhaps when the death of required, however, to produce a spiral fracture with a fall (1).
a child is the ultimate risk of the misdiagnosis of child abuse, Anorher author (54) emphasized that children old enough to
we should not play the odds but use every mecLical test at our run can fall and fracrure their femurs if there is a significant
disposal to identify the child at risk for abuse so we can try to rwisting motion at rJle time of injury. In delayed follow-up, long
protect him or her from funher possible fatal abuse. bone fractures may show exuberant caJlus because of a Jack of
Sty and Sta.rshak (J 45) reponed a false-negative rate of 12.3% immobilization, and mulriple fractures may be presenr in differ-
in skeletal surveys of abused children, and suggested that a tech- eoc stages of heal ing (2). Juxtaconical calcification may be seen
netium bone scan is the best screening test for occult fractures. without fracture when there is Jiaphyseal periosteal separation
Technetium bone scans, however, may fail to diagnose either due to tracrional or torsional force when the limb is grasped or
epiphyseal or metaphyseal fractures and often fail to show skull pulled along the shaft of the bone (12).
fracrures (113,145). Jaudes (73) found that when results of ei ther Metaphyseal and epiphyseal fracrures of the long bones are
a bone scan or a skeletal survey were normal in an abused child, classically associared with child abuse (28,139). In toddlers, these
the use of both tests often revealed additional occult fractllres. fractures can occur when the child is violendy shaken by the
Technetium bone scans are especially useful in the diagnosis of extremities (Fig. 7-10) with direct violent traction on or rotation
occultrib fractures (40,143), but consisrent interpretation is di ffI- of the extremity (13). Metaphyseal fractures may be character-
cult in children younger than 18 monrhsofage. Technetium scans ized by impaction into the epiphysis, with profound production
are not useful for dating fractllres, because increased isotope up- of new periosteal bone. Buclde fractures may be present in multi-
take may occur at a fracture as early as 24 hours after injlllY and
scan abnormalities may persist for years (58). Kleinman et al. (91)
reponed that a follow-up skeletal survey 2 weeks after the initial
series detected 27% more fractures and provided assistance in dat-
ing in 20% of previously detected fractures.
Other imaging techniques may be useful in investigating sus-
picious x-ray slUdy or bone scan findings. Markowitz and co-
workers (105) found that sagittal and coronal sonograms of in-
jured knees in abused children were helpful in diagnosing epi-
physeal fracrures when compared with the normal side. They
cautioned that epiphyseal fractures due to rickets in neonates
can be confused with child abuse on ultrasound evaluation. Rog-
ers and Poznanski (130) pointed out that acute interruption of
rhe physis in trauma of any etiology can be seen on MRI. They
recommended multiplanar gradient-echo imaging with a repeti-
tion time of 50 to 700 ms, an echo time of 200 ms, and a flip
angle of 20 degrees for optimal imaging of the physis.

INTERPRETING IMAGING STUDIES IN

CHILD ABUSE
There is no predominant parrern of diaphyseal fracture in child
abuse. Tradi tionally, a mid-shaft spiral Fracture is believed to be
caused by a violent rwisting injury to the extremity of the child.
In a study of 23 long-bone fractures in battered children, Hern-
don (69) found spiral fractures in 78%. He suggested that in
children younger than 3 years of age, a spiral fracrure of a long
bone is highly suggestive of child abuse. Other authors (61),
however, found that 71 % of diaphyseal fracrures were transverse
in abused children. In al10ther study of 34 patieors in the first FIGURE 7-10. When a toddler is violently shaken by the extremities,
year of life, rhere was no difference in fracrure panerns berween long bone fractures can occur through either direct violent traction or
rotation of the extremity. These children are also at risk for c1osed-
those injured by trauma and rhose injured by abuse. Loder and head injury because of violent motion of the head during the shaking
Bookout (102) reviewed 69 long bone fractures in abused chil- episode (arrow).
 Chapter 7: Child Abuse 255

TABLE 7-4. SPECIFICITY OF SKELETAL

TRAUMA FOR ABUSE

High Specificity
• Any metaphyseal lesion
• Posterior rib fracture
• Scapular fracture
• Spinous process fracture
• Sternal fracture
Moderate Specificity
• Multiple fractures, especially bilateral
• Fractures of different ages
• Epiphyseal separation
• Vertebral body fracture or subluxation
• Digital fracture
• Complex skull fracture
Low Specificity
• Clavicular fracture
• Long bone shaft fracture
• Linear skull fracture

Data from Kleinman PK, ed. Diagnostic imaging of child abuse.

Baltimore: Williams & Wilkins, 1987.

pie sites, and these injuries seldom produce exuberant callus.

Repeated injury causes irregular metaphyseal deformities. Perios- A
teal avulsion produces new bone formation within 2 to 3 weeks
of injury and can be confused with osteomyelitis (2). New bone
formation may be delayed, however, in children with malnurri-
tion. Metaphyseal fracrures composed 40% of fractures in one
series (61) but less than 15% in another (94).
Kleinman (81) ranked rhe speciflciry of skeletal rrauma for
abuse (Table 7-4). Distinguishing between an accident and child
abuse is based on both locarion and cype of fraccure. He cau-
tioned that both moderace- and low-specifIcity x-tay findings
of child abuse become more highly specific when there is an
inadequate explanacion for rhe injury.

The Corner Fracture of Child Abuse

The so-called pathognomonic fract:llre of child abuse is the cor-
ner or bucket-handle fraccure of che metaphysis (1,2). On x-ca)'
scudy, there is no gross displacement of the epiphysis, buc a
corner or chip fracture is seen at the edge of the involved metaph-
ysis (Fig. 7-11). If a significant portion of the metaphyseal rim is
L
involved, a bucket-handle fracrure pattern is produced. Anocher
fracture pattern thac may be seen is a faint mecaphyseallucency
JUSt adjacenc to the physis. Classic:dly, chesc fraccures have been
believed to result from avulsion of metaphyseal fragments
through the periosteal attachment of the epiphysis (28,98).
B
KJeinman etaL (85,87) challenged this view based on their hisro-
FIGURE 7-11. A: An 11-month-old girl with a history of right thigh
pachologic study ac auropsy of metaphyseal fractures of abused swelling was seen. X-ray studies of the right femur show corner or
infants. They found chat in bucket-handle or corner fractures, "chip" fractures of the distal femur (bottom arrows). Faint periosteal
rhere was actually a full-chickness metaphyseal fraccure extending calcification is also visible along the lateral cortex (top arrow). Such
fractures are suspicious for child abuse. B: A technetium bone scan
through the primary spongiosa of bone just above the zone of showed increased uptake of isotope in the distal and proximal femur
provisional caJcificacion. This fraceure corresponded ro the zone (arrows).· (Figure continues.)
 256 Germ"a! Prine;pies

FIGURE 7-11. (continued) C: A hea ling epiphyseal plate fracture of

c the proximal femur is seen (arrow).

of metaphyseal lucency occasionally seen on x-ray. Cenrrally, DATING FRACTURES

the amounr of metaphysis remaining attached co the physis was
thin, but peripherally, the fracture line curved away from the X-ray proof of unexplained fractures in various stages of healing
physis so that a substantial metaphyseal rim remained arrached is believed to be strong evidence of child abuse (3) (Fig. 7-13).
co the physis. On x-ray study, this metaphyseal rim formed the The orthopaedist often is asked to estimate the age of fractures
basis for both corner and bucket-handle fractures (Fig. 7-12). with some cerrainry to corrobol'ate a history of injury given by
In healing fracrures, biopsy specimens showed metaphyseal ex- caretakers (Fig. 7-14). Whereas most experienced orrhopaedists
tension ofhyperuophied chondroeytes (89,122). These fracrures can roughly estimate the age of fractures based on x-ray appear-
are mOSt likely caused by either violenr shaking or traction inju- ance, specific guidelines have been established For estimating the
ries co the extremiry and are specifically suggestive of child abuse age of fracrures in children (118) (Table 7-5). Both age and
(I) (see Fig. 7-10); however, they are not the most common nutritional starus can affect the appearance of callus around heal-
fracrures in abused children, with their incidence in large series ing fractures (47). Growth lines presenr on radiographs may be
ranging from 15% to 32% (61,80,94,102). SubepiphyseaJ-me- helpful in dating fractures (52). In general, fractures on x-ray
taphyseal lucency can also be caused by systemic diseases such study are acute unril callus appears, then their age is based on
as rickets and leukemia.

TABLE 7·5. GUIDELINES FOR ESTIMATING THE

AGE OF FRACTURES IN CHILDREN

X-Ray Appearance Peak Changes

Resolution of soft tissue 4-10 days

swelling
New periosteal bone 10-14 days
toss of definition of fracture 14-21 days
'line
Presence of soft callus 14-21 days
Presence of hard callus 21-42 days
Remodeling of fracture 1 year (early-3 months;
FIGURE 7-12. In the corner or bucket-handle fracture, full-thickness late-2 years to maturity)
metaphyseal fracture extends through the primary spongiosa just
above the zone of provisional calcification. Centrally, the amount of
metaphysis remaining attached to the physls is thin, but peripherally, After O'Connor, JF, Cohen J. Dating fractures. In; Kleinman PK, ed.
the fracture line curves away from the physis so a substantial metaphy- Diagnostic imaging ofchild abuse. Baltimore; Williams & Wilkins,
seal rim remains attached to the epiphyseal plate (arrows). On x-ray 1987. '
study, this metaphyseal rim (dark shaded area) forms the basis for both
the corner and bucket-handle fractures.
 Chapter 7· Child Ab/lSc 257

FIGURE 7-13_ A: A 7-month-old boy presented with a nondis-

placed left distal tibial fracture with periosteal calcification ex-
tending up the tibial shaft (arrows). B: A skeletal survey revealed
dense, sclerotic cortical thickening of the contralateral tibia con-
sistent with healed fracture (arrow). The presence of multiple
fractures in different stages of healing is very suggestive of child
A,B abuse.

FIGURE 7-14. A 3-year-old female was brought to the clinic

with a swollen elbow. The mother stated that the child had fell
only a week ago, but x-ray studies of the elbow showed a heal-
ing supracondylar fracture of the distal humerus that was likely
2 to 3 weeks old based on presence of soft callus (arrows). Child
protective services was contacted and a full examination includ-
ing skeletal survey was performed. No other signs or risk factors
for child abuse were detected. The mother then admitted that
the child had indeed fallen 3 weeks ago. She was allowed to
take her child home after treatment and was counseled about
the need for prompt medical care when her children were in-
jured.
258 General Principles

AB C
FIGURE 7-15. A: A 6-year-old patient presents with a nondisplaced transverse fracture of the distal
radius (arrow). B: At 4-week follow-up, soft callus is seen enveloping the fracture site (arrow). C: At 6-
week follow-up, hard callus is seen and early remodeling is occurring at the fracture site.

rhe presence of eirher sofr or hard callus some weeks larer (Fig. in error. Kaplan poinred out that overdiagnosing battered child
7-15). The mosr difficult fracrures to dare are rhose rhar are syndrome can be harmful ro the family, with the parents being
completely healed with substantial remodeling, and often rhe placed at risk of losing custody of their child and also facing
only sign of fracruring is a thickened cortex (Fig. 7-16). criminal charges (78). Even direct allegations of child abuse may
turn out to be false. Bemet (22) poinred OLlt that patients or
family friends may make false statements abour an abuse situa-
LABORATORY STUDIES AND tion through misinterpretation, confabulation, famasy, delu-
CONSULTATIO S sions, and other mechanisms. The American Academy of Child
and Adolescent Psychiatry (9) has published guidelines for the
An abused child should have a complete blood cell coum with evaluation of abuse that state that the possibility of false allega-
sedimentarion rare, liver function studies, and urinalysis. C1ot- tions needs to be considered, parricuJarly if allegations are com-
ing from the parem rather than the child, if the parems are
ring studies should be performed routinely, especially in patiems
engaged in a dispure over custody or visiration, and/or rhe child
wirh ecchymosis, to rule out a blood disorder as a cause for the
is a preschooler.
bruises. If there is any suspicion ofsubstance abuse by any family
Normal metaphyseal radiologic appearance should nor be
member, a toxicology screen should also be performed on the
confused with child abuse. The radiologic metaphyseal variants
parienr (61). Any signifiGlI1[ nonorrhopaedic injury should
include acure angulation of rhe ossified peripheral rip of rhe
prompr appropriate consultations by neurosurgery, general sur-
metaphysis adjacent to the physis (most commonly seen in rhe
gery, plastic surgery, or ophrhalmology (2). Any female patienrs prox.imal tibia, disral femur, proximal fibula, distal radius, and
who require pelvic examinarion to rule out sexual abuse should distal ulna), which is bilateral in 41 % of individuals. A bony
have a gynecologic consultation. beak may be seen medially in the proximal humerus and tibia
in rare cases and is bilateral in 77% of individuals. Conical
irregularity in the medial proximal tibia may be seen in 4% of
THE DIFFERENTIAL DIAGNOSIS individuals and is biJareral in 25%. Spurs may exrend beyond
the metaphyseal margins in borh the distal radius and lateral
Although it is exrremely imporram nor ro miss the diagnosis of aspect of rhe disral femur, with bilateral varianrs in 25% of
child abuse, it is equally imporram not to make the diagnosis individuals (82).
 Chapter 7: Child Abuse 259

The signs of child abuse found on x-ray study also can be

mimicked by systemic diseases such as scurvy, osteogenesis im-
perfecta, Caffey's disease, osteomyelitis, septic arthritis, fatigue
fracture, osteoid osteoma and other tumors, rickets, leukemia,
hypophosphatasia, neuromuscular disease, metastatic neuroblas-
toma, congenital indifference to pain, osteopetrosis, kinky hair
syndrome, and prostaglandin therapy (2,21). Fractures due to
both vitamin D deficiency ricketS and drug-induced rickets have
been mistal(en for child abuse (163). There has been an increase
in the incidence of syphilis in females of childbearing age, and
congenital syphilis can mimic fractures of child abuse with dia-
physitis, metaphysitis, and multiple pathologic fractures in dif-
ferent stages of healing (l00). McClain et al. (l06) reported a
2-year-old child who died of undiagnosed acute lymphoblastic
leukemia. The child had been reported as a possible victim of
child abuse because of ecchymosis on the back and extremities.
They emphasized that the clinical signs of leukemia, including
fever, pallor, petechia, purpura, adenopathy, hepatosplenomeg-
aly, and bone pain, should be sought in children with bruising
of unknown origin. Physiologic periostitis (Fig. 7-17), in con-
trast to lesions from child abuse, is usually bilateral with no
excessive uptake of isotope on bone scan (40). The presence of
metabolic disease and pathologic fractures does not exclude the
possibility of child abuse. Duncan and Chandry (51) reported
a 3-month-old girl with multiple fractures associated with rickets
who died suddenly at 5 months of age. Child abuse was sus-
pected but not proven. Three years later, evidence of child abuse
was found in a subsequent sibling in the same family. Several
A,B diseases are commonly brought up in custodial hearings as alter-
FIGURE 7-16. A: An 18-month-old child presents with a l-month-old native possibilities to child abuse to explain trauma findings,
nondisplaced fracture of the distal tibia (large arrow). The fracture line
is beginning to fade. but periosteal calcification is seen medially (small
and these diseases should be carefully explored in the differential
arrows). B: At 5 months after injury, the fracture shows almost complete diagnosis.
remodeling (large arrow) with the only sign of past injury a thickened
medial cortex of the tibia (small black arrows). Subtle signs of past
fracture are best noted by comparing the x-rays of the injured side to
the contralateral uninjured side. OSTEOGENESIS IMPERFECTA
Undiagnosed osteogenesis imperfecta should always be consid-
ered when a child presents with multiple fractures of unknown

FIGURE 7-17. A 10-month-old infant with physiologic

periostitis of the femurs (arrows). This type of x-ray appear-
ance may be confused with fractures of child abuse. but
this periostitis tends to be bilateral with a uniform appear-
ance in contrast to multiple fractures in different stages of
healing seen in battered children.
260 Gerzerat Principles

etiology, but it may be a very difficult diagnosis clinically. Os- first year of life and then there was spontaneous improvement.
teogenesis imperfecta due to spontaneous mutation can occur These patients presented with vomiting, followed by diarrhea,
without a family histOly (123). The so-called hallmark of os- anemia, hepatomegaly, episodes of apnea, neutropenia, and
teogenesis imperfecta is an intensely blue sclerae, but this feature edema. The most common x-ray findings were metaphyseal cor-
is consistently present only in eype I (137) and may be com- ner fractures, rib fractures, diaphyseal fractures, periosteal reac-
pletely absent in patients with rype IV osteogenesis imperfecca tion of long bones, expanded costochondral junctions, and de-
(123). Sillence and Butler (138) nared that patients with either layed bone age. Only 31 % of patients had osteopenia on x-
eype II or III osteogenesis imperfecca may have blue sclerae at ray study. They suggested that a self-limiting period of copper
birth but the sclerae can become normal by adolescence. The deficiency was the cause of this problem, but limited serum
rare eype II osteogenesis imperfecta has normal sclerae, bue bone copper assays were inconclusive. Other authors (4,6,36) doubt
abnormalities and osteopenia are severe and early death is likely the existence of "temporaly" britrle-bone disease because of the
(123). Blue sclerae may be present in normal young children rariey of fractures associated with proven copper defJciency syn-
and can be misleading as a sign of pathologic bone fragiliey. The drome. Judicial authorities (34,103,160) have commenced rhat
presence of abnormal teeth, known as dentinogenesis imperfecca, although one patient in the series of Patterson et al. had injuries
may be helpful in a diagnosis of osteogenesis imperfecca if the due to child abuse, this fact was not included in the report, and
child is old enough for teeth to have erupted. Plain x-ray studies, they had concerns that assumptions proposed by medical expertS
however, may show long bones of normal densiey in both types that injuries may be considered solely due ra disease may inhibit
I and IV osteogenesis imperfecra. Another radiographic sign of full investigation of such injuries by civil authorities and place
osteogenesis imperfecta, wormian bones of the skull, is consis- children at risk for further abuse.
tently present only in eype III and is often absent in eypes I and
IV (123). Some authors believe that the presence of metaphyseal
fracture is pathognomonic for child abuse and, therefote, helpful Sudden Infant Death Syndrome
to distinguish abuse from osteogenesis imperfecta (5), but other In sudden infant death syndrome (SIDS), there is a distinct
authors (45,123) believe that there is no particular fracture pat- possibility of child abuse (56), but other causes of sudden death
tern that renders the diagnosis of osteogenesis imperfecta likely. must be excluded. Byard et al. (26) reported a 5-month-old
Patients with osteogenesis imperfecca tend to bruise to excess, girl who died suddenly because of spontaneous subarachnoid
which simulates lesions of child abuse (135), and sudden infant hemorrhage from undiagnosed Ehlers-Danlos syndrome. They
death has also been recorded in patients with undiagnosed os- recommended collagen analysis in patients with unexplained
teogenesis imperfecta (119). multifocal spontaneous hemorrhages to exclude this rare syn-
Sometimes, when the diagnosis of osteogenesis imperfecta drome. Sperry and Pfalzgraf (144) reponed a 9-month-old infant
cannot be made on clinical grounds, the diagnosis can be made whose diagnosis of sudden infant death syndrome became uncer-
by biochemical assay. Gahagan and Rimsza (60) stated that 87% tain when postmortem x-rays showed healing symmetric clavicu-
of patients with osteogenesis imperfecta have abnormal procolla- lar fractures and a healing left medial humeral epicondyle frac-
gen that can be detected by current techniques. A skin biopsy ture. Subsequent investigation showed that the child had
is performed for fibroblast culture, and fibroblasts are assayed for undergone "chiroptactic" manipulation 4 weeks before death
both abnormally low levels of procollagen and primary abnormal by an unlicensed therapist to correct "shoulder dislocations,"
procollagen (27). Steiner et al. (146) reported that over a 4-year and the parents were exonerated of abuse chatges.
period, 48 patients were referred to them for collagen analysis
to rule out the presence of osteogenesis imperfecta in cases of
suspecred child abuse. Only six of these children had abnormal Accidental Trauma
collagen test results, and in five of those six patients, the diagnosis
In considering the differential diagnosis of child abuse, acciden-
of osteogenesis imperfecta could have been made on clinical
tal trauma should always be considered. The orthopaedist, how-
and radiographic grounds. They concluded that routine collagen
ever, should be comfortable with the diagnosis of accidental
biochemical testing for osteogenesis impetfecta is unwarranted
trauma only when the acute injury is brought promptly to medi-
in these children and collagen analysis should be reserved for
cal attention and has a plausible mechanism of injury and there
the rare instances when diagnostic uncerrainry persists in cases
are no risk facrars for child abuse.
of suspected child abuse.
Even when a child has osteogenesis imperfecta, fractures may
be due to abuse. Knight and Bennett (93) reported on a young
child with osteogenesis imperfecra whose abuse could nor be TREATMENT AND LEGAL REPORTING
proved uncil linear bruising of the face suggestive of slapping REQUIREMENTS
was documented.
Once child abuse is recognized, the first step in treatment is
hospital admission. This is therapeutic in that it places the child
Temporary Brittle Bone Disease
in a safe, protected environment and provides the opportunity
In 1993, Patterson et al. (I23) described 39 patients with a for additional diagnostic work-up and, more importantly, inves-
variant of osteogenesis imperfecta that they described as a tern po- tigation of the family's social situation by appropriate personnel.
rasy brittle-bone disease in which fractures were limited to the In universiey settings, multidisciplinary teams often are available
 Chapter 1: Child Abuse 261

[0 evaluate and treat such children, but in other circumstances, through a multidisciplinary team or, more often, the decision
the orthopaedist may be primarily responsible for coordinating of the primary physician, who may be the orthopaedist. Final
barh evaluation and treatment. Court cus[Ody may be required disposition choices may include return to the family, rerum [0
for children of uncooperative families who refuse admission, and a family member who does not live in the child's home, or
hospitalization should be continued until a full investigation is placement in a shelter or a foster home setting. The risk of
completed by the appropriate child protective services. In the reinjury and death is significant if the abused child is rerurned
United States, the physician is required by law [0 report all [0 the unsafe home, so the orthopaedist must strongly support

suspected child abuse [0 appropriate child protective services or child protective services in cus[Odial actions when it is believed
legal authorities. When the reporting is done in good faith, the that the child's injury truly occurred from abuse at home. Not
physician has immunity against criminal or civil liability for only must [he definitive diagnosis of child abuse be documented
these actions, but only in three states-Ohio, California, and in the chan but a separate notarized affidavit may be necessary.
Alabama-is this protection extended [0 include absolute im- Commonly, custodial actions by child protective services are
munity (38). The distinction is critical. Absolute immunity reviewed in a court hearing in a matter of weeks, and the physi-
means that the physician who reportS suspected child abuse can- cian is likely called to testify in the hearing. Criminal charges
not ever be held for damages sought by families for allegedly also may be brought against the perpetrator of the child abuse,
inappropriate reportS of child abuse or neglect. The granting of and the physician likely also serves as a witness in these proceed-
absolute immunity, even for physicians, is not encouraged by 1I1gs.
the American legal system because in theory it would protect
individuals who mal(e false reports of child abuse in order [0
harass families and would deprive the injured parries their legal THE COURTROOM
right [0 seek damages fot harmful actions. In contrast, physician
immunity based on good faith reporting ofsuspected child abuse The orthopaedist fills a dual role in the courtroom in child abuse
is contingent on the physician having a reasonable belief that proceedings. First, he or she serves as a material witness whose
abuse or neglect has occurred. Although in theory this protection testimony is confined to the physician's personal involvement
seems to be quite adequate, recently there has been a dramatic in the legal matter. The testimony may include clarification to
rise in the number of lawsuits filed by families seeking damages the court of information contained in progress notes in the chart
for alleged, unfounded reports of child abuse and neglect. Al- or of other past documentation. As a material witness, the physi-
though it is true that by the time these lawsuits are eventually cian, like the layman, cannot render opinions about the facts as
resolved, physicians have almost never been held liable for good stated during his or het testimony. In addition, however, the
faith repons of child abuse; in a substantial number of these physician may also be sworn in as an expert witness (64). This
cases, the physicians first lost at trial level before eventuaJly pre- is an individual considered by the court to have special knowl-
vailing at appeal. Considerable expense, frustration, and loss of edge and experience that qualifies him or her to render opinions
time can be experienced by the physician in defending against about certain facts presented in the courtroom. The limits of
such allegations as the families and their attorneys pursue multi- the physician's expertise are usually defined by the attorneys in
ple forms of legal theories in court in an attempt [0 evade the court before the testimony of the expert witness.
immunity provisions (38). On the other hand, failure [0 report Physicians usually are reluctant to testify in court for many
suspected child abuse may expose the physician [0 charges of reasons. The courtroom is an unfamiliat setting for almost all
malpractice (1). All states require physicians to report not only physicians, and the adversarial natute of the American law system
cases of definitive child abuse or neglect but also cases when makes it a hostile environment. In the courtroom, the perception
abuse is just suspected or is considered a possibility. Physicians of truch is JUSt as important as the truth itself, and opposing
have been held liable for damages for their negligence in failing arrorneys will search for inconsistencies in the testimony or unfa-
[0 diagnose child abuse when the child subsequently was rein- miliariry with the record to discredit the physician witness. To
jured by more abuse, and ironically, the parents also may be avoid being a poor witness, the orthopaedist must meticulously
able [0 colleer additional compensation for losses due [0 medical prepare to give testimony.
expenses. In order for families [0 be successful in these lawsuits, The orthopaedist preparing to testify in a child abuse case
they must be able [0 prove that the failure [0 make the diagnosis should begin with a thorough review of the child's medical rec-
of child abuse was negligent and that, had the diagnosis been ords and a review of recem medical literature on the subject of
made, steps would have been taken [0 protect the child from child abuse (64). Often, there is a pretestimony discussion with
additional abuse. Although the probability of a physician being child protective services counsel in family court cases or the
held liable under such circumstances is low, the amount of dam- district attorney's office in criminal cases. Such meetings should
ages can be high if the family does prevail when the child has preferably be in person, and the orthopaedist's professional train-
suffered permanent sequelae (38). ing and expertise are examined to determine whether he or she
After admission, the orthopaedist proceeds with care of the may serve as a material witness, an expert witness, or both. The
child's musculoskeletal injuries and coordinates various medical attorney should be provided the orthopaedist's curriculum vitae,
consultations. There should be frequent communications with and another copy should be made available to rhe court. If the
child protecrive services [0 stay current with the results of their orthopaedist is to serve as a material witness, the factual informa-
investigations. Recommendations for disposition of the child tion of the case as well as the limitations of the physicians' knowl-
after completion of medical treatment may be a group decision edge are discussed, as are questions that may be posed during
262 General Principles

testimony. Orthopaedists functioning as expert witnesses should if it identifies the abuser. Some states, however, restrict such
indicate televant infotmation that should be provided through testimony. In Maryland, a physician may not testify regarding
questioning duting testimony. In addition, anticipated testi- any disclosures made by a child abuse victim unless the disclosure
mony from any opposing expert witness and cross-examination is admissible under a recognized exception to the rule prohibiting
questions from the opposing attorney should be discussed. The hearsay evidence (46). The orthopaedist should ask about any
opposing attorney also may request an informal pretestimony possible restrictions on his or her testimony with the attorney
meeting. The orthopaedist should request a list of questions that in pretrial discussion. In testimony, the orthopaedist will want
will be asked in this session ahead of time and request that both to use the courtroom setting to advocate for the safery and well-
the prosecution attorney and the opposing attorney be present being of the child (64). Questions regarding medical findings
during the session, which is often recorded. The next step may will often be prefaced in the courtroom by the words "reasonable
be a deposition in which both attorneys question the witness medical certainty," a term that is poorly understood by most
under oath to "discover" the testimony that the witness will physicians. Chadwick (35) offered a definition of reasonable
provide in COutt. The primary purpose for a deposition in the medical certainty as "certain as a physician should be in order
discovery process is to keep attorneys from later being surprised to recommend and carry out treatment for a given medical con-
in court by testimony of witnesses (35). Preparations for deposi- dition." He offered an example that the certainty for the diagno-
tions should be meticulous. Any testimony the physician gives sis and treatment of leukemia must be much higher than that
during the deposition will be recorded, and later in court, any for diagnosis and treatment of a viral upper respiratory infection.
inconsistencies between testimony and prior depositions will be During testimony, the orthopaedist's words should be care-
vigorously attacked by attorneys in cross-examination. Deposi- fully chosen and should be understandable by a lay jury. Testi-
tions are rarely used in criminal prosecutions (64). mony should be objective, honest, and thorough (64). Attorneys
A subpoena is issued requiring a physician witness to appear may frame questions in ways that are difficult to understand,
at the courtroom at a certain time, but often there may be hours and the orthopaedist should not hesitare to ask the attorney to
of delay before the testimony actually begins. Through prior clarify a question (35). Answers should be brief, without volun-
arrangements with the attorney, the orthopaedist may be placed teering extra information, but the perception listeners will have
"on call" if he or she works within a reasonable distance of the of the answers should be carefully considered by the orthopae-
courtroom and can be available a short time before their actual dist. In particular, attorneys may phrase yes or no questions that
testimony is needed. The physician has no legal right to such could place misleading words in the mouth of the orthopaedist.
treatment and must be prepared to honor the exact conditions In such situations, when neither response is appropriate, the
of the subpoena if alternative arrangements cannot be made. If orthopaedist should answer in a sentence that provides an accu-
significant delays are encountered to giving tesrimony and the rate answer (64). Physicians are considered expert to the court
attorneys are nor responsive to physician hardship, then the or- because they have more information than is usual and custom-
thopaedist should contact the judge directly to remedy the situa- ary, and they are to provide the judge and jury with an unbiased
tion (35). In the courtroom, the orthopaedist should be conser- expert opinion (64). Language should be straightforward, and
vatively dressed and appear attentive, competent, poised, and at visual aids may be used in providing clear testimony. The expert
ease (35,64). should use testimony as an educational process for the court, in
Once called to the stand, the orthopaedist is sworn in and which the common experience and knowledge of the jury is
identified. Next follows qualification, direct examination, and used to build understanding with common sense explanations
then cross-examination. In the qualification process, the attorney of medical findings (35).
asks the physician fairly detailed questions about the orthopaed- Cross-examination by the opposing attorney follows direct
ist's training and background to establish whether he or she is examination. The opposing attorney's role is to challenge the
a credible witness (64). The attorney wishes to impress the judge material presented by the physician witness to protect the defen-
or jury with the orthopaedist's qualifications as a witness, dant (64). This may involve an attempt to bring into question
whereas the opposing attorney may challenge the witness with the physician's credibility, the medical record, the physician's
questions ro cast doubt on his or her expertise (35). During this training or expertise, or the physician's objectivity or composure
phase, the attorneys also may establish the limits of the physi- and clarity of thought before the jury (64). Attorneys may ac-
cian's expertise as an expert medical witness. Next, the attorney complish this by finding inconsistencies with prior statements,
will proceed with direct examination. A series of questions are asking leading questions as well as questions that allow only
asked that aim at developing a logical and progressive line of certain desired answers, and minimizing physician qualifications
thought leading to a conclusion (35). In child abuse cases, in (35). The attorney may frame a question that contains certain
particular, the testimony will lead to the fact that the abuse elements that the physician agrees with and others that are mis-
has occurred and that it has been appropriately diagnosed. In leading, and the question will often end with "Isn't that so,
addition, the physician expert witness may be asked to give an doctor!" The physician witness should be firm in answering such
opinion of the risk for subsequent abuse if the child returns to questions, clearly stating what in the question they agree with
the home where the alleged abuse occurred. Almost never will and what they do not. It is also common to encounter questions
the physician witness be asked about the guilt or innocence of from attorneys based on hypotheses that are extremely unlikely,
the caretaker accused of abuse, but the orthopaedist in certain and the physician needs to point out that unlikelihood (35).
circumstances will come close to answering the "ultimate ques- Part of the strategy of aggressive cross-examination is to provoke
tion" (35), by testifying about a child's statement of history the physician into arguments or unprofessional behavior that
 Chapter 7: Child Abuse 263

could discredit the physician or his or her testimony before the her child and arrange for a visit in which the mother's parenting
court. In panicular, juries will allow aggression on the part of strengths are assessed. Parents requiring additional suppOrt are
the attorney, but they expect physician witnesses to respond linked to community agencies and family resources 034,142).
professionaUy, even under extreme duress (64). Inexperienced Such suppOrt seems to enhance parent and child interactions,
potential physician witnesses can prepare themselves by ei~her and mothets report a diminished need ro punish or restrict their
watching trials or participating in mock trials (35). Brent (24) children. Antivictimization programs teach children certain con-
assembled an excellent series of vignettes of expert medical wit- cepts believed to facilitate self-protection, such as identification
ness case studies in court and provided detailed instructions with of strangers, types of touching, saying "no" to inappropriate
regard to the responsibilities of such experts. Both redirect exam- advances, and telling someone about inappropriate behavior.
ination and recross-examination may follow cross-examination Parenting education offers instruction in specific parenting skills
at the discretion of attorneys, but usually these procedures are such as discipline methods, basic child care, infant stimulation,
very short (35). child development, education, and familiariry with local suppOrt
services and introduction to other new parents in the community
Disposition Following Custody Hearings (56). Continuing abuse can be prevented by the orthopaedist's
prompt recognition of child abLise in the emergency departmenr
After a hearing or trial, the child historically either remained in
the protective custody of the state or was returned to the home, and appropriate intervention.
but the danger of further abuse exists in bmh siruations. In a .The most important issue in dealing with child abuse is (0
study of206 care and protection petitions brought to the Boston help both the child and the family through early recognition of
juvenile courtS (14), 31 % were dismissed with return of the the problem and appropriate therapeutic measures by all health
child to the parents. During a 2-year follow-up of these dismissed personnel. The failure to diagnose child abuse may result in
cases, 29% had reports of further misrreatment and 16% were serious injury to or death of the child.
returned to court under another care and protection petition.
One risk factor identified by the study was a previous appearance
in court. Half of dismissed cases with this risk factor returned ACKNOWLEDGMENTS
to COUrt again. Of the children ordered permanenrly ['emoved
from parental custody by the court, 6% returned to court with Special thanks is given to Jennifer Surber for technical assistance.
evidence of further abuse by another caretaker. Another alterna-
tive pathway of custody is gaining popularity with the court
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87: 1242-1258. fractures in young children: distinguishing accidental injuries from
141. Smecrs AJ, Robben SGF, Meradji M. Sonographically derecred costo- child abuse. Pediatrics 1991:88:1-476.
chondral dislocarion in an abused child. Pediatr Radiol 1990:20: 155. Tracy T Jr, O'Connor TP, Weber TR: Bartered children with duo-
566-567. denal avulsion and transection. Am Surgeon 1993;59:342-345.
142. Smirh PB, Poerrner J, Fields JD. Preventing child abuse and neglect 156. Touloukian RJ. Abdominal visceral injuries in bartered children. Pedi-
in rexas. Texas Med 1990:86:44-45. atrics 1968;42:642-646.
143. Smith FW, Gilday DL, Ash JM, Green MD. Unsuspected costo- 157. Wall J. Re AB (Child Abuse: Expert Evidence.) [1995] 1 FLR 181.
vertebral fractures demonstrated by bone scanning in the child abuse
158. Wasserman DR, Leventhal JM. Maltreatment of children born to
syndrome. Pediatr Radio11980: 10: 103-1 06.
cocaine-dependent morhers. Am] Dis Child 1993; 147: 1324-1328.
144. Sperry K, Pfalzgraf R. Inadvertent clavicular fractures caused by"chi-
159. Wilson FF. Estimarion ofage of continuous contusions in child abuse.
ropractic" manipulations in an infant: an unusual form of pseu-
Pediatrics 1977:60:750-752.
doabuse.] Forensic Sci 1995:35:1211-1216.
145. Sly JR, Starshak RJ. The role of bone scintigraphy in the evaluation 160. Wissow LS. Child abuse and neglecr. N Engl] Med 1995;332:
of the suspected abused child. Radiology 1983: 146:369-375. 1425-1431.
146. Steiner RD, Pepin M, Beyers PH. Studies of collagen synthesis and 161. Wolfner GD, Gelles RJ. A profile of violence toward children: a na-
structure in the differentiation ofchild abuse from osteogenesis imper- rional study. Child Abuse Neg11993: 17: 197-212.
fecta.] Pediatr 1996:128:542-547. 162. Young We. Sadistic ritual abuse: an overview in detecrion and man-
147. Strouse PJ, Owings CL. Fractures ofthe first rib in child abuse. Radiol- agement. Primary Care 1993;20:447-458.
ogy 1995: 197:763-765. 163. Zeiss J, Wycliffe ND, Cullen BJ, et al. Radiological case of the month.
148. Sullivan PM, Brookhouser PE, Scanlan JM, et al. Patterns of physical Am] Dis Child 1988:142:1367-1368.
and sexual abuse of communicatively handicapped children. Ann Otol 164. Zuravin SJ. Unplanned childbearing and family size: their relationship
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 FRACTURES AND DISLOCATIONS
OF THE HAND AND CARPUS IN
CHILDREN
THOMAS J. GRAHAM
PETER M. WATERS

OV RVIEW OF PEDIATRIC HA D I JURI ES T riquerral Fractures

Epidemiology Hamate Fractures
Praerical Anatomy of rhe [mmarure Hand Pisiform Fractures
Evaluation of Pediatric Hand Injuries Luna te Fractures
General Principles of T reatmenr Perilunar Injuries
Complicarions Lunaromalacia or Kienbock's Disease
Trapezium Fractures
SPECIFIC FRACTURES OF nu. P DIATRIC HANIJ
Soft Tissue Injuries About the Carpus
Fractures of the Phalanges
Fracrures of the Metacarpals
DISLOCATIO S OF THE HA 0 AND CARPU
ARPAL INJURIES IN CHILDRF. Dislocations of the Inrerphalangeal Joinrs
General Principles Dislocations of the Carpomeracarpal Joints
Specific Carpal Fractures Dislocations of the Carpus
Capitate Fractures Dislocation of the Distal Radioulnar Joinr

OVERVIEW OF PEDIATRIC HAND occur (18,104,234,235). This is why injuries of rhe hand and
INJURIES wrisr are among rhe mosr common in rhe skelerally immature
popularion (88, I 04,232). They accoum for up (Q 25% of frac-
For the growing child, the hand is rhe primary insrrumenr of rures recorded in pediarric popularions (Table 8-1).
protection, social interaction, and discovery. Therefore, it is not
surprising that it remains one of the most ftequently injured
pares of the body in children. The recognition and appropriate Biphasic Distribution of Pediatric Hand Fractures
rreatmenr of these injuries have immediate and long-ranging
Fractures of rhe hand have a peal< incidence in the adolescent
effects on the child's abiliry (Q participare in sociery.
age group. The mosr common mechanism of injury in this age
group is from participation in spores. The second peak is in the
Epidemiology toddler age group secondary to crush injuries (12,70,104,127,
234,235).
Overall Incidence The prevalence of rhese injuries increases sharply after rhe
Several faCtors combine to make the pediarric hand vulnerable eighrh year 104,234,235). This may be due co rhe changing
to injury. Among these are the usage pattern of this relarively balance berween injury-resisrant canilage and bone in rhe matur-
exposed appendage and the child's curiosiry abour the surround- ing hand, and rhe fact that children participate more aggressively
ing world. Youngsrers are often profoundly ignoram of rhe dan- in conract spons around this age. The number of hand fractures
gers in rheir environment, even ar home, where mosr injuries in children peal<s around age 13, which coincides with adoJes-
cems in organized conran spons (Fig. 8-1).

Thomas J. Graham: Curtis National Iland Center, ;lnci Deparrmenr of At-Risk Population
Orthopaedic Sorgery, Union Memorial Hospital. Baltimore, Maryland.
Peter M. Waters: Department of Orthop~cdic Surgery, Harvatd School of Worlock and StoweI' (235) conducred a true incidence study of
i'.1cdicine and Children's Hospital, Boston, MassachusettS. pediarric hand fracrures in Nottingham, England, by carefully
270 Upper Extremity

is the most commonly dislocated joint in the immature hand

TABLE 8-1. INCIDENCE OF PEDIATRIC HAND
(84,130).
INJURIES
Fracrures of the phalanges outnumber metacarpal fractures.
Peak age: 13 years The right and lefr hands are equally affected by skeleral trauma.
Annual incidence: 26.4 per 10,000 children
The border digits (index and small fingers) are the mosr com-
Percentage of all pediatric emergency patients: 1.7%
Right side incidence equals left monly injured rays (I 8,104,234,235). More boys than girls pres-
Male incidence is greater than female incidence em with hand fractures.
Most common areas
Nonphyseal: distal phalanx (crush)
Physeal: proximal phalanx
the index and small fingers are more commonly fractured Incidence of Physeal Fractures
Pathologic forces may be transmitted through rhe physis in a
child's hand, because this often is the path of least resistance.
Injuries involving the physis are less common than extraphyse,ll
fractures. The prevalence of physeal injuries in the hand varies
defining the at-risk popularion. They projected an annual inci- From 10% to almost 40% in rhe reponed series (104,127,138,
dence of 26.4 fractures per 10,000 children. Bhende et al. (18) 198,234,235). S-H II fractures predominate in all reporrs. The
reponed their experience in a busy pediatric emergency deparT- proximal phalanx is rhe most commonly injured single bone,
ment in Pittsburgh, Pennsylvania. A tOtal of 27,294 parients involved in about 70% of patienrs. The small a.nd thumb rays
were seen in a 6-month period ar their center, of which 464 are the mosr commonly injured (roughly 40% and 30%, respec-
(1.7%) had a final diagnosis of "hand injury." Eighty-seven pa- tively) (04).
tienrs susrained 92 fractures. Those sustaining skeletal trauma
were significantly older than the rest 01.5 years vs. 8.25 years).
A thletic Injuries
Incidence of Specific Fractures Second to the home, playing fields and school settings are the
There is disagreement about which is the most common fracture most common sites of injuries for children. American football
in the child's hand. Some researchers cite the distaJ phalanx is the predominanr contributor to athletic hand injuries. Skiing
crush injury as the most frequent (88); others recognize the is well known for causing ulnar collateral ligament (UCL) inju-
Salter-Harris (S-H) II fracrure of the proximaJ phalanx base ries, or the bony equivalent, at the thumb MCP joint (21,37,
(I 04,234,235). Many pediatric hand injuries occur about the 76). Pediatric hand injuries have been reported in almost every
metacarpophalangeal (MCP) joint (50,214). Dislocations of the sport, including boxing, swimming, soccer, and gymnastics (40,
pediatric hand are relatively uncommon injuries. The MCr joint 76,85,104,138,182,226,240) .

400

300
361
•MALES

FEMALES

200

3-4 5-6 9-10 11-12 13-14 15-16

FIGURE 8-1. Total number of fractures of the hand, 1970-1975, Malmo, Sweden. (Reprinted from
Landin LA. Fracture patterns in children. Acta Orthop Scand Suppl 1983;202.54; with permission.)
 Chapter 8: Fractures and Dislocations of the Hand and Carpus in Children 271

Practical Anatomy of the Immature Hand 15 months and 14 years, respectively. The appearance of rhe
secondary ossification centers of the middle and distal phalanges
Adults and children have different patterns of hand injury be-
lags behind by 6 ro 8 monrhs, bur fusion occurs at the same
cause of different usage parrerns and the unique character of the
time as that of the proximal phalanx. The epiphyses of the smal1
child's skeleton and soft tissues. Knowledge of physeal architec-
finger phalanges appear later than rhose of the orher rripha-
ture, soft tissue origins and insertions, and the influence of the
langeal digits (index, long, and ring fingets).
strong ligaments and the periosteum is helpful in recognizing
At the metacarpal level, the secondary ossification cenrers
and ueatingchildren's hand fractures. In this section, the skeletal
appear distally in the index, long, ring, and small rays at 18 ro
articular anaromy of the immature hand is described, with spe-
27 months in boys and at 12 ro 17 monehs in girls. The proxi-
ci:1I emphasis on structural relationships and their influence on
mally located thumb metacarpal secondary ossification ceneer
mechanics. In later pans of rhis chapter, the relcvJnt pathologic
appears 6 to 12 momhs after its counterparrs in the fingers.
anaromy is covered as specific injuries are discussed.
These secondary centers fuse at the metacarpal and phalangeal
levels at the same time, about 14 ro 16 years.
Osseous Anatomy
Phylogenetically, rhere are porenrial epiphyses at both the proxi-
mal and distal ends of all rhe tubular hand bones. However, Physeal Anatomy
secondary ossification ceneers develop only at the disral ends of
The microscopic anatomy of the physis and its influence on
the metacarpals of rhe index, long, ring, and small rays, and fracture geometry have been the focus of intense study. The
proximally in the thumb. Conversely, the secondary centers of
zones of the physis have distinct morphology and molecular/
ossification are manifested only at the proximal ends in all digirs
chemical composition that contribute to the unique biomecha-
(95,211).
nics of fracture propagation in the skeletally immature patient
(31). Although there is an expanded discussion in Chapter 5,
Secondary Ossification Centers some characteristics of physeal injury specific to the hand are
In boys, rhe proximal phalangeal secondary ossification cemer presented here.
appears ar 15 ro 24 momhs and fuses at 16 years (Fig. 8-2) (95, The zone of chondrocyte hypertrophy (zone Ill) is the least
211). In girls, the appearance and fusion occur earlier, at 10 to resistant ro mechanical stresses. It is devoid of the inherent stabi-
lizing properties of collagen maintained in juxtametaphyseal
zones I and II or the calcium presenr in zone IV (88,215). There-
fore, the fracture often involves zone III as the path of least
Middle and distal phalanges reslStance.
A 16-36 mos Near skeletal maturity, the irregularity of the physeal zones
F 14-16 yrs increases (31). Thus, a fracture line may actually be transmitred
through several zones. This variable path through irregular ro-
pography may contribure to the phenomenon of parcial growth
arrest seen with fracrures involving the physis.
Furthermore, the pattern of physeal injuries appears ro be
somewhat age dependent. Intraarricular epiphyseal fractures (S-
H ][1 or IV) are more prevalent as the child nears skeletal matu-
Metacarpal head
riry; SoH I and I1 fractures that leave the epiphysis intaCI are
A 12-27 mos more likely ro occur in younger patients (90,232).
F 14-16 yrs
(small digit later) The high level of metabolic activity about the physis is fueled
by a rich blood supply that is particularly well suited ro resist
injUlY and combat future growth disturbance. The generous per-
fusion of the physis and epiphysis from both periosteal and endo-
chondral vessels probably contributes ro the maintenance of nOt-
mal growth patterns after fracture. The ability of these vessels
to maintain blood supply even after significant displacement of
fracrures has been consistently demonstrated.

Pseudoepiphyses and Double Epiphyses

A persistent expression of the distal epiphysis of the thumb meta-
carpal is called a pseudoepiphysis (97). The pseudoepiphysis
appears earlier than its standard counterpans, then fuses rapidly.
By the sixth or seventh year, ir has been incorporated and is
FIGURE 8-2. Appearance of secondary ossification centers (A). Fusion inconspicuous. Pseudoepiphyses also have been noted at the
of secondary centers to the primary centers (F). proximal ends of the finger metacarpals, usually of the index
272 Upper xrremitJ

of the relative pauciry of supporting strucwres aligned to resist

these forces. The physes are unprotected by the collateral liga-
ments, volar plate, and mechanically weak extensors. The flexor
tendons provide only a modicum of protection, and also may
propagate the fracture through the physis, especially in the termi-
nal phalanx (196).

Tendons
As a rule, extensor tendons insert ontO epiphyses. The terminal
tendon of the digital extensor mechanism and the extensor pol-
licis longus both insert on the terminal phalangeal epiphyses of
their respective rays. The central slip of the extensor digirorum
communis terminates ontO the dorsal aspect of the epiphysis of
the middle phalanx. Likewise, the extensor pollicis brevis insem
011[0 the epiphysis of the proximal phalanx of the thumb.
The thumb abductors-the abductor pollicis longus and bre-
vis-have more broad-based insertions 011[0 the epiphysis and
A,S C metaphysis of the first metacarpal. The multiple slips of the
FIGlJhE 8-3. Abnormal epiphyseal appearance. A: Double epiphysis. abductor pollicis longus vary in number and have insertions 011[0
B: Pseudoepiphysis. C: Notched epiphysis. the bone, capsule, and fascia of the thenar eminence.
The digital flexor tendons-the flexor digitorum profundus
and the flexor pollicis longus-insert at the metadiaphyseal re-
gion of their respective terminal phalanges. The flexor digirorum
superftcialis insertS OntO the central three fifths of the middle
ray. Ics only clinical significance is that it must be differenriatcd
phalanx.
from an acute fracture (Fig. 8-3).
A "double epiphysis" can be seen in any bone of the hand,
but these anomalies are more common in the metacarpals of the
index finger and thumb. There are variable expressions of the Collateral Ligaments
double epiphysis, but the true emiry must be considered only Interphalangeal
when a fully developed growth mechanism is present on both At the imerphaJangeal joint level, the collateral ligaments origi-
ends of a tubular bone. The double epiphysis must be delineated nare from the collateral recesses of the phalangeal head, span the
from the pseudoepiphysis or metaphyseal "notching" (57,97, physis, and insert onto both the metaphysis and epiphysis of the
221,233). middle and disral phalanges (Fig. 8-4). This accounts for [he
The double epiphysis is usually seen in children with other rarity of lateral SoH III injuries at [he interphalangeal joints.
congenital anomalies, but its presence does not appear to influ- The collaterals also insert onto the volar plate, which also spans
ence bone growth appreciably. When fractures occur in bones the interphalangeal joints. This three-sided box protects the
with a double epiphysis, growth of the involved bone appears physes and epiphyses of the interphalangeal joints from laterally
to be accelerated (233). Peripbyseal notching can be confused directed forces (50).
with trauma or the double epiphysis. The location of the notches
can coincide with the physis or may be slightly more distanr
from the epiphysis. Notching is a benign condirion that should Metaca.rpophalangeal Joint
not influence the structural properties of the bone to a clinically At the MCP joint of the fingers, the colJateralligamenrs originate
significanr level (233). from the metacarpal epiphysis and insert almost exclusively onto
the epiphysis of the proximal phalanx (Fig. 8-5). This anatomic
arrangement accounts for the frequency oflateral SoH III injuries
Soft Tissue Anatomy
at the MCP level. Some fibers may originate from the distal
The marerial strength of the child's soft tissues to withstand metaphysis of rhe metacarpal, bLl[ rhis represents only a minor
tensile forces often exceeds that of the adjacent physis and epi- and variable component of the Jigamenr's substance. The liga-
physis (156). For this reason, ligament ruptures and tendon avul- mentous anaromy about [he thumb MCr joint mos[ closely
sions occur less often in children than physeal or epiphyseal resembles chat of the inrerphaJangeaJ joinrs because of its growth
fractures. cenrer arrangement.
Knowledge of the relationships between the bony elements The anatomy of the supporting structures at the Mer level
and supporting soft tissues in the pediatric hand has been en- accounts for the high percentage of SoH II and III fractures
hanced by cadaver dissections of skeletally immature specimens ar this level. The physis is relatively unprotected by soft tissue
(24, J02). The coJJateral ligaments, volar plate, and mechanically restraints, and therefore muSt rely almost solely on the inherent
weak extensors provide little protection for the physis, because stability of rhe physis to resist frac[ure forces.
 Chapter 8: Fractures and Dislocfltiom of the HtlIltl and Carpus in Children 273

A I ; \
B
FIGURE 8-4. The anatomy of the collateral ligaments at the distal (A) and proximal (B) interphalangeal
joints. The collateral ligaments at the interphalangeal joints originate in the collateral recesses of the
juxtaepiphyseal region and insert into both the metaphyses and epiphyses of their respective middle
and distal phalanges. Additional insertion into the volar plane (arrows) is seen at these levels.

Other Soft Tissues

Volar Plate
The volar plare, a swur srabilizer of rhe interphalangeal joint
and MCP joint, is particularly well suited ro resisr hyperexten-
sion forces. Irs origin is from the volar metaphysis of the respec-
tive proximal digital segment (Fig. 8-4B). The volar plare inserrs
OntO the epiphysis of rhe distal segment. The plate itself receives
insertional fibers from the accessory collateral ligaments, which
are best developed at the proximal interphalangeal (PIP) joint.

Periosteum
Litde had been written about the specific role of the periosreum
in the stabilization of fraCEures in the tubular bones of rhe hand.
Because ir is so well developed in the child's hand, it can be a
significant asset or liability in fracmre management. It can mini-
mize displacemenr of rorsional fractures of the diaphysis and
may aid in maintaining the stability of orher reduced fractures.
Conversely, the rhick periosreum can become interposed be-
rween displaced fracture fragments, rhus preventing an effec(ive
closed reducrion.

Evaluation of Pediatric Hand Injuries

Unique Challenges
Many factors make rhe injured child uncomfortable, including
pain, the novel surroundings, and "whire coa(" fear. He or she
may temporarily refuse to offer either the injured or uninjured
hand for examination. Patience and minimizing the contribuwrs
to anxiety are essential. The child's hand posrure and movements
FIGURE 8-5. The collateral ligaments at the metacarpophalangeal
joint both originate and insert almost exclusively on the epiphyseal can be observed ro gain clues about the location and severity of
regions of the metacarpal and the proximal phalanx. the injuries by watching rhe child interact with the environment.
274 Upper Extremity

In addition to performing a standard, comprehensive examina- Persistent limitation of active motion in a child usually means
tion of the upper extremity, nontraditional methods of assess- that significant bony or soft tissue injury is present. Stability of
ment may be needed in children, such as an assessment of tendon each joint in question should be assessed in a systematic fashion.
function by having the child grasp the examiner's pen. It often Collateral ligament integrity should be checked by stressing the
is helpful to examine the uninjured hand first to familiarize the Mcr and interphalangeal joints in both 30 degrees of flcxion
child with the techniques of examination. and full extension. If the amount of deviation resulting from
Many factors may be at work to make interaction with the stress on a particular joint is markedly different from the adjacent
involved adults another obstacle to effective examination. These digit or the same digit on the contralateral side, the stabilizing
range from guilt over the injury to the rare child abuse issues. structures may be injured. Likewise, the quality of the end point
Calming the adults pays dividends: more information can be determined on stress examination can be an important clue to
gained, and a cooperative parem can help the physician commu- the degree of tissue disruption.
nicate with the child.
Volar Plate Integrity. Integrity of the volar plate is assessed
by hyperextension of the joint. A significant increase in passive
Tissues Are Unique
extension compared with an adjacent or the contralateral digit
Small Structures usually indicates a volar plate injury that requires immobilization
The hands of the child are much smaller than those of the exam- in flexion.
iner, making precise palpation and some diagnostic maneuvers
difficult. Stress Testing ofa DislocatedJoint. Stress testing of the relo-
cated joint also is important in determining further treatment.
Loose Areolar Tissue A functional relocation test can be performed to determine the
The loose areolar tissues and generous fat of the child's hand, range of motion through which a relocated joint is stable. Active
especially on the dorsal aspect, can hide significant deformity range of motion of the digit is performed by the patient, and
and swelling. the congruence of the reduction can be assessed clinically and
radiographically. Motion of the joint should be painless jf the
Physiologic Hyperelasticity anesthetic block has been successful. If the digit is prone to
Many children maintain a physiologic hyperelasticity that would subluxation or tedislocation in a narrow range of active motion,
be judged pathologic in most adults. However, joint stability the need for operative intervention or long-term immobilization
and proper tracking of congruous articulations should not be must be consideted.
affected by this. Therefore, it is important to conduct a compari-
son examination of the contralateral side when injury to a stabi- Neurovascular Injury. One clue to possible nerve injury is ex-
lizing structure is being considered. cessive bleeding at the time of the original injury or during
evaluation in the emergency departmenr. Because of the proxim-
ity of the digital artery to the digital nerve, there is a high concor-
Clinical Examination
dance between extensive pulsatile bleeding and laceration of the
The examination begins immediately on entering the room, digital nerve.
when the child's level of comfort, hand posture, and exrremity
use pattern has not been altered by examination. Neurologic Evaluation. It is particularly difficult to determine
sensory function in a young child. Meaningful objective data
Basic Examination are difficult to obtain, and gross observations, such as withdtawal
The physician should look for swelling, ecchymosis, deformity, to stimuli, are inadequate grounds on which to base therapeutic
and obvious open injuries. The uninjured hand has a normal decisions. A helpful examination maneuver to assess nerve integ-
cascade of semi-flexed digits; deviation from this posture may rity is the wrinkle test. Immersion of a normally innervated digit
indicate injury. For examples, digital flexor tendon lacerations in warm water for up to 5 minuces results in corrugation or
or mal rotated fractures interrupt the cascade. wrinkling of the volar skin of the ruft. This finding is absent in
Palpation for tenderness should be anatomically specific to a denervated digit. The wrinkle test also can be performed simply
increase diagnostic accuracy. Another valuable diagnostic tool is by observing the digit as it soaks in the solution as part of the
osseous percussion to assess for fractures. However, it is best to preoperative preparation.
defer these potentially painful maneuvers to the later stages of Objective sensibility testing requires patient cooperation and
the examination. maturiry. For example, two-point discrimination is a learned
test. Techniques to increase its validity would be performance
Dynamic Evaluation of repeated trials, testing of multiple uninjured digits, and use
Range ofMotion. Range of motion should be measured and of the test only in children over 5 years of age. There is no role
recol:ded. The integrity of extrinsic flexor and extensor musculo- for pin-prick or sharp sensation testing in a young child.
tendinous units can be assessed by observing the excursion of
the digits with wrist flexion and extension (the tenodesis effect). Sedation and Anesthesia. After nerve function has been ade-
The digirs should extend with wrist flexion and flex as the wrist quately assessed and documented, conscious sedation or local
is extended. anesthesia may be worthwhile to perform reduction maneuvers,
 Chapter 8: Fractures and Dis/ocrttiollS of the Hand and IOPUS in Children 275

assess joint laxity or tendon integrity, explore wounds, and apply spontaneously between 8 and 14 years of age (Fig. 8-6). This
splints. If the patient is relaxed and pain ftee, the opportunity entity can be confused with an acute fracture or epiphyseal sepa-
to effect good ftacture care is enhanced. The specific protocols ration, but the histolY, the clubbed appearance of the affected
for using analgesic agents, conscious sedation, and local or re- digit, and bilaterality would argue against an acute cause (63).
gional anesthesia are discussed in Chapter 3. Trigger thumbs in young children are sometimes mistaken for
interphalangeal joint dislocations because of the fixed flexion
Radiographic Examination posture of the interphalangeal joint. Attempted reductions are
painful and do not resolve the problem. The key diagnostic
Special Considerations feature of the trigger thumb is the palpable nodule at the Al
A careful clinical evaluation is the prerequisite for conducting pulley region.
propel' radiographic examination. This is especiaUy true in the
multiply injured hand, in which cateful localization of areas Thermal Injury
of tenderness or deformity can direct a thorough radiographic Thermal injury to the growing hand (frostbite, burns from flame
assessment. Several imaging factors can mal<e it difficult to ob- or radiation) can cause bizarre deformities from alteted apposi-
tain information necessalY fot a cotrect diagnosis and effective tional and interstitial bone growth. An ischemic necrosis of the
treatment. physes and epiphyses can result (Fig. 8-7). The clinical result
can be manifested by bone width, length, or angulatory growth
Lack of Osseous Detail
disturbance due to the unpredictable effect on the growing ele-
Knowledge of the age-specific morphology of the hand and wrist
ments (98,159).
bones is essential. In addition, an appteciation of the telation-
ships of the ossific nuclei to each othet can allow recognition of
Osteochondrosis (Thiemann's Disease)
physeal fractutes or soft tissue injuries that may produce only
Epiphyseal narrowing and fragmentation can be a characteristic
subtle widening of the interosseous spaces or small angular varia-
of Thiemann's disease, thought to be an osteochondrosis of the
nons.
phalangeal epiphyses. This hereditary entity usually involves the
Normal Variants midcUe and distal phalanges and typically resolves without ag-
Irregularities and normal variants are relatively common in the gressive treatment, although some permanent joint deformity
young hand. Imaging of the contralateral, presumably unin- has been reponed in some patients (52,191).
jured, side usually is the most effective way to resolve many of
the questions that arise in interpretation of the radiographs of a Tumors
traumatic injury. A familiarity with some of the better recognized Benign ganglia of the wrist and hand may cause limited motion,
variations also helps to detetmine whether skeletal injury is pres- pain, and obvious swelling. Generally, clinical examination of
ent. The examiner should not hesitate to consult an atlas of child the ganglion of the affecred joint or CYSt of tendon sheath is
development and normal radiographic variants (95,211). diagnostic. Radiographs are typically normal excepr for the soft
tissue changes.
Plain Radiographs The rare bone, cartilage, or muscle malignancies of the hand
Anteroposterior (AP) , lateral, and oblique radiographs usually have a much firmer consistency to palpation. Radiographs reveal
are needed to evaluate the injured hand or digit completely. the bony changes in an osteogenic sarcoma and may demonstrate
Oblique views are patticularly useful in assessing intraarticular periosteal reaction in an adjacent rhabdomyosarcoma.
ftactures. Specialized views for detailing particular anatomic
areas can compliment the standard hand and wrist series. Inflammatory and Infectious Processes
A common pitfall in treating children's finger fractures is Dactylitis from sickle ceJl anemia can masquerade as either an
failing to obtain a true lateral film of the injured digit. Overlap infectious or ttaumatic process. Historical evidence of sickle cell
of the adjacent fingers must be overcome by isolating the digit disease in the patient or family and the characteristic fusiform
or splaying the fingers. digital swelling indicate this pathology.
Stress views are now rately used for evaluation of ftactures. The inflammatoty arthropathies (juvenile rheumatoid arthri-
With the advent of low-radiation mini-fluoroscopy units, real- tis, scleroderma, systemic lupus) may cause joint effusion or
time assessment of articular congruity and joint stability tenosynovitis that can be confused with trauma.
thtoughout a motion arc can be conducted. An infectious process often can be mistal<en for a traumatic
one, but local and systemic evaluation usually makes this distinc-
Differential Diagnosis tion evident.

Nontraumatic entities are often interpreted as acute injuries.

These entities are rare but may cause swelling, deformity, and General Principles of Treatment
limited range of motion. Nonoperative Management
Congenital Most children's hand fractutes heal without complications.
In 1927, Kirnet (116) described palmar and radial curving of the Many do not require reduction, and brief immobilization is
terminal phalanx of the small digit distal phalanx that occurred sufficient. Minimally displaced fractures without malrotation
276 Upper Extremity

A B

c
FIGURE 8-6. A and B: A 12-year-old boy presented with incurving of the tip of the right small finger.
The anteroposterior and lateral radiographs show radial and palmar incurving of the distal phalanx,
characteristic of Kirner's deformity. C: Two years later, healing has occurred, but the deformity has
persisted.

can be treated with closed reduction and immobilizarion for 3 finger traps is poorly rolerared in children. Furrhermore, ir is
to 4 weeks. difficulr to find a size match that permirs adequare disrracrion.
Ske1eral traction is rarely useful in rreating fractures of the hand
Pain Control in a cbild.
Conscious sedation, careful regional anesthesia, or even general
anesthesia should be considered to facilitate reduction and appli-
cation of immobilizarion. The choice of anesthesric technique Gentle and Prompt Manipulation
is age dependem. Digital block administered ar rhe level of rhe The likelihood ofiarrogenic physeal injury substamially increases
metacarpal head frequenrly is used for fracture reduction in chil- with repeated, forceful manipulations. Likewise, late (more than
dren and adolescems. Axillary blocks, hematoma blocks, and 5-7 days) manipulation of a periphyseal fracwre should be
rapid fracwre manipulation withour anesrhesia should be avoided. Prompr reducrion is advisable unless anesthesia is con-
avoided in young children. traindicated. In the acute period, swelling is ar irs minimum,
reducrion is more easily performed, and immobilizarion can be
Traction more effecrively applied. Swelling irself is nOt an indication to
Skin or skeleral rracrion has lirrle role in rhe rrearmenr of chil- postpone fracture care; fracture reducrion is rypical1y the best
dren's hand fracwres. Applicarion of external devices such as way to comrol swelling and deformiry.
 Chapter 8: Fractures and Dislocations of the Hand and Carpus in Children 277

tempt to "escape," so long arm immobilization in a "boxing

glove" or "mitten" cast is important to prevent loss ofimmobili-
zation. The use of rigid materials other than accepted casting
materials (e.g., tongue blades, aluminum splints, arm boards) or
wrapping the hand and digits around rolls of tape or gauze
should be discouraged.

The Safe Position

Like the adult hand, the child's hand should be placed in the
correct position for immobilization, the "safe position." Maxi-
mal MCP flexion with extension of the interphalangeal joints
places the collateral ligaments at their maximal length and helps
prevent contracture. However, the likelihood ofMCP joint con-
tracture is small in children.

Follow-up Frequency
Nondisplaced fractures that were simply immobilized can be
reevaluated at 3 ro 4 weeks when the cast or splint is discontin-
ued. Fractures that required reduction or specialized immobiliza-
tion should be evaluated weekly to ensure that reduction has
not been lost. Because children's hand fractures heal rapidly,
close follow-up, especially in the first 7 to 14 days, is necessary
to detect displacement before it is too late for closed correction.

Surgical Management
Meticulous Soft Tissue Handling
As in all hand surgery, gentle tissue handling is mandatory. Care-
ful handling of the thick periosteal layer is important, because
creation of periosteal flaps, later sutured back anaromically, en-
FIGURE 8·7. An 11-year-old girl sustained a frostbite injury to the right
hances healing and remodeling. The periosteal layer also provides
hand at age 5 when she lost her mitten. There has been premature an excellent cover for implants and is a good sliding surface,
fusion of the physis of the middle and proximal phalanges and widen- allowing smooth tendon excursion.
ing and irregularity of the bases of the shortened phalanges. Although
not demonstrated in this photograph, the thumb has been spared, be-
cause it is usually enclosed in the hand while the child is exposed to Preservation of Growth Potential
the elements.
Careful manipulation of and around the physis is of obvious
importance. Excessive tissue stripping at this level should be
avoided. Thoughtful consideration of whether the physis needs
to be exposed to effect fracture reduction, and whether it should
Postreduction Management be crossed by an implant, is warranted. The smallest diameter
Types of Immobilization nonthreaded wire that effectively holds the fragments should be
Immobilization is best applied when the child is under the influ- used. Wires are left in only 3 to 4 weeks, so they should be left
ence of the sedative or anesthetic used for fracture teduction. protruding (bur protected) for easy removal.
An appropriate amount of cast padding material should be ap- Implant choices must be individualized to the fracture pattern
plied. Too much padding renders the splinr or cast ineffective and to the patient's size. Smooth wires, tension bands, and mini-
in conrrolling the reduction, but roo little may lead to skin screws are preferred over larger implanrs in children. For most
compromise from thermal injury or pressure. The risk of com- fractures requiring fixation, smooth wires are the implant of
partmenr syndrome may be decreased by the use of splints rather choice.
than circumferential casts.
For fractures of the phalanges and metacarpals, immobiliza- Postfracture Care
tion of the injured digit with at least one of the adjacent digits Formalized therapy rarely is necessary in children. Simple libera-
is advocated. The axiom "Never immobilize a single digit" tion from immobilization and instructions ro the patient and
should be followed. Below-elbow (shorr arm) immobilization is parents regarding range of motion, strengthening, and activity
acceptable, provided cooperation is reasonable. For more proxi- return usually are sufficient. In rare circumstances (complicated
mal ftactures or fractures in very young children (under age fractures, multiple trauma, or failure ro achieve desired func-
3-5), long arm immobilization is necessary. Children will at- tional results in an appropriate time period), formal hand ther-
278 Upper Extremity

apy may be indicated. If corrective splinting is to be used, the Surgical Anatomy

child and caregivers must be comfortable with its application and
The skin, nail elements, soft tissues, and bone of the distal digit
use. Serial static splinting may be preferred to patient-adjustable
are closely related (Fig. 8-8). The dorsal periosteum of the distal
dynamic splints.
phalanx is the underlying nutritional and Structural suppOrt for
the sterile matrix or ventral nail. The germinal matrix, made up
of the dorsal and intermediate nail, is responsible for generating
Complications the nail plate. The volar aspect of the distal phalanx anchors the
The clinician should not be nonchalant about any aspect of the pulp through tough, fibrous septae that stabilize the skin againsr
child's treatment simply because the pediatric hand is so forgiv- shear forces. The terminal extensor tendon inserts onto the epi-
ing ill its abilicy to remodel and regain motion. Recognition of physis of the distal phalanx. The Hexor digitorum profundus
the porential pitfalls is important, as is the development of a bypasses the physis to insert ontO the metadiaphysis of the distal
systematic plan for rectifying complications if they occur. phalanx.

Mechanism of Injury
Pitfalls to Avoid
The two primary mechanisms of injury about the distal phalanx
Failure to Appreciate the Severity of Injury are crush trauma and hyperfJexion force.In a crushed fingertip,
A complete set of high-quality radiographs should be obtained; the soft tissues are injured and the bone is fractured. Conversely,
with the surgeon accompanyi1ng the child to the radiographic if violent forced Hexion is exerted on the extended distal phalanx,
suite if necessary. Contralateral views should be obtained as there is a greater potential for bony injury of the dorsal epiphysis.
needed, and normal variants identified. The spectrum of injury produced by both these mechanisms
Specific problem fracrure patterns (phalangeal neck, inter- varies. Many crush injuries result only in minor tissue disruption
condylar, osteochondral "slice," or any mal rotated fracture of and need little or no intervention (Fig. 8-9), whereas other inju-
the rubular bones) need to be recognized to select appropriate ries may require bony fixation, meticulous nail bed repair, and
treatment. skin coverage.
Mallet injuries result from an axial loading or flexion force
Inadequate Postreduction AJignment applied to the extended tip of the finger. Although the underly-
Radiographs after reduction must be scrutinized for subtle hints ing pathology can be variable, the digit usually is flexed at the
of maJalignment or associated injuries. The reduced digits should distal interphalangeal (DIP) joint and active extension is impos-
be checked for malrotation by evaluating the plane of the finger- sible.
nails with the fingers semifJexed or with the tenodesis maneuvers
previously described. Restoration of length, particularly in frac- Fracture Patterns
tures of the metacarpals, is best evaluated with radiographs, but
clinical foreshortening of the ray may be the first clue to ma- Fractures of the distal phalanx can be divided into those that
Ireduction. are extraphyseal and those that are physeal (Table 8-2).

Overdependence on Remodeling Extraphyseal Fractures

Although remodeling in rhe immature skeleton is extensive, it
Extraphyseal fractures of the distal phalanx are common and
is not a substirute for inadequate treatment (I 62). Bony remod-
can take the form of a simple distal tuft fracture or an unstable
eling occurs in the AP plane, especially in younger patients and
diaphyseal fracture underlying a nail bed laceration. They can
injuries close to the physis. Correction of medial-lateral malal-
be divided into three cypes (Fig. 8-10).
ignmenr is much more limited, except at the Mcr and carpo-
A transverse fracture (Fig. 8-10A) may occur either at the
metacarpal (CMC) joints, where multiplanar motion exists. Lit-
distal extent of the terminal phalanx or through the diaphysis.
tle, if any, rotational remodeling should be performed.
Distal fractures are separations between the diaphysis and the
most disral extent of the phalanx and also can include a series
of radial fracture lines propagating through the distal tuft. Trans-
verse fractures through the diaphysis are almost always associated
SPECIFIC FRACT RES OF THE
with a significant nail bed injury.
PEDIATRIC HAND
A longitudinal splitting of the nail tissues and bone (Fig. 8-
Fractures of the Phalanges lOB) is much less common. This pattern is the result of excessive
hoop stress when the tubular distal phalanx is subjected to crush-
Injuries of the Distal Phalanx
ing forces. The "cloven-hoof' appearance of the fracture is char-
The terminal aspect of tbe digit is among the most frequent acteristic (Fig. 8-11). The fracture can be completely contained
sires of injury in children. The distal phalanx and irs accompany- wirhin the shaft or can continue to be propagated through the
ing soft tissues are relatively unprotected and are offered by the physis and even into the joint (12).
curious child as a first contact with the environment. Comminuted fractures take the form of semilunar separations
 Chapter 8: Frnctllres alld DisLocations of the Hand and CarpllS in hiLdren 279

Distal phalanx

Sterile matrix

Nail-.....-f--i
folds
Germinal
Terminal extensor tendon Dorsal nail
Intermediate nail
> Germinal matrix

·~ij~~::~!~~~~;I~~~i~N~a~i~1p~l~a~te~~~~Jv~e~n:tral
matrix

(sterile matrix)
tI:::~::T-t-- Terminal nail
DIP -+:::;::::::1. tendon

Lateral
::=~1\ffi-+- Triangular
band
ligament
Spiral
oblique
retinacular
ligament Fibrous septae

A Flexor digitorum profundus B

FIGURE 8-8. Anatomy about the distal phalanx. A: The skin, nail. and extensor apparatus share a close
relationship with the bone of the distal phalanx. Specific anatomic structures at the terminal aspect of
the digit are labeled. B: This lateral view of the nail demonstrates the tendon insertions and the specific
anatomy of the specialized nail tissues.

A B
FIGURE 8-9. A and B: Crush injury to the fingers of a 4-year-old in which the lacerations were closed
by primary repair; only minimal nail bed repair was necessary. Of concern is the depth of the laceration
about the germinal matrix tissue. Meticulous repair must be undertaken in this area, as well as at the
sterile matrix level.
280 Upper Extremity

TABLE 8-2. CLASSIFICAnON OF FRACTURES

OF THE DISTAL PHALANX

Extraphyseal (see Fig. 8-10)

Transverse diaphysis
Longitudinal splitting
Comminuted.sep~rations
Physeal
Dqrsal mallet injuries (see Fig. 8-.13)
Salter-Harris I or 11
Salter-Har'ris III or IV
Salter-Harris I or II joint dislocation
Avulsion of extensor + Salter-Harris 'fracture
Reverse mallet injuries (see Fig, 8-14) .
Avulsion of flexor with bone (jersey finger)

A,S c
FIGURE 8-10. Three types of extraepiphyseal fractures of the distal
phalanx. A: Transverse diaphyseal fracture. B: Cloven-hoof longitudinal
splitting fracture. C: Comminuted distal tuh fracture with radial frac-
ture lines. at the distal tuft, or multifragmem fractures of the distal diaphy-
sis (Figs. 8-10C and 8-12). Usually sustained as a result of a
crush injury, these fractures are often accompanied by significant
injury to surrounding soft tissues of the distal tip.
A rare but clinically important fracture, sometimes called a
reverse mallet injury, can occur in the distal phalanx. This is an
avulsion fractLJre of the volar metaphysis caused by traction on

FIGURE8-12. Extraepiphyseal distal phalanx fracture. The fracture line

FIGURE 8-11. Extraepiphyseal fracture of the distal phalanx, the is slightly distal to the insertion of the flexor digitorum profundus ten-
cloven-hoof longitudinal splitting fracture. In this patient, the fracture don. The accompanying soh tissue disruption (arrow) can be appreci-
line (arrow) does not appear to extend across the physis. ated on the radiograph.
 Chapter 8: Fractltres arid Dislocations of the Hilnd and Carpus in Children 281

the flexor digitorum profundus tendon. These fractures occa-

sionally extend into the physis. The DIP joint usually is held in
neutral or slight dorsiflexion.

Physeal Fractures
The clinical appearance of a physeal fracture resembles that of
an adult mallet finger. Four basic fracture patterns involve the FIGURE 8·14. A flexor digitorum profundus avulsion fracture of the
physis, and all result in the characteristic flexed postLIre of the distal phalanx, the jersey finger.
DIP joint.
Fractures often cause the flexed postLIre of a mallet finger in
the child. However, a "typical" mallet injury, avulsion or lacera-
tion of the terminal tendon at the DIP or distal phalanx level, seal fragment (146). This "epiphyseal dislocation" is clinically
can occur in a patient of any age. The mallet equivalent fractLIres challenging to diagnose because the distal fragment can remain
are of four types (Fig. 8-13). An open S-H I or II fracrure with relatively coJinear with the axis of the digit, whereas the displaced
flexion of the distal fragment occurs predominandy in young epiphysis is dorsally dislocated by the traction of the extensor
patients (under 12 years of age). The characcerisuc flexed posture mechanism.
is adopted because of the unapposed flexor digitorum profundus Even more rarely, the epiphysis separates or is fracrured si-
force acting on the distal fragment. Because this fracture is almost multaneously, with an avulsion of the terminal extensor from
always accompanied by nail bed laceration, there is a high risk the fragment. This variant may leave the DIP joint unreduced,
for infolding or incarceration of the germinal or sterile matrix or the free epiphysis may setde into a reasonable articular rela-
in the fracture site. This constellation of clinical findings has tionship at the DIP joint (190). These injuries may be unrecog-
been labeled a Seymour fracture (195). nized initially when they occur before the secondary ossification
In teenagers, a true bony mallet can occur with a displaced center appears.
SoH III or IV fracture. Instead of an avulsion of the terminal
tendon from its distal phalanx insertion, a fracture results in Jersey Finger
inability to actively extend the DIP joint. This rare injury causes an inability to actively flex the DIP joint.
RareJy, an SoH I or II fracrure causes extrusion of the epiphy- Forced extension of the flexed DIP joint can result in either a
bony injUlY or a soft tissue disruption involving the inserrion
of the flexor digitorum profundus (Fig. 8-14) (J 25,227). If a
fracture occurs at the tendon insertion, the flexor digitorum
profundus is sometimes prevented from retraction by tethering
on the A5 or A4 pulley. The location of the bony fragment on
radiography will identify the level of tendon retraction. Soft
tissue avulsion of the flexor digi torum profundus usually retracts
to the level of the palm.
A

Diagnosis
Signs and Symptoms.
Status ofthe Nail and Nail Bed. Because almost half of patients
with nail bed injuries seen in an emergency department have a
B
concomitant fracture of the distal phalanx, a high index of suspi-
cion for bony injury must be maintained when an obvious open
nail bed injury or a subungual hematoma is present (Fig. 8-15)
(241). A subungual hematoma that involves more rhan 50% of
the nail plare often indicates a distal phalangeal fraerure.
Occasionally, smaller matrix lacerations can bleed enough to
cause pain simply from the pressure developed under rhe nail
c plate. More ofren, rhe nail plare is lifred from under the folds,
which may decompress any underlying hematoma. Rarely, the
nail is completely avulsed withour an accompanying sofr rissue
injury to the sterile or germinal matrix.

Tissue Loss. The disral aspect of rhe fingers and rhumb are ar risk
for significanr uauma. Partial or complere terminal ampurations
D occur in patients of all ages. Most of rhese injuries are incomplete
FiGURE 8-13. The mallet-equivalent fractures. amputations, through a level thar includes variable amounts of
282 Upper Extremit)'

FIGURE 8-15. A: A crush injury to the thumb of a 4-year-old with a stellate nail bed
laceration and fracture of the tuft. B: Avulsion of the nail plate after crushing trauma
A is accompanied by a distal phalanx fracture. This must be treated as an open fracture.

the specialized nail tissues. Complete amputations at the distal Hematoma Evacuation. If a hematoma is the only outward man-
phalangeal level generally are distal to the physis. ifestation of underlying injury, observation Ot simple evacuation
may be sufficient. Indications for a hematoma evacuation in-
Radiographic Findings. A thorough series of films focusing on clude significant subungual hematoma (> 50% of the nail plate),
the distal phalanx and DIP joint is neceSS:lLY to evaluate the painful pressure under the nail, or evidence of infection. The
injury completely. Specialized imaging, such as computed to- decompression can be performed with a hypodermic needle used
mography (CT) scanning or magnetic resonance imaging (MRl), as a drill. A heated paper clip or cautery tip can be effective, but
is not needed to evaluate this region. a margin of safety is necessary to avoid funher tissue injury.
DaCruz et aJ. (53) reponed a high incidence of late nail defor-
Treatment Options mity if the hematoma was not decompressed.
The fracmres associated with nail bed lacerations are true open
injuries and require attention ro both the osseous and soft tissue Naif Bed Repair. If nail bed repair is required, the nail is removed
elements. Any open fracture requires mechanical debridement, with a blunt septal or Freer elevator. Partial nail removal is sel-
irrigation, and appropriate antibiOtics. Most of these injuries dom appropriate, because the extent of the injury may not be
occur in children under 5 years of age and do not require treat- appreciated. Further exposure of the proximal nail tissue (get-
ment beyond initial repair. The stability of the phalangeal frac- minal matrix or dorsal/intermediate nail) by incisions in the
ture is evaluated, and if the phalanx is nOt stable enough to act eponychial fold may be necessary. The nail bed is repaired witn
as a foundation fot nail bed repair, pinning is performed. interrupted absorbable 6-0 or 7-0 sumres under loupe magnifica-
The repair or reconstruction of the soft tissues surrounding tion. The likelihood of nail deformity is minimized by this surgi-
the distal phalanx is just as critical as the osseous repair. When cal intervention.
indicated, meticulous nail bed repair, neurorrhaphy, tenorrha- After careful approximation, the nail bed is stented to avoid
phy, and skin coverage must be performed. scarring tnat cou.ld hinder subsequent nail growth. If the nail
has not been too badly damaged, it can be used to stent the nail
Extraphyseal Fractures. folds after it has been denuded of all soft tissue remnams and
Stabilization. Options for stabilizing extraphyseal fractures in- has been perforated centrally to allow free drainage of subungual
clude closed splinting, percutaneous fixation, or open reduction. fluids. Other substitutes, such as a plastic stem fashioned from
Most fracrures are stable, and require only simple splinting. a culmrette tube, a foil sumre pack, or a commercially available
However. a smooth Kirschner wire may be insened eirher into stem, also can be used. The use of the nail itself or some inert
the phalanx from the tip or occasionally across the DIP joint in foreign material has been controversial (68,189,241). The nail
fracrures with marked comminution or very proximal fractures. itself is thought to be more stable and may assist in "molding"
A hypodermic needle is a good subsrimte for the standard the repair, but the risk of infection must be considered if the
smooth wires (145). preparation before insertion is inadequate. Sandzen and Oal<ey
 Chapter 8: Fractures and Dislocations of the Hand and Carpus in Children 283

(184) argued that this risk is lower in children than in adults. at the distal tip often is unsatisf)ring because the durability, sensi·
Suturing of the replaced nail may help prevent migration from bility, and appearance are suboptimal.
underneath the nail folds. Anchoring the stent with a suture has If most of the distal phalanx is spared, only a relatively trans-
been described, but this may cause incidental injury to the sterile verse nail bed and soft tissue laceration exists. Simply allowing
or germinal matrices. the tissue to heal, with or without a small amount of bony
resection, is an option. In addition, results are ofren surprisingly
Physeal Fractures. good wirh healing by secondary intention over a small amoum
Nonoperative Management. Nonoperarive treatment of a mallet of exposed bone.
finger in a child, as in an adult, is overwhelmingly favored. When The spectrum of injury can range from a minimal nail bed
the injury is closed, there is seldom an indication for operative lacerarion, manifesting as a minor subungual hematoma, to the
intervention in a typical bony mallet. Even when there is some significant laceration and unstable periphyseal injury (Fig. 8-
displacement of the dorsal epiphyseal fragment, good results can 17). Campbell (36) advocates an aggressive approach for open
be obtained with splinting (Fig. 8-16). bony mallet fingers, even with minimally displaced fractures.
Amputation at the distal tip can involve skin, nail tissue, and Late complications such as tendon imbalance, nail growth or
bone. These injuries are often worrisome to parents of a young adherence problems, premature physeal closure, and even
child because of the potential loss of digital length. However, chronic osteomyelitis can occur with relatively innocuous
it is important to remember that the growth for the distal pha- trauma.
lanx comes from the physis that often is proximal to the level
of the amputation, and long-term digital shortening is rare. Operative Management. When an S-H IV bony mallet fracture
Support for nail growth is a primary consideration. When less is displaced and adequate reduction cannot be obtained by closed
than 50% to 60% of the distal phalanx remains, the likelihood of means, operative stabilization should be considered. Although
nail deformity in the form of a hooked or "parror's beak" nail most of these fractures can be neated closed, a large dorsal frag-
is high. Often, lesser injuries can be treated with simple dressing ment (typically >50%) or significant DIP joint subluxation may
changes or allowed to heal by secondary intention. Skin grafting require operative intervention (50,198). Closed manipulation

B
FIGURE 8-16. A: A very unstable fracture that necessitated extrication of the nail bed with subsequent
repair. B: Stabilization of the bony elements with a longitudinal smooth pin.
284 Upper Extremity

FIGURE 8-11. A: Although mallet fractures ofthis pattern and amount of displace-
ment often can be treated by closed methods, the extreme deformity and dorsal
prominence was of concern to the patient and his parents. It was therefore elected
to open the fracture to reduce and stabilize the fragment. B: This intraoperative
photograph demonstrates the amount of articular surface involved and the attach-
ment of the terminal tendon. B

and percutaneous pin stabilization of the reduced joint are gener- A jersey finger avulsion of the flexor digitorum profundus
ally used. requires open repair. The profundus tendon needs to be identi-
The Seymour fracture is an absolute indication for open re- fied surgically at the level of retraction. This may be at the A2
duction and stabilization. The sterile matrix must be extricated or A4 pulley of the flexor tendon sheath (Fig. 8-20), or it may
from the fracture at the physeaJ level. Not until the soft tissue have retracted to the lumbrical origin off the flexor digitorum
is removed will the fracture reduce appropriately. Those rare profundus in the palm. If the vincular blood supply and synovial
fractures with epiphyseal dislocation require operative interven-
tion to restore joint congruiry and to reestablish continuiry of
the extensor apparatus.

Surgical Procedures. When a complex injUlY cannot be reduced

or stabilized using a closed technique, a dorsal approach is neces-
sary to expose the fragment and reduce the fracture (Fig. 8-18).
It may be necessalY to take down the collateral ligament to
obtain reduction. Although we prefer to avoid it, fixation of the
fragment itself is advocated by some clinicians (88,92,104,117,
162,175). When the epiphysis is completely displaced from its
articular contact and its relationship with the remaining distal
phalanx, open reduction through a dorsal approach is necessalY.
Several different approaches for exposure of the DIP joint have
been described, primarily for use in the treatment of arthrosis
:~ ===~:-
~
=--.
~ _--....:...5
and mucous cySt excision (48,65), for example, an H- or S-
A,B ~------ , C
shaped incision or an extended Y flap (Fig. 8-19).
FIGURE 8-18. Three exposures of the distal interphalangeal joint. A:
Once the joint is exposed and the fragment with its attached H-type flap with the transverse limb over the distal interphalangeal
terminal tendon is retrieved (or the ftee fragment and avulsed joint. B: S-shaped exposure of the distal interphalangeal joint. C: An
tendon), repair can be performed with a smooth wire, pullout extended Y exposure of the DIP joint; the apex of the V part of the
incision is at the distal interphalangeal joint. In all these exposures, care
wire, tension band, or heavy suture (99). Pinning of the DIP is taken not to injure the germinal matrix or its blood supply, which is
joint is necessalY to majntain joint and physeal congruiry. located in the sulcus just prOXimal to the nail fold.
 Chapter 8: Fractllres find Dislocations of the Hand and Carpus in Children 285

FIGURE 8-19. In this volar fracture in a 17-year-old athlete, a fracture through the epiphysis extends
into the joint (large arrow). The flexor digitorum profundus with an attached fragment of the metadia-
physis has retracted to the level of the A4 pulley (small arrow).

FIGURE 8·20. The reversed cross-finger subcutaneous flap. A full-thickness skin flap is elevated from
the donor digit based on the side opposite the injured digit. The subcutaneous tissues are then elevated
from the epitenon, based on the side of the injured digit. The subcutaneous tissues are reflected in a
reversed fashion into the defect, and a thin full-thickness skin graft is applied to the recipient. The full-
thickness skin flap from the donor is then replaced over the vascular epitenon. Division of the flap can
take place at 2 weeks. (Reprinted from Atasoy E. Reversed cross-finger subcutaneous flap. J Hand Surg
1982;7:481-483; with permission.)
286 Upper Extremitj

barhing from rhe fibroosseous shearh are borh losr, rhe repair tether it proximally, thus allowing it to advance distally co cover
should be immediate. Ideally, a primary repair under little or the defecr. The void lefr behind is closed, convening the Vinto
no tension should be performed within a week. Treatmenc of a Y (Fig. 8-21).
chronic flexor digicorum profundus avulsions may include no The thenar flap was first described by Gatewood in 1926
repair, flexor digicocum profundus renodesis, DIP joim fusion, (78). This innovative procedure buries the amputated tip inco
and delayed repair. the tissue about the thenar eminence. The disadvantage of this
flap is rhe extreme flexion that muSt be maintained for the dura-
Soft Tissue Coverage ofAmputations. Soft tissue coverage over tion of the attachmenr. Other clinicians (145) have described
the dorsal aspect of the distal phalanx and reconstruction of rhe flexion contracrures with this flap, and they have suggested that
nail folds are among the mOSt difficult challenges in hand sur- the candidates fot this seldom-needed procedure be young. I
gery. The surgical approach for rhe dorsal injLl1y must be tissue also advocate the thenar flap only in patients under 20 years of
specific. Simple healing by primalY closure is preferred. In the age. If it is selected for coverage, rhe U- or H-shaped flap of
rare complete avulsion of tne nail bed wirh exposed disral pha- skin and subcuraneous tissue must be located as close co the
lanx dorsally in a young child (under 5 years), the ampurated thumb MCP flexion crease as possible co minimizes PIP joint
nail bed and pulp can be replaced wirh minimal defaning. In flexion.
addirion to simple nail bed repair or nonvascular replacement The cross-finger flap is one of the most versatile recon-
of rhe ampurared parr, composite grafts ofskin and subcutaneous structive procedures used about the distal tip (113). If tissue is
rissue from local or distant sites (e.g., the adjacenc digirs, the inadequate for primary dosure or local advancement, a cross-
toes) have been used (42,196,242). finger flap permits coverage without the need fot a distant flap
The simpliciry and predicrabiliry of bony recession, rraction (e.g., groin, cross-chest). This flap requires a nontraumatized
neureccomy, and primary closure musr nor be forgorren in the adjacent donor. Like the reverse cross-finger flap (Fig. 8-22),
midsr of more elaborate techniques. A well-performed primary the donor flap is based on the side of the injured digit, but
closure of a rraumatic amputarion can hasren a rerum co high- insread of using only the subcutaneous fat as a flap applied to
level funcrion wirh minimal discomforr and disability. Ablarion tbe dorsum, the cross-finger flap brings skin and subcutaneous
of rhe germinal mauix, when indicated for signiftcanr nail loss, tissue to the volar side (Fig. 8-23).
and neureccomy minimize the need for future revision surgeries. A pedicled neurovascular island flap is an appropriate alterna-
Of course, amputation in a child's hand should be reserved for tive when durable sensible tissue is needed. This flap can be
only rhe most significanr tissue disrurbances thar are nor recon- designed and advanced on a local neurovascular bundle or trans-
srrucrable in orher ways. ferred from a remote location, and it is particularly useful in the
thumb for unilateral volar tissue loss (Fig. 8-24).
Reconstruction Options. Oprions for reconstructing the disral tip The more autonomous volar and dorsal blood supply of the
injury include V-Y volar advancement, a thenar flap, a cross- thumb is rhe basis of Moberg's volar advancement flap for cover-
finger flap, a pedicled flap, and a neurovascular island flap. age of tissue loss at the distal thumb (Fig. 8-25) (155). Bilateral
The triangular V-V volar advancement flap was described in mid-lareral incisions permit advancement of the volar skin to
1970 by Atasoy et at. (8). Adequate skin on rhe volar and lateral cover an acral defecr. Coverage is made easier by flexing the
sides is needed. The flap is designed so that the apex of the interphalangeal joint of rhe thumb. Transverse division of the
triangle proximally is ar rhe DIP crease, and the base of the more proximal skin can sometimes be performed, with skin
triangle is the amputation margin. The triangle of skin is liber- grafting into the defecr. In a child, the skin usually is more
ated carefully with sharp dissection of the fibrous septae that pliable and permits primary closure.

Thin full thickness

skin grofl ....

FIGURE 8-21. V advancement flap. This triangular volar flap

is elevated to cover a distal defect in the author's original de-
scription. A V is formed with its apex at the distal interphalan-
Eievoted geal joint flexion crease. The base of the triangular flap is the
thin full margin of the amputation. The fiber septae are elevated from
thickness flop the distal phalanx. Care is taken to advance the volar skin by
sequential division of small fibrous tethers to the volar side.
When adequate immobilization of the flap is realized, it can
be sutured in place over the tip. (Reprinted from Atasoy E,
loakimidis E, Kasdan ML, et al. Reconstruction of the ampu-
Elevated subculo tated finger tip with a triangular volar flap. J Bone Joint Surg
flop a inloct skin [Am] 1970;52: 921-926; with permission.)
 Chapter' 8: Fractures and Dislocations of the Hand and CarjJlIS in Children 287

A B

. , -
·<:'fI

f .
;
.
1"1:
:
:1.
l
•
I
.
~ .
I

,.

r- .
• 'I
- I

.. -!ill
,
if !;1
t ~,!
i.~ •.;,ti
't, "i'l~'f.~
.'
•
FlBJ ,'):
t,f.'l: ;;.~
J
','-!, .f •

'.~~l
;'r,~ :~,
:r
~c .''<.
c -~ .;~
,,--,
.': ~FI:~~Ff o
FIGURE 8-22. The cross-finger flap. This 17-year-old boy was working on his car when his distal tip was
caught in the area of the fanbelt. A: Extensive volar and distal loss was appreciated, but there is only
minimal injury to the bony elements and laceration of the nail bed. The patient and parents were
strongly against amputation and therefore were offered the option of a cross-finger flap. The most
proximallevei of injury is at the distal interphalangeal joint flexion crease. B: A flap of skin and subcuta-
neous tissue is elevated from the dorsal aspect of the adjacent donor digit based on the side of the
index finger. The vascular epitenon is left behind to nourish the donor digit and support a graft. The
flap is then brought to the volar aspect and sewn into the recipient. Care is taken to contour the flap
to recapitulate the appearance of a normal digital tip. C: An excellent functional and cosmetic result
was realized in this case. D: More than 50% of the nail was supported by the distal phalanx, and this
can be maintained by performing good nail hygiene to avoid any type of hooked-nail deformity.
288 Upper Extremity

A B

c D
FIGURE 8-23. A pedicle neurovascular island flap for distal thumb coverage. A and B: This 16-year-old
guitarist sustained a sharp distal tip amputation of the thumb. Because of the importance of this digit
to his musical abilities, he strongly wanted this to be resurfaced with a durable, sensible, and contoured
flap. A neurovascular island flap was based on the radial digital nerve and large accompanying vessel.
The flap was designed in a V-V fashion. C: After the flap was mobilized, it was brought up to cover the
distal tip, and care was taken to contour the flap. D: Excellent contour of the distal thumb was realized
with intact sensibility. The patient was able to play the guitar without decrement in his skills. (Courtesy
of Richard S. Idler, M.D.)
 Chapter 8: Fractures and Dislocations of the Hand and Carpus in Children 289

A,B C
FIGURE 8·24. Volar V-V advancement flap for coverage of volar tissue loss. A: A volar oblique tissue
loss is a particularly good indication for an advancement flap when there is adequate tissue remaining
between the distal interphalangeal joint crease and the level of the injury. In this case, the nail tissues
were uninjured. 8: The flap is fashioned with its apex at the distal interphalangeal joint and mobilized
to cover the tip. The defect is closed behind the flap, thus creating the Y. C: The result is a very cosmetic-
appearing digit that has good durability and sensibility.

AUTHORS' PREFERRED METHOD

19 OF TREATING DISTAL
,~ PHALANGEAL INJURIES

Extraphyseal Fractures
For distal phalangeal fractures dut do nOt involve the physis,
the decision concerning treatment is based on the stability of
the fracture and the status of the nail bed. Most simple closed
Fractures are treated with immobilization. In a young child, this
may involve a mitten cast; in an adolescent, splinting of the tip
and DIP joint, leaving the PIP free for motion, may be all rhat
is necessary. Gende manipulation of some fractures may improve
slight angularion. Immobilization is worn for 3 to 4 weeks ar
most, unril clinical union has broughr comforr. Prorection dur-
ing contacr acrivity can be continued if rhe digir is ar risk.
For fractures accompanied by a nail bed lacerarion, adequare
local anesthesia (a meracarpal block) is insrilled wirh or without
conscious sedation. A Penrose drain is inserted at rhe base of
the digit, the nail plate is completely removed with a Freer eleva-
ror, and meticulous mechanical debridement and copious irriga-
tion are performed. In the rare unstable distal phalangeal bony
injury, rhe fracture is pinned.
Pinning of rhe phalanx is best performed wirh image intensifi-
carion with a Jow-radiarion fluoroscopy unir. We use 0.028- or
0.035-inch smooth wire, depending on rhe parienr's size. A 22-
gauge hypodermic needle can be used if other resources are una-
vailable. The wire or needle is leFt protruding From rhe disral
FIGURE 8-25. A thenar flap was chosen in this case. An H-flap tech-
nique was used. Another common technique is use of a composite graft end of rhe phalanx, to malce larer removal easier. The DIP joint
from the toe pulp. is crossed iF sufficient srability is nOt achieved by pinning the
290 Upper Extremity

fragments of the terminal phalanx, but this is avoided if possible. and the transient sensory clisrurbance with prolonged volar pro-
The pin is maintained for about 3 to 4 weeks. tection. The finger is held in neutral to 15 degrees of extension;
With a stable platform established, sterile germinal matrix extreme hyperextension is contraindicated, because it may cause
repair proceeds. Using 6-0 or 7-0 absorbable on a sparulated skin hypoperfusion and necrosis (178). Loss of flexion can occur
needle minimizes damage to the friable tissues of the nail bed. with prolonged hyperextension but is rare with closed treatment.
The injured nail is discarded, and petroleum- or antibiotic-im- The patient and parent should check the skin at least daily
pregnated gauze is placed under the nail folds. This covering of to prevent skin necrosis from splint pressure. A follow-up visit
the repaired matrix simply falls off in several weeks. at 5 to 7 days will reveal problems if the patient does not under-
A bandage that protects the distal phalanx usually is all that stand the instructions. Radiogtaphs are tal<en weekly for the first
is necessary after nail bed repair. Leaving the PIP free is appropri- 2 weeks, then every 2 weeks to monitor for loss of reduction
ate in older, cooperative patients, but younger patients may need and volar subluxation (188).
immobilization up to and including a long arm dressing for this The presence or absence of an open injuty and rhe fracture
very distal injury. The parents and patient are told that it may configuration dictate the need for operative intervention. If un-
take several cycles of nail growth (3-6 months) before the final acceptable reduction of the fracture fragments or subluxation or
morphology of the nail is known. dislocation of the DIP joint remains after closed manipulation,
then surgery is performed to reduce the fragment and DIP joint.
We prefer to perform this percutaneously. The dorsal fragment
Physeal Fractures can be pinned with a 0.028-inch smooth Kirschner wire driven
into the epiphysis in a parallel direction (Fig. 8-27). The wire
Dorsal Mallet Injuries
is left protruding from the skin for later removal. Pinning of
We attempt to reduce the fracture in almost all closed mallet the DIP joint also often is necessary. If this is not feasible, a
injuries. The reduction maneuver recreates the deformity by dorsal approach is used to expose the dorsal fragment in these
gentle flexion. The distal fragment is then extended to restore mallet equivalent injuries (Fig. 8-19). Care is taken to avoid the
the anatomy. Reduction is held while the splint is carefully ap- vessels that nourish the germinal matrix, which are located in
plied. We apply a splint (either volar or dorsal) then obtain the shallow sulcus proximal to the nail fold. This area can be
radiographs to evaluate the reduction in the immobilized state appreciated by viewing the distal digit from the lateral side. This
(Fig. 8-26). averts interruption of tissue perfusion and prevents the major
Our normal splinting regimen is 24-hoLir wear for no less complication of hematoma.
than 4 weeks, and typically for 6 weeks. This time frame can If the patient is near skeletal maturity, a tension band, pullout
be adjusted depending on the amount of bony apposition and wire, or suture anchor can be used for fixation. Although a neu-
age of the patient. A cooperarive patient can be furnished with tral position or slight (10 degrees or more) hyperextension is
both volar and dorsal splints, if it is understood that any flexion preferred for closed treatment, the joint should nor be repaired
of the DIP during changing of the splint will prolong the immo- open in hyperextension because this position tends to persist.
bilization period. The two-splint regimen has almost eliminated Neutral alignment of the DIP joint is favored if the fracture is
the infrequent skin problems seen with dorsal splinting alone open.

FIGURE 8-26. A: A 13-year-old boy sustained an

open type II fracturewhen a fellow football player
stepped on his hand. B: After the wound was
cleansed, a closed reduction was performed, pre-
B serving the nail. Normal function resulted.
 Chapter 8: Fractures and Dislocations of the Hand and Carpus in Children 291

A 8
FIGURE 8·27. A: A 14-year-old boy sustained a displaced type III fracture of the distal phalanx when
he was struck on the end of the thumb with a ball. B: Open reduction and Kirschner wire fixation were
required when manipulation failed to reduce the fracture because of the displacement caused by the
action of the extensor pollicis longus tendon on the fracture fragment.

Reverse Mallet Injuries or many of the innovative but arduous flaps reported frequently
in the literature. Instead, we have provided a basic list of options
For reverse mallet, flexor digitorum profundus avulsion injuries,
that will suffice in most patients. Knowledge of the indications
we prefer bone-to-bone fixation whenever possible. If the frag-
for and the technical aspects of these procedures permits the
mem is toO small or comminuted, repair of the tendon to the
surgeon to approach most distal tip reconstructive challenges in
fracture bed is adequate. Pinning of the joim is avoided so that
a logical fashion.
passive motion can be started early. In patients underl5 years
of age, 4 weeks of immobilization yields results equivalem to Postoperative Care and Rehabilitation
those of protected motion protocols in adults. The immobilization used for an extraphyseal fracture depends
on the stability of the fracture and the age of the patient. Young
Soft Tissue Management children with fractures that require reduction are immobilized
For terminal Joss of skin and subcutaneous tissue only, we again with long arm mitten casts. As the child ages, or with stable
stress the necessity of wound cleansing and dressing changes to injuries, the degree of immobilization is decreased. For an adoles-
all injuries left to heal by secondaty intention. This method of cent, this may mean that only the digital tip is splinted to the
treatmem is not benign neglect, but tather a reasonable approach mid-middle phalangeal level, thus allowing PIP motion.
that usually results in superior functional and cosmetic results. Treatment of physeal fractures is similar to that described
Skin grafts from the groin, antecubital fossa, or hypothenar gla- for extraphyseal fractures. If there is a persistem extensor lag,
brous border rarely are used for coverage. Donor morbidity, continued splinting even after pin removal can effect improve-
hyperpigmentation, lack of sensicivity, and appearance are po- ment. Removal of the pin at 3 weeks and full-time spliming for
temial drawbacks of skin-grafting procedures. an additional 2 to 3 weeks is reasonable. This is particularly
Dorsal loss is the most difficult to reconstruct. We attempt useful when a pin was placed across the DIP joint to gain sta-
tension-free closure first, then consider local tissue relaxation bility.
and advancement before opting for a reverse cross-finger flap or Antibiotic use is advocated with open fractures, but in only
distam flap. Distal tip and volar loss on the remaining bone, the most complex, comaminated injuries should a patiem be
the status of the nail tissues, and the avai labiJ ity of sufficien t admitted for intravenous antibiotic administration. A seven-day
volar skin distal to the DIP flexion crease must be considered. course of oral agents usually suffices. Amibiotics do not replace
We have found the volar V-Y advancemem, cross-finger flap, the need for thorough mechanical debridement.
and thenar flaps to be good options. If the distaJ phalangeal fracture was pinned with a smooth
We have not detailed microsurgical reconstruction methods wire or hypodermic needle, the implam can be removed at 3 or
292 Upper Extremity

4 weeks, usually in the office setring. There is no need for seda-

tion or local anesthesia.
The covering of the nail bed, whether native nail plate or
foreign material, falls off with dressing changes or activities of
daily living. Monitoring of the soft tissue healing often is moni-
tored for several weeks after injury. Waiting several months to
evaluate the stams of nail growth and adherence is imperative.
No formal hand therapy is required, because the child's own
use pattern returns the DIP joint to good function in a matter
of weeks. In some patients, DIP joint motion is more limited,
especially wl1en there has been an arthrotomy for articular resto-
rat,ion. The patient can be taught an exercise program that specif-
ically includes middle phalanx blocking exercises to restore DIP
flexion.

Prognosis
Functional and cosmetic results are generally favorable. Even a
small amount of extensor lag or a minor longimdinal nail ridge
are well tolerated by most patients. During the early dialogue
with parents, the potential for long-term impact of the injury
should be emphasized. They must understand that any injury
in a skeletally immature patient may interfere with longitudinal
or angular growth, and that articular injury may accelerate the
FIGURE 8-28. A patient with a distal fingertip amputation that has
degenerarive process later in life. However, rhese problems are gone on to develop a hook-nail deformity.
rare. The appearance of the nail is important to most parents,
and rhe possibiliry of growth failure, plate deformiry, and nonad-
herence should be described. Although DeCruz cited a high rate
of nail deformity with subungual hematomas and distal phalanx
fractures, this has not been the norm in our institutions. matrix of the injured digir can be used. In the rare instance that
an underlying deformity of rhe distal phalanx is causing the
Complications problem, splitting the sterile matrix for exposure and smoothing
Inability to Maintain a Stable Bony Foundation. Pinning the the dorsal aspect of the phalanx can help.
distal phalanx, with or without crossing the DIP joint, provides One specific complicarion of losr nail suppOrt is a hook-nail
stability and improves the chances for healing of the dorsal aspect or "parmt's beak" nail, in which the nail plate takes a significant
of the distal phalanx. volar curve over rhe end of an abbreviated distal phalanx (Fig.
8-28). This is a porential hygiene and cosmetic problem and
Osteomyelitis. Osteomyelitis is best prevented by meticulous may prevent the tip from being funcrional. Arasoy et al. (9)
debridement and irrigation of the fracture and soft tissue injuty described an "antenna" procedure for reconstrucring rhe hook-
at the initial evaluation. Ifinfection appears later in the trearment nail. Elevating the sterile matrix and supporting the nail tissue
course, the usual principles for skeletal infection musr be fol- with a volar advancement flap, rhenar Aap, composite graft from
lowed. The infected tissue must be thoroughly debrided, weigh- the toe, or a cross-finger fhp can significantly improve the ap-
ing the oprions of skin coverage or shortening amputation. The pearance and eliminate marginal and distal skin compromise.
amount of bony support of rhe nail is a key issue in the retention The name antenna comes from the multiple (usually rhree) small
of the germinal matrix, because a hook-nail may result when a wires used ro suPPOrt the matrix postoperatively (Fig. 8-29).
significant amount (>50%) of the distal phalanx is los[.
Extensor Lag. Some extensor lag (10 degrees or less) is not
Impaired Nail Growth. The problem can be one of poor uncommon after appropriate treatment of a mallet injUlY. Con-
growrh or adherence. If ir is a growrh problem, rhe germinal tinued exrension splinring can be rried bur loses efficacy afrer
matrix has been injuted, and the absence can be complete or the third or fourth month. A digital cast may be an excellenr
partial. One option for trearment is to resect the area of a "nor- way to avoid a potential lapse in splint wear that is required
mal nail" and replace it wirh a full-rhickness or split-thickness over a long period. Terminal tendon reconstruction with a der-
skin graft (42); nail bed grafting from the adjacent bed, anorher modesis procedure has been described for this situation. A spir;ll
digit, or toe is a sound alternative. These grafts can be vascu- oblique rerinacular ligament reconsrruction has been used to
larized or nonvascularized. The results in children have been correct "chronic mallet," bur rhe procedure is rechnicalJy de-
superior to those in adults 019,196,197,242). manding (214). Release of rhe central slip insertion into the
If rhe problem is naillifr-off or lack of adherence, rhen similar middle phalanx (Fowler procedure) can lessen rhe DIP extensor
fesection and grafting techniques can be used to conrour rhe lag and the PLP secondary swan neck deformiry. If the amount
sterile marrix. Partial-thickness grafring from the adjacent srerile of lag is unacceprable and is accompanied by the rare occurrence
 Chapter 8: Fractures and Dislocations of the Hand and Carpus in Children 293

A B

c
FIGURE 8-29. A and B: Postoperative photograph views of the patient shown in Fig. 8-28 who had the
antenna procedure. This involved a volar V-Y advancement flap chosen to cover the distal tip. The sterile
matrix of the nail was elevated and is supported by the three smooth wires and transferred flap tissue.
C: Line drawings demonstrating technique of elevation and support of the sterile matrix with wires. (A
and B Courtesy of William B. Kleinman, M.D. C reprinted from Atasoy E, Godfrey A, Kalisman M. "An-
tenna" procedure for the "hook-nail" deformity. J Hand Surg 1983;8:55; with permission.)

of arthrosis at the DIP joint due ra ptemarure physeal closure, concepts are integral to understanding the radiograph and the
the only tealistic options may be DIP fusion or interposition clinical manifesrations of skeletal trauma children.
arthroplasty. These are radical steps in children, and we have The ph)'ses are located proximally in the phalanges. The phy-
not used them. If the impairment does not severe I)' compromise sis of the thumb metacarpal also is located proximally; those of
function or limit future vocational avenues (e.g., musician), then the other four metacarpals are distal (Fig. 8-2). The collateral
the patient can make the decision later in life. ligaments at the PIP and DIP joints originate from the collateral
recesses of the proximal bone and insert onro both the epiphysis
and metaphysis of the distal bone. The ligament also insem on
Proximal and Middle Phalanges
the volar plare (Fig. 8-4). The collateral ligaments at the MCr
The proximal and middle phalanges have similar characceristics joints of the fingers originate and insert almost exclusively Onto
with respect to their osteology and soft tissue anaramy. Other the epiphyses of the opposing bones. The thumb MCP collateral
facrars, such as the tendon balance around each segment, con- ligaments most closely resemble those of the interphalangeal
tribute to the unique fracture characteristics seen at the individ- joints, having epiphyseal and metaphyseal insertions distally
ual members of the osteoarticular column. (Fig. 8-5).
The volar plate has a metaphyseal origin from a recessed part
Surgical Anatomy of the phalangeal neck and inserts distally onto rhe epiphysis.
Some pertinent aspects of the unique anatomy of the child's It receives fibers from the collateral ligaments (Fig. 8-4).
hand affect the pattern of fractures abom the phalanges. These The extensor tendons insert onto the dorsal aspect of the
294 Upper Extremity

epiphysis of the middle and distal phalanges. At the middle

phalanx, the flexor digiwrum superficialis insertS over about two
thirds of the central portion of the middle phalanx onto the
sublimis ridge. The flexor digiwrum profundus has a metaphy-
seal insertion OntO the distal phalanx.
The periosteum is imponam in fracture stability, reduction
maneuvers, and potential remodeling capability. It is a well-
developed structure that may occasionally block reduction when
it is inrerposed in the fracture. The periosteal hinge may be a
useful adjunct in fracture reduction.

Diagnosis
Anatomic Considerations. The epiphysis and physis at the
MCP level are relatively unprotected for two reasons: the collat-
eral ligaments and volar plate insert exclusively proximal to the
physis, and there are two epiphyses opposed at this joint. Con-
versely, the periphyseal bone of the middle phalanx is stabilized
by the insertion of the collaterals onto both sides of the physis.

Fracture Forces. Pure torsion or lateral bending forces are rare: A,B
a combination is typically responsible for fracrures of the phalan- FIGURE 8-30. Type A fractures of the proximal phalanx. A: Classic Sal-
ges. These fractures can affect the periarticular areas or the shaft. ter-Harris type II fracture with the Thurston-Holland fragment. B: The
Forces resulting from a violent lateral bending moment or a intraarticular Salter-Harris type III or type IV fracture pattern. C: The
extra-octave Salter-Harris II type of fracture with metaphyseal buckling.
significant injury directed in the AP (flexion/extension) plane
can cause a phalangeal neck fracture. This fracture propagates
through the subcondylar fossa and the distal diaphysis. Fractures
caused by hyperextension forces are found predominately about
the proximal phalanx. They also observed that physeal fractures
the PIP joint and, to a lesser extent, at the MCP joint.
occurred in the hand 34% more often than elsewhere in the
appendicular skeleton. Leonard and Dubravcik (127) cited a
Injury Mechanisms. Most fractutes of the proximal and middle
41 % incidence of physeal fractures among their 276 pediatric
phalanges result from axial loads, torsional or angular forces,
hand fracrures.
such as catching balls or collisions in sPOrts. Crush injuries in-
clude direct injuries from implements such as hammers or clos- Two Variations. Physeal fractures of the proximal phalanx are
ing doors. of two varieties: SoH rype II extraarticular fractures and S-H
types I1I and IV intraarticular fractures (Fig. 8-30). Both of these
Classification patterns can be caused by lateral bending moments, but the
Four panerns of phalangeal fracrures can be recognized: fractures more prevalent S-H II results from additional rOtational forces.
involving the physis, the shaft of the phalanx, the unique fracture Physeal fractures abour the middle phalanx are rare. A lateral
anatomy about the phalangeal neck, and the condylar area (Table avulsion mechanism can cause an S-H III or IV fracture, bur
8-3). the entire epiphysis rarely separates through the physis, or in an
S-H II pattern. A dorsal avulsion of bone by the central slip can
Physeal Fractures. Hastings and Simmons (I04) reported that be caused by forced flexion against an extended digit, producing
the proximal phalanx was the most commonly injured bone in a dorsal SoH III fracture. Furthermore, the lateral band can
their series of 354 pediatric hand fractures, and rhis has been subluxate volar ro the axis of rotation of the PIP joint, creating
corroborated by other clinicians (12,90,127,215). This was due a boutonniere deformity.
in part to the large number of SoH II fractures of the base of Children rarely sustain comminuted imraanicular fractures
of the PIP joint, considered "pilon" fractures or fracture-disloc-
ations (207). These injuries usually involve the proximal aspect
of the middle phalanx. They often occur in adolescent athletes
and usually resulr from an axial load sustained while catching a
TABLE'S-3. CLASSIFICATION OF PROXIMAL
AND MIDDLE PHALANX ball or conracting an opponent. Fracrure fragments from the
FRACTURES volar side may have arrached volar plate; the dorsal fragment is
likely ro have the central slip attached. The central aspect of the
Physeal
joint may be depressed, and comminution is frequent (Fig. 8-
Shaft
Phalangeal neck 31).
Intraarticular (condylar)
Gamekeeper's InjurieL A VCL avulsion injury at the base of the
thumb proximal phalanx is similar ro the adult gamekeeper's or
 ChI/pteI' 8: Fmrtures and Dislocatiom of the Hand and Cl1rpw in Children 295

sk.ier's thumb. The fracture itself usually is an S-H III Injury

(Fig. 8-32). Despite rhe obvious fracrure deformity, the focus is
on the ligament that may be attached to the small fragment.
Rarely, the ligament tears away from the bone, in addition to
the fracture of the epiphysis. If the UCL (with or without a
bony attachment) is excluded from its bed by the adductOr apo-
neurosis, then open repair is necessary. This injury is called a
SteneI' lesion aFter the clinician who described the exclusion of
the UCL from its proximal phalangeal insertion by the adductOr
aponeurosis (206). [n his 1962 account, Stener described this
lesion in 25 of 39 patients with complete ruptures of the thumb
MCr joint UCL. This derangement is significant because heal-
ing of the ruptured collateral ligament back to its original bed
cannot occur owing to adductor interposition. The purely liga-
mentous injury is discussed in the later section of this chapter
on Dislocations of the Hand and Carpus.

FIGURE 8-31. Pilon fracture of the middle phalanx, in which there is Shaft Fractures. Fractures of the phalangeal shaft are not as
comminution or central joint depression of the epiphysis.
common as those around the joints, perhaps because of the stabi-
lizing influences of the flexor sheath and thick periosteum, and
the relatively shorr lever arm of the digit.

A,B c
FIGURE 8-32. The spectrum of presentation of ulnar collateral ligament injury of the thumb. A and B:
On stress examination, a widening of the physis is seen. No true intraarticular fracture can be appreci-
ated, yet instability at this level is inferred by this radiographic finding. The arrow demonstrates the
direction of force and location of the pathology. Varying sizes of fragments (B and C) can be associated
with ulnar collateral ligament avulsion fractures (arrows). The size of the fragment is important with
respect to the congruity of the metacarpophalangeal joint.
296 Upper Extremity

Phalangeal fractures may be transverse, spiral, or spiral-

oblique (Fig. 8-33). Any of these types can be comminuted.
The characrerisric displacemenr is an apex volar parrern. The
proximal fragmenr is pulled inro flexion by rhe inrrinsic influ-
ence, and rhe disral fragmenr is extended by rhe force of rhe
cenrral slip and lareral band insertions (Fig. 8-34).
Wirh an oblique fracrure, rhe deformity involves shorrening
and rotarion. The displacement seen on radiography usually is
minimal, but careful clinical evaluation of rotarional alignment
is crirical. If a spiral-oblique fracture appears widely displaced,
sofr rissue inrerposirion (exrensor mechanism or periosreum)
may be an impedimenr to reduction. Direct rrauma ro the pha-
lanx, or a high-energy bending or rorsional injury, can result in
comminution (Fig. 8-35).

Neck Fractures. Exrraarticular fractures of the disral aspecr of

the phalanges are often locared ar rhe phalangeal neck. Displaced
neck fracrures, also referred ro as subcondylar fracrures, can
occur in young children as a result of getting a finger trapped
~B C
in a closing door wirh a subsequenr arrempr ro wirhdraw it.
FIGURE 8-33. Metacarpal shaft fractures. Fracture in the distal shaft
(A). Transverse (B) or spiral oblique (C) fractures. In fractures of the phalangeal neck, rhe head fragment remains
arrached ro the collateral ligamenrs and tends ro rotare inro ex-
tension (59). This displacemenr through rhe phalangeal neck
disruprs the archirecture of the subcondylar fossa. Because rhis

A B
FIGURE 8-34. A and B: Two views of a transverse mid-diaphyseal fracture of the proximal phalanx that
demonstrates the characteristic apex volar deformity. The volar flexion of the proximal fragment and
dorsiflexion of the distal fragment are secondary to the tendon forces acting across the fracture site.
The arrows demonstrate the actual direction of displacement.
 Chapter 8: Fractures and Dislocations of the Hand and Carpus in Children 297

A B
FIGURE 8·35. A: A crushing mechanism resulted in a complex comminuted fracture of the proximal
phalanx in this child. Longitudinal splitting elements seemed to involve the proximal phalangeal growth
mechanism. Excellent alignment was maintained and healing progressed. B: There was little disturbance
of growth, but the subcondylar fossa (arrow) was somewhat obliterated by callus. There was only minor
loss of flexion in this digit, and this will be allowed to mature before decisions are made concerning
subcondylar fossa reconstruction.

region accommodates the infolded volar plate and volar phalan- resisted. Rarely, there is a subtle deviation of the phalangeal
geallip during interphalangeal ~exion, malunited neck fracrures segment that reflects the depression of tile condylat support.
result in a mechanical block to interphaJangeal flexion. EvelY fracture of the proximal and middle phalanges must
be carefully examined fot clinical malrotation. Malrotation of
Intraarticular (Condylar) Fractures. Phalangeal fractures that the digit can be detected by deviation of the plane of the nails
involve the joint can result from combined longitudinal and with the fingers semi flexed or by an abnormal cascade with wrist
angulatOlY forces, and osteochondral fractures may result from tenodesis. This may tesult from deformity at any level in the
shearing suess. Fractures can be associated with subluxations or osteoarticular column. Fracture at the middle or proximaJ pha-
dislocations of the joint. Despite heightened awareness of these lanx can result in significant rotational deformity.
fractures, they are difficult to identify and hard co treat (l04,
127). Radiographic Findings
Fracture patterns include smalllateraJ avulsion fracrures, uni- True AP and lateral radiographic views are mandatory in the
condylar or intracondylar fractures, bicondylar or transcondylar assessment of phalangeal fractures, and oblique radiographs of
fractures, and a rare shearing injury in which nearly the entire the digits in question should be obtained.
articular surface and irs underlying subchondral bone are sepa- One of the most significanr factors influencing the long-term
rared from the distaJ aspect of the phalanx. A T or Y condylar results in many phalangeal fractures is failure to recognize the
pattern can be caused at rhe interphalangeal joints by an axial extent of injury on the originaJ radiographs. This is especially
loading injury but is uncommon in children. true in unicondylar and bicondylar fractures. The presence of
the physes proximally and the complex periarticular architecture
Signs and Symptoms distally add to the difficulty of diagnosing subtle injuries.
Aside from swelling and minor ecchymosis, many of these de- Physeal and diaphyseal fractures usuaJly can be detected by
formiries are nor clinically obvious. The child generally refuses clinical and radiographic examination. However, a proximal
co actively move the digit, and attempts at passive motion are shaft fracture of me proximal phalanx with volar angulation can
298 Upper bxtremity

be obscured by overlap of the digits on radiography. If rhere is Straight-Line Method. Injuries about the MCP joint are com-
a questionable finding on standard radiographs, special views or mon, but sometimes the relationships in this region where twO
tOmograms may assist in making a definitive diagnosis (130). epiphyses meet can be confusing. One radiographic technique
Examinarion under fluoroscopy can be especially helpful when particularly helpful in assessing alignment about the MCP joint
trying to characterize proximal phalangeal shaft fractures near is Campbell's straight-line method (Fig. 8-36) (36). Although
the physis. best for discovering MCP dislocations, it also can assist in evalua-

A B

FIGURE 8-36. The straight-line method of assessing alignment

about the metacarpophalangeal joint. The long axes of the
metacarpal and proximal phalanx should align, as they do in this
normal hand (A). If there is a fracture in the proximal phalanx,
as in this patient's opposite or injured hand (8 and C), the axes
will not be colinear (arrows). (Courtesy of Robert M. Campbell,
c Jr., M.D.)
 Chapter 8: Fl'flalires i7ud Dislocations 0./ the Hand and Carpm in Children 299

rion of fracrures abour rhis joim mar may be associared with sligh[ overlap of [he subchondral surfaces on the [rue lareral
displacemenr or joinr subluxarion. The phalangeal line is drawn projection. This small inconsistency is of[en overlooked as poor
down [he cenrers of [he phalanges and meracarpals. In rhe unin- technique, but rhe "double densiry" shadow is made by rhe
jured digir, these Jines are colinear, but fracrure deformiry or offset of rhe displaced condyle (Fig. 8-37). A rorared unicondyJar
dislocation abour the Mep joim can skew [his relarionship. fracture is best idenrifled on [he oblique view.

Double Density Sign. The most difficult fracrure ro recognize "Distal Epiphysis" Means Fracture. In phalangeal neck frac-
on radiography is [he paniaJ condylar or unicondylar pattern. rures, rhe rorared head can be confused wirh an epiphysis. How-
The AP films may look complerely normal, and [here is only a ever, [here is no epiphysis a[ [he disral end of [he phalanx; [his

A c

FIGURE 8-37. A 12-year-old girl injured her

left proximal interphalangeal joint playing vol-
leyball. She was treated for a sprained finger
because no fracture was appreciated in the ini-
tial radiographs. The first film (A) that was ac-
cepted as an anteroposterior view was actually
rotated. On the lateral projection (B), the me-
dial and lateral condyles are at distinctly differ-
ent levels (arrows). This represents the double
density shadow made by the offset of the dis-
placed condyle. Six weeks later, the patient had
a significant angular deformity secondary to a
malunited single condyle fracture (C). (Re-
printed from O'Brien ET. Fractures of the hand.
In: Green DP, ed. Operative hand surgery, 2nd
ed. New York: Churchill Livingstone, 1988: 737;
B with permission.)
300 Upper Extremity

represents a pathologic condition. The adequacy of the subcon- The reduction maneuver requires maximal Mep joint flex-
dylar fossa must be evaluated on the lateral view. ion, which relaxes the skin of the web space and the intrinsic
muscles. Then the digit is manipulated into the opposite direc-
Treatment tion of the deformity. Temporary immobilization (light plaster
Most phalangeal fractures can be treated nonoperatively. Out- or loose "buddy taping") should be used while radiographs are
comes are uniformly good for most of these fractures. Despite obtained after reduction to minimize the chance of redisplace-
the favorable biology of youth, certain fractures require a more ment during posirioning for the radiographs.
aggressive approach.
Operative Indications. Despite the high rate of success with
Physeal Fractures. Most phalangeal fractures are fractures of closed trearment of phalangeal base fractures, irreducible frac-
the proximal phalangeal base. One of the most common frac- tures have been reported (12,47,103,127). Reduction was pre-
tures has a readily recognizable name that is both descriptive venred by various tissues, including periosteum and flexor or
and memorable. Rang (175) coined the term extra-octavefracture extensor tendons. In significantly displaced fractures, the distal
to describe the SoH II fracture of the ulnar aspect of the proximal fragmenr can herniate through the extensor apparatus (Fig. 8-
phalangeal base. The digit has the clinical appearance of supra- 39).
physiologic deviation in an ulnar direction. Such an arrangement Some SoH Il fractures may be reducible but unstable after
may be beneficial to the span of a pianist (Fig. 8-38). Most of reduction. These tend to be higher energy injuries with more
these fractures can be treated with closed reduction and immobi- internal disruption of the supporting soft tissues. Inserrion of a
lizarion for abour 3 weeks. smooth percuraneous pin afrer reduction may be warranted.
Rarely is rhere any long-term functional compromise or growth
Closed Methods. If displacement is minimal, simple splinting in disrurbance (Fig. 8-40) (l 03,] 93).
the safe position for 3 weeks is indicated. If the fracture is dis- A displaced SoH III fracture of the proximal phalangeal base
placed, manipulation can be performed with local anesthesia or is particularly difficult to treat. The fracture fragments can be
conscious sedation. Placing a hard object (such as a pencil) in sizable and may involve more than one fourth of the joint sur-
the web space and using it as a fulcrum to assist reduction has face, affecting the stability of the articularion. If a significam
been perpetuated in orthopaedic training (232), but this manip- amount (>25%) of the articular surface is involved, or if residual
ulation technique may create a transient nerve injury from a displacemenr exceeds 1.5 mm, most clinicians advocate open
focal crush. reduction and internal fixation (104,193).

A B
FIGURE 8-38. A: An extra-octave fracture in a 12-year-old girl. B: The deformity was corrected with
the metacarpophalangeal joint in full flexion.
 Chapter 8: Fmetures and Dislocatiom of the Hand and Carpus ill Children 301

If open reduction and inrernal fixation are required, the alter-

natives are intraepiphyseal Kirschner wires or small screws that
are inserted parallel ro the joint surface (35,73). The Ja[[er have
little use in the small phalanges of children.
Comminuted fracture-dislocations of the middle phalangeal
epiphysis are rare in children, so the recommendations for treat-
menr are extrapolated from experience in adults. Displacemenr
of the fragmenrs, compression of the cenrral aspect, and instabil-
ity of the joinr all complicate this injUiY. The alternatives for
treatmenr are open reduction with inrernal fixation and closed
dynamic traction.
Anaromic resroration of these pilon fractures (209) is desir-
able, but the morbidity of opening the PIP joinr is well k11own.
If the fragmenrs are large, then open reduction and smooth wire
fixation may be possible. This can be accomplished by elevating
the lateral bands, taking care w protect the central slip insertion
on the dorsal fracrure fragment. A cenua! depression of the epi-
physis may require elevation. The implications for potential fu-
rure growth are ominolls.
The other alternative, dynamic traction, avoids open manipu-
lation of the PIP joint (1,192). This may take one of several
forms, but the concepts of ligamenrotaxis and early motion for
articular remodeling are the basis for this treatment. Agee's force-
couple concept is innovative but somewhat arduous ro apply
and wear (l). Likewise, Schenck's large outrigger device has dem-
FIGURE 8-39. This displaced type I phalangeal base fracture was irred- onstrated remarkable results bur is cumbersome (192). The use
ucible by closed means. The distal fragment can herniate through a rent
in the sagittal band, periosteum, or extensor mechanism to become of distraction devices is evolving, and development of new exter-
incarcerated in the fracture. nal oxawrs and lower profile disrracrors with articulating ele-
mems may provide better options.
Primary arthrodesis and volar plate arthroplasty have no role

A B
FIGURE 8-40. A: Anteroposterior radiograph of a Salter-Harris II fracture at the base of the middle
finger. The radiograph reveals slight angulation and can look relatively benign. However, it is imperative
that a clinical examination be performed with assessment of the digital cascade for malrotation. B:
Tenodesis of the wrist with passive extension results in relatively painless digital flexion. In this case,
the unacceptable malrotation is evident by the degree of overlap of the middle finger on the ring finger
and the widening of the interspace between the index and middle fingers.
302 Upper Extremity

A B

FIGURE 8-41. A: A 12-year-old boy presented with this heal-

ing angulated fracture of the shaft of the proximal phalanx of
the little finger 2'12 weeks after injury. B: Closed osteoclasis
corrected the deformity, and the finger was immobilized in
flexion in an ulnar gutter splint. C: The splint was discontinued
4 weeks later when these radiographs were made. Nearly nor-
mal function had returned when the patient was seen 3
c months after injury.
 Chapter 8: Fractures and Dislocatiom of the Hand and Carpus in Children 303

in children's phalangeal fractures.These are salvage procedures years of age, but older children have difficulty tolerating more
that should be contempJated only afrer skeletal maturity. than 10 to 15 degrees of deformity. Coonrad and Pohlman (46)
concluded that angulations of 30 and 20 degrees respeccively
Shaft Fractures. Nondisplaced and smble fractures can be will be remodeled in these groups. Favorable factOrs for remodel-
ueated successfully with simple immobilization. Fractures that ing are young age, juxtaphyseal location, and deformity within
are unstable after reduction or cannot be reduced by closed the plane of mocion of the involved joint.
methods require operative intervention. The fracture orienta- Late c1inicaJ malunion is a frequent problem. Prompt referral,
tion, amount of comminution, success of closed manipulation, accurate clinical and radiographic assessment, and appropriate
and stability aU influence the treatment decisions for phalangeal fraccure stabilization will prevent this problem.
shaft fractures. The stabilizing influence of the flexor sheath and
periosteum help keep reduced fractures in place. Safe position Surgical Management. Stein (205) advised closed reduction and
splinting for 3 to 4 weeks should be adequate for clinical union crossed Kirschner wire fixation of transverse phalangeal shaft
(46). fractures that could not be maintained in less than 20 degrees
Phajangeal fractures in the proximal third of the shaft can of angulation in a well-molded splint (Fig. 8-42). Closed pinning
have significant volar angulation because of tendon forces. They also is an option for spiral and oblique fracture patterns. If com-
can be difficult to see on radiography, and malunion may result minution is significant or reduction cannot be obtained or main-
from inadequate treatment. If significant remodeling does not tained, open treatment is indicated.
occur, a claw hand can be caused by imbalance of the extensor Open reduction can be performed through a dorsal incision.
mechanism (3). Splitting of the extensor tendon provides excellent exposure of
fracwres of the proximal phalanx, and the lateral bands can be
Limits ofRemodeling. Failure of closed reduction also can cause elevated to gain access to the fracture. The choice of implam is
persistent malrotation, instability of a uansverse mid-shaft frac- smooth wires or screws. In adolescent athletes, the goal of early
cure, or unacceptable angulation (Fig. 8-41). Simmons and Lo- motion and protected return to activity may influence implant
vaJlo (198) reported that angulation of up to 20 to 25 degrees choice.
in the plane of mocion may be acceptable in children under 10 For fractures of the distal third of the proximal and middle

A B
FIGURE 8-42. A and B: A minimally comminuted transverse fracture of the proximal phalanx with a
short oblique component was difficult to control by closed methods. (Figure continues.)
304 Upper Extremity

FIGURE 8-43. Pericondylar or subcondylar phalangeal fractures tend

to rotate due to their ligamentous attachments. These fractures are
difficult to reduce and control by closed means because of the interposi-
tion of the volar plate and ligamentous forces. (Reprinted from Wood
BE. Fractures of the hand in children. Orthop Clin North Am 1976;7:
527-534; with permission.)

c
FIGURE 8-42. (continued) C: Crossed Kirschner wires were used to sta-
bilize the fracture. The distal-to-proximal wire exits dorsal to the physis
and therefore does not jeopardize the growth potential.

phalanges, the extensor tendon should not be split, but instead

deviated to the radioulnar side for access to the fracture. To
permi t this, part of the distal aspect of the transverse rerinacular
ligament must sometimes be incised at its insertion onto the
dorsal apparatus.

Phalangeal Neck Fractures. Some clinicians have reported suc-

cessful dosed treatment of fractures of the phalangeal neck.
However, this is difficult because these fractures tend to be un-
stable and displace due to the persistent attachment of the distal
fragment on the collateral ligaments (Fig. 8-43).
Closed manipulation is by digital distraction and volar-
directed pressure on the distal fragment with hypetflexion of
the PIP joint. Percutaneous pinning usually is necessary to
maintain the reduced position (Fig. 8-44) (59). This is difficult
because of the small size of the fragment. Under fluoroscopy,
one or two small Kirschner wires are inserted through the
collateral recess and across the fracture. These wires should
engage the contralateral cortex proximal to the ftacture site.
An alternative is to insert the pins through the articular surface
of the proximal phalanx in a longitudinal fashion, crossing FIGURE 8-44. Displaced phalangeal neck fracture of the proximal pha-
the fracture to engage the proximal fragment. This carries the lanx revealing loss of subchondral fossa at the proximal interphalangeal
joint joint. If this is not corrected to anatomic alignment, there will be
risk of growth disturbance, because the pins cross the physis a mechanical block to flexion.
of the proximal phalanx.
 Chaprer 8: FrlICt/ll'eS and Dis/ow/iolls of rbe Hlmd flnd CllrpllS ill Cbile/I'm 305

FIGURE 8-45. A: A 10-year-old boy sustained a displaced

radial condylar fracture of the proximal phalanx when he
injured his ring finger playing football. B: The oblique view
is most helpful in determining the extent of displacement.
C: Open reduction and internal fixation the day after injury
B resulted in normal function.

Intraarticular Fractures. The treatment options for displaced sion. Care should be taken to preserve the blood supply of the
intraarricular fractures of the phalanges are closed reduction with fracture fragments entering through the collateral ligaments.
percutaneous pinning and open reduction with internal fixation Fracture stabilization is by either Kirschner wires or mini-screws
(20,104,193). The percutaneous technique involves the use of (Fig. 8-45).
a towel clip or reduction clamp to effect and maintain reduction Rarely, severe metaphyseal comminution leaves a void after
while percutaneous pins are inserted. If this is not feasible, open anatomic alignment of the arricular fragments. This may require
reduction and internal fixation is indicated through a dorsal or supplemental bone grafting and more extensive fracture srabiliza-
lateral incision with reduction of the fragment under direct vi- tion with a condylar blade plate.
306 Upper Extremity

AUTHORS' PREFERRED METHOD Operative Indications

OF TREATING PROXIMAL AND U nsrable fractures can be percuraneously pinned afrer reduction.
~ MIDDLE PHALANGEAL Small (O.028-inch) smooth wires that hold the epiphysis reduced
,~ FRACTURES
can be placed through the metaphyseal flag or the Thurston-
Holland fragment, or the physis can be crossed if necessary.
Physeal Fractures If closed reduction is nor possible, a dorsal exposure of the
All nondisplaced fractures are treared wirh simple immobiliza- fracture allows extrication of rhe impediment and fixarion with
rion unril pain free. Mosr displaced SoH I and II fractures abour smoorh wires. This is rarely necessary.
rhe hand can be treated with closed reduction (Fig. 8-46). This Salter-Harris III fractures of borh rhe middle and proximal
should be performed under comfortable conditions for the pa- phalanges are diHlculr ro reduce and maimain by closed meth-
tient, including local anesrhesia and conscious sedarion. Simply ods. The rare dorsal S-H III fracture of rhe middle phalanx base
flexing rhe digir maximally at the MCr joinr and applying rhe can somerimes be treared by closed reducrion and splinring in
appropriare maneuver (e.g., radial deviarion for extra-ocrave frac- extension. If the fragment does not reduce, open reducrion and
rures) successfully reduce rhe fracture. Checking rhe clinical flxarjon are warranted ro avoid rhe farer development of a bou-
alignmenr and rorarion, as well as rhe radiographs, is jmperarive. ronniere deformity. A dorsal approach, wirh an incision berween
We place the patient in a safe position splint for 3 ro 4 weeks. the central rendon and rhe lateral band, is preferred. The dorsal
One interval radiograph is obtained at 5 to 7 days to ensure fragmem can be excised if it is small and the patient is near
that the reducrion is being held. The rapidity of healing limits skeletal marurity, and rhe central slip can be repaired back to
rhe ability to remanipulate the fracture if reducrion has been lost. bone. The fragmenr usually should be pinned so the epiphysis
The remodeling potemial of fractures angulated in the flexion- is restored. The rIP joim may need to be pinned for up ro 3
extension plane is significant because of their proximity to the weeks ro permit healing.
active physis. Remodeling in the medial-lateral plane is more If rhe epiphyseal fragment is displaced more rhan 1.5 mm
limited because of the minor adduction-abduction range of mo- or involves more than 25% of the articular surface, or if joint
tion ar the MCr joint. stability is compromised, then open reducrion and internal flxa-

A B
FIGURE 8-46. A: Salter-Harris II fracture of the proximal phalanx of the thumb. B: Gentle closed reduc-
tion, performed under fluoroscopic control, yielded an anatomic reduction. The large surface area con-
tact about the physis helped stabilize the fracture without the use of implants. Rapid healing and
excellent function resulted.
 Chapter 8: Fracture>" lWri IJij-!olfltioll5 (IFilli' flalld alld C{/rjlw in Children 307

tion are indicated. This is more common in the proximal pha- Postreduction Care
lanx at the MCP joint. The fracture is exposed through a dorsal
Fractures of the middle phalanx should be immobilized in more
incision between the sagi((al band and the extensor tendon. The
of a functional position, with moderate flexion of the PIP and
joint capsule is incised dorsally while preserving the collateral
DIP joints added to maximal Mep flexion. For fracrures of both
ligaments. If there is an associated collateral ligament or soft
segments, immobilization should be for 3 to 4 weeks. Tenderness
tissue disruption, this should be repaired simul taneously.
usually has abated ar this time, and many children show evidence
Smooth wires are driven parallel to the joint to reduce and srabi-
of bony healing at this inteL'val. Buddy taping can be used for
lize the epiphysis. It rarely is necessary to pin the fragment to
an additional 2 weeks. Formal therapy or dynamic splinting
the shaft. Mini-screws can be used in larger patiems and larger
usually is not required to regain motion. Protecrion during sporr-
fragments but add li((le stability. Motion can be starred at 7 to ing activities should be continued until motion and strength are
10 days, and the pins are removed at 4 to 6 weeks. However, fully restored.
intraarticular fractures typically take longer to heal.

Percutaneous Pinning
Rare Intraarticular Fracture-Dislocations Unsrable spiral-oblique fractures of the pL'Oximal and middle
The very rare pilon fracrure or intraarticular fracture-dislocation phalanges require closed reduction with pinning (91). The frac-
at the proximal phalanx base presems a management dilemma ture orienration dictates the angle of pin insertion. Ideally the
in children and adults (209). The treatment alternatives are open pins should be placed at 90 degrees to the fracture line. Traction
reduction with anatomic restoration and dynamic traction (1, through fingertraps or an assistant and the aid of image intensifi-
192). Opening the PIP joint is worthwhile when a large enough cation are indispensable. Placement of rhe pins in the mid-axiaJ
fragment exists and the epiphysis has not been too distorted. If line prevents iatrogenic injury of the more volar neurovascular
structures in the mid-lateral line.
rhe child is in later adolescence, treating the complex fL'ac-
ture-dislocation with elevation of the epiphyseal bone (with
bone grafting) is reasonable. Open Reduction
Outstanding results with the use of the traction method in
aduJts have been reported, and the benefits of early motion to Open reduction rarely is required except in older adolescents
both the bone and soft tissue present a strong argument against or for irreducible fractures in younger children. The surgical
open reduction. If the child is not within 1 to 2 years of marurity, approach for phalangeal shafr fractures can be dotsal or mid-
a significant physeal injury at this level has growth consequences. lateral. The dorsal appL'Oach with rendon splitting is better for
Open reduction may increase that risk. Although the utility of fractures of the proximal two thirds of the phalanx. The extensor
tendon is split 10ngitudinaJly in rhe center, with care to avoid
dynamic traction methods in skeletally immature patients is un-
injuring the underlying periosteum. The periosteum can be in-
proven, the healing and temodeling porential of childL'en makes
cised to one side of the phalanx so that the tendon and periosteal
them particula.rly good candidates for minimal intervention in
incisions do not coincide. Repair of the twO layers afrer anatomic
these complex injuries.
reduction should keep knots away from the sliding surface be-
tween them; thus, the knots in rhe periosteum should be buried
close to rhe bone, and the tendon sutures should be tied so the
Shaft Fractures knots face rhe subcutaneous tissue.
Closed Reduction Technique Fractures of the distal third of the proximal and middle pha-
langes are best approached through elevation of the lateral bands
After satisfactOlY anesthesia is obtained, displaced shaft fractures or deviation of the extensor apparatus. Access can be gained
are reduced by longitudinal traction followed by coL'rection of through a dorsal skin incision or a mid-lateral incision; however,
the angular deformity with flexion OL' the totatory deformity the latter might be preferable to keep the skin incision away from
with appropriate pL'onation or supination. For reducrion of a the tendon. The insertion of the cemral slip on the epiphysis of
proximal phalangeal fracture, rhe MCr joint is maximaJJy flexed the middle phalanx should not be detached, because rhis could
to L'elax the intrinsic muscle pull and to stabilize the proximal result in a lare boutonniere deformiry.
fL'agment. RecL'eation of the deformity with exaggerated dorsi-
flexion of the distal ftagment disengages the fracture fragments
and allows the periosteum to assist in guiding fracture alignment. Complex Injurie
Checking the reduction with respect to length and displace- Combined injuries that affect several tissue systems are common
ment in the coronal, sagittal, and roratory planes is essential. in the digits. Because of their curiosity and desire to explore,
Three or four plasrer srrips are carefully applied anteriorly and children are vulnerable to injury from machinety and household
posteriorly while molding rhe fractured digit and one adjacent equipment. Skin, rendon, neurovascular structures, and bone
digit intO the safe position. Despite best effortS, it is difficult to can all be injured in the same digir (Fig. 8-47). Anatomic reduc-
obeain more than 75 to 80 degrees of MCP flexion. The lighter tion and stable fixation are the goals in older children wirh these
plasreL' dressing is stable enough to permit tacLographs to be complex injuries so that early motion can be achieved.
taken; if alignment is adequate, the splint is reinforced. Open fracrure care is of paramount importance, followed by
308 Upper Extrl'l1lity

FIGURE 8-47. A: 14-year-old boy sustained a near-amputation of his

ring digit while using a bandsaw. B: 90-90 intraosseous wiring was
supplemented with Kirschner wire fixation to provide a stable base
for soft tissue repair. Good healing was achieved in the 2 intervening
A,S months since the original operation.

esrablishment of a srable bony foundarion. Markedly commi- cross-pinning can be performed. This is best performed by flex-
nuted fractures or injuries with bone loss may require sraged ing the PIP or DIP joint and placing small (0.028-inch) wires
bony reconstrucrion, wirh srabilizarion in the acute setting by rhrough rhe collateral recesses to engage the proximal fragment
minimal internal or external means. Again, stable fixation is the in a crossed fashion. Wires can be removed ar 4 weeks and
absolute goal so rhat early marion can be achieved. Bone grafring motion starred soon rhereafter. If an acu re subcondylar fracrure
of defects can be performed ar rhe rime of secondary closure or cannot be reduced by closed manipulation, open reduction and
skin coverage. similar percutam:ous pinning are indicated. Elevaring the lateral
Vascular reconsrruction, as necessary, is performed nexr, rhen bands to gain access would be the choice of approach to the
rhe nerve status is assessed. Primary neurorrhaphy usually is fa- proximal phalanx; deviating the extensor mechanism to the ra-
vored, but larer nerve grafting may be considered for large seg- dial or ulnar side for middle phalangeal subcondylar fractures
mental nerve defecrs in unridy wounds. Tendon surgery princi- would yield the best access. Care is taken to maintain rhe blood
ples are the same for children and adulrs. A viable bed must be supply to the small dis[al fragmenr to lessen the risk of avascular
established, and rhe status of rhe tendon and the fibroosseous necrosIs.
theca must be assessed. Repair of the tendon by an experienced
surgeon usually is besL Tendon grafring or other salvage proce-
dures have a very limited role in children. Flexor rendon rehabili- Limited Remodeling Potential
tation in a child somerimes can be complicared due to lack of
If the fracwre is unrecognized or neglected, significant loss of
cooperation, so individualizing rhe protocol may be necessary. In
Aexion may result. Rarely younger children may remodel a[ rhis
patients under 15 years of age, casr immobilization and prorected
end of rhe bone even through it is distaD( from the physis.
motion protocols yield rhe same end results.
Usually rhe residual deformiry is funcrionally limiring. If rhe
parieD( presents when rhere is srill a slighr fracrure line presenr
Neck Fractures in rhe healing, malaligned bone, percuraneous pin osteoclasis
can be performed. Using fluoroscopy, one or twO smoorh pins
Pin Fixation
are inserred into rhe fracrure and used to "joys rick" me disraJ
If recognized early, minimally displaced subcondylar fracrures fragment into a reduced position. The fracrure is then srabilized
can be rreated with gentle manipulation and immobilization with percutaneous pins. This approach may lessen rhe risk of
(Fig. 8-48). Because rhe disral fragmenr is dorsally displaced, avascular necrosis with lare open reduction. Rarely rhese frac-
flexion of rhe fragment with thumb pressure may reestablish [ures can be opened as lare as 2 ro 3 weeks by raking down rhe
rile anatomic relationships, and iIl1mobiliz:ltion in flexion can early callus wirh a combination of sharp dissecrion and blunr
main rain reducrion. However, most of rhese fractures al·e more dissection with a Freer elevaror. Again, flxarion wirh crossed pins
displaced and unsrable. If the fracture is reducible but unsrable, is rhe besr way to srabilize rhe injury.
 C/)(Jpter 8: FI'III'III rl'.\ IIlId Dislol'atiolls of till' H,wd alld Carpw in Children 309

FIGURE 8-48. This minimally displaced type III fracture was amenable to closed reduction. Although
the anatomy of the subcondylar fossa was altered by the fracture. excellent active and passive motion
of the PIP joint was maintained. Excellent function was realized after 3 weeks of splinting and an early
aggressive motion program.

Intraarticular Fractures at the articular surface. Often the subcondylar fossa must be
cleared of bone, and failure to perform this step results in a
Open Reduction Usually Necessary
flexion block despite anaromic joinr reducrion. Provisional or
Intraarricular fractures of rfle phalanges are likely ro require permanent flxarion can be obtained with one or [wo smooth
either percutaneous reduction and pin stabilization or open re- wires. The direction of these wires is dictated by the fracture
ducrion and inrernal fixation. Figure 8-49 illustrates an intraar- configuration. Oblique cross-pinning is best for subcondylar and
ticular fracture of tfle proximal phalanx treated by open reduc- some transcondylar fractures, but small avulsions and unicondy-
tion through a dorsal incision. A mid-lateral incision can be used lar fractures may be stabilized bener by pinning parallel to the
to approach an inrraarticular fracture at the DIP joint, and a joint. Rotational conrrol of the fragment may require multiple
volar incision can be used ro expose the PIP joint. The same implants. Pinning or screw placement through the collateralliga-
concepts of careful tendon and periosteal handling described menr should be avoided so that there is no tethering of the soft
above hold true. Longitudinal division of the transverse retinacu- tlssues.
lar band on the side of a single condyle fracture is preferred. Full motion should be verified before closing the wound.
Rarely, the extensor tendon/lateral band interval must be ex- The decision to leave the pins as rerained implanrs or ro bring
pJoited on both sides of the digit ro inspect and manipulate the them out of the skin for later removal must be individualized.
fragment. Exposure of the fragment with minimal soft tissue In younger children, the pins are left: out of the skin, and a stel'ile
stripping is important. This may be difficult, because an abun- dressing and cast are left intact until removal. In cooperative
dant amounr of early caJius forms in these fractures, and clearing adolescenrs, treatment is more aduJdike, with early motion pro-
this rissue can be arduous. Flexion of the PIP or DIP joint tocols. In this case, the pins are buried to lessen the risk of skin
provides berter access ro the fracture. irritation and superficial or deep infection. Countersunk] .5- or
Somcrimes the fragment has been slighrly comminuted or 2-mm mini-screws are not too prominent to become rrouble-
plastic deformation has occurred, making a perfecr ht all around some later. Late removal of these implants at this level rarely is
the fragment impossible. Tl1erefore, reducrion must be judged necessary.
310 Upper £'.:r:tremity

A,B c

FIGURE 8-49. Authors' treatment of a

complex unicondylar fracture of the proxi-
mal phalanx. A: Anteroposterior film dem-
onstrating the intraarticular component of
fracture and comminution on the radial as-
pect. B: The double density sign (arrows).
C: Oblique film better characterizes the
displaced rotated condylar fracture frag-
ment. The step-by-step operative ap-
proach follows. D: Dorsal approach to the
fracture fragment. E: Incision between the
central tendon and lateral band. (Figure
D,E continues.)
 Chapter 8: Fractures find DisloCfltiollS of t.he Halld find Carpus in Children 311

F G

FIGURE 8-49. (continued) F: Careful han-

dling of the periosteal flap (open triangle).
The fracture fragment is exposed and de-
brided of the early callus. G: Flexion of the
digit shows how the displacement is exacer-
bated (arrows) because of the pull of the col-
lateral ligaments. H: A mini-screw is applied
after reduction of the fragments. This can be
preceded by provisional smooth wire fixa-
tion. The reduction must be judged by the
articular surface and not the area in the me-
taphysis, because part of this may have been
reabsorbed or debrided. Two screws were se-
lected because of comminution of the frac-
ture, but care was taken not to hinder motion
by incarcerating the collateral ligament.
Great care must be taken not to tether the
ligament when placing definitive fixation. By
6 weeks' follow-up, excellent motion had
H been obtained.
312 Upper Fxrrl'lI1i,y

FIGURE 8-50. A: An avulsion fracture of the proximal phalanx with

its attached collateral ligament destabilized the digit. B: It was ap-
proached extraarticularly through a mid-axial incision and secured
A, B with a mini-screw, permitting early motion.

For a simple collareral ligamem avulsion fracture, protecred are removed ar rhe same time as rhe immobillzarion. For periarri-
early morion usually is sarisfacrory rrearmenr. The digit should cular fracrures in an older child, an interval of prorecred morion
be buddy raped ro the adjacenr digir ro prevent recurrenr angula- or further immobilization may be considered. For example, pins
rory or rorarory suess on rhe healing ligamenr avulsion. Rarely, can be removed ar 3 weeks and motion starred ar 4 weeks. Periar-
interphalangeal or meracarpophalangeaJ joinr insrabiliry requires ricular fractures musr be monitored more closely rhan orhers for
open repair. The surgical approach can be rhrough a mid-axial the progress of morion recovety. Alrhough linJe formal hand
incision, and anhroromy can be avoided. Secure fixarion allows therapy is needed, the child must reestablish a usage pattern of
early motion and less risk of long-term conrracrure (Fig. 8-50).
Cenain inrraarticular fracrures present even greater challenges
because of their parrern or orienration (Fig. 8-51). Inrraarticular
shear fracrures call be [['eared with anhroromy and small
J(jrschner wire fixarion. SupplemenraJ bone graft may be neces-
sary. This osteochondral slice fracrure can be problematic despi te
appropriate rrearmenr. Ir is even more complicated when it is
missed or irs severiry underappreciared in the aCllte serring.
When multiple injuries about the inrerphalangeal joinrs occur
(Fig. 8-52), rhe rreatmenr approach must maximize fixation of
all injuries.
Pathologic fracrures of rhe phaJanges are rare, The mosr corn-
man is secondary ro enchondromas and orher benign rumors of
bone. Rarely, they occur wirh remore or recenr osreomyelitis.
An inrcresting pericondylar fracture in a child with a congenital
deformiry is shown in Fig. 8-53.

Postoperative Care and Rehabilitation

FIGURE 8-51. This intraarticular shearing fracture ofthe proximal pha-
The durarion of immobilizarion afrer surgical inrervenrion for lanx is one of the more difficult ones to treat. There is little bony sup-
phalangeal fractures is usually 3 ro 4 weeks. Percuraneous pins port for the articular cartilage, which makes fixation difficult.
 ChtlpuI' 8: Fmrtllrn tll/(! lJi.doCflliof/.' oIthe Ilf/Ild fmd Cf/rpw iii Children 313

A,B c
FIGURE 8-52. A: A 4-year-old with a significant crush injury to the long digit resulting in a metadiaphy-
seal and subcondylar fracture of the proximal phalanx with a combined paraepiphyseal fracture of the
middle phalanx. The PIP joint appears reduced. B: Reduction was followed by longitudinal wire fixation.
Healing of the fractures with minimal deformity was realized. C: There appears to be a possibility of
partial growth arrest (arrows) of the middle phalanx physis, which presented little clinical problem.

the digit for the soft tissues and joints to improve their flexibility. remaining, the location of the fracture with respect to the physis,
The border digits, index and small, seem to be the most difficult and the magnitude and the plane of malalignment (23).
to activate after fracture surgery. If full motion and strength
are not achieved at home, then formal hand therapy may be Age. The younger the patient, the more time and potential exist
necessary. for remodeling. However, several clinicians argue that significant
Patients who have more extensive surgery, such as for com- remodeling can stilJ occur when as little as 2 years of growth
plex fractures or replantations, are more prone to develop motion remains (88,175).
limitations. Flexion can be lost from the mechanical block of
Fracture Location. Fractures near an open physis have a greater
scar or bone in the subcondylar fossa. Extension can be limited
potential to remodel. This is why so few of the prevalent proxi-
after surgical manipulation of the extensor apparatus. Attention
mal phalanx base fractures cause later deformiry, and why there
must be directed to both flexion and extension in the postopera-
is even greater emphasis on anatOmic restoration of pericondylar
tive regimen. Static or dynamic splinting may be instituted if
injuries, which are so distant from the physis.
progress is slow.
Malalignment. Angular deformity usually is not strictly limited
Prognosis to the coronal or sagitral plane, but most of the displacement
Considering the frequency with which most surgeons care for may be present in one of these directions. Deformity in the
these injuries, the number of true complications and functional flexion-extension plane is thought to remodel reliably. Several
impairments is low. Despite appropriate treatment, however, clinicians have observed remodeling in the range of 20 to 30
some patients have motion loss, malunion, and growth disturb- degrees in the sagittal plane in children under 10 ycars of age
ance. and about 10 to 20 degrees of remodeling in older children (46,
198).
Factors Affecting Remodeling
The factots that influence the remodeling of fractures are the Limits ofRemodeling. Deformiry in the coronal or adduction-
patient's age at the time of injury and the amount of growth abduction plane is considerably less. This is rarely quamified
314 Upper Extremity

A B
FIGURE 8-53. A: A subcondylar fracture (arrows) in an 8-year-old boy with complete complex syndactyly
of the two ulnar digits. B: Because closed reduction and splinting failed to control it adequately, it was
stabilized with a single longitudinal pin. Recovery was complete.

bur is probably 50% or less than remodeling in the sagirral plane. pose to these changes. As Rank and Wakefield stated, "Unless
The abiliry of border digits ro withsrand more coronal plane rhe joint irself has been the subject of direct injury, we need
angulation before overlap occurs may dicrare differenr recom- never fear secondaty joint changes in children to the extent that
mendations for acceptable residual angulation. Likewise, the po- we do in adults" (176). In the rare occurrence of traumatic
tenrial of the second and fifrh rays to remodel is higher due ro arthrosis, emphasis should be on the patienr, not on the radio-
their relative freedom of motion in abduction. Radial abduction graphs: minimal pain and excellent function often accompany
deformiry of the index finger and ulnar abduction deformiry of a significant architectural disturbance. Nonsurgical treatment
the smaJl digit at the proximal phalanx level may be rob·ated options are few, so the timing of intervenrion is likely to be the
up ro 20 degrees. It is likely that only 10 degrees will remodel most important factor. Only when pain and functional Jimira-
ro an acceptable amounr in the other digits. No significant tion compromise the pacient's daily activities or when the defor-
amount of coronal remodeling (5 degrees or more) occurs at the mity threatens to affect future vocational choices should recon-
middle phalanx. struction be considered.
We agree with Green that little remodeling occurs at the Reconstruction options include osteoromy, vascularized joint
distal aspect of the phalanges (90). However, in one report a transfer, interposition or dim·action arthroplasry, prosthetic
dispbced phalangeal neck fracture demonstrated suiking remod- joinr replaccmenr, and anhrodcsis (99). Amputation may be
eling in a 7-year-old boy. Dramaric improvement in the radio- appropriare for a complerely dysfunctional digit. All these inrer-
graphic appearance and the morion of the digit OCCUlTed 14 venrions are considered salvage surgery.
months after the injuty without surgical intervention (151). Per-
haps very young children can reconstitute their anatomy, bllt Complications
early anaromic reduction remains the treatmenr of choice for Failure to Recognize a Displaced Fracture. Recognition of a
displaced phalangeal neck (subcondyJar) fractLIres. displaced inrraarticular fracture is difficult, and the impact of
an unrecognized injury is functionaJly significant (Fig. 8-54).
Late Deformities There usually is a suggestion of pathology on the lateral film,
Posmaumatic degenerarive joint disease is rare in children, bur bur it is subtle. The AP film is nororious for concealing the true
inrraarrieuJar injury and sepsis are two factors rhar may predis- nature of this injury. The oblique film most effectively shows
 Chflplt'r 8: Frnc/Ilrrs al/{I Dis/ocrztiollS u( thi' Hllnd and Carp"s i/1 ChiLdrm 315

FIGURE 8-54. A: A 3-year-old girl sus-

tained a fracture of the neck of the proxi-
mal phalanx of the index and middle fin-
gers when they were caught in a door.
The displaced fracture in the middle fin-
ger gives the appearance of an epiphysis
at the distal end of the phalanx. B: Unfor-
tunately, no true lateral radiograph of
the injured finger was obtained. Close
scrutiny of this lateral hand radiograph
shows a dorsally displaced neck fracture,
rotated almost 90 degrees (arrow). No re-
duction was performed because the dis-
placement was not appreciated. C: Eigh-
teen months later, remodeling is not
correcting the deformity. The proximal in-
terphalangeal joint is hyperextended,
and the patient had a significant loss of
A flexion.

c
316 Upper Ex·tremi()'

the fracrure configuration. Fluoroscopy can be useful in examin- against this when applying immobilization, and frequem follow-
ing the small joinrs. up is suggested.
U nforrunately, roo often displaced phalangeal neck fractures If the fracture is unstable in the first 7 ro 10 days after injury,
are not recognized. The fracrure may be confused with an epi- closed reducrion with percutaneous smooth wire fixation is an
physis, or a minor avulsion fracrure, or it may be believed ro be excellent option. The reduction must be carefully assessed and
nondisplaced. Unfortunately, many children with these fractures ensured before proceeding with fixation. If the fracture cannot
presenr late with a malunion and loss of inrerphalangeal flexion. be reduced, then soft tissue or bony interposition may necessitate
Malrotated fractures also are often missed until healed. The open redLlction. Percutaneous pinning is still favored, but mini-
radiographs can be benign in appearance but the clinical appear- screw fixation in patients close ro maturity can be considered
ance profound. Every patient with an acute phalangeal shaft or for some fracrure patterns.
physeaJ fracrure should be examined for malrotation.
Malunion. Because children's fractures heal so quickly, a signif-
icant amount of callus is sometimes encounrered in patients
Redisplacement. Although most phalangeal fracrures are suc- who were not referred in a timely manner, or in those who lost
cessfully rreated by closed means, some fractures are difficulr ro reduction in the interval since the last assessmenr (Fig. 8-56).
control (Fig. 8-55). In general, the closer the patient is ro skeletal This complication can be ptevented by examining the child
maturity, the more likely it is that reduction will be lost, espe- within 24 ro 48 hours of the injury, and frequent clinical and
cially with transverse or shorr oblique fractures of the proximal radiographic examinations should be performed in the first 7 ro
phalanx. Because of surrounding tendon forces, the fracrure 10 days. Rereduction and pinning or internal fixation is always
tends ro angulate with the apex volar. The physician must guard easier than reconstructing a complex malunion.

A B

c D
FIGURE 8-55. A and B: An 8y,-year-old girl with a mildly displaced fracture of the neck of the middle
phalanx. C: Closed reduction was successful on the day of injury. A plaster splint was applied. D: Two
weeks later. the fracture had redisplaced and the deformity was worse than it was originally. Closed
pin fixation could have prevented this problem.
 Chapter 8: Fracture.> tlnd Di.>Lorat'iollS oj/he Halld and Carpus in ChiLdrm 317

A,S c
FIGURE 8-56. A: Deformity in the ring finger of a 13-year-old. Band C: Radiographs revealed a malunion
of the radial condyle with intraarticular incongruity. It is difficult to appreciate this from the lateral
film, but the hint of a double density shadow is seen (arrow). The lateral alignment and flexor function
in the digit was essentially normal. Accelerated arthrosis is possible, but no reconstructive options should
be offered because of normal function.

Late Osteotomies. If (he deformity is significam, (he ma.lunion only way to improve or restore articular anaromy. This proce-
should be allowed co marure biologically, while regaining maxi- dure is seldom perFormed, and there is little information about
mal motion, scrength, and ussue e1as(iciry. Os(eoromy should it in the literature. Ie may be best to Follow the child and consider
be performed through (he sire of deformiry or, if feasible, at a a salvage procedure, such as fusion or arthroplasty, only if signifi-
site where good fixation can be obtained and the bone has a cant symptoms persist.
realistic chance of proceeding co union. For maJunions of (he
diaphysis of the phalanges, osteotomy usuaJly is performed at
Fracture Take-Down. Juxtaanicular maJunions are among the
(he basilar metaphysis. Ie is easier to make the correction at (his
most challenging problems facing the reconstructive surgeon. If
level because (he (issues are more subs(amial and (he bones are
the child is under 10 years of age and the problem is recognized
larger for holding flxa(ion.
in the first 2 weeks after injury, callus take-down and anatomic
If the malunion is at the subcondylar or intraarticular level,
restoration either by percutaneous osteoclasis or open repair can
tile osteoromy needs co be a( (he site of deformiry. If (he fracrure
be successful. The status of the joint must be evaluated and any
is mature, then realistic reconstructive goals must be established.
fracture callus in the subcondylar fossa (hat may inhibit flexion
Imaging studies such as CT scanning, romography, or dynamic
must be removed. The interval of time from injury to reconstruc-
fluoroscopy can be used ro assess (he effect of the articular incon-
tion can be extended to 3 weeks in children up to their mid-
gruiry and the "extra" bone in the subcondylar fossa that may
teens. There are no physes on the distal ends of rhe phalanges
be impinging on the volar lip of the flexing phalanx. Motion
that would permit significant remodeling.
can be rescored by simply removing the mature bone from the
subcondylar fossa, but this does litde to improve joim congruiry.
When the child is still young, it may be more reasonable to Growth Disturbance. If the origina.l injury involved the physis,
accept the intraarticular deformiry and perform the osteotomy growth disrurbance can occur, resulting in stunted longitudinal
of the fossa on Iy For motion recovery. growth or angulatolY deformiry (Fig. 8-57). Fortunarely, this is
Intercondylar osteotomy is exceedingly difficult, but it is the rare. It is more likely when there is a vascular injury or infection.
318 Upper Extrem;ry

A B

FIGURE 8-57. Types of growth disturbances after fracture in the skeletally immature
patient. A: Partial growth arrest. Seven months after a Salter-Harris type IV fracture
of the middle phalanx, there is mild angular deformity and a bony bar crossing the
physis. B: Recovery and remodeling. In this 3-year-old boy, the true extent of the
cause of his swelling little finger was not appreciated. Anteroposterior view shows
a rounded appearance of the epiphysis of the proximal phalanx. C and D: Six weeks
later, the anteroposterior view reveals some bone formation adjacent to the dis-
placed epiphysis, and a true lateral view shows the epiphysis as rotated 90 degrees
c (arrow). (Figure continues.)
 Chapter 8: Fractures and Dislocations of tlJe Hand and Carpus in Children 319

E G

FIGURE 8-57. (continued) E and F: Twelve months later,

anteroposterior and oblique views show a persistently dis-
torted epiphysis. G: Appearance at age 18 (15 years after
injury) shows complete correction. He also had normal clini-
F cal appearance and function.
320 Upprr Eamllity

Fractures of the MetacaJopals Mechanism of Injury

Direct trauma, rotational forces, and axial loading may all cause
Fractures of the Finger Metacarpals
ftactures at the metacarpalleve!. AJI these forces can be generated
Unlike the phalanges, the metacarpals are relatively protected by striking an object or participating in contact sports, the two
by their position within the hand and the stout soft tissues that etiologies that produce most metacarpal fractures in children.
surround them. There is significant variation in the relative mo-
bility of the metacarpals. The stability of the second and third Physeal Injuries
rays at the CMC joint is in contrast to the significant motion Epiphyseal and physeal fractures of the metacarpal head are com-
of the thumb and medial two rays. mon in the fifth ray but are rare in the index, long, and ring
digits (13,36,104). Light and Ogden (131) reported five patients
Surgical Anatomy who sustained metacarpal epiphyseal fractures of the central
Fractures of the metacarpals occur at the epiphyseal or periphy- three rays. Longitudinal growth disturbance resulred after axial
seal region, the neck, the shaft, or the base. Because the collateral loading mechanisms in these patients, but the prevalence of
ligaments at the MCr joinr level originate and insert almost growth disturbance after metacarpal fracture is probably mini-
exclusively on the epiphyses, the physes are relatively unpro- mized because most of these injuries to the physis occur in older
tected from injUlY (Fig. 8-5). This is especially true when the children (12-] 6 years of age). Fractures of the metacarpal neck
forces have a combined axial load with a rotational component. are more common than physeal injuries.
Failure at the physis or an intraarticular fracture can be caused
by any combination of forces. S-H II, [II, and IV fractures of Pediatric Boxer Fracture
the metacatpals have aJl been reported (131,142,162,188). The mechanism of metacarpal neck fracture in the child is the
The metacarpal neck is the most common site of fracture in same as that seen in the adult "boxer's fracture." Bending mo-
this bone. The geometry of the metacarpal and the way the ments concentrated at the metacarpal neck can be generated
hand is used in a punching motion make the metacarpal neck by a force concentrated more dorsally on the epiphysis. These
susceptible to fracture. The cortical bone of the subcondylar fractures have a component of axial loading and an element of
fossa is relatively thin and sUI)porrs a broad metaphyseal area. tangential force, and the inherently weaker architecture of the
The angulation of the metacarpal as it approaches the articular neck fails under these combined forces.
region also may playa role.
Fracture patterns of the metacarpal diaphysis are similar to Direct and Torsional Forces
those in the phalanges. Transverse fractures, resulting from a Torsional forces that cause oblique and spiral fractures in other
direct blow to the hand, are relatively uncommon. Most meta- tubular bones also may act on the metacarpals. AJthough the
carpal fractures resulting from torsion have a spiral or oblique border digits are more susceptible to this injury, the interior rays
pattern. Fractures of the central rays are stabilized by the trans- can JUSt as easily be grasped and torqued in a wrestling match
verse metacarpal and intervolar plate ligaments, making signifi- or bicycle accident. The other way in which the diaphysis can
cant displacement uncommon. Diaphyseal fractures of the bor- fail is by exposure to direct trauma. A transverse fracture can
der digits (index and small) displace more readily. result by three-point bending when the bone is stabilized on its
proximal and distal end and force is directed to the mid-diaphy-
Role of Periosteum sis. A classic example of this mode of failure would be when the
Each metacarpal has a thick periosteal layer that provides an hand is stabilized on the ground and is stepped on, as In a
excellent gliding surface between it and the undersurface of the football pile-up.
extensor tendons. This layer can either aid or hinder the closed
management of fractures in this area. The periosteum can serve Patterns of Fracture in the Finger Metacarpals
as a hinge for reduction (particularly in neck fractures) or can Table 8-4 lists the types of finger metacarpal fractures.
prevent significant displacement. Conversely, the periosteum
can become interposed between fracture fragments (especially
Epiphyseal and Physeal Fractures. Although S-H II fractures
in spiral fractures) and prevent reduction. If open treatment is
of the fifth metacarpal are common among patients 12 to 16
necessary, the periosteal layer must be respected, and careful
handling improves healing and motion potential.

Avascular Necrosis
TABLE 8-4. CLASSIFICATION OF FINGER
McElfresh and Dobyns (142) and others (74) recognized that
METACARPAL FRACTURES
a tense effusion can develop after intraarticular fracture of the
metacarpal epiphysis. The pressure can tamponade the vessels Epiphyseal and physeal fractures
that enter the epiphysis circumferentially adjacent to the physis Neck fractures
Shaft fractures
(51). Synovial vessels also may be disrupted by trauma. These
Metacarpal base fractures
vascular injuries can leave the physis devoid of blood supply and
suscepti ble to necrosis and growth arrest.
 Cllt/pter 8: FI'f/twres mid DisLo(fltiollS oj'tllr Hand fwd (,Ill'jiw i /I ChiLdrcn 321

FIGURE 8-58. A: A Salter-Harris type II fracture of the metacarpal head.

S: A head-splitting fracture of the metacarpal epiphysis.

years of age, fractures that involve the epiphyseal and physeal

regions of the other digits are rare (13,36,104). Intraarricular,
head-splirting fracrures at the metacarpal epiphysis and physis
consistent with S-H II, III, and IV patterns seldom occur at the
metacarpal level (Fig. 8-58).
In their report of five head-splitting fractures in the central
three digits (131), Light and Ogden emphasized the role of open
reduction and internal fixation. They postulated that fractures
resulting from an axial loading injuJY were more likely [Q develop
longitudinal growtl1 disturbance.
The rich blood supply of the epiphyseal and periphyseal areas
has already been described, but special consideration of intracap-
sular bleeding in metacarpal fractures is warranted. McElfresh
and Dobyns (142) and Prosser and Irvine (174) empl1asized the
possible pathogenesis of avascular necrosis: it may be caused by
vascular tamponade resulting from intracapsular bleeding associ-
ated with distal metacarpal fractures. Although the influence of
the fracture itself on the development of avascular necrosis can-
not be ruled out, these clinicians advocated joint aspiration as
a preventive measure in the management of these complex inju-
nes.

Metacarpal Neck Fractures. The metacarpal neck is tl1e most

frequent site of metacarpal fracrure in children. It is unknown B
why neck fractures are so much more common than pl1yseal FIGURE 8-59. A: A true boxer's fracture of the metacarpal neck of the
fractures. Neck fractures in children are analogous to boxer's fifth ray. B: This fracture occurs more in the diaphysis and should not
be considered a boxer's fracture.
fractures in adults (Fig. 8-59). They are more common in the
322 Upper Extremity

fifth and fourth rays than in the radial triphalangeal digits. This superimposed images of the adjacent metacarpals to appreciate
is why the term boxer's fracture is a misnomer, because trained the position of the fragments. Oblique films also can help in
pugilists take the punching impact on the second and third rays this evaluation.
(those with a stable CMC joint), not the medial two rays. If a fracture involves the base of the metacarpal, the standard
radiographic series should be supplemented with a 30 degree
Metacarpal Shaft Fractures. Patterns of metacarpal shaft frac- pronated or supinated oblique view. These show the extent of
rures are transverse, oblique, or spiral. These injuries tend to joint involvement and demonstrate a.ny associated joint subluxa-
occur in older children. Like fractures in other tubular bones, tion or dislocation.
the pattern of shaft fracture yields clues to the pathologic forces The most gracile of the metacarpals is the ring or fourth
that caused the fracture, and indicates the mechanism of reduc- ray; this is a consistent finding in children and adults. Oblique
tion. Aside from recognition of the pattern, the amount of short- nutrient arteries that can be confused with fractures usually are
ening, angular displacement, and rotation is critical to making seen on the volar radial aspect of the metacarpals. These lucent
treatment decisions. lines usually appear to affect only one cortex, and there is no
interruption in the outer contour of the cortex.

Metacarpal Base Fractures. The CMC joint is protected from

injury by its proximal location in the hand and the stability Treatment
afforded by the bony congruence and soft tissue restraints. The Epiphyseal and Physeal Fractures.
fourth and fifth CMC joints are more mobile than the second Closed Reduction. If the fracture pattern is consistent with a
and third rays. Injury at this level is uncommon in children and collateral ligament avulsion fracture, management can be based
usually results from high-energy trauma. on the amount of displacement and fracture stability (Fig. 8-
Fracture through the metaphyseal region of the base can 60). Many of these fractures can be treated by closed methods.
occur as the result of a direct blow or an axial load (often deliv- Gentle reduction under metacarpal or wrist block should be
ered while punching). These are typically small compression in- followed by careful application of a safe position splint (Fig. 8-
juries that usually are stable. Significant injuty at this level often 61).
results from a fall from a height or a crushing mechanism, and
is associated with fracture-dislocation at the CMC level.
Pin Fixation. If the fracture is reducible but unstable, percutane-
ous pin fixation is recommended. If the metaphyseal flag (the
Signs and Symptoms Thurston-Holland fragment) is large enough, the wire can gain
Deformity and significant swelling accompanying a metacarpal purchase through it, but usually the pin must cross the physis.
fracture can be hidden in the dorsal hand. In young children, If this is the case, the use of small-diameter smooth wires is
the capacious areolar tissue can accommodate a large amounr advocated. Care must be taken to minimize the number of passes
of blood and edema. that may further damage the physis.
Any fractured element of the osteoarticular column can cause
rotational and length deformity of the entire ray. In metacarpal
fractures, the border digits (index and small) are more prone to Open Reduction. Displaced intraarticular head-splitting frac-
displace significantly because they have only minimal stabilizing tures require open reduction and internal fixation. Immediate
influence from the transverse metacarpal ligaments (88). A small aspiration of intraarticular hematoma, which may compromise
amount of displacement at the metacarpal level can translate the physeal and epiphyseal blood supply, also should be consid-
into significant clinical malrotation at the more distal digit. ered (142,174).
Mini-screw fixation may be preferred over smooth wire fixa-
tion for greater stability, although either implant is acceptable.
Radiographic Findings. Metacarpal fractures usually are not The goals ofsurgical treatment are anatomic reduction and stable
difficult to identify on radiography. A metacarpal head-splitting fixation, permitting early motion.
fracture or Some periepiphyseal fractures can be occulr, however,
and these may have the greatest impact on long-term outcome.
The Brewerton view is helpful in evaluating the metacarpal Neck Fractures.
head and is taken with the dorsum of the hand against the Nonoperative Procedures. Metacarpal neck fractures are most
cassette and the MCP joints flexed about 65 degrees. The central often treated successfully by closed methods. Adequate anesthe-
beam is angled 15 degrees to the ulnar side of the hand (122). sia, closed reduction with the Jahss maneuver, and application
This projection focuses on the metacarpal heads of the supinated of a safe position splint are normally the definitive treatment.
and slightly dorsiflexed hand and may highlight subtle bony The Jahss maneuver is performed by flexing the Mep joint
detail in this area. It demonstrates better the relationship at the to 90 degrees, to relax the deforming force of the intrinsic mus-
MCP joint. An oblique film also may disclose a coronal fracture cles and the tightened collateral ligaments (1 J Oa). The proximal
pattern. phalanx exerts upward pressure on the metacarpal head as the
It is sometimes difficult to measure the amount of displace- physician applies pressure on the dorsal aspect of the proximal
ment or angulation of a metacarpal neck fracture on a standard metacarpal fracture, forcing it toward the volar side to place
lateral radiograph. Therefore, it is helpful to mentally subtract upward pressure on the proximal phalanx. Jahss suggested im-
 Chapter 8: Fractures flnd Dislocations of the Hand and Carpus in Childrm 323

A B
FIGURE 8·60. A: A small avulsion fracture from the collateral recess in a child near skeletal maturity
can be treated by closed means (arrow). B: In another child, close to growth plate fusion, this fracture
propagated through the vestige of the physis (arrow). Likewise, this can be treated by closed means. In
both of these fractures, aspiration should be contemplated.

mobilization in a posinon of MCP and PIP flexion, bur we This technique should be reserved only for patients at or near
do not advocate this type of immobilization because of central physeal closure. Through a small incision near the metacarpal
stiffness and skin compromise. Immobilization in the intrinsic base, access to the intramedullary canal is made with a drill or
plus or safe position in the appwpriate splint, with the PIP awl. Prebent Kirschner wires, with the sharp tip removed, are
joints free, usually suffices. Recently, we have been limiting the introduced in an antegrade fashion. The wires assist in fracture
immobilization to a level just distal [Q the MCP flexion crease reduction and stabilization. Several wires are stacked in the canal
and encouraging early motion of the liberated segments. for immediate stability. The wires are cut flush with the proximal
COrtex. This technique is particularly well suited for the small
Operative Procedures. A few children near skeletal maturity have and index metacarpals, but fractures in all the triphalangeal rays
metacarpal neck fractures that are difficult to reduce or maintain. can be treated in this fashion. Because intramedullary wires are
Options for treatment ate percutaneous pinning and open likely [Q cause gwwth disturbance in an active physis, this tech-
reduction. As the child matures, less angulation can be accepted nique should be reserved for special situations in which immedi-
at the metacarpal neck. For fractures at the index and long ate stability and early motion are needed for patients at or near
metacarpal neck, dosed reduction may be successful in reestab- skeletal maturity.
lishing anatomic relationships, bur continued insrability may
necessitate percuraneous pinning to maintain the reduction.
Open reduction may guarantee anatomic restoration, but the Shaft Fractures.
dissection and manipulation may further compromise the phy- CLosed Reduction Usually Adequate. Treatment of fractures of
seal blood supply (Fig. 8-62). Stabilization with percutaneous the metacarpal shafts is similar to that of phalangeal fractures.
pins is typically elected. Minifragment screws are seldom used Closed reduction and splint immobilization suffice for mosr
in this region. metacarpal fractures. An unstable shaft fraccure can be managed
IntrameduHary (bouquet) pinning has been used for metacar- by closed reduction and percuraneous pinning. Open reduction
pal shaft and neck fractures in adults and adolescents (72,87). and internal fixation of a metacarpal shaft fracture ate rarely
324 Upper Excremity

A B

FIGURE 8-61. A: A 12-year-old boy with a displaced

Salter-Harris type II fracture of the second metacarpal
and an undisplaced fracture of the proximal shaft of
the third metacarpal. B: Reduction was incomplete,
but good remodeling is noted in this radiograph made
4 months later. C: Eighteen months later, remodeling
is complete and there is a full range of motion in the
index metacarpophalangeal joint. (Courtesy of Sigurd
c C. Sandzen, Jr., M.D.)
 Chl/pter 8: FmClures lind Dis/oCfltions oIthe Hand and Carpus in ChiLdrm 325

A B

FIGURE 8-62. A and B: A dorsally angulated fracture of the second meta-

carpal in a 14-year-old boy. Closed reduction was unstable. C: Closed reduc-
tion and percutaneous Kirschner wire fixation was performed. Because
of the lack of mobility of the second carpometacarpal joint, a proximal
transfixation pin is usually unnecessary when the fracture involves the sec-
ond metacarpal. (Reprinted from O'Brien ET. Fractures of the hand. In:
Green DP, ed. Operative hand surgery, 2nd ed. New York: Churchill living-
stone, 1988: 715-716; with permission.) c
326 Upper /;~\·tremi(y

FIGURE 8-63. Radiographs of ring and small finger diaphy-

seal metacarpal fractures initially treated with closed reduc-
tion and splinting. The malalignment with a flexion defor-
mity is evident on the lateral view. Multiple diaphyseal level
metacarpal fractures are usually unstable with a high rate of
loss of reduction with closed treatment. Percutaneous pin
treatment is preferred.

indicared in children; one exception may be mulriple adjacenr Metacarpal Base Fractures.
displaced metacarpal Fractures. Associated Injuries. Fractures of the meracarpal base or frac-
ture-dislocations at the CMC joinr are high-energy injuries with
significanr tissue disruption. PaJpation of the muscle compart-
Pin Fixtltion Options. Some rransverse or spiral oblique Fractures
menrs For signs of evolving compartmenr syndrome and careFul
may be diFficulr co control by closed mer hods. Pinning of the
neurovascular assessment are always indicated.
fracture fragments co the adjacenr srable meracarpal or percura-
neous pin fixarion of the fracture irself may hold fragmenrs in
Pin Fixation Techniques. Sandl,en (187) advocated closed reduc-
a favorable position (Fig. 8-63). If a long spiral-oblique fracture
tion and percutaneous pinning for isolated dislocarions of the
is associated with significanr ma.lrotarion, percutaneous pinning
small ray CMC joint. Closed treatment is aided by JongitLIdina.l
or mini-screw fixation may be considered. The latter may permit
traction and careful manipulation. A paJpable and audible reduc-
early motion, which may minimize tendon adhesions. Another
tion may accompany successful manipulation. If the reduction
oprion for stabilization of rransverse and some oblique fractures
is unstable (which is the rule rather than the exception), consid-
is inrraosseous wires combined with smoorh Kirschner wire fixa-
eration can be given to percutaneous pinning. The pins can be
tion, but the magnitude of the dissection and volume of hard-
placed transversely berween the metacarpaJs and through the
ware argue against this opcion.
base of the fractured or dislocated metacarpal, or they can be
placed through the collateral recess, across the medullary canal,
Open Reduction. Although this procedure is rarely indicated in and across the CMC joint. The latter pattern is more technically
children, thc capaciry of rhe dorsal meracarpaJ area co accommo- difficult, and care must be taken to avoid rhe physis. IF the
dare a screw or a plare is greatcr than that in the digir. For medullary canal can be accessed through the collateral recess,
long spiral oblique Fractures, inrerFraglllenrary screws can be an rhe pin can be driven From distal to proximal, crossing rhe re-
excellenr option. Anacomic reduction can be obtained, rhe duced CMC joint.
screws can be countersunk so as nor co interFere wirh rendon
glidi ng, and the excellent stabili ry can perm it early morion. Open Reduction. Open reduction may be necessary co effect re-
For a severely comminuted Fracture, especially iF there is bone ductiorr and ensure stable fLXation (Fig. 8·64) (118,230). Various
loss, plate fixarion can be used. Bone grafring should be consid- incisions can be used to gain access to the CMC joint. Longitudi-
ered iF there has been bone loss. Plaring requires more exrensive nal incisions adjacent to the affected ray permit invesrigation
soFr rissue dissecrion and occupies more space rhan wires or of the Fracture-dislocarion and allow fasciotOmies if necessary.
screws. Tendon adhesions are a significant concern with plate Percutaneous pinning can be performed in any of the ways de-
fLxation. If plating is used, rigid fixation must be ensured so thar scribed previously. Regardless of lhe pinning method chosen,
early motion can combat these porential complicarions. the physes should be avoided.
 Chapter 8: Fracturrs and DisLocations of the Hand and Carpus in Children 327

A c

o
FIGURE 8-64. A and B: An l1-year-old boy sustained a fracture of the proximal shaft of the second
metacarpal and a fracture-dislocation of the third carpometacarpal joint when his hand was caught in
a cyclone fence he was attempting to climb. C and D: Closed manipulation reduced the third metacarpal
joint, but buttonholing of the second metacarpal in the volar soft tissues necessitated open reduction
and Kirschner wire fixation. Normal function resulted.
328 Uppl'l" F~·rmllit.y

AUTHORS' PREFERRED Epiphyseal and Physeal Fractures

TREATMENT OF FINGER
For epiphyseal and physeal fractures, the joint is approached
METACARPAL FRACTURES
through a gently curved or longitudinal incision JUSt ro the side
of the metacarpal head. The arthrotomy can be made in a ten-
Role of CLosed Manipulation
don-splitting and tendon-sparing manner; both choices are rea-
There is a limited role for closed manipulation and immobiliza- sonable and typically do not affect later extensor function. The
tion in the treatment of displaced physeal and epiphyseal frac- tendon-splitting approach is performed by incising in the mid-
tures. It is difficult to gain access to the head-splitting variant portion of the tendon without disturbing the underlying perios-
and very difficult to control these highly unstable intraarticular teal layer. We prefer the tendon-sparing approach. A longitudi-
fractures. When the patient is seen soon after the injury, the nal incision 2 or 3 mm lateral ro the extensor tendon, through
likelihood of successful closed manipulation may be greater. As- the sagittal band, permits elevation. Another option is to create
pirating the hematoma from the joint is a prerequisite to success- a T-shaped incision in which the longitudinal peritendinous as-
ful fracture manipulation. pect is joined by a perpendicular incision in line with the flbers
Fractures of the metacarpal neck are particularly suited to of the sagittal band. In either approach, the extensor mechanism
closed treatment. Again, it is best to perform these reduction is then elevated to a limited extem by dorsal retraction on the
maneuvers early after the injury so that swelling is at a minimum. hood. The periosteum is carefully handled, although very little of
The Jahss maneuver (previously described) is our treatment of it needs to be reflected when approaching intraarticular fractures.
choice for closed reduction of metacarpal neck ftactures. Under The capsule itself can be incised either transversely or in a T-
wrist block and conscious sedation as necessary, an appropriate shaped fashion, depending on the imraarticular fracture pattern.
reduction maneuver often aligns the fracture, improves comfort, This is the least traumatic and most easily reconstructable ap-
and provides information about the "personality" of the fracture. proach into the MCP joim.
We can then determine the difficulty of the reduction, the pres- The joint capsule can be entered with a T- or L-shaped inci-
ence of interposed tissue, and the instability of the fracture. We sion to expose a head-splitting fracture. The arthrotomy decom-
advocate the more low-profile splint that permits motion with presses any hematoma in the joint. Direct manipulation of the
most of these fractures that have been reduced and are believed fragments with a dental pick (respecting the hyaline cartilage)
to be stable. aligns the fracture. The use of reduction clamps or a transverse
The fracture pattern and amount of comminution usually smooth wire can provide provisional stabilization while mini-
determine if closed reduction of metacarpal shaft fractures is screws are placed. We prefer mini-screw fixation, but 0.035-
possible. Some long spiral-oblique fractures can be successfully inch wires can be used if the fragments are toO small or if multiple
treated with closed methods because their fracture surfaces can fractures are present.
be readily approximated, and the large surface area can help Salter-Harris II fractures seldom require open reduction.
stabilize the fracture and promote healing. Other oblique frac- They typically occur in adolescents, but enough remodeling is
tures demonstrate a tendency to shorten and rotate, and may left about the physis that up to 30 ro 35 degrees of angulation
require stabilization with pins (younger patient) or screws (ado- probably can be accepted. If the reduction can keep the angula-
lescent). tion in the AP plane within 25 or 30 degrees and there is no
It is sometimes difficult to effect or maintain reduction in rotational deformity, casting for 3 to 4 weeks is usually adequate,
transverse fractures of the mid-shaft, but we attempt closed treat- with functional bracing and guarded motion started at rhat rime.
ment of single metacarpal fractures. We have more success in If the fracture is unstable, percutaneous pinning with a single
reducing and holding fractures of the central rays (long and ring smooth Kirschner wire is best (Fig. 8-G5). Engaging a large me-
digits) than with fractures of the border digits. If the transverse taphyseal fragment is difficult but feasible. Avoiding the extensor
fracture can be reduced, but is unstable, percutaneous intramed- mechanism with the pin is important and is best done with a
ullary pining through the collateral recess or tangentially from lateral approacl1 of the pin. The pin can cross the physis near
the base is used. We try ro cross the fracture with a pin that is its center and test in the head. Penetration into rhe joint must
as close to perpendicular to the transverse fracture as possible. be avoided.
Fractures and fracture-dislocations of the CMC joint can be
reduced closed as described previously. We attempt to perform
a closed reduction, but recognize the tendency of these injuries Metacarpal Neck Fractures
to redislocate if they are not stabilized. Our assessment of stabil-
Reduction Techniques
ity after the reducrion dictares the need for fixation, but pinning
Fractures at the meracarpal neck are treated with closed reduc-
across the CMC joint is almost always required. Additional pins
tion and safe position splinting. Rarely, a fracture is quite un-
to adjacem metacarpals can be used to add stability.
stable and difficult to control by closed means. After careful
assessment of sensation, anesthesia in the form of a wrist block
Techniques for Operative Management (wirh the possible addition of conscious sedation) can be used.
If the metacarpal neck of rhe small or ring digit is fractured,
Despite early treatment, expert reduction maneuvers, and careful an ulnar nerve block usually suffices. A median nerve block is
application of immobilization, some fracture patterns cannot be necessalY for comforrable reduction offractures in the index and
adeq uately closed. long meracarpals.
 Cbapler 8: Fractures tlllef DisloCfltions of/he Hand alld Carpus hi Childl'OI 329

A B

FIGURE 8-65. A and B: This markedly comminuted and dis-

placed transphyseal fracture of the fourth metacarpal ray pre-
sented in this 7-year-old boy. C: Effective closed reduction, fol-
lowed by percutaneous pinning, stabilized the metaphyseal
aspect of the fracture and resulted in near-anatomic reduction
and an excellent final result. The Salter-Harris type II fracture of
the small finger metacarpal required no additional treatment
aside from the splint used for the pinned ring finger ray. This
c secondary injury healed uneventfully.
330 Upper Extremity

We advocate the ]ahss maneuver described previously for fluoroscopy unit available so that the adequacy of the reduction
reduction of these fractures. Sometimes, additional manipula- and the location of the pinning can be determined intraopera-
tion with palmar pressure to the metacarpal head can effect fur- tively. One limiting factor to the use of percutaneous pinning
ther reduction of the neck fracture. The reduction can be is the amount of bony purchase that can be achieved. We avoid
checked with fluoroscopy before applying the splint, or careful tethering the collateral ligaments with the pin, which is why we
splinting can be performed and plain radiographs obtained. pin in maximal MCP flexion. We seek the collateral recess as
the entry site for the pin and often perform cross-pinning, mean-
Postreduction Immobilization ing two collateral recess pins from opposite sides that cross near
We recommend the following measures for the application of mid-shaft. Sometimes the pin simply slides down the intramed-
immobilization: ullary canal and has good purchase; this is perfectly acceptable.
This method also requires 3 to 4 weeks of immobilization.
1. An adequate but not excessive amount of cast padding should We make sure that the pins that penetrate the skin do not
be applied. Skin integrity is important, but too much cast have any direct contact with the cast padding or plaster, because
padding diminishes the ability of the plaster to hold the frac- motion of the splint could cause pin track problems. This is
ture reduction. why we pad the pins adequately. We also bend the pins to
2. Using plaster strips in the anterior and posterior aspects of prevent migration.
the hand and wrist permits good molding. Applying two or
three thicknesses ofsplints on the anterior and posterior sides,
followed by careful molding of the fractured rays into a safe Shaft Fractures
position, can temporarily hold the reduction. Repeating this Uncomplicated Fractures
sequence two or three times over already hardened underlay- We usually are successful in treating most metacarpal shaft frac-
ers offers the best chance to stabilize fractures that are difficult tures with closed reduction and immobilization for 3 to 4 weeks.
to maintain. We mold the splint to provide adequate three-point bending.
3. Before applying too many thicknesses of plaster, it is prudent Downward pressure at the apex-dorsal fracture site should be
to wrap a single layer of cast padding around five or six balanced with upward pressure at the head and the proximal
thicknesses (on each of the volar and dorsal sides) and check shaft. Correct rotation and acceptable length must be verified
the radiographs. This permits evaluation of the reduction before applying the splint to keep the MCP joint flexed about 70
without obscuring by plaster. degrees. The PIP joint can be free, thus avoiding even transient
4. Careful molding with application of the splints is performed stiffness. Because the ability of the metacarpal shaft to remodel
by using palmar pressure at the metacarpal head level and is small compared with that of the metacarpal neck, rotation
continued dorsal pressure on the proximal metacarpal. To and angulation must be carefully assessed. Careful assessment of
avoid leaving finger impressions that could cause areas of skin the appearance of the hand and angulation in the AP and lateral
damage, continuous smoothing of the plaster to eliminate planes on radiography ensures the success of reduction.
areas of depression and air bubbles is advisable.
5. If the reduction is adequate, more plaster can be applied to Multiple or Unstable Fractures
make the splint as rigid as possible. Occasionally, shaft fractures are unstable or accompanied by
6. For immobilization, the safe position at the MCP and PIP adjacent shaft fractures. Options for stabilizing these fractures
joints could be used, but we have had success with a more include percutaneous pinning and open reduction and internal
extended MCP joint and a free PIP joint in most of our fixation. Some of these fractures can be stabilized with cross-
patients. If the safe position is elected, the wrist should be pinning technique or other pinning constructs that traverse the
extended about 10 to 15 degrees and the MCP joint flexed intramedullary canal. Checking the roration of each ray after
maximally. Because children rarely develop significant stiff- stabilization is key.
ness, it may be advisable to extend the splint past the PIP. Another option is to pin the reduced distal fragment to the
7. The typical period of immobilization for metacarpal neck adjacent metacarpal with two parallel transverse wires (0.035-
fractures is 3 to 4 weeks for most children. or 0.045-inch). An additional proximal pin placed parallel to
8. We change the initial splint to a cast of similar nature at 2 the distal pins helps stabilize the construct. We avoid flattening
weeks if needed, depending on the integrity of the cast. We of the hand: attempts to recreate the longitudinal and transverse
typically assess the fracture reduction at 5 to 7 days to ensure arches of the hand are important when dealing with adjacent
that rare remanipulation is not necessary. If the integrity of metacarpal fractures.
the original splint is good and the reduction is being main- If the metacarpal shafts of the ring and small digits are in-
tained, we continue the original immobilization for the entire volved, additional stabilization of the proximal fragment to the
treatment course. adjacent metacarpal is required. If the fracture is quite proximal,
we consider pinning the CMC joint to avoid further influence
of CMC motion.
Unstable Fractures
The pins are bent and cut off, and the sharp ends of the
If the fracture of the metacarpal neck is reducible but unstable, pins are covered with a prefabricated cover for cast padding. An
we consider percutaneous pinning. This is important in unstable additional safe position splint is then applied. Fracture healing
neck fractures in the index and long metacarpals. We have a in the shaft of the metacarpal may be slower than in the areas
 Chapter 8: Fractures and Dislocations of the Hand and Carpus in Children 331

about the physis, so we usually keep these pins in for 5 to 6 branch, or a Bier block. The fracture can then be immobilized
weeks. Careful assessment of clinical union is important because in a short arm ulnar gutter splint, leaving the PIP joint free to
with excellent reduction, very little fracture callus may be seen move for about 3 to 4 weeks, or until nontender.
on radiographs. When the patient is nontender to palpation
about the fracture site and radiographs show evidence of fracture Complex Fracture-Dislocations
union after the fourth or fifth week, the splinting is discontinued.
Fracture-dislocations at the CMC base are more challenging.
Few repoftS in the literature address this subject, and the patterns
Open Reduction
of presentation and treatments vary. Researchers have reported
Open reduction and internal fixation of metacarpal shaft frac- isolated (I87), multiple (I 18,230), dorsal (187,230), and volar
tures are rarely indicated. Muhiple adjacent fractures, fractures (118) dislocations. The treatments have varied from closed ma-
with interposed soft tissue blocking reduction, or open commi- nipulation and immobilization to open treatment (I 18, I 87).
nuted fractures may be exceptions. Most of these patients are I nitial closed treatment failed in a complex case of fracture-dis-
pre- or true adolescents. We occasionally use interfragmentary location of the medial four CMC joints, and later operative
screw fixation for long spiral-oblique fractures with good bony treatment was necessary (230). We advocate an initial attempt
apposition. Mter careful reduction and stabilization of the frac- at closed reduction to diminish the pain and deformity in the
ture in anatomic position, screws can be inserted, typically 1.1, area of the injury. Regional (wrist) or Bier block and conscious
1.5, or 2.0 mm in diameter. We overdrill the proximal cortex sedation usually provide adequate anesthesia. We use fingertraps
to effect comptession with imerfragmentary screw fixation. for distraction. An audible and palpable "clunk" accompanies
Countersinking the heads of the screws is advisable to minimize a successful reduction, but we remain concerned about instabil-
prominence and potential adhesions. ity. We question the adequacy of simple closed treatment for this
injury. An isolated fifth ray fracture-dislocation can be stabilized
Surgical Approach with a well-padded splint, but this is not our choice; stability
Whichever method of internal fixation is chosen, the approach is must be ensured by pinning.
similar. The metacarpal shaft is approached through an incision
centered over the dorsum of the web spaces adjacent to the Percutaneous Pinning
fracture. To minimize potential extensor adhesions, we prefer Percutaneous pinning of the reduced fracture-dislocation can
to use this interval rather than a direct incision over the bone. be performed with oblique and transverse pins between the
The incision can be extended proximally if necessary. The exten- metacarpals and across the CMC joint in single- or double-
sor tendon is retracted to gain access to the shaft. The thick ray injuries. We also use longitudinal Kirschner wires inserted
periosteum should be meticulously respected and repaired ifpos- through the collateral recesses and down the canal to eventually
sible. The periosteum usually cannot be repaired after plate fixa- cross the CMC joint (l18). However, inserting these pins can
tion. The interfragmentary screws often can be covered by the be difficulr, and the physis is at greater risk fot pin penetration.
periosteal layer, especially if coumersunk. Because the fractures An easier arrangement is to place oblique and transverse pins
should be crossed at 90 degrees with the interfragmemary screws, through the bases of the metacarpals, then perform intermetacar-
some of the screw heads could be in the plane of the metacarpals pal transverse pinning, respecting the transverse arches of the
and would not be problematic on the dorsum. hand.
With multiple metacarpal fractures, an approach through an Radiographs (including appropriate oblique views) are
incision in the intermetacarpal space is particularly helpful. We needed to verify the reduction and pin placement. Very unstable
usually can reach adjacent metacarpals easily through a single ulnar-sided dislocations tend to slip if not pinned after reduc-
incision between them. Ifall four metacarpals are fractured, mak- tion. Furthermore, fragments can rotate (up to 180 degrees) and
ing one incision in the intermetacarpal space on the dorsum block reduction. If the surgeon is not completely comfortable
between the index and long finger and a second between the with the reduction, then proceeding to open reduction is advo-
ring and small digits permits access. If needed for developing cated.
compartment syndrome, fascioromies of the interosseous mus-
cles also can be performed through these incisions. Open Reduction
If reduction cannot be achieved by closed means, or if there are
Plate Fixation multiple irreducible CMC dislocations (especially if the CMC
If mini-plate fixation is chosen, options are a flat plate or a dislocation is volar), two dorsal incisions in the II-III and IV-
semitubular plate. The plate that conforms to the bone architec- V web areas at the CMC level are necessary. These incisions
ture and offers the best stability should be chosen. Usually, a allow access to the bony injuries at the two adjacent rays and
five-hole or seven-hole plate is selected, and the hole directly permit volar and dorsal fasciotomies if needed for developing
over the fracture site often is left unfilled. The engagement of at compartment syndrome. Bony reduction is performed, ensuring
least four cortices proximal and distal to the fracture is advisable. that the articular fragments are not rotated or blocking reduction
at the CMC joint. Either pinning method described can be used.
Metacarpal Base Fractures: Closed Procedures
Postoperative Care and Rehabilitation
We usually gently manipulate basilar fractures of the metacarpal For fractures treated by closed methods, no formal therapy is
after a regional block of the ulnar nerve and its dorsal sensory needed after casting. In vety active children and young athletes,
332 Upper Extremity

a light splint can be worn for protection from direct trauma and
as a signal to the patient and his or her peers that the hand is
not quite back to normal. Free motion of the digits and wrist
is permitted while the patient is in a controlled environment,
and the splint is weaned off by 7 or 10 days.
Epiphyseal and physeal fractures successfully stabil ized by
mini-screw fixation should be aggressively rehabilitated. After 3
to 5 days, a removable splint is applied. Active-assisted motion
is performed six to eight times a day. Interval splinting is discon-
tinued after 3 to 4 weeks. Dynamic splinting rarely is required.
Neck fractures treated with percutaneous pinning are main-
tained in a safe position spJim with the PIP joint free for 3 to
4 weeks. The pins are removed at the end of this period, and
more aggressive mobilization of the Mep joint with active and
active-assisted motion is begun. If the intramedullalY technique
was used, unrestricted active motion is starred after 3 to 5 days
of hand rest. A removable splint can be furnished for interval
wear. The intramedullary pins need not be removed.
For shaft fractures, the postoperative care is dew'mined by
the method of fixation used. Percutaneous pin fixation should
be protected for 4 to 6 weeks in a splint. Because dorsally angu-
lated shaft fractures may redisplace if fixation is removed toO
soon, pins should be removed after radiographs demonstrate
bridging callus. After pin removal, a motion program can com-
mence. If a spiral-oblique fracture was fixed wirh screws, motion
can safely start within a week of surgery, depending on the status
of the wound.
Percutaneous pins stabilizing fracture-dislocations of the
metacarpal base should be left: in place for at least 5 or 6 weeks.
It is important to assess the patient clinically and with a complete A B
radiographic series to determine the progress of healing. When
FIGURE 8-66. A: A 12-year-old boy sustained a minimally displaced
the pins are removed, active and active-assisted motion of the Salter-Harris type II fracture of the proximal phalanx in a fall. B: One
adjacent joints can begin. year later, the patient presented with mild pain in the metacarpopha-
langeal joint. The metacarpal head shows considerable deformity sec-
ondary to avascular necrosis. (Courtesy of James H. Dobyns, M.D.)
Prognosis
Most metacarpal fractures of all rypes heal well and leave little
residual deformity or functional limitation. The factors that may
hinder the eventual outcome are summarized for each type of
after fracture and may be influenced by the direct injury and also
fracture in Table 8-5.
by the imracapsular pressure caused by the contained hematoma
(Fig. 8-66). Avascular necrosis may result in significant irregular-
Complications iry of the articular surface, but symptoms rarely are significant
Avascular Necrosis ofthe Metacarpal Head. Avascular necro- enough to warrant surgical intervention.
sis of parr or all of the intraarricuJar metacarpal head can occur If the insult occurs in a growing child, remarkable remodeling
of the adjacent arricular surface may still result in a functional
joint. Part-time splint protection while the joint is sympcomatic
is all that is needed in most patients. Rarely, significant joint
incongruity as a residual of avascular necrosis may require recon-
TABLE 8-5. ADVERSE FACTOR5 FOR FINGER structive surgery. There are several reconstructive options for
METACARPAL FRACTURES
incongruous joints with early arthrosis, but none are very satis-
Epiphyseal and physeal fractures factory. The most predictable treatment IS arthrodesis;
Avascular necrosis. malreduetion/malunion arthroplasty (interposition, perichondral resurfacing, distraction,
Neck Fractures or implant) and vascularized joint transfer rarely are appropriate
Excessive apex dorsal angulation. malrotation
in children (199).
Shaft fractures
Malrotation, soft tissue interposition. nonunion
Metacarpal base fractures RotationalMalalignment. Even a smaJJ amoum « I 0 degrees)
Loss of reduction. malreduction of articular fragments, late in-
stability of rotational maJaJignment of the metacarpals can cause overlap
of the digits in flexion and functional disturbance (Fig. 8-67).
If rotation was not corrected and maintained by closed reduction
 ChfJpter 8: Fmrtllre.f fJnd DisloCfltioll.' of the Hand fJ/ld Carplls in Children 333

FIGURE B-67. A and B: A 15-year-old boy presented with severe

overlapping of the ring finger on the little finger when he made a
fist. Four months earlier, he had a spiral fracture of the metacarpal
that had healed with a severe rotatory malunion. C: Distal osteot-
omy through the deformity stabilized with pin fixation corrected
the malrotation. Basilar rotational osteotomy is another treatment
alternative. (Reprinted from O'Brien ET. Fractures of the hand. In:
Green DP, ed. Operative hand surgery, 2nd ed. New York: Churchill
A Livingstone, 1988.731; with permission.)

B c

and percutaneous pinning, decisions about the timing and type relatively large cancellous surfaces permit correcrion of rotational
of treatment are important. The COlTection can be performed maJaJignment. Kirschner wire fixarion usually is satisfactory, bur
electively severaJ months after the original injury. This permits a small T plate applied to the tension side of rhe bone is an
the fracture to mature and allows the tissues to stabilize. acceptable al ternative.
We advocate proximal shaft or basilar osteotomy to COtTeer
malrotarion of even a distal deformity (in contrast to performing Nonunion. Experience with metacarpal nonunion is limited.
an osteotomy at the site of the deformity to con·eer angulation). Although treatment approaches have varied, rhe results have all
Performing rhe correcrion away from the sire of original fracrure been satisfactOry. Ireland and Taleisnik (J 10) reported on rwo
has many advantages. The bone in this area heals well, and the parients, noting rhat their report of this entity was rhe first in
334 Upper Extremity

rhe lirerarure. A 10-year-old girl undelwent bone grafring and Musculoskeletal Units Inserting on the Thumb Metacm'-
pinning of painless bur clinically deformed second and third pal. The opponens pollicis has a vety broad inserrion over the
metacarpal non unions 7 monrhs after injury. She healed une- central metacarpal shaft and base. It plays an inregra.l role in the
venrfully. A second metacarpal nonunion in a 3-year-old boy concerted motions that allow thumb opposition. The opponens
healed sponraneously after 2 years of follow-up. Ogden (162) poJlicis also may parricipate in fracture situations by pulling the
successfully [I'eated nonunions of the second and third meracar- distal fragment into relative adducrion and flexion, along with
pals of a child by reduction and pinning withom bone grafting. the units that insert distally on the flexor surface.
These parienrs all appeared ro be relatively asym promaric. Unless At the metacarpal base, the abducror pollicis longus has one
clinical deformity is presenr, following these "nonunions'" (per- of its multiple potential inserrion sites. The abducror pol/jcis
haps unrit maturity) may be a reasonable alrernative. When re- longus can have inserrional slips ro the fascia of the thenar emin-
consrruction is performed, open reduction and bone grafring ence, the trapezium, and the CMC capsule. It also is the prime
are rhe standard. Fixation choices are percutaneous pins or small deforming force in some fracrure-dislocations or subJuxarions
plates. (15) about the thumb CMC joint. In addition, the flexor pollicis
brevis can have part of its origin from the more medial aspecr
of the metacarpal base. This may add to the flexion force and
Fractures of the Thumb Metacarpal apex-dorsal angulation in some fractures of the metacarpal shaft.

hacrures of the thumb metacarpal neck and head are uncom- Bony Architecture at the MCP joint. The "double saddle"
mon and usually result from direct injUly. Fracrures of the meta- architecture of the articular surfaces of the thumb metacarpal
carpal shafr are common, and typically closed reducrion is ade- and distal trapezium is uniquely well suited to provide mobility
quate. Metaphyseal and physeal fractures of the thumb for positioning the thumb in space. It also locks into a stable
metacarpal have received most of rhe artenrion in the literature arrangement when pinch force is initiated. When rhe meracarpal
because of their frequency and potential impacr on function. is fracrured, the mobility presenr at the CMC joinr can make
reduction difficult. There is no volar plate or well-developed
Anatomic Considerations collatera.l ligament system to provide reinforcement. When the
Muscle Forces. The muscles that originare or insert on or distal base becomes untethered from the reSt of rhe column, it can be
to rhe metacarpal may influence fracture geomerry. Depending diFficult to balance the remaining distal metacarpal fragment
on the vector of pull, these musculotendinous units act as stabi- ontO this moving target.
lizers or deformers of parricular fracture patterns. The other soft
tissues (collateral ligaments, volar plate, periosteum) also inBu- Classification
ence rhe pathoanaromy. Their relative positions in rhe thumb Head and Shaft Fractures. Fractures of the rhumb metacarpa.l
ray were described earlier in this chaprer. head and shaft are similar to those of the rriphalangeal digits
(Table 8-6). There is lirtle need ro subclassify these injuries,
because of this similarity and because they are n'eated in a similar
Musculotendinous Units Inserting Distal to the Thumb Meta- manner to their medial counterparts. The focus of this secrion
carpal. Like the tendon insertions on the terminal phalanges is on the variable parrerns of metacarpal base fractures, including
of rhc flngers, the flexor pollicis longus inserTS on rhe metaphysis
fracrures that involve rhe physis and epiphysis (Fig. 8-68).
and rhe extensor pollicis longus on the epiphysis, on their respec-
tive palmar and dorsal surfaces. The distal twO thirds of the
Thumb Metacarpal Base Fractures. Type A fractures occur
proximal phalanx is devoid of tendinous inserrion. The base of
between the physis and rhe junction of rhe pmximal and middle
the proximal phalanx and its intimate structures (the volar plate
thirds of the bone. They often are rransverse or slightly oblique
and sesamoid bones) are the site of multiple attachmencs that
and angulared apex-lateral, with an element of medial impaction
playa role in fracture mechanics. The adducror pollicis has inser-
(Fig. 8-69).
rion inro the extensor apparatus and onro rhe medial aspect of
Salter-Harris Il fractures are prevalent ar the thumb metacar-
rhe proximal phalanx. The aponeurotic expansion plays a role
in rhe pathologic anaromy of thumb UCL ruptures by excluding
rhe rom VCL from irs otiginal bed (the SteneI' lesion) (206).
The flexor pollicis brevis has twO insertions: rhe fibers inserr
onro the volar medial aspect of the proximal phalangeal base TABLE 8-6. CLASSIFICATION OF THUMB
and inro rhe medial sesamoid and volar plate tissues. Most of METACARPAL FRACTURES
the abductor poJ/icis brevis insertion is onto the sesamoids and
Fractures of the head
volar plate. Fractures of the shaft
All three of these structures (adductor pollicis, abductor pol- Fractures of the thumb metacarpal base
licis brevis, flexor pollicis brevis) can deform fracrures occurring Fractures distal to the physis
ar the mcracarpal level. Thejr direction of displacement or activ- Salter-Harris II fractures-metaphyseal medial
Salter-Harris II fractures-metaphyseal lateral
ity in fracture srabilization is dictated by their relative positions Intraarticular Salter-Harris III or IV fractures
and directions of pull. The fiber orientarion and the point of
insertion determine the degree and partern of fracture deformity.
 Chapter 8: Fractures tJlJd Dislocations of the Hand and Ca/pus ill Children 335

the reverse pattern, with the metaphyseal fragment on rhe lateral

side and the shaft displacement medial. This may result from
more significant trauma and usually is more difficult to treat by
closed methods.
The type D fracture is an S- H 1II Ot IV fracture of the thumb
base that most closely resembles the adult Bennett's fracture.
c::JD Several clinicians have related anecdotal expetience with this

o injury (23,79,88,193) and have underscored the rarity of this

pattern. The deforming forces are similar to those for rype B
injuries, but the intraarticular component of the fracture permits
Type A Type B Type C Type 0
the base-shaft fragment to subluxate laterally at the CMC joint.
FIGURE 8·68. Classification of thumb metacarpal fract\Jres. A: Me-
taphyseal fracture. Band (; Salter-Harris type II physeal fractures with
lateral or medial angulation. D: Salter-Harris type III fracture (pediatric Signs and Symptoms
Bennett's fracture). .
Swelling and ecchymosis are obvious signs of significant injury
to the metacarpal. Most of the swelling appears to be in the
thenar eminence. Depending on the level of injury, the thumb
can be mal rotated or angulated. Active thumb motion usually
pal base. Most of the patterns have the metaphyseal flag on the is limited.
medial side (type B) and the shaft fragment angulated laterally The planes of motion for the thumb are different from those
and slightly proximally from the pull of the abductor polJicis of the rest of the hand. When conducting the physical examina-
longus. ]n addition, the adductOr pollicis may adduct the shaft. tion, motion of the thumb in radial and palmar abduction
Although this common pattern resembles Bennett's fracture with should be assessed carefully. The integrated motion of opposi-
respect to the deforming forces, it does not have an intraarricular tion also should be scrutinized. Malrotation is more challenging
extension. to judge, but the perpendicular relationship of the thumb's nail
The less common type C thumb metacarpal base frac(llre has plate to those of the other digits provides a good guide.

Radiographic Findings
A standard set of hand films can be supplemented by a hyperpro-
nated view of the thumb that accentuates the detail at the CMC
joint. Biplanar images of the thumb are a must. Type B ftactures
often appear well reduced on one view (the lateral view of the
thumb) bur are significantly displaced on the AP radiograph.

Fracture Eponyms
We avoid the use of eponyms to describe fracture patterns about
the metacarpal base. The use of terms such as children s Bennetts
fracture or baby Bennetts do little to assist the evaluator in devel-
oping a plan of rreatment. This is why we discourage the use
of the terms Bennett's fracture (15) and Rolando's fracture. Terms
to charactetize the size, location, intraarricular or physeal exten-
sion, degree of comminution, and displacement of this complex
set of fractLIres are more descriptive.

Treatment
Head and Shaft Fractures
The need for anatomic restoration of intraarricular or peri-artic-
ular fractures of the distal metacarpal has already been empha-
sized in other sections. Fractures of the thumb metacarpal shaft
can be treated much the same as those of the medial four rays.

Thumb Metacarpal Base Fractures

TypeA.
Closed Reduction. Type A fractures usually can be treared by
closed methods. Although swelling about the rhenar eminence
limits manipulation of the fracrure and diminishes the effecrive-
FIGURE 8-69. Thumb metacarpal fracture. This transverse fracture
does not involve the growth plate. It was successfully reduced and went ness of immobilization, most fractures can srill be treated success-
on to heal nicely. fully by closed reduction and immobilization.
336 Upper Extremify

A B

FIGURE 8-70. A: A 10-year-old boy with a severe

head injury was first noted to have this markedly
displaced type A fracture of the first metacarpal 3
weeks after injury. B: One month later, the radio-
graph shows union of the unreduced fracture with
some early remodeling. C: Seven years later, the
radiograph shows that complete remodeling has
occurred. Functioning was normal. (Remodeling
around this multiaxial joint can be compared with
that seen in fractures around the proximal hume-
c rus.) (Courtesy of Sigurd C. Sandzen. Jr., M.D.)
 Cbapter 8: Fractures III/(! Dislocations of the Hand find CarpllS in ChiLdreJI 337

The maneuver is performed wirh local anesrhesia and is ac- imporranr and has been emphasized by Smirh and Peimer (201).
complished by exerring an exrension force on [he metacarpal Orher clinicians have documenred signiflcanr remodeling in S-
head; hyperextension of the MCP joinr should be avoided. Pres- H II fracrures in rhis area (13,117). If closed reducrion is accom-
sure is applied ro rhe apex of rhe fracrure ro effecr reducrion. plished and mainrained in a shorr arm rhumb spica splinr, radio-
Wirh rhe proximiry of the fracrure ro rhe physis, exacr reducrion graphs should be obrained afrer splinr applicarion and again in
may nor be required, because remodeling is rapid in rhis region rhe firsr 5 co 7 days co reassess rhe srarus of rhe reduction.
of rhe bone (Fig. 8-70). Ogden (162) and ochers (l 04, 117) have
Percutaneous Pins. If closed reduction is possible but rhe resulr-
shown thar lareral angularion of up ro 30 degrees can adequarely
ing relarionship is unstable, percutaneous pinning is an excellenr
remodel.
alternative (Fig. 8-71). Three options for pin conftguration are
direct fixation of rhe reduced fragmenrs (however, rhis is prohibi-
Percutaneous Pins. If rhere is inrerposed rissue or if rhe reduction tively difftculr because of the small size of the meraphyseal flag);
is roo unsrable to mainrain in a spline, percuraneous pinning pinning across rhe CMC joint in a posirion where the fragmenes
can be used. Because of rhe fracrure partern, ir is highly likely are reduced; and pinning from rhe flrsr ro the second metacarpal
(har rhe physis will need ro be crossed by rhe smoorh wires. CO srabilize rhe larger shafr-base fragment. Combinarions of rhese
Pinning across rhe CMC joinr can even be performed, bur ir is confIgurarions may need co be used for more complicared or
usually reserved for more proximal fracrure parterns. unstable fractures.

Open Reduction. Open reduction must be performed if rhe epi-

Types Band C.
physeal fragments cannot be aligned and mainrained by closed
Closed Reduction. Type Band C fracrures deserve an artempr
means. Burr (35) observed thar medially displaced type C frac-
at closed reducrion, bur rhe mobiliry of rhe meracarpal base and
rures require open reducrion (Fig. 8-72). This ofren is due co
the swelling abour the ray make rhis difftcult. Comminution
rhe interposed periosreum blocking rhe reducrion (232).
and soft rissue inrerposition (or transperiosteaJ "butconhoJing"
in type C fracrures) (123,232) may furrher complicate rhe sirua- Type D Fractures.
rion. Regardless of the merhod used to obrain reduccion, ana- Nonoperative Treatment. Mosr of rhe experience with crearing
comic rescorarion of rhis injury, which involves rhe physis, is type 0 injuries has been in adul(s. Numerous rrearmenr methods

A B
FIGURE 8-71. A: The reduction of this type B fracture was unstable. B: A single percutaneous pin was
necessary to maintain alignment. An excellent functional result followed.
338 Upper Extremity

A B

FIGURE 8-72. A: The small metaphyseal flag on the lateral aspect of

the thumb base looks fairly innocuous in one projection (arrow). How-
ever, it was a herald of more marked displacement of the distal frag-
ment in a medial direction. B: This was well imaged with the aid of
fluoroscopy when closed reduction was attempted. Closed reduction
maneuvers were unsuccessful, because the physeal fracture appeared
to have interposed tissue and was difficult to manipulate. C: Open re-
duction was performed through a curvilinear incision over the carpo-
metacarpal joint. The fracture was stabilized by Kirschner wires that
crossed the fracture site, the physis, and the carpometacarpal joint. An
additional pin was placed between the first and second metacarpals
to keep the thumb in good position. Near-anatomic reduction was real-
C ized with rapid healing and excellent function.
 Chapter 8: Fractures fl1ld Dislocatiom of the Hand and Carpus in ChiLdren 339

have been described, including splinting, rracrion devices, pin- fracture, including trans-CMC pinning, was successful in a re-
ning, and special screw fixarion (208). For lype 0 fractures in POrt by Rang (175). Segmuller and Schonenberger (193) recom-
children, closed reduction has been cried with variable resulrs mended open treatment as a way ro ensure anacomic reduction
by Gedda (79). He reporred 105 patients with fracrure-disloc- and fracrure stability. The implant choice can be individualized,
ations of the thumb crapeziometacarpal joint, only (wo of whom but smooth wires are favored co minimize potential injulY co
had open physes. One parient did well with 4 weeks ofimmobili- the physis and articular cartilage (Fig. 8-73) (88,193).
zation; the other, who required repeated reduction attempts, had
significant loss of mobility, early physeal closure, and petsistent Traction. AJthough nOt an initial choice for the treatment of
subluxation at a 4-year follow-up. Griffiths (%) reported (Wo intraarticular metacarpal base fractures, oblique skeletal traction
chi Id hood Bennecr's fractures, both [L'eated by closed means. is an alternative treatment that may have a role in some complex
Healing of the fracture was delayed in the first patient, but the injuries. Span berg and Thoren (203) described this method,
outcome was good at 1 year. In rhe second parient, significant which has rhe advantage of minimal tissue dissection but offers
clinical and radiographic deformity was present at follow-up, no direct control of the fragments. More severe comminution
but no pain or motion loss resulted. 01' sIan compromise overlying the rhenar area are possible indica-
tions for this merhod.
Open Reduction. The best results have been reponed with opera-
tive means ro resrore anaromy. Blount (23) used skeletal traction EwemaL Fixation. In a severe open injury with porential bone
through the head or shaft of the proximal phalanx co creat this loss, there is another alternative rhat we have used extensively
injury in an adolescent. Percutaneous pinning of the reduced in our adult patients with crush injuries to the hand from farm-

A B
FIGURE 8-73. A: A 14-year-old boy sustained this Salter-Harris type III fracture of the proximal thumb
metacarpal when he fell out of a pickup truck. There is slight lateral subluxation of the carpometacarpal
joint. B: Uneventful healing and normal function followed open reduction and Kirschner wire fixation.
(Reprinted from O'Brien ET. Fractures of the hand. In: Green DP, ed. Operative hand surgery, 2nd ed.
New York: Churchill livingstone, 1988:769; with permission.)
340 Upper E'(tremity

ing or indusuial accidents. Buchler et al. described a quadrilateral glabrous border of the skin. We carefully avoid Injury to the
external fixator system between the ftrst and second rays toat small rerminal branches of rhe dorsal sensory branch of the radiaJ
keeps rhe column our ro lengrh, permits sofr tissue management, nerve, the palmar curaneous branch of the median nerve, and
and maintains the first web space span (32). Staged reconstruC- the lateral anrebrachial cutaneous nerve. All these branches may
tion can then be performed, including bone grafting and skin innervare rhis area. The origins of the thenar eminence muscles
coverage. can be reflected medially and the capsule enrered. The joint is
inspected fOJ loose fragments and cartilage damage, and the frac-
ture is reduced and pinned.
AUTHORS' PREFERRED We prefer ro avoid multiple pins (or attempts) and minimize
TREATME T 0 F TH UMB the number of pins crossing the physis. In some larger fragment
METACARPAL FRACTURES fractures, parallel pinning can minimize the potentiaJ injury to
rhe physis. Pinning of the firsr metacarpal to toe second is a
Closed Reduction sound practice toat stabilizes the entire construct and avoids
rransarticular or rransphyseal pinning.
For mOSt thumb metacarpal fractures, closed manipulation and Type C fractures can be particularly difficult to manage. They
splinting is the appropriate and definitive treatment. Intraarticu- are often more widely displaced, and the distal fragment may
hr fracrures of the head and complex shaft fractures in the distal be buttonholed chrough the thick periosteum. We still acrempc
aspect of the bone with soft [issue interposition may be the closed reduction, but the threshold to progress to open reducrion
exceptions ro this ruJe. is low. The same concepts for rhe open trearment of type A and
Base fracrures usually can be managed by closed methods. B fractures hold true in the tteatment of this variant.
Type A and B fraccures can be reduced under adequate conscious Type D fractures require open reducrion and internal fixa-
sedation supplemented by radial and median nerve blocks. The tion. Pinning across the CMC joint sometimes is needed to
maneuver for reduction consists of palmar-directed pressure ex- maintain the congruity of the joinr thar has been subluxated.
erted over the apex of the fracture, with counterpressure applied This added stability allows the pericapsular structures time to
to the metacarpal head. Pressure applied distal ro the head will heal. Pinning across to the second metacarpal sometimes can
only extend the MCP joint and affects the fracture minimally. accomplish the same stability.
A well-molded splint can then be applied and postreduction
radiographs obtained. Posroperative Care and Rehabilitation
Immobilization of 4 to 6 weeks usually is adequate, depending
Acceptable Angulation on che fracture severity and rate of healing. Pins usually are
removed before G weeks. Original stiffness usually subsides
The amount of residual angulation considered acceptable in basi- quiclJy. Attention should be focused on the interphalangeal
lar metacarpal fractures is based on our experience and the re- joint of the thumb in all phases of rehabiliration. If there is
portS in rhe literarure 004,118,162). Because the motion at the some limitation of motion at the CMC joint due to the primary
adjacent CMC joint is multiplanar and the fractures are near pathology, additional motion may be required from the adjacent
(or involve) the physis, the remodeling potential is great. Malan- articulations.
gulation of about 20 degrees or Jess remodels quite predictably;
even angulation of 30 degrees appears to exhibit significant re- Return to Sports. Return to conract SPOrtS and hand-intensive
modeling, but the improvement in radiographic appearance is activities is a complex issue that involves the patient, parenrs,
less predictable. Clinical deformity and functional loss are still and coach, as well as the physician. The decision is based on
unlikely, even at that degree. multiple factors such as the nature of the injury, rhe temporal
relationship to the season of play, and the level of participation
required. Many patients wito less severe injuries who are in-
Pin Fixation
volved in minimally hand-intensive aspects of spons may be
If closed methods are successful but the fracture remall1s un- candidares for early return (within 1 or 2 weeks to permit wound
stable, it should be pinned wito smooth wires (0.028- or 0.035- healing). Protective orthoses can be worn, and a removable splint
inch). Driving the pins in a lateral-w-medial direcrion is usually and systematic motion program can be conducted when not
a reliable way to secure the larger fragments. Pinning across the parriciparing. For example, a football lineman with a central
CMC joint or ro the adjacent mcracarpal can be performed to mecacarpal fracture may receive a "playing cast" for pracrice and
increase stability. We have not encoun[(:"red growth disrurbance games and can be protected with a thermoplastic safe position
when rhe physis and joint have been crossed by a single smooth splint between games (17). [f the injulY was more severe or if
wIre. greater dexrerity is needed for adequate participation, the player
must regain a full range of painless motion before returning to
the sporr. The inrerval between clinical union and regaining the
Open Reduction proper dexreriry for athletic endeavors usually is 2 ro 4 weeks.
Displaced S-H III and IV fracrures require open reduction and There are no srock answers to these questions, which are
internal fixation. We prefer to perform an open reduction being faced with increasing frequency in a society that places
rhrough an L-shaped incision overlying the CMC joim at the such emphasis on athletic achievement. Recommendations must
 Chapter 8: FrrtcwreJ and DiJLorntiom of the Hand and Carpus in ChiLdren 341

be based on the surgeon's preference and experience. Recalling level of participation in athletics has made the wrist a focus of
the admonition to "do no harm" is an excellent guiding principle both acute and chronic injury in the child (183).
when rrying to reach an imporranr decision. However, it is some-
times difficult to convince the patienr, parenrs, and coach of the Anatomy
relative importance of presenr sporting involvement versus long-
term hand function. The unique chondroosseous composition of the bones of the
maturing carpus make them relatively immune co fracture
Prognosis throughout early development. Likewise, the inherent hypetelas-
The temodeling capabilities of fractures near or involving tne ticity of young tissue protects the ligamentOus anacomy about
physis are extensive. This is especially true about tne basilar the carpus.
thumb joint, where multiple planes of motion encourage remod-
eling. Even residual deformity that exists in the metacarpal of Ossification of the Carpus
the thumb can be concealed by excellent function. The other
The human wrist begins as a single cartilaginous mass, but by
elements of the osteoarticular column adapt positively to limita-
the 10th week the carpus transforms into eight distinct entities
tion at one link. Even malrotation is tolerated better by the
with definable intercarpal separations. Although there are some
thumb than any of tne tripnalangeal digits. Malreduction pre-
minor changes in contour, these precursors greatly resemble the
dictably hinders long-term function only when the fracture in-
individual carpal bones in their mature form (129). It is dis-
volves a significant portion of the joint. Arthrosis is accelerated
tinctly unusual for the capitate not co demonstrate an ossification
if the joint remains significantly incongruous.
center by the sixth month, and failure to ossify by the first year
may indicate a congenital anomaly.
Complications The catpal bones ossify in a predictable pattern, with only
The complications described for the other tubular bones of the slight variations (Fig. 8-74) (95,211). The appearance of the
hand-parricularly those involving the finger metacarpals-can
be seen in the thumb ray. Nonunion, malunion, and aseptic
necrosis can all complicate the treatmenr course of thumb meta-
carpal fractures.
For the rare nonunion, extended immobilization may result
in late consolidation (%), but bone grafting and rigid fixation
can be performed if the nonunion is recalcitrant. Symptomatic
malunion is uncommon, but basilar osteotomy and fixation can
restore the relationships needed for improved function.
Intraarricular incongruity is a potential short- and long-term
problem: pain, motion limitation, and accelerated arthrosis may
all be sequelae. Surgical intervention should be delayed as long
as possible, and the available options discussed with the patient
and parents. Salvage procedures (e.g., fusion, interposition, or
implant arthroplasty) have already been described. Surprisingly
good function can accompany a poor radiographic appearance, 6-8 mos
so the surgeon must remember to treat the patient, not simply
the radiographs, in a child with degenerative arthrosis.

CARPAL INJURIES IN CHILDREN

2-3 yrs
General Principles
Epidemiology
Fractures and dislocations about the child's wrist are rare, and 4 yrs
injuries to the immature carpus often present diagnosric and
therapeutic dilemmas because of the difficulties in examining
an injured child and the limited ability of radiographs to detail 5-7 yrs; (F) 16-18 yrs
the immarure skeleton (13,158).
The neighboring physis of the distal radius is among the
body's most frequently injured (49). When the typical history
1 yr; (F) 16-18 yrs
of a fall on an outstretched hand is elicited and wrist pain is the
presenting complaint, it is likely that the forces were transmitted FIGURE 8-74_ The age at the time of appearance of the ossific nucleus
of the carpal bones and distal radius and ulna are shown. The ossific
through the distal radial physis, not the carpus (218). Nonethe- nucleus of the pisiform (not shown) appears at about 6 to 8 years of
less, the impact of a highly mechanized society and the increased age.
342 Upper Extremity

hamate on tadiography closely follows that of the capitate at larjties between wrist injuries in skeletally mature and immature
about 4 months. The ossiftcation center for the triquetrum ap- patients. The incidence of scaphoid fracture in rhe entire popula-
pears during the second year and is almost always present by 3 tion peaks in the late teens co mid-twenties (62,88). In skeletally
years of age. The lunate begins ossiftcation around the fourth immature patients, the peal< is at about age 15 (198). This peak
year. The scaphoid hegins co ossify in the ftfth year, usually comes after a steady increase, paralleling the evolving ossiftcation
slightly predating the appearance of the trapezium. Scaphoid of the scaphoid from its cartilaginous precursor.
ossiftcation begins distally and progresses proximally; this factOr During the first decade of life, fractures to the scaphoid are
affects certain pathologic processes that are discussed later (l62). extremely rare but have been reported (22,93,124,182,198,202,
The trapezium and uapezoid demonsuate ossification centers on 216). The rarity of scaphoid fractures in very young children is
radiography in the ftfth year, with the trapezoid lagging slightly somewhat comforting because of the difftculties in evaluating
behind. The pattern of ossiftcation usually concludes with the them. However, fractures have been reported in children as
bony development of the pisiform at the ninth or tenth year. young as 4 years (22), and there has even been a reporr of bilateral
Within each chondral mass, ossification occurs around a de- scaphoid fractures in an 8-year-old child (75).
fined centrum in an eccentric, centrifugal fashion (170). The
scaphoid, trapezoid, lunate, uapezium, and pisiform may dem- Mechanism of Injury: Differences in Children
onstrate multiple centers of ossification (136,162). Although
these variations are well recognized, they may be confusing in The mechanisms and pathoanaromy of scaphoid fractures vary
the setting of acute trauma to the wrist region. considerably between adults and children (Fig. 8-75). The famil-
iar mid-waist fracture in adults who fall on an outsrrerched hand
is uncommon in childhood (135,223).
Anatomic Relationships to Carpal Fracture Patterns Fracture of the distal third of the scaphoid, often an extraar-
The ossific nucleus remains cloaked in its cartilaginous cover ticular injury, is the most common injury (216). Many scaphoid
during developmenr. This is thought to provide a unique protec- fractures rhat occur in teenagers and younger children result
tion that makes fracture in the immature carpus extremely rare from direcr rrauma to rhe bone itself, not from the usual hyper-
(13,88). This observation is supponed by epidemiologic studies dorsiflexion injury (22,124).
of fractures of the scaphoid that show them co be infrequent in Fractures at the scaphoid waist are becoming more common
children under 7 years of age but more common through the in older adolescents as rigorous participation in contact athlerics
teenage years (93,124). A critical ratio of cartilage to bone at increases. These adult-like injuries carry wirh them the same
which fractures become more prevalent has never been detet- risks of nonunion and avascular necrosis as their counterparts
mined. In addition, biomechanical studies of fracture propaga- in skeletally mature patients (153).
tion in the immature carpus are lacking. Proximal pole fracrures are distinctly rare in children and
Although this section focuses on injuries to the wrist, the often represent a ligament avulsion fracture of the scapholunate
surgeon must appreciate the frequency and mechanics of fracture ligament. The scaphoid also can be fractured as a component
about the distal radius, because this provides the platform for of a grearer arc injulY (140).
surgery on the carpal bones. An in-depth discussion of fracrures
about the distal radius in children appears in Chapter 9.
Fracrures abour the radial platform account for almosr half
of the pediatric fractures in some series (23,49,58,234). A signifi- j
I
cant number of these fractures involve rhe distal radial physis, A
placing it at or near the cop in frequency of physeal injuries
(126,154). Concomitant injury of the radius and carpus should
always be suspected in children, as in adults.

Force Transmission During Carpal Injury

It is important to understand the force transmission characteris-
tics about the distal radius and wrist, because simultaneous frac-
tures of the radial platform and carpus have been reported in
children (3,45,94,158,21 6). Examples of these combined inju-
ries are given here and in Chapter 9. Although these combined
injuries are rare, they must be recognized and treated appropri-
ately co maximize functional outcome.

Specific Carpal Fractures

Scaphoid Fractures: Epidemiology
The scaphoid is the most frequently injured carpaJ bone in chil- FIGURE 8-75. The three types of scaphoid fractures. (A) Distal third,
dren (13,41,93). This is also true in adulrs, one of the few simi- (8) Middle third. (C) Proximal pole.
 Chapter 8: Fractures and Dislocations of the Hand and Carpus in Children 343

Regional Mechanisms Vary is advisable (Q keep a high mdex of suspicion for orher I nJunes
abour rhe carpus (2,41,75,205).
Distal Scaphoid
Despire the frequency wirn which rhese injuries are seen in
Disral pole fracrures usually nave a dorsoradial or dorsovolar
both children and adults, rhere is still debare abour rhe mecha-
fragmenr resulring from an avulsion injury. The srrong scapho-
nism of fracrure. The direcrjon of force, irs magnirude, and rhe
rrapeziaJ Jigamenrs can direcr force through the disral scaphoid,
posirion of rhe inrercalared segments of rhe hand-forearm unlr
and rhe capsular arrachmenrs on borb sides may conrribure addi-
all exen influence.
rional force. The ligamenr/bone inrerface typically remains in-
racr, wirh mechanical failure through rhe bone subsrance. The Influence of Dorsiflexion
fracture line can skirr rhe periphery of rhe ossific nucleus, resulr-
Cadaver srudies by Frykman demonsrrared rhar grearer degrees
ing in a chondral injury alone or a small osreochondral fragmenr of wrisr dorsiflexion correlate wirh increasingly more disral frac-
rhar may be discernible on radiography. rures in rhe upper exrremity (74). This work was reproduced by
A systematic study of fracture parrerns of maruring bones is Weber and Chao (223), and ir is generally agreed thar exrreme
needed, but rhe observarion rhar immarure bones fail before dorsiflexion (more rhan 90 ra 95 degrees) is neccssary ra cause
rhcir surrounding sofr rissue sr('ucrures is well accepred. There volar, rension-side scaphoid fracrures ar rhe mid-waisr. Wherher
is specularion rhar recenrly ossified areas are weaker rhan more rhe fracrure occurs in rhe proximal or disral parr of rhe middle
marure ones (46). rhird is derermined by the extenr of radial or ulnar deviation ar
The differenr fracrure patrerns in rhe disral scaphoid may rhe time of impact.
indicare a vulnerability of the bone (Q rension forces from several
surrounding soft tissues, including the radioscaphoid ligamenr, Tension Versus Compression Forces
radioscaphocapirare ligamenr, scaphorrapezial ligamen rs, and Some clinicians argue rhar rhe fracrure is caused by rension or
capsular arrachmenrs, as well as rhe dorsal radiocarpal or inrercar- ben.ding loads concenrrared on rhe volar side ar rhe c\isral pole
pal ligaments (Fig. 8-76) (44,216). (74,223). In this scenario, rhe proximal pole is srabilized and
prorected by rhe concavity of rhe radius and rhe radiocarpal
Middle Third ligaments while rhe exposed disral pole is subjected ro force
Fracrures ar rhe middle rhird of rhe scaphoid account for abour applied on rhe radial half of (he palm. Orher clinicians posrulare
a rhird of rhose in immarure parients. These fracrures occur a compression mechanism for midwaisr fracrures (43). The com-
closer ro the mid-reenage years and usually are more recognizable pressive forces may be exerred from rhe capitate onra rhe concave
on radiography. Because they are encounrered wirh advancing acerabllillm of the scaphoid, or possibly from rhe dorsal lip of
maruriry and in situarions where rrauma has been signiflcanr, it the disral radius. This may explain some of rhe vobr radiaJ com-

Arc/Del

DT1/ST

RSC Cap--f'IJI~

RS-L

.~
RT
l
~
•
A B
FIGURE 8·76. The volar and dorsal extrinsic and intrinsic carpal ligaments. A: Selected volar ligaments
about the wrist. RS-L, radioscaphoid-Iunate; RTlLRL, radiotriquetral/long radiolunate; RSC, radioscapho-
capitate ligament; Arc/Del, arcuate or deltoid ligament; UCLC, ulnocarpal ligament complex, including
ulnocarpal volar ligament, disc-triquetrai and disc-lunate ligaments. B: Dorsal ligaments about the wrist.
Cap, capsular attachments; RT, radiotriquetral ligament; DTl/ST, dorsal transverse intercarpal ligament
or scaphotrapezial ligament.
344 Upper Ev:tremitJ

A B

c D
FIGURE 8-77. A: A displaced mid-waist scaphoid fracture with comminution, including a butterfly frag-
ment (arrow) from the volar radial aspect. B: Computed tomographic scan demonstrates the comminu-
tion. C: Open reduction with internal fixation was performed with two smooth wires and bone graft
from the distal radius. D: Normal healing and function resulted.
 ChaptN 8: Fractures lind Dislocations of ,he Hr/lld lIUe! CarpltS in Childrm 345

TABLE 8-7. CLASSIFICATION OF SCAPHOID

FRACTURES

Fractures of the distal pole

Extraarticular distal pole fractures
Intraarticular distal pole fractures
Fractures of the mid-waist
Fractures of the proximal pole

FIGURE 8-78. A proximal pole scaphoid fracture can destabilize the

scapholunate articulation. The scapholunate interosseous ligament can
avulse a fragment of bone from the proximal pole (arrows). Small proxi-
mal pole fractures, therefore, are not innocuous and may herald signifi-
cant disturbance in wrist mechanics.
Classification
Table 8-7 lisrs the rypes of scaphoid fracrures.

minurion in a parrern resembling "burrerfly" fragmenrs (Fig. 8-

Type A: Fractures of the Distal Pole
77).
Fracrures of rhe distal pole are rhe mosr frequenr scaphoid frac-
5uicr deviarion in rhe sagirtal or coronaJ plane is nor com-
rures in children. The multiple sofr (issue auachments in rhis
monly encounrered ourside rhe laborarory. Torsional forces also
area can lead to variations in fracrure parrern, but rhe mosr
influence rhe rypes of fracrures seen (71). The unique shape of
imporranr factor affecring prognosis is wherher the fracture in-
rhe scaphoid ar irs mid-secrion aJso may playa role in rhe parrern
volves the arriculations of rhe scaphoid wirh adjacent bones (Fig.
of fracture propagation through rhis region.
8-79).
Proximal Pole
Fracrures ar (he proximal pole of rhe scaphoid are rare in chil- Type AI: Extraarcicular Distal Pole Fractures
dren. Because rhe partern of ossificarion follows the distally de- Fractures of the distal pole can be eirher volar or dorsal avulsions;
rived blood supply (124), a fracrure ar the proximaJ end of rhe rarely, a direct volar impaction injUlY occurs. The srour scapho-
scaphoid may propagare rhrough rhe interface between newly trapeziaJ ligaments can contribure the rensile force rhar accounrs
ossified rissue and rhe carrilaginous anlagen, or the injUlY may for mosr of rhe fracrures. The volar and dorsal capsules also can
be srricrly transchondral. Proximal pole fracrures can occur at be a facror. Most exrraarricular fracrures are volar fracwres rhar
rhe margin of the radioscaphocapitate ligament or slightly proxi- probably resulr from rhe combined influence of the radial leaf
mal to that area. More proximal fracrures may represenr desrabi- of the scaphotrapezial ligamenr and rhe volar capsule acring in
lizarion of the scapholunate joint, because the interosseous liga- rension. The fragmenrs vary in size, and their radiographic ap-
ment may avulse a smaJl fragment of bone from the proximal pearance is age dependem. The dorsal rransverse imercarpalliga-
pole rarher rhan a mid-subsrance ruprure (Fig. 8-78). mem arraches ro the distal scaphoid and may comribure tensile

A,B c
FIGURE 8-79. A and B: Small extraarticular distal fractures of the scaphoid (arrows) are likely to be the
result of traction forces by the capsular condensations on the volar aspect, or the radial leaf of the
scaphotrapezialligament. C: Extraarticular dorsal fractures can likewise be the result of capsular attach-
ment, but the dorsal transverse intercarpal ligament (open arrow) also may playa role in their propaga-
tion.
346 Upper Extremity

forces wirh wrisr hyperflexion. This ligamenr, usually implicared stout than rhe radial. Ir is more difficult to generare rhe pure
in dorsaJ rriqunral avulsion fracrures, also can cause a fracrure tensile forces in this ligamenr because of irs location and rhe
of rhe distal scaphoid. orientation of rhe insertion to the more sloping arricular surface
The tissue condensation on rhe radial side thar has been con- of rhe distal ulnar scaphoid. If rhere is more of an elemenr of
sidered rhe "radial collareral ligamenr" may be implicated in straight dorsiflexion, or a radiaJ-direered vecror force on the rhe-
more radial distal pole fracrures. These rissues are raur in wrisr nar area, rhis complex can be put on tension.
extension and ulnar deviarion and may provide an addirional
force in rhe development of rhe volar exrraarricular fracture. Type B: Mid-waist Fractures
The waist of the scaphoid can be defined eirher by dividing
Type A2: Intraarticular DistaJ Pole Fractures the bone into thirds or considering the area bounded by the
These fractures may be simply larger fragmenc coumerparrs [0 radioscaphocapitate ligament. In any case, fracrutes of the mid-
type IA fractures with an inrraarticular component (Fig. 8-80). waist can take many forms in children (Fig. 8-8 I). Many of
The ulnar leaf of rhe scaphorrapezial ligament is eypically more these fracrures appear incomplete or at a minimum nondis-

A B

FIGURE 8-80. Two variations of a IB intraarticular fracture of the distal pole

of the scaphoid. A: The more prevalent type is on the radial aspect of the volar
distal scaphoid. This fragment has attached to it the radial leaf of the scaphotra-
pezial ligament (arrow). B: It is rare to have an intraarticular fracture slated to
the ulnar aspect of the scaphoid. butthe stout ulnar leaf of the scaphotrapezial
ligament may be attached to a fracture fragment (arrow). C: Radiograph of
an intraarticular distal pole scaphoid fracture. Closed reduction produced an
c excellent result.
 Chapter 8: Fractures and Dislocations of the Hand and Carpus in Children 347

FIGURE 8-81. Mid-waist scaphoid fractures can differ in their location, orientation, and amount of
comminution. All these factors influence the stability and potential healing of these injuries.

placed. Comminured fracrures are rare bur can occur wirh higher Type C: Proximal Fractures
energy (Fig. 8-77). Fracrures of rhe proximal rhird of rhe scaphoid and proximal
Displacemem and comminurion are orher imporranr facrors pole presenr diagnosric and rherapeuric dilemmas. Because rhis
ro consider. Significanr fracrure fragmenr displacemem is rare in area is che lasr ro ossify, radiographs may be difficulr ro inrerprer.
isolared scaphoid rrauma. When a scaphoid fracrure is associared The cenuous blood supply of chis region presenrs rhe same prob-
wirh more exrensive carpal injury, such as a fracrure-dislocarion, lems in children as ir does in adulcs.
displacemenr is more likely.
Nor aJI mid-waisr fracrures can be lumped inro rhe same Bipartate Scaphoid Controversy: Traumatic versus
caregory. An appreciarion for rhe locarion of rhe fracrure as ir Developmental
reJares ro rhe radiaJ and capirare arricular surfaces is imporranr Louis ec al. (36) argue rhar rhe concept of rhe bipartite scaphoid
in rrearmenr planning (Fig. 8-82). should be dismissed in favor of a rraumaric eriology for rhe

A B
FIGURE 8-82. A: A barely detectable fracture line is located in the mid-waist of the scaphoid (arrow).
B: In contrast, this mid-waist scaphoid fracture has occurred at the junction of the middle and distal
thirds. Articulation between the scaphoid and capitate has been rendered incongruous by displacement
of the distal pole (open arrow). There is mild comminution in the radial aspect (closed arrow).
348 Upper Extremity

radiographic appearance of a dissociated proximal pole (Fig. 8- of injury and clinical examination raise the suspicion of a scaph-
83). In contrast, Doman and Marcus (60) demonstrated bilateral oid fracture. Occult fractures of the scaphoid occurred in 12%
bipartite scaphoids by MRI in a child with no history of anteced- of patients in one series (41).
ent trauma. These clinicians argued that congenital bipartite A long arm thumb spica cast in the initial 2 weeks after wrist
scaphoids can exist apart from syndromic conditions, but are injury optimally immobilizes the area and prevents cast slippage
less prevalent than Pfitzner's estimate of 0.5% (168). There is or damage in children, known for their propensity to escape
also specularion that the abnormal morphology associated with immobilization. At clinical follow-up in about 2 weeks, radio-
many of the preaxial dysplasias may predispose the usually gracile graphs are obtained out of plaster to assess the presence of a
scaphoid to fracture and possible avascular necrosis (129). The fracture line or the position of fracture fragments. If pain is
debate continues concerning the existence of a congenital bipar- markedly diminished and there remains no radiographic evi-
tite scaphoid. Bunnell (30) enumerated five criteria that must dence for a scaphoid fracture, immobilization may be discontin-
be met to classifY such a variant as a congenital bipartite scaph- ued or changed to a removable orthosis. Gradual motion pro-
oid: (a) similar appearance of a bipartite scaphoid bilaterally, (b) grams need not be formalized for most children.
absence of historical or clinical evidence of antecedent trauma, If there is persistent pain with normal radiographs, replace-
(c) equal size and uniform density of each component, (d) ab- ment in a cast and repeat examination and radiography can be
sence of degenerative change between the scaphoid components performed 2 weeks later. A bone scan can be considered; it is a
or elsewhere in the carpus, and (e) smooth, rounded architecture sensitive test but lacks specificity. Bone scans are particularly
of each scaphoid component. difficult to interpret in growing children because of the increased
uptake about the physes. Furthermore, the invasive nature of
Signs and Symptoms the tesr and the prolonged periods of scanning may be difficult
for the child to endure. MRI provides a noninvasive alternative,
Snuff Box Tenderness bm motion artifact is again a problem.
As in adult scaphoid fractures, the primary cause of delayed
union or nonunion in a child is delayed diagnosis. Recognition Confirmed Fracture
of this fracture is even more challenging in children. Swelling If a scaphoid fracture is appreciated at the first clinical follow-
commonly obliterates the anatomic snuffbox when the scaphoid up, immobilization can be continued. The debate over whether
is fractured. Tenderness to palpation in this area has long been long arm or short arm immobilization is best continues. Consid-
recognized as a sign of scaphoid fracture. Painful, limited wrist ering a child's activity level and potential lack of cooperation,
motion accompanies this injury. long arm immobilization may be best. However, if treatment is
begun promptly, most scaphoid fractures in children heal within
Trapping the Scaphoid
6 to 8 weeks (41) if immobilized in a short arm cast. Longer
Anorher diagnostic maneuver that may prove helpful in isolating
periods of immobilization-8 weeks to 4 months-should be
injury to the scaphoid is "trapping" the scaphoid between the
considered for fractures that occur in later adolescence or frac-
examiner's thumbs. By placing one thumb in the anatomic snuff
tures that were initially unrecognized.
box and the other on the distal tubercle of the scaphoid, pain
Recommended casting positions have included radial devia-
with scaphoid motion can be better assessed. Because many
tion with or without flexion (6,223,236). Conversely, ulnar de-
scaphoid fractures occur in the distal region in children, palpa-
viation opens the fracture gap in mid-waist fractures. The posi-
tion of the volar radial tubercle is especially important.
tion of the cast and the joints immobilized are a matter of
individual preference and experience with particular techniques.
Radiographic Findings Because most of these different casts furnish roughly the same
Study of radiographs must be complete and meticulous. Malfor- union rates (around 90%), the importance of the final casted
mations of the maturing carpus have been described with certain position is probably not paramount. We recommend a thumb
congenital anomalies (l73), and often the scaphoid has more spica cast that permits interphalangeal joint motion. Positioning
than one potential center of ossification (202). AP, lateral, the wrist in slight flexion and radial deviation maximally coapts
oblique, and dedicated scaphoid views make up the standard the fragments.
series. Fractures of the mid-waist may be appreciated on all views. Including other joints in the scaphoid cast has been suggested.
Distal pole fractures are typically best imaged on the lateral or Inclusion of the elbow is controversial. Eliminating forearm rota-
pronated oblique view. CT scanning of acute fractures or poten- tion is thought by some to neutralize the forces that displace
tial nonunions or mal unions of the scaphoid furnishes detailed scaphoid fractures (212). However, other investigators consid-
information about scaphoid morphology (l86). The scans are ered long arm immobilization unnecessary (4). This issue was
made in the longitudinal axial plane of the scaphoid, and three- largely resolved with the prospective, randomized work of Gell-
dimensional reconstructions can be made if necessary. man et al. on the treatment of nondisplaced scaphoid waist frac-
tures in adults (80). This group randomized stable fractures to
either long or short arm casting, then changed the cast to a short
Treatment
arm cast at 6 weeks. The long arm group had 100% union, bur
Presumed Fracture two of the 23 fractures treated with short arm immobilization
Even if radiographs of the acutely injured wrist appear normal, failed to heal. The healing time was protracted in patients with
application of a thumb spica cast is advocated if the mechanism short arm casts (9.5 vs. 12.7 weeks).
 Chapter 8: Fract/lres find DisloCfltions of the Hand alld CarpllS in Children 349

A B

FIGURE 8-83. A: This 9-year-old boy fell on an outstretched

hand and had significant radial-sided pain and tenderness, but
original radiographs failed to reveal any bony abnormalities. It is
difficult to judge the scapholunate relationship in the immature
carpus. B: About 1.5 years later, the patient still had radial-sided
wrist pain, and radiographs demonstrated a mid-waist scaphoid
nonunion. This would not be considered a bipartite scaphoid,
but instead an injury that was sustained while the cartilaginous
anlagen persisted. Later ossification demonstrated the bony in-
jury. C: After 2 months of casting, the fracture appears to be on
c its way to union.
350 Upper FwremilY

In children, long arm immobilization is unlikely to cause fixation should be considered. Thete is no role for open reduc-
significant functional debility (or impose resrraints thar may af- tion without internal fixation (144). The implant choice musr
feer occuparion, thus causing economic hardship), so long arm be individualized, and size is a significant consideration. Smooth
thumb spica immobilization is a sound iniriaJ rreatment for rhese wires are velY effective in the treatment of scaphoid fractures,
fractures. Ir is also a much more secure construcr. including those in children. Smooth Kirschner wires of 0.035
Inclusion of the thumb interphalangeal joinr or other digits or 0.045 inch are relarively casy to inserr and provide good
(namely the index and long fingers in the rhree-flngered chuck stabiliry. Inserting a Herbert screw or a similar implant is more
cast) is seldom practiced today. This is an effective method for rechnically demanding. The abiliry to use such an implant is
eliminating forces about rhe scaphoid but is cumbersome and based on rhe size of rhe fragments and the surgeon's experience.
difficult to apply. Mintzer and Waters (152) reponed open reducrion and inter-
I n one study of adulr scaphoid fractures, good results were nal fixation of an acute displaced scaphoid fracture in a 9-year-
recorded with dynamic splinring (26), but rhere would be liule old girl. They elected to operate because of the inirial displace-
if any indication for rhis flexible splint in children. menr ar the fracture site and rhe flexion (humpback) deformiry
of rhe disral fragment. Through the usual volar approach, a
Fractures Presenting Late Herbert screw was used to srabilize the fracture, which went on
Vahvanen and Westerlund (216) reported three children wirh ro unevenrful union; good wrist funcrion resulted.
scaphoid fracrures recognized lare. At the rime, these children
had bone resorption at the fracrure site, although all achieved
union after lengrhy immobiliozarion (7,12, and 14 weeks). Seg-
AUTHORS) PREFERRED METHOD
muller and Schonenbcrger (193) reported rhree children with
OF TREATMENT OF SCAPHOID
delayed union of rhe scaphoid and significanr bone cysr forma-
FRACTURES
tion, in whom union was obrained wirh immobilization for sev-
eral monrhs. Healing of delayed unions in rhe pediatric scaphoid
We treat almost all nondisplaced or minimally displaced scaph-
wirh lengthy immobilizarion has been verified by orher clinicians
oid fractures with cast immobilization when there is no associ-
and should be the firsr alternative used for a pediarric scaphoid
ated injury. The indications for open reduction in adults include
fracrme that is recognized lare (93).
any fracture displaced more than 1 mm or 10 degrees, and some
The favorabJe biology for bone healing in children is probably
minimally displaced fractllres in special circumstances (e.g.,
the reason for the success of closed rrearmenr of scaphoid frac-
professional athletes, surgeons) (152). We are not as aggressive in
tures, whether initiared in acure fraerures or in rhose that present
children, preferring instead to treat nondisplaced and minimally
late. The faer that most scaphoid f['aerures in children are mini-
displaced complete fractures with casting.
mally displaced or nondisplaced enhances rhe abiliry to treat
Fractures with more than 1 mm of displacemenr or angular
these fractures by closed means.
deformiry of more than 10 degrees are considered for more ag-
gressive treatment. Acceprable displacement depends on the level
Displaced Scaphoid Fracture of the fracture and the maturiry of the child's bones. The most
accepted indications for open reduction and internal fixation of
Closed Reduction and Casting. acute fracrures of the scaphoid are significant displacemenr and
There are no reports detailing specific experience with closed
association with addirional carpal injury.
rreatment of significanrly displaced fracrures of the scaphoid in
children. In the rare displaced ped iarric scaphoid fracture, closed
reduerion should be a([empted. Several researchers have de- Role of Closed Treatment
scribed maneuvers to reduce the displaced scaphoid fracture
(115,132). Traction and ulnar deviation usually extend rhe distal For scaphoid fracture trearment, we favor long arm thumb spica
pole that is probably displaced into a flexed posture, but holding immobilization for the initial 4 to 6 weeks, followed by shorr
the reduerion when the wrist is returned to a more anatomic arm immobilization until clinical and radiographic union occurs.
posirion with a molded cast is difficult, and rhere is some tisk We use long arm immobilization even in presumed scaphoid
of skin compromise over rhe distal pole. McLaughlin (144) em- fi'acrures as an initial treatmenr: it protects rhe patient and under-
phasized the difficulry in obtaining anatomic reduction in his scores the potential graviry of rhe injury.
observations of inrraoperatiw fragmenr relationships wi th differ- Radiographs should be obtained in the first 7 to 10 days,
ent wrisr poswons. then monthly. Clinical examinarion yields similarly important
Placing percutaneous smooth wires under fluoroscopy may information about rhe progress toward union. We have rarely
be a more realistic method for closed trearmenr if reduction is needed tomograms or CT scanning to assess the relative position
to be effected. The possible collapse pauern of the lunate must
of fragments, but they may be considered when loss of reduction
be corrected to achieve maximal resulrs. is questioned.

Open Reduction and Internal Fixation

If displacement exceeds I mm or if there is significant angulation
Open Reduction and Internal Fixation
(IO degrees or more) on any of rhe images during a treatment If we opr to proceed wirh surgical rreatment, fractLIres of the
course for fractllre of the scaphoid, open reducrion and internal middle and disral thirds are exposed through a volar approach.
 Chapter 8: Fractures and DisLocations of the Hand and Carpus in Children 351

The tendon sheath of the flexor carpi radialis is divided on its of this approach to include selected patients with more distal
radial side [0 protect the palmar cutaneous branch of the median fractures that are minimally displaced. The morbidity from the
nerve. The tendon is reuacted ulnarward as the incision is taken dorsal exposure can sometimes be less than that of the volar
down to the scaphoid thl"Ough the floor of the sheath. The radio- route; experience with patient selection and the geometry of the
scaphocapitate ligament and part of the long radiolunate liga- scaphoid are prerequisites for using this approach.
ments are carefully divided and tagged for later repair. The
scaphoid fracture is assessed for fragmem position, reducibility, Follow-up Care and Rehabilitarion
and stability after reduction. Bone grafting may be considered The protocols for immobilization with closed and open treat-
if there is extensive comminurion. We prefer to obtain this graft ment have already been detailed. After the cast is removed, a
from the volar or dorsal distal radius, avoiding the morbidity of program may be started that emphasizes recovelY of a full range
iliac surgery. of painless motion before embarking on any strengthening. For
Once the scaphoid is reduced, the method of fixation Can young patiems immobilized less than 2 months, it usually is
be chosen. Smooth wires (0.035-, 0.045-, or 0.062-inch) are unnecessary to use formal therapy modalities. For some adoles-
preferred in pediatric scaphoid fractures. At least twO wires cents, and if an operatively u'eated fracture was accompanied by
should be placed to stabilize the fracture and minimize rotationaJ otner injuries about the carpus, some formal rehabilitation may
displacement. If the patient is near skeletal maturity, a Herbert be needed. There is little role for dynamic splinting.
screw can be inserted as described by its originator (106,107). Continued Follow-up with radiographs and clinical examina-
Pins, if used, can be left under the skin of the thenar eminence tions ensures that no carpal collapse pattern is present and that
or allowed to penetrate the skin. A short arm thumb spica splim avascular necrosis of the scaphoid has not complicated the frac-
is used if the patient is cooperative and the fracture was well ture course.
stabilized. If a bon<: screw was used, early motion can be started at If the child or adolescent is amenable, we remove the smooth
the second to fourth week, with imetval splinting for protection. wires in the office under local anesthesia. We have not found it
When smooth wires stabilize the fracture, rigid immobilization necessary to remove a Herber[ screw in any patient who nas a
is continued until healing is demonstrated on radiography. united fracture, but the implication of long-term indwelling
Rare proximal pole fractures can be approached through the metal is unknown.
same volar approach or a dorsal incision based over the anatomic
snuff box. The scaphoid can be delivered into the interval be-
Complications
tween the first and third dorsal compartments by ulnar deviation
of the wrist. The radial arrety and its branches are vulnerable Nonunion
on this approach and must be protected (Fig. 8-84). Nonoperative Treatment. Scaphoid nonunion is distinctly rare
The dorsal approach is particularly useful in surgery for proxi- in children, bur reports of this complex entity do exist (41,55,
mal pole fraceures and non unions. We have expanded the use 134,139,163,170,202). Abollt 20 Ilonunjons have been reported

A B
FIGURE 8-84. A: A 15-year-old male athlete sustained a proximal pole scaphoid fracture that was mini-
mally displaced. B: After long discussion with the family, it was decided to perform open reduction and
internal fixation. This was performed through a dorsal approach with Herbert screw fixation. Excellent
results were obtained. (Courtesy of James E. Culver, Jr., M.D.)
352 Upper Exmmi~y

A B
FIGURE 8-85. A: A 10-year-old boy was first seen after a fall on the outstretched hand. The radiograph
shows an old fracture of the waist of the scaphoid. There was no definite history of an old injury. B:
The fracture went on to solid healing after 9 months of immobilization. Motion and strength of the
wrist were normal. (Courtesy of Norman H. Higgins, M.D.)

in rhe world literature, with rhe largest series detailing eighr pholunare ligament injury, or scapholunate advanced collapse
cases. This pauciry of material emphasizes the rariry of this com- (the SLAC wrisr) 037,222) have never been demonstrated in
plicarion and also limits our understanding of treatment meth- the pediatric wrist. Studies detailing bipartite scaphoid when
ods. There is convincing evidence that immobilizarion, lengrhy radiographic union was not demonstrated after fracture suggest
if necessary, is the cornerStOne of treatment of scaphoid non- that only minimal clinical symptOms have been presem at long-
unions in children (Fig. 8-85). The evaluation of serial clinical rerm follow-up (124,136). Therefore, it is unknown howaggres-
and radiographic paramerers must be thorough, and tenderness sively scaphoid nonunion should be rreated in children.
about the scaphoid and continued radiolucency may persist even Most patients have tenderness to palparion about the scaph-
after union has been achieved (124). oid in the snuff box or over the volar tubercle. Motion between
the fragments is likely to be demonstrated on fluoroscopy. How-
Operative Treatment. Open reduction, bone grafting, and in- ever, somerimes there is a strong canilaginous bridge between
ternal fixation are the standard procedures for treatment of twO ossification centers that were separared by a rraumatic injuly.
sc~phoid nonunions in adults and also have been used in chil- This may permit normal motion of the scaphoid in daily activi-
dren 034,139,170,202). The volar approach is typically used, ties and possibly with even higher demand occupations. If this
along wirh aUtOgenous bone grafr and inrernal f1x~tion (Fig. 8- is true, the morbidity of bone grafring and open reduction must
77). The concepts of operative scaphoid nonunion treatment be balanced against the potential for improved results. Our bias
in children are similar to those in adults and are familiar to is decidedly against leaving the child with an established non-
pra((irioners who do scaphoid surgeLy (Fig. 8-86). However, the ul1lon.
rechnical demands of rhe procedure may be amplified because We probably will never have sufficienr data to provide mean-
of rhe patient's small bone size. This may be a factor in the ingful conclusions. Natural history studies would be necessary to
choice of implant, and smooth wires usually are better suired resolve this issue, and the rariry of scaphoid nonunion probably
rhan a scaphoid screw. makes this unfeasible. With the refinement ofMRJ as a diagnos-
tic rool, fractures in the immature carpus may be better diag-
Sequelae. The altered kinemarics rhar predispose rhe adulr wrist nosed (124), and we may see a greater number of defined chon-
to accelerared degenerative change after scaphoid nonunion, sca- dral injuries that can be studied.
 Chapter 8: Fractures and Dislocations of the Hand and CalpUS in Children 353

A B
FIGURE 8-86. A: A 15-year-old boy developed a nonunion of the scaphoid. A thumb spica cast for a
period of months failed to bring about union. The cyst at the mid-waist grew. B: Formal takedown of
the nonunion via a volar approach plus intercalary bone grafting with Herbert screw fixation permitted
union and had excellent function.

Pathologic Fracture type of mechanism causes abutment of the capitate waist against
Nonunion of a pathologic fracture has been reporred in an ado- the lunate or dorsal aspect of the radius. Isolated fractures of
lescent girl. As a 7-year-old, she had osteomyelitis of the scaphoid the capitate are rare and usually result from high-energy trauma
that was treated by operative drainage and intravenous antibiot- (82,239). They can be diagnostic challenges: the proximal frag-
ics. She was asymptomatic for 6 years, and then wrist pain re- ment of the capitate can rotate 180 degrees, thus presenting a
cutred with activity. Nine years after the original episode, she confusing radiographic picture in the immature wrist. In an
presented with a frank nonunion of the scaphoid. After two adult, it usually is easier to determine that such a displacement
opetations to gain union, without the complication of infection has occurred, bur in a child whose ossification is incomplete,
in either, the patient went on to have a good resuk In retrospect, the malposition may be more difficult to ascertain. Radiographs
evaluation of the initial radiographs demonstrated a loss of nor- of the contralateral side are needed when attempting to evaluate
mal density of the scaphoid with disturbance of the normal some of the more complex injuty patterns about the pediatric
trabeculation. wrist.

Avascular Necrosis
Naviculocapitate Syndrome
Idiopathic avascular necrosis of the scaphoid, similar to Preiser's
disease of the adult carpus, appears to have no counterpart in The navicuJocapitate syndrome is well described in adults (217),
children. One child with radial hypoplasia demonstrated changes and this same combination, originally described by Gouldes-
consistent with avascular necrosis in a very gracile scaphoid that brough (86), also has been seen in children. Anderson treated
was thought to fail under normal compressive loads (129). The two 13-year-old patients with scaphoid-capitate fractures in
patient had significant pain and was treated with scaphoid exci- combination with distal radial fractures (7).
sion and inrerposition arthroplasty.
Associated Fractures Common
More commonly, fracture of the capitate occurs wirh fracrures
Capitate Fractures
of other carpal bones (Fig. 8-87). Typically, the scaphoid is
Impaction or compression fractures of the capitate have been injured by forces transmitted in a dorsiflexion, ulnar deviation,
reported by several researchers (129,217). A hyperdorsiflexion intercarpal direction through the radial column (7,86).
354 Upper Extremity

Triquetral Fractures
Small triquetra I avulsion fractures are common in adults. It is
likely that they are so commonly seen by practitioners dealing
with hand injuries that a rrue incidence or l1revalence could
never be determined. This injury can happen in the maturing
carpus, especially as ossification nears completion. The probable
mechanism is an avulsion force from the dorsal ligament StruC-
tures (Fig. 8-88).

Extremely Rare Injury

Although there are no published papers specifically reponing
this injury in children, its treatment should be conservative, as
in the adult wrist. A shorr period of immobilization with icing
is likely to be enough symptomatic treatment to permit early
motion. O'Brien (FT. O'Brien, personal communication) ob-
served a triquetral body fracrure in a child that required open
reduction and internal fixation.

FIGURE 8-87. A 12-year-old boy sustained multiple carpal fractures

when a heavy weight crushed his wrist. Sixteen months later, he had Associated with Global Injuries
an established nonunion of the capitate that required bone grafting
to obtain union. (Courtesy of James H. Dobyns, M.D.) A significant fracture ro the triquetra I body aJso can occur with
a more global carpal disruption. The parh of the gre:lrcr arc
(140) can go through the triquetrum (Fig. 8-89) (45,124). If a
rranstriqucrral fracrure is seen, attention must be direcred toward
the radial sryloid, scaphoid, and mid-carpal joint as weJl. Ag:lin,
Treatment
Treatment of a capitate fracture depends on the chal'aerer of the
particular injury, as well as the trauma sustained by surrounding
tissues. Obtaining a film of the wrist in distraction mighr be
one of rhe most valuable methods for determining whether an
injury ro rhe inrercarpus has occurred. Before full ossification
has been complered, small osteochondral fragments in the mid-
carpal region may indicate a greater arc injul)1 or isolated capitate
fracture. MRl may be a useful adjunct in these complex injuries.

Nonoperative Treatment
If the displacemenr of the capirate, or even the capitate and the
scaphoid, is minimal, 6 to 8 weeks of immobilization is an effec-
tive means of treatment (7). In one repon of simulraneous scaph-
oid and capitate fracture, closed reduction and immobilization
proved ro be acceptable treatment for the bony injuries, but the
position of radial deviarion and extreme ~exion necessalY to
mailltain this reduction caused a compression neuropathy of the
median nerve in a child, requiring decompression (45).

Operative Treatment
If displacement of the proximal pole of the capirate is significant,
open reduction with or without internal fixation should be con-
sidered. These JIl;ltOmic relationships must be restored for the
mechanics of rhe carpus and ro avoid future problems of is-
chemic necrosis of the proxlmal pole. Nonunion of rhe capitate
has been reported in a significant crush injury ro the hand of a
13-year-old girl. Bone grafting was performed about 1.5 years
later with good success (149). We are aware of no literature FIGURE 8-88. A minimally displaced dorsal triquetral avulsion fracture
detailing avascular necrosis after capitate fracture in children. (arrow). These can be treated with short-term immobilization.
 Chapfer 8: Fmrtures and Dislocation.,· of the Hand and arpllS in Children 355

in a 12-year-old boy (23). Open reducrion of rhe lunate through

a volar approach (without internal 7 necessary), as a growth
arrest of the radial physis resulred from this complex fracture
mechanism.

Perilunar Injuries
Perilunar injuries with or wirhout fractures of the carpaJ bones
have been reported by several researchers (Fig. 8-90) (41,45,
166). Because of the unique chondroosseous nature of rhe ma-
ruring lunate, a small osreocartilaginous fracture may go unrec-
ognized on radiography and heal unevenrfully. Otherwise, lunate
fractures in children are decidedly rare.
The pattern of progressive perilunar instability can occur in
a child (140). In some of these patients, a scaphoid fracture is
the focus, and an appreciarion for the force transmission rhrough
the wrist will be lost. In these trans-scaphoid injuries, soft tissue
injury to the inrrinsic ligamenrs must be suspecrd and appropri-
ate diagnostic and therapeutic inrerventions instituted (Fig. 8-
FIGURE 8-89. The greater arc (white arrow) is associated with fractures
91). T ranscarpal dislocations are discussed later in this chapter.
of the carpal bones, which may include the scaphoid, lunate, capitate,
hamate, and triquetrum. In this depiction, the radial styloid also has
been fractured, creating a trans-styloid pattern. The dark arrow depicts
the lesser arc, in which forces are transmitted through soft tissue struc- Lunatomalacia or Kienbock's Disease
tures only, resulting in progressive perilunar instability. Numerous vari-
eties of injuries associated with these patterns of forced transmission An analogue to rhe adult Kienbock's disease or lunatOmalacia
can be seen. (Reprinted from Mayfield JK, Johnson RP, Kilcoyn RK. Car-
has been observed in children under 10 years of age (Fig. 8-92)
pal dislocations: pathomechanics and progressive perilunar instability.
J Bone Joint Surg (Am] 1980;5:226-241; with permission.) (16,177). It was unclear in these reports whether a histOry of
trauma preceded the clinical picture. The symptOms were vague
and oflow grade, and radiographs revealed only mildly increased
density of the lunate with no change in external morphology.
disrracrion films may be helpful. Closed rrearment for some of Advanced imaging studies such as tomography, MRl, or scintig-
rhese complex disl"Uprions, including rhe rriquerrum, is effecrive. raphy were nor used to evaluate these patients. Immobilization
for up to 1 year has been used with success to treat this Kim-
Hamate Fractures bock's variant in children. The lunate itself has remodeled in
Ali (5) reponed on a 16-year-old boy wirh a fracrure of the satisfactOry fashion; furthermore, if there is altered lunate archi-
hamate body and a pisorriquerral dislocarion. The patient also tecture, usually there are few symproms, and good motion recov-
had an evolving companmenr syndrome of rhe voJar forearm ery is expected.
from rhe signiflcanr crush injury. The parienr underwenr open
reducrion and inrernal flxarion for rhe bony lesions, but an ulnar
Trapezium Fractures
nerve palsy persisted 3 months afrer rhe surgery.
There are no specific anicles derailing fracrures of the hamu- A fracture of the trapezium is extraordinarily rare in adulrs or
lus in children, but such fracrures can occur in someone nearing children. Direct palmar trauma may cause a rrapezial ridge frac-
skeletaJ maturity. Those who play racquet sportS or golf would rure. A dorsal impaction fracture may result from a hyperexten-
be specifically susceptible. The evaluarion and treatment of this sion injury (Fig. 8-93), or a small ligamenr avulsion can be seen.
entity in chiJdren may differ from rhose in adults. Early excision In general, immobilization and symptOmaric trearment are ade-
may be roo aggressive in a skeletally immarure patienr, and closed quare.
rrearmenr should be favored initially.

Pisiform Fractures Soft Tissue Injuries About the Carpus

There are no specifIC discussions of pisiform fracrures in children Ligamentous Injuries
In the literatllre. Direct rrauma causing a comminuted fracture Ligamenrous injuries about the pediarric wrist are even more
or a flexor carpi ulnaris avulsion injury may occur in lare adoles- uncommon rhan osseous injuries. The special viscoelastic prop-
cence. Most of rhese fractures can be neated symptomatically,
enies of the carpal strucrures probably provide protection from
as in adults.
catastrophic ligament injuries in rhe immature wrist. Also, the
difficulties with physical examinarion and radiographic imerpre-
Lunate Fractures tation may disguise some injuries.
Bloum described a fracture-dislocation of the lunate in associa- Fracture-dislocations of the pediatric wrist have been de-
tion wlth a crushing type of physeal fracrure of the distal radius scribed (2,166). These were not subtle injuries: they were easily
356 Upper Extremity

FIGURE 8-90. A: This 6-year-old boy was first seen

with a dorsal perilunar dislocation 6 months after
falling downstairs. He had been treated with ste-
roids by a pediatrician because of a presumptive
diagnosis of juvenile rheumatoid arthritis. B: Open
reduction and pin fixation was performed through
a dorsal incision 6 months after injury. C: Seven
months later, most of the displacement had re-
curred, but motion was quite good and the patient
A had no pain. (Courtesy of William F. Benson, M.D.)

B c
 Chapter 8: Fractures and DisioCtltions of the Hand and Carpus in Children 357

c E
FIGURE 8-91. A and B: A 9'12 -year-old boy sustained a trans-scaphoid perilunate dislocation ofthe wrist
when he fell 60 feet off a viaduct. C and D: Closed reduction was performed 8 days after injury because
the correct diagnosis had initially been unrecognized. Plaster immobilization was maintained for 4'12
months because of transient avascular necrosis of the proximal pole and delayed healing. E: Three years
after injury, there was slight irregularity of the proximal pole, but the patient had normal function.
(Case courtesy of c.L. Colton.)
358 Upper E'(rremiry

FIGURE 8-92. A 12-year-old boy sustained a wrist injury and developed

a small area of segmental rarefaction in the lunate, consistent with
avascular necrosis (arrow). This may represent a pediatric form of adult
Kienbbck's lunatomalacia. (Courtesy of Greg Goldsmith, M.D.)

detectable and resuJred from high-force mechanisms. These ch il- FIGURE 8-93. A 15-year-old girl sustained a nondisplaced scaphoid
fracture that healed uneventfully with closed treatment. She continued
dren, 10 and ] 2 years old, probably had bony and soft tissue to complain of dorsal wrist pain 10 months after the injury. Bone scan
makeup approximating that of an adult wrist and also sustained revealed increased uptake in the area of the distal scaphoid and proxi-
enough crauma ro manifest this combined injury. Another com- mal triquetrum. No plain radiograph abnormalities could be appreci-
ated. A limited magnetic resonance imaging scan demonstrated a non-
bined injury about rhe wrisr was reponed by Giddins and Shaw union of an intraarticular fracture of the trapezium (arrow). The
(83). [n this case, lunare subluxation was associared wirh a disral scaphoid is identified by an open triangle, the triquetrum by a closed
radius physeal fracrure. Insrabiliry of rhe lunare was initially triangle. Excision of the fragment brought pain relief, and normal func-
tion returned.
recognized and treared surgically 6 weeks afrer rhe injury by
repair of rhe dorsaJ ligamenr and pin flxarion of rhe lunare.
There are a few reporrs of isolated ligamenrous injuries of a
child's wrisr. Gerard (81) reponed a 7-year-old girl who sus-
tained only low-energy injuries from a fall from a sranding pos- widening or malalignmenr in rhe carpus. An appropriare index
ture at 3 monrhs of age. The parenrs related rhat rhe child ex- of suspicion, experience, and judicious use of ancillary studies
cluded rhe affected hand from normal activiry, and a painful (e.g., arthrography, stress radiography, and reaJ-time fluoro-
limiration and clinical deformiry of the wrist were present ar rhe scopic evaluation) are advocated.
time of evaluarion at 7 years. A volar intercalated rype of insrabil- If several facrors in the history and examinanon pomt [Q
iry wirh carpal collapse was present when rhe radiographs were potential Iigamenrous injury, shorr-term immobilization and
reviewcd. Thc distinct parrern was absent on the contralareral reexamination are appropriare. Ofren rhere is a marked diminu-
uninjured side. Operative reconstruction was chosen, using an rion in clinical symptoms, and uncomfortable intervention is
extensor carpi radialis grafr and pinning. AJrhough follow-up was avoided.
brief, clinical and radiographic results were considered excellenr. The goals of a mobile, painless wrisr and [he prevention of
Hyperelasticiry syndromes may predispose parienrs ro aber- accelerared degcnerarion wirhin rhe carpus arc most often mer
ram carpal mechanics. Atraumatic bilateral peri lunar dislocation by a systematic evaluation and treatment process. If aggressive
patrerns have been observed in association with Marfan's syn- inrerventiol1 is neccssalY, the timing may have to be considered.
drome (] 67). A complere examination of rhe parienr ro derer- It is difficult to make a general recommendation abour trear-
mine wherher global hyperlaxiry is presenr would be useful in ment for rhese extremely rare injuries. Some difficult decisions
evaluaring wrisr findings rhar seem out of the ordinary. Films would have ro be made in, for insrance, a lare adolescent athlete
of rhe contralateral extremiry also can provide vital informarion. with an acure scapholunate injulY. We would probably rreat
True intercarpal and radiocarpal ligamentous injuries are rare these pariems as adulcs, with anaromic reducrion, repair of soft
in children, but rhe diagnosis should srill be considered if clinical tissues, and internal and external immobilization as necessary
findings suggeSt ir. Despire rhe infrequency of rhese injuries, until healing occurs. Some formal rehabilitation may be needed
clinicians may fInd themselves quesrioning an apparent subtle to recover motion and strengrh. IfligamenlOus disruprions occur
 Chapter' 8. Fmullre, and Dis/oCt/fiom of the Halld alld Carp/ls ill Children 359

in an extremely young patient, it is not unreasonable to permit unlike an "acquired Madelung deformity," as reporred in one
the temodeling potenrial of the immature carpus and the innate patienr by Vender and Watson (219). Management is described
ability of children to regain useful and painless range of motion in Chapter 9.
to work in the child's favor. Whether a sports injury to the wrist is acute or secondary to
repetitive loading, a sensible approach that includes input from
Distal Radioulnar Joint Disruption the patient, parents, and coaches is advocated. We strongly rec-
ommend using the traditional and tested methods of treating
Dislocation of the distal radioulnar joint also is rare in children, injuries and tty to disregard any outside influences that may be
although with higher levels of athletic pareicipation, we may at wotk fotcing a more aggressive approach to these young ath-
stan to see more open soft tissue destabilizing injuries (J 00). letes. The definitions of aggressive and conservtltive are sometimes
Fracrure through the ulnar physis occurs with some frequency, clouded in this population. Some argue that internal fixation of
and this route of force transmission may be somewhat protective a minimally displaced scaphoid fracture in a high-perfol-mance
to the distal radioulnar joint and triangular fibrocartilage com-
athlete is a safe and predictable method that brings about rapid
plex (120,128). The pediauic Galeazzi equivalent is a fracture
union and returns the patient to rhe previous level of athletic
of the l'adius accompanied by a fracrure of the distal ulnar physis
involvemenr. However, we do not advocate such an approach
tnat desrabilizes rh.e distal radioulnar joinr. Galeazzi fracrures
in children.
and their equivalents are discussed in Chapter 9.
There may be some debate about scholarship candidates who
Acute lesions of the uiangular fibrocareilage complex are rare
have little growth remaining before their final season of high
in ch.ildhood. If there is a high index of cJinical suspicion for
school spons. These decisions must be individualized, and the
such an injury in a child, arrhrography may be used eo confirm
the diagnosis. Cadaver dissections by Mikic (147) failed ro dem- patienr's desires and the pareicular aspects of the sporr are impor-
onsuate triangular fibrocartilage changes of a degenerative na- tanr factors to be considered.
[LIre in any specimen under 27 years of age. Although this infor- Physicians, parenrs, and coach.es can work together ro effecr
mation may not be directly applicable, it does lower the significant change in the realm of education and safety. It is
likelihood of a significant triangular fibrocarrilage complex in- imporeanr eo have proper coaching, conditioning, and equip-
jury, with or without distal radioulnar joint disruption. menr when teaching young arhletes. This applies to both team
A radiocarpal dissociation from the distal ulna usually is a activities and individual sportS. Proper use of safety equipmenr
catastrophic injulY that results from high-energy mechanisms. is necessalY and beneficial. Such equipmenr includes materials
Subtle injuries also can occur; comparison radiographs and clini- for prevenring injury to the upper extremity, such as the wrist
cal examination are imporranr steps in evaluation. Many of these guards used in in-line skating or the hand and wrist protecrors
less significant injuries can be treated with. immobilization In used in gymnastics (Fig. 8-94). Innovative rypes of immobiliza-
full supination, which reduces the distal radioulnar joinr. tion and prorection that are approved by rules committees of
the particular level of play, whethu it be the local school board
Athletic Injuries of the Immature Wrist all the way up to the NCAA or NFL, are used. The concept of
the playing cast has been well studied and is an excellenr adjuncr
Injuries to th.e upper extremity have been largely neglected in to return athletes safely eo the field or court while minimizing
sports medicine because of the focus on catastrophic, high-pro- the danger to themselves and other parricipanrs.
fjle lower extremity injul·ies. However, as our young patients
parricipate with greater sophistication at earlier ages, the number
of wrist injuries is increasing. This is especially true in high.-
velociry, h.and-inrensive spores, where the demands on the hand • AUTHORS' PREFERRED METHOD
and wrist are the greatest 07,56). ,~ OF TREATMENT
Significanr injuries eo the wrist are underrecognized and can
be undertreated unless the physician is familiar with these pa-
Distal pole fractures occurring in preadolescents are created
thologies. In addition, the health-care professional attendingath-
symptomatically. Shorr-term (2-3 weeks) splinring or casting is
letic comests or evaluating the injured player in the early period
usually adequate.
must temper the athlete's and coaches' desire for him or her [Q
Our experience with teenaged athleres has forced us to con-
cominue play if the extenr of the injuries may make this unfeasi-
template an emerging subset or carpal injuries-the "typical"
ble. Acute injuries ro the wrist can occur as a result of direct
conract from a ball, high-energy collisions, and attempts to brace scaphoid waist fracrure in a skelcrally immature patient. If dis-
against opponenrs or falls oneo the turf. Fractures of the carpal placed (1 mm or more of fracture gap or 10 degrees of angula-
bones, ligamentous injuries, or a combination injury may resulr. tion), open reduction and internal fixation are indicated. We
Conversely, there is increasing recognition of the effect of favor a variable pitch screw inserred through a volar approach,
long-term, repetitive exposure to particular activities specifically after anatomic reduction. For some fractures in the proximal
involving the wrist. The stresses that high-performance gymnas- third, a dorsal approach for inserrion can be used.
tic maneuvers place on the radial physis have been discussed and If there is a mismatch between the size of the scaphoid, or
characterized in the literarure (38,179,183,184). Similar physcal the fracture fragmenr, and the prospective implant, then smooth
injuries have been reported at the distal ulna as a result of gym- wires can be used for stabilization. The same concepts of ap-
nasrics (238). The clinical and radiographic manifestation is nor proach and implanr insereion hold.
360 Upper Extremity

A B
FIGURE 8-94. Wrist guards for gymnastics. A: The "Iion's'paw" protector used mainly for vault. B: Hand
and wrist protectors used primarily for the uneven parallel bars.

DISLOCA IONS OF THE HAND AND Most of these pure dislocarions can be easily relocated by
CARPUS longicudinal rraerion and recreation of the hyperextension force,
followed by rhe rerminal reduction maneuver. The DIP joint
Dislocations of the Interphalangeal Joints
congruity is assessed clinically and with radiographs. Two ro
In children, rhe sofr rissue srabilizers of rhe interphalangeal joints three weeks of splinting, similar ro rhe splinting used for mallet
(rhe collareralligaments, rhe inserring rendons, and volar plare) injuries, will allow rhe ligaments [Q heal. Morion recovery usually
exceed the physeal rissue in strengrh and abiliry [Q wirhsrand is full, and lare instability is rare.
parhologic forces. It is for rhis rcason rhar failure through rhe Irreducible or complex dislocations of the DIP occur almosr
bony elemenrs is much more common in rhis age group. Occa- exclusively in adults, bur some clinicians have included imma-
sionally, dislocations do occur, as do fraccure-dislocations (Fig. [Ure pariems in rheir series (J 64,171,185,194). The reports thar
8-95). have included younger parients have lacked specific derails of
The specific anawmy and inrerrelationships of rhe bones and operative findings, and have mixed pure soft rissue injuries wirh
sofr rissues in rhe pediarric hand have been exrensively discussed fracrure-dislocarions (210). However, some importanr faers
earlier in rhis chapter. We refer the reader ro these seerions for have been common ro most reports:
a thorough descriprion of rhe inserrions of the volar plate, collar-
1. Tb.e disral phalanx is dorsal and blocked from reduction by
eralligaments, and musculotendinous units about rhe interpha-
rhe interposed volar plare, having been avulsed from the mid-
langeal joints.
dle phalanx. Other rissues that may be inrerposcd are rhe
collateral ligamenrs and [he flexor digirorum profundus
(211 ).
Interphalangeal Joint Dislocations
2. Relocation of the complex dislocation, performed rhrough a
The Distal Interphalangeal Joint dorsal approach, usually requires division of ar leasr one col-
A hyperexrension force or axial load on a slighrly flexed rerminal lareral ligament, removal of the inrerposed volar plate, and
plulanx can resulr in dislocation of the DIP joinr wirhour frac- relocarion of rhe flexor digirorum profundus.
rure. Mosr sofr rissue disruprion is volar and lareral, resulring in 3. Pinning of the joinc is an option for a period of 3 weeks
rhe distal phalanx coming co rest in a position dorsal ro rhe uncil soft rissue healing is adequate to srart early morion.
middle phalanx. The collateral ligaments and volar plate typically No lare insrability was reported, and motion recovery was
fail at rheir middle phalangeal origin. uniformly sarisfacroly.
 Chflpt'r>r 8: Frfl(tu)'r>s (/nd DisiocflliollJ of the J-/rwd find Carpus ill Chi/tiroJ 361

FIGURE 8-95. A: A 15-year-old boy sustained a dor-

sal dislocation of the proximal interphalangeal joint
with a Salter-Harris type II fracture of the middle
phalanx when he jammed his little finger playing
baseball. B: Closed manipulation successfully re-
duced the dislocation and the fracture. B

The Proximal Interphalangeal Joint whether [here was a perceived deformity of rhe digir [har was
Injuries of rhe PIP joint are rela[ively rare in children, in compar- reduced by manipulation.
ison wirh rheir occurrence in adulrs. Bony injuries abour rhe Radiographs will reveal a fracrure, if present, bur ofren are
rIP joint garner rhe mosr arrenrion because of [heir porentially unclear wirh respecr ro [he skeleron. Diffuse sofr [issue swelling
disastrous results, bu[ injuries ro [he soft [issues of[en lead ro is appreciated. Care must be taken ro smdy [he congruiry of rhe
persistent swelling, insrability or sriffness, and rendon imbalance. reducrion ar rhe PIP joinr. A loss of concentricity can be quire
subtle, evidenced by a dorsaJ V space insread of a smooth aniClI-
The Jammed Finger. The jammed finger or "coach's finger" Jar mating.
is a popular rerm in rhe lay community used ro describe rhe Evalua[ion under meracarpal block anesrhesia is helpful in
swollen digir resulring from an axial loading injury wirh variable derermining rhe integrity of rhe sofr rissue srrucrures abour rhe
angularory and rorarional forces. The pain and deformiry usually PIP joint. A sucss examinarion of [he collarcral ligamcnts can
arc localized ro rhe PIP joint, and flexion is difficulr. The pediar- be conducred. Passive range of morion can be recorded pain-
ric parient often has rrouble localizing rhe discomfon ro rhe lessly, and acrive morion can be assessed.
volar, lareral, or dorsal aspecr of [he joinr. By [he rime rhe physi- A closed bouronniere deformity is inferred when active exren-
cian has seen rhe pa[ienr, seve raj coaches or parents have already sion from a flexed posrure is impossible, bur extension can be
rried ro "pull ir back in place." mainrained if rhe digi r is passively placed ar neurral. Orher pro-
A[ flrsr evaJuarion, li[t1e more is known abour rhe pa[hoana- vocarive maneuvers for diagnosis of an exrensor mechanism in-
romy rhan j[ is primarily focused ar [he PIP joinr. The hisrOly jury include a resr of cenrral slip continuity described by Elson
should include quesrions abour rhe mechanism of injury, and (66). With [he parienr's digir flexed 90 degrees ar rhe PIP joinr
362 Upper ExtrI'mit),

over a table edge, inability to extend the PIP joint coupled with with a spectrum of injuries to the volar plate, some may present
fixed extension of the DIP joint indicates a central slip rupture. as irreducible joint dislocations.
For many of these presentations, no specific pathologic entity
is defined. The soft tissue swelling and vague pain can persist Dorsal PIP Dislocations. Dislocations about the PIP joint in
For nearly a year, and the affected PIP joint may always be slighdy which the middle phalanx is displaced dorsal to rhe proximal
more voluminous. Radiographs typically show no bony sequelae phalanx are rhe most common (Fig. 8-96). Failure of the collat-
or accelerated degeneration, although cartilage or bone bruise is eralligaments and the volar plate are all a part of the patllOgenesis
a likely part of the injulY. of the dislocation. These structures may even block artemprs ar
Treatment of the "jammed finger" consists of initial icing reduccion, crearing a rare irreducible dorsal dislocarion.
and elevation For 72 hours, with immobilization in a hand-based Many dorsal dislocations are berter termed subluxations or
splint to permit resr. Edema reduction and motion should then sprains, because the injury to the fibers of rhe collateral ligaments
Follow, and warm soalcs may bring some relief. Buddy taping to does not resulr in Frank loss of joint congruity or cause insrabil ity
the adjacent digit protects the injured member and promotes of the articularion through a normal arc of morion. In facr, many
earlier motion recovery. of these injuries eirher go unseen by rhe physician or are seen
A documented cemral slip rupture is treated with extension after they are reduced by the patient or orher atrendant. Many
splinting For four weeks, followed by dynamic extension splint- of these reductions take place on the playing field or gymnasium,
ing for 2 to 4 weeks. The splint permits motion, while preventing and the patient returns to an arhletic contesr.
volar subluxation of the lateral bands. Rarely, operative interven- With a dorsal dislocation, neurovascular status typically is
tion is required For closed extensor mechanism injuries. PrimalY normal, bur pain and deformity are obvious. Fracture is ruled
tendon repair, with or without joint pinning, usually is reserved out with standard radiographs, wirh rhe addition of an oblique
For special circumstances. The grearer strength of the f1exor sur- film to better assess the condylar area. After adequare anesrhesia,
face muscles usually allows recovery of f1exion, even after several rhe dislocation is reduced with longitudinal tracrion and hyper-
weeks of extension splinting. extension, followed by gende flexion of the middle phal:-tnx back
OlltO the proximal phalanx articular surface.
True Pip Dislocations. PIP dislocations can be dorsal, volar, The quality of the reduction and the stability of the joint
or lateral. Although a significant number of these injuries are mUSt be assessed. Radiographs should demonstrate a concentric
incomplete ligament avulsions or intrasubstance tears, combined reduction. Most dislocations are stable throughout the normal

FIGURE 8-96. A: Lateral radiograph of a volar plate

avulsion injury. There is a small fracture fragment volarly
from the epiphysis of the middle phalanx. Note the asso-
ciated soh tissue swelling. These fractures should not
be treated with prolonged immobilization. Early buddy
taping and motion lessen the risk of a flexion con-
tracture. B: Dorsal dislocation of the proximal interpha-
A,B langeal joint in a 10-year-old girl.
 Chapter 8: Fractures and Dislocations of the Hand and Carpus in Children 363

range of motion, but others may redislocate as the PIP joint is the collateral ligament(s) with nonabsorbable suture. However,
brought into more extension. Eaton (65) described the active we reserve this treatment for unstable joints, because we have
stability test to determine the adequacy of reduction and the found that postreduction instability is rare, because most of these
need to potentially treat by operative means. Simply asking the patients tend toward stiffness.
blocked and reduced patient to perform active flexion and exten- The "gray area" between open and closed treatment of these
sion to determine stability is the cornerstone. If the joint remains injuries is when reduction can be accomplished, but significant
stable in this arc, then 2 to 3 weeks of buddy taping are adequate. instability is present. In this young population, we still make an
Extension-block splinting, as advocated by McElfresh et al. attempt at closed treatment if the joint can be reduced. If the
(142), may be needed for fracture-dislocations. Our regimen joint needs to be splinted in more than 60 degrees of flexion to
for splinting of injuries that are reducible and stable in at least remain stable, we advocate primary ligament repair. We ap-
some range is detailed below: proach the digit through a mid-axial incision on the side of the
collateral ligament rupture. Secure primary repair or suture to
1. For a completely stable joint with no lateral instability or
bone is accomplished. Pinning of the joint is avoided if possible.
volar plate laxity, we allow early motion with buddy taping
Motion is begun at the second week.
to the s:de of the greatest lateral tenderness.
Dynamic splinting may be necessary for terminal motion
2. For a closed reduction that is stable, yet associated with a
recovery. The fibrous masses that have been described above
degree of lateral instability «20 degrees) or volar plate laxity
usually present little impediment to motion recovery. If the mass
«20 degrees hyperextension), splinting of the PIP joint for
is troublesome, it can be excised after the other tissues have
2 to 3 weeks in about 30 degrees of flexion is the initial
stabilized. Waiting about 6 months may allow the surgeon to
treatment. Buddy taping can continue for 2 to 3 additional
combine a capsulotomy or tenolysis, if needed, with the excision.
weeks.
3. For significant volar plate injury without lateral instability,
Volar PIP Dislocations. Although volar PIP dislocations are
a greater degree of PIP joint flexion is used for about 3 weeks.
uncommon in the pediatric population, there are common
We typically splint at 5 degrees less than the maximal exten-
themes that can be appreciated from the few reports (111,160,
sion at which the joint starts to dislocate; this is usually be-
165):
tween 45 and 60 degrees. The joint is extended slowly every
7 to 10 days until full extension is realized at the third or 1. These injuries often go undetected. The delay in diagnosis
fourth week. The joint has been left free to flex throughout ranged from 1 to 52 months in one series (165), and the
this treatment course. Bowers (29) has reported development single patient reported in another series was 3 weeks old
of a swan neck pattern in two children with volar plate rup- (160).
ture after dorsal dislocation, and both needed volar plate 2. Interposition of soft tissues (the volar plate, lateral band)
repair. More aggressive early dorsal block splinting may per- can hamper attempts at closed reduction. Likewise, fracture
mit healing of the injured plate and prevent such a deformity. fragments can render the dislocation irreducible by closed
means (11 1).
There is considerable disagreement concerning primary repair
3. Long-term results are often suboptimal. It is difficult to ascer-
of torn collateralligamems associated with PIP joint dislocations
tain whether the late treatment is the ultimate cause, or con-
in adults (135,141,180,188). With the paucity of experience or
tributing factors like the violence of the initial trauma or
reports of this pure ligamentous injury in children, even less of
extent of tissue involvement also may playa role.
a consensus exists. Redler and Williams (180) did include four
skeletally immature patients in their series of 14 complete coliat- Volar dislocation is an extensor-side injury. The interval be-
eralligament ruptures. They reported complete functional recov- tween the lateral band and the central tendon may be the site
ery. Blount (23) and Vicar (220) described a patient in whom for herniation of the proximal phalangeal head, or the central
the collateral ligament was interposed in the PIP joint and had slip may rupture from its middle phalangeal insertion. Thomp-
to be extracted to permit reduction. In Vicar's patient, the injury son and Eaton (213) recommend 3 weeks of extension splinting
was several weeks old, but the open repair was successful. followed by intermittent dynamic splinting fot patients in whom
Other researchers (28,232) described a tumescence at the site a congruous reduction is obtained. If the reduction is blocked
of the collateral ligament avulsion (from its proximal phalangeal by soft tissue, exploration may be necessary. We approach the
origin) that has been bothersome to patients and may cause digit from the dorsum, and exploit the injury interval to evacuate
functional limitation. These fibrocartilagenous or fibroosseous the joint. Careful reconstruction of the extensor tendon is per-
masses have been excised with uniform success. Another peculiar formed, and splinting in extension is continuous for 3 to 4
injury was reported by Whipple et al. (228) in which the volar weeks. The flexion typically is regained without roo much diffi-
cartilage surface of the middle phalanx was folded into the joint, culty over the course of the next 6 weeks. Some dynamic splint-
in a dorsal fracture-dislocation. The cartilage flap was easily ing can be used to assist or accelerate motion recovery.
restored, and excellent function was realized within a month.
We have been very pleased with simple closed reduction, Lateral PIP Dislocation. Garroway et al. (77) emphasized the
coupled with either short-term immobilization in an extension role of torsional forces in the development of complex disloca-
block splint or simple buddy taping. If the dorsal dislocation tions about the PIP joint. Although his five classes spanned volar
cannot be reduced, evacuation of interposed tissue is necessary. and dorsal dislocations, and no specific mention of these injuries
When the joint is to be opened for reduction, we primarily repair in children was made, the concept of multiaxial force in the
364 Upper Ewremity

parhogenesis of PIP dislocarions was underscored. Ir is rare (Q Volar Dislocation

have forces direcred purely in one plane, and simply labeling
This is a rare injllly, bur can occur in children. One of [he classic
[he injury as a dorsal or volar rissue disruprion is pracrical bur
mechanisms seems ro be carching rhe digir in rhe spokes of a
incomplere. The rissue rhar is likely damaged in all rhese injuries,
bicycle or exercise equipmenr. This injury reflecrs a disruption
(Q an exrem, is me collareral ligament.
of the dorsal apparatus, and rhis must be respected. Therefore,
Kiefhaber and co-workers (114) focused arremion on the col-
splinring is in exrension for up ro 4 weeks, followed by a spring-
lateral ligament system and relared displacemem of rhe digit in
loaded extension splint.
the coronal plane (Q rissue parhology. More rhan 20 degrees
A dorsal epiphyseal fracture may indicate a cenrral slip avul-
of lareral deviarion (Q genrle mess reliably indicated compJere
sion fraerure rhar may require open trearmenr.
ligamenrous disruption. The order of failure was also elucidated
in rhis srudy: I1rsr, rhe collateral ligament is detached from the
proximal phalangeal origin; then the accessory and proper collat- Lateral Dislocations
era Is are separated as forces move distally; the final area of failure
is rhe distal volar plare inserrion from the middle phalanx. Injury ro [he collareral ligamenrs is a likely componenr of all
T rearmenr of the collareralligamenr in rhe serting of a volar rhese dislocarions, regardless of rrue "direcrion." Conversely,
and dorsal disJocarion has already been described. Protecrion of isolated ruprure, or pure lateral dislocarion, is probably rare. An
the collateralligamenr can be accomplished wirh rigid spliming incompetent colJateralligamenr is best rreared by closed means.
or buddy taping. The exrenr of me injUlY, evidenced by the The exception ro this is when there has been an incarceration
amounr of lareral deviation (Q srress and rhe qualiry of the end of a lareral band in the dislocated joint.
poinr, may mirigate for more aggressive trearmenr in some pa-
tiems. If the joinr can be dislocared by applying lareral suess, Metacarpophalangeal Joint Dislocations
rhen consideration should be given (Q collateral repair. If a frac-
[lire is presem in conjunction with rhe lareral stress injury, con- The most common sire for dislocation in rhe child's hand is the
sideration could be stronger for opening rhe injury through a MCP joinr (84,130,200). The thumb MCP joinr dislocates mosr
mid-axial approach and srabilizing the bone and repairing rhe ofren as a resulr of a hyperexrension force. The gamekeeper's or
soft rissues (47). skier's rhumb can be rhoughr of as a momentary dislocation or
subluxarion. A small epiphyseal fragment may accompany rhe
VCL, or a pure soft tissue injury can result. The mosr common
complex or irreducible dislocation is ar the index MCP joinr.
~ AUTHORS' PREFERRED METHOD
,~ OF TREATMENT Dorsal Dislocations of me Triphalangeal Digits
The mosr common dislocarion of rhe MCr joinr is dorsal dislo-
The variables that must be considered when planning a trear-
carion of rhe index digit (Fig. 8-97). The injury resulrs from a
menr course for PIP level injuries in a child include extenr and
hyperextension force thar causes a ruprure or avulsion ot rhe
anaromic locarion of sofr rissue disruprion, presence or absence
volar plare (33). When rhe proximal phalanx becomes siruared
of fracture, reducibiliry, and stabiliry afrer reducrion. Almost
dorsal ro rhe metacarpal, rhere is JirrJe quesrion ot rhe diagnosis.
all rIP dislocarions deserve an arrempt at closed reduction and
The digir is supinated, ulnady deviared, and shortened. The
srabiliry assessment. Indeed, the srandard prorocol of anestheric
interphalangeal joints are slighdy flexed. Mosr parienrs have
block, teduction, active and passive motion testing, and radio-
volar skin dimpling over rhe metacarpal head.
graphic assessment suffice in mosr circumstances.
Radiographs can confirm rhe diagnosis, especially when [here
is gross malalignmenr of rhe bony e1emenrs or rhe sesamoids are
seen in rhe joint. The position of the volar plare in children over
Dorsal Dislocation
10 years of age can be inferred by sesamoid position in rhe
If rhe reducrion was easily obrained and good morion arc and index and thumb rays (211). Rarely, other digirs have visible
stabiliry are presenr, we prescribe a short period (less rhan a sesamoids, and rhis same diagnosric rechnique can be used. Ie
week) of dorsal blocking prorection. This can be followed by is oEren suggesred rhar rhe presence of rhe sesamoids in rhe joinr
active motion with buddy taping. connores a complex dislocarion, but this finding is not absolure.
If there is a proclivity for the joim (Q redislocate at 30 degrees Orher clues ro dislocarion at rhe MCP joinr can be gleaned
of flexion or more, we exercise more ofa standard dorsal blocking from radiographs. Robins (181) observed simple narrowing of
splinr regimen: 45 to 60 degrees for 5 (Q 7 days, followed by rhe Mcr joinr space in MCP dislocarion. Campbell (36) de-
30 (Q 45 degrees for 5 (Q 7 days, followed by 15 (Q 30 degrees scribed rhe concept of the "phalangeal line" as a guide ro derer-
or buddy raping unriJ swelling is decreased and stable motion mining rhe presence of fracrure or dislocarion ar rhe MCP joint.
is realized. The enrire course usually lasts 2 (Q 3 weeks. He showed thar a line drawn down the axis of the proximal
If surgical inrervenrion is indicated in rhe rare severe inrraar- phalanx should pass rhrough the axis of rorarion of the metacar-
ricular fracture, irreducible dislocation, or a combinarion, the pal head in rhe uninjured digit. When a fracture or dislocation
u!rimate goal of srable fixarion (Q permir early morion musr be was present, the phalangeal line became skewed (36). The COI1-
observed. These problem fracrures rypically occur in adolescents, cepr of "parallelism" of rhe meracarpal and the phalanx is an-
so "adult principles" govern. orher expression of Campbell's concept. This finding is nor un i-
 Chapter 8: Fractures and DisLocations of the Hand and Carpus in Children 365

FIGURE 8-97. A: A 3-year-old boy with a com-

plete complex dislocation of the index finger
metacarpal joint. B: Note the parallelism in this
lateral view. Open reduction was performed
through a volar approach, and normal function
A resulted.

versally seen in the complex dislocation. The surgeon should be dislocation, Kaplan (112) described the position of the metacar-
especially cognizant of the infrequent occurrence of adjacent pal head with respect to the surrounding soft tissues. The meta-
MCr dislocations. These most often occur wirh more violent carpal head becomes "picture-framed" by the flexor tendon to
trauma and can be difficult to diagnose clinically because of the ulnar side and the lumbrical w the radial side. The superficial
hand swelling. Radiographs may be difficult to interpret, because transverse metacarpal ligament and the Datawry ligaments can
projections may obscure adjacent MCr joints. settle dorsally around the metacarpal neck, and the palmar apo-
To explain the pathoanatomy of an irreducible or complex neurosis captures the metacarpal on the volar side. The collar is
366 Upper Extremity

tightened by longitudinal traction, and this common reduction

maneuver can actually conven a reducible dislocation to an irred-
ucible one. The volar plate can become interposed between the
dorsal metacarpal head and the dislocated proximal phalanx,
further blocking reduerion.
Reduerion is effeered by further hyperextending the joim,
then attempting to capture the volar plate with the dorsal lip of
the proximal phalanx. Inrraarticular infiltration of anesthetic
fluid can assist reduction by "floating" the volar plate out of
its displaced position. The success rate for closed reduerion of
complex dislocation is low. Operative reduction and clearing of
the joint usually are required. If a reasonable attempt at closed
reduerion has failed, open reduction is warranted.

Volar Approach. When closed reduction is unsuccessful, open

methods are needed. Many surgeons prefer the volar approach
for reduction of the MCr dislocation (Fig. 8-97). The volar
approach affords excellent exposure of the metacarpal head and
the structures that incarcerate it (11,14,23,84,92,112,130,143).
The authors that prefer this approach accept the risk of potential
injury ro the digital nerves that are draped over rhe articular
surface of the metacarpal head. Kaptan and others advocate divi-
sion of multiple structures, including the Al pulley, the distal
edge of the palmar aponeurosis, the superficial transverse meta-
carpal ligament, and the natatory ligaments. Other clinicians
believe that division of the Al puJley alone (130) or the trans-
verse metacarpal ligament alone (104) is sufficient.
McLaughlin modified the volar approach to the MCr joint
by incorporating it with a mid-lateral incision into the digit, FIGURE 8-98. A relatively rare dorsal dislocation of the long finger
choosing to extend the incision along the radial mid-lateral line was irreducible by closed means. A dorsal approach permitted visualiza-
(143). He used a skin hook to extract the volar plate from its tion of the joint and extrication of the volar plate. Excellent function
ensued after early motion was started.
position in the dislocated joint. Reduction was accomplished
without the need for additional soft tissue releases.
Metacarpophalangeal dislocations in the other rri phalangeal
joints are uncommon (Fig. 8-98). Baldwin et a1. (0) described
an irreducible fifth ray MCr dislocation in which the metacarpal By relaxing the flexor pull by simply flexing the wrist and
head was entrapped by the abductor digiti quinti and flexor digits, the joint can be approached through a tendon-splitting
digiti minimi on the medial side and the long flexor tendons to incision. Either a transverse or hockey stick capsulotomy can be
the lateral side. Open reducrion with incision of the volar plate used, but the injury may have stripped rhe capsule to an extensive
was necessary to correct the defOl·miry. degree. Use of a Freer or septal e1evaror defines the joint, and
Metacarpophalangeal dislocations in the central rays are rare may sweep away the soft tissue thar was interposed. Throughout
(Fig. 8-99) (161). Lateral fracture-dislocations at the MCr joinr the procedure, protection of the metacarpal head articular sur-
sometimes occur, and are often S-H III fractures of the phalan- face is paramount.
geal base. Open reduction usually is necessary co treat the frac- Pushing the volar plate back into position may be the only
ture. treatment needed for the joint. At times, a flexor tendon is
The optimal treatment is prompt recognition and reduction wrapped around the condyle. If the volar plate is difficult to
of the Mcr dislocation. The window of opportunity for success- reduce, it can be split from the dorsum in a longitudinal fashion.
ful reduction is difficult to define. Although reasonable results This maneuver relaxes the plate, and permits it to slip back to
have been obtained when the dislocation is reduced within the anatomic position. The volar plate need not be repaired or su-
first 3 to 4 months, this is still suboptimal treatment. After 6 tured back to surrounding tissues after its reduction.
months, results are less predierable, and accelerated arthrosis may
necessitate an early salvage procedure. Postoperative Therapy. Regardless of the approach used, there
is universal agreement that early motion is necessary. The mini-
Dorsal Approach. Most surgeons use a dorsal exposure for re- mal amount of tissue dissecrion facilitates this, and a minimal
duction of complex MCr joint dislocations. Described by Bec- soft dressing is all that is needed in the acute postoperarive pe-
ron et at. (14), this simplified technique avoids the catastrophic riod. Rarely, a dorsal blocking splint may be needed to prevent
complication of digital nerve transection, while still permitting hyperexrension that may lead to redislocation. There exists no
adequate joint access. report of redislocation at the MCr level after open reduction.
 Chapter 8: Fractures and Dislocations of the Hand and Carpus in Children 367

A B
FIGURE 8-99. A: A 9-year-old girl sustained this radial fracture-dislocation of the middle finger in a
fallon the stairs. B: Six weeks after closed reduction and immobilization in a radial gutter splint for 3
weeks, there was full motion and normal stability.

Missed MCP Dislocations. Early reduction of the MCr dislo- :He the metacarpal head have contracted, and release of any tighr
cation has been stressed by Hunt et :1.1. (109). It is universally structure is indicated. Dorsal clearing of the joint ofren is needed
agreed that early reduction and an early motion program should to remove the fibrous tissue that has occupied the void left by
be accomplished within the first 7 days (J 12,143). Despite ap- the dislocation.
propriate radiographs and clinical examination, inexperience
with these injuries can lead to a missed dislocation.
Dorsal Dislocation of the Thumb Ray
Significant motion limitarion and deFormity characterize this
In many ways, MCr joint dislocations of the thumb are similar
enriry, although pain is typically minimal. Operarive interven-
to those of the triphalangeal digits. The hyperextension mecha-
rion is rhe only reasonable alrernative, thus we caution against
nism is the same, as is the proclivity of the dislocation to be
vigorous arremprs at closed reducrion when a dislocarion has
irreducible. Because of the rhumb's differing anatomy and Func-
been present more than 2 or 3 weeks.
tional importance, it is considered separately.
Murphy and Stark (J 57) discussed the treatment of missed
The pathophysiology was elucidated by Farabeuf in 1876
dislocations. They perFormed open reduction of MCr disloca-
(69). His classification system is complete and quite useFul. It
rions that had been negJected For 3 weeks to 3 months. Both
describes tissue injury and explains the implications for and like-
volar and dorsal appwaches were used, and the UCL had to be
Iihood of reduction. The Focus of the system is the integri ty and
resected in some patiems. Transarticular pinningw;:\s maintained
position of the volar plate, the status of the collateral ligaments,
for 3 weeks. There was decreased morion ar the MCr joint, bur
and the relative position of the metacarpal and proximal phalanx.
it was still thought to be in the useFul range. Late complications
The components of the classification are incomplete dislocation,
included partial growth arrest. BarenFeld (11) achieved normal
simple complete dislocation, and complere complex dislocation
motion in a patiem whose dislocarion was reduced 3Yz months
(Fig. 8-100).
aFter injury. Lipscomb and Janes (133) reported a 20-year follow-
lip of an unreduced thumb MCr dislocation. They related that
a "new metacarpal head, joint, and ligament apparently formed Incomplete Thumb MCP Dislocations. Incomplete disloca-
spontaneously." 1t is likely tllat the exceptional remodeling tions occur when the volar plate ruprures, but the collateral
about the adjacent epiphyses adapted to the new Forces contrib- ligaments remain intact. In its most benign form, an intrasub-
uted by the bones in their new position. stance injury or partial avulsion of the volar plate occurs, which
We agree that surgical. reduction will likely require both volar may result in supraphysiologic extension at rhe MCr joint.
and dorsal approaches. The multiple srructures that can incarcel'- OFten, the volar plate ruptute is complere, and the MCr joint
368 Upper .Extremity

can be classified as an incomplere dislocation. This is besr shown

by stress radiographs and examination.

Simple Complete Thumb MCP Dislocation. The simple com-

Complete simple plere dislocation of the thumb MCr is the mosr clinically ob-
vious. The proximal phalanx is dorsally displaced, and its long
axis is 90 degrees to that of the metacaJpal.
Many of rhese dislocacions can be reduced by closed means
(Fig. 8-101). The reducrion maneuver previously described for
interphalangeal joint reducrion is particularly useful, including
insufAarion of rhe joint wirh lidocaine. This maneuver resembles
rhat described by Burron and Eaton (34), who recommended
exrension of the thumb interphalangeal joint ro lifr rhe flexor
pollicis longus and volar plate away from their posirion poren-
Complete complex rially blocking rhe reducrion. Many clinicians have warned
againsr excessive longirudinal rracrion when attempting reduc-
tion. The resulting force may conven a reducible injury into a
complex dislocarion (92,143).
If reducrion is successful, rhumb spica casring for 3 weeks
usually is sufficient ro permir healing of rhe volar plare and
FIGURE 8-100. Simple and complex dorsal dislocation of the thumb collareral ligaments. Care musr be raken during cast applicarion
metacarpophalangeal joint. so as nor ro deviare rhe rhumb in a radial or ulnar direcrion,
because of the porential of concomirant collateral ligament rup-
rure.

subluxares as rhe proximal phala.nx perches on the dorsum of Complete Complex Thumb MCP Dislocation. The disloca-
rhe metacarpal. rion rhar represents rhe mosr rissue disrurbance, and the one rh,u
A period of immobilizarion usually is adequare treatment. normally requires open reduction, appears as the mosr clinically
Three weeks is sufficient for more significant injLL[ies, and dis- inconspicuous. In a complere complex dislocarion, the long axes
continuarion of the splint when renderness subsides is reasonable of rhe proximal phalanx and metacarpal can be parallel. The
for low-level rrauma. If a child desires to rerurn to arhleric partic- rhumb is shonened and swollen abour rhe MCr joint.
iparion, prorecrion with a hand-based rhumb spica orthosis is Ir is difficulr co obrain closed reducrion of a complere com-
recommended. A pure ligamenrous injury ar rhe ulnar collareral plex dislocarion, alrhough occasionally closed manipularion can

FIGURE 8-101. Complete simple dislocation. A 9-year-old

boy with a dorsal dislocation of the thumb metacarpopha·
langeal joint. The dislocation I'acks parallelism, and closed
reduction was successful.
 Chapter 8: Fractures and Dislocations of the Hand and arpllS in Children 369

B
FIGURE 8-102. Complete complex dislocation. A: Closed reduction attempts failed to reduce this dorsal
metacarpophalangeal dislocation in a 7-year-old boy. Note the relative parallelism between the dislo-
cated thumb and metacarpal. B: After open reduction through a volar incision. Normal function resulted.

reduce the joint (200). Even if closed reduction is successful, Fracture-Dislocation

some surgeons advocate open ligament repair if significant lateral
Dorsal fracrure-dislocation of rhe rhumb Mcr joinr is a rare
instability is present.
injury thar also usually requires rrearmenr (Fig. 8- 103).
As a rule, this injUlY must be treated by open reduction (Fig.
8-102). Farabeuf (69), Weeks (225), and Bohart (25) recom-
mended a dorsal approach ro the joint, but a volar approach Thumb MCP VCL Injury (Gamekeeper's Thumb)
usually is advocated to reliably extricate the volar plate. Four Types in Children Ulnar collareralligamenr injury of rhe
The volar approach is made through a Brunner incision. The child's thumb MCr is not given much arrenrion in the volumi-
digital nerves of the thumb are cenrral in an uninjured thumb, nous literature on gamekeeper's thumb. Forced abduction stress
and become dangerously tenred over the metacarpal head in a ar rhe child's rhumb MCr joint resulrs in four types of injury:
complete dislocation. Great care must be exercised to avoid their (a) a simple sprain of rhe UCL; (b) a rupture or avulsion of the
injury. The flexor pollicis brevis muscle is followed down ro rhe imenion or origin (229) of the ligament; (c) a simple SoH I or
volar plare, then rhe plare can be removed from the displaced II fracrure of the proximal physis; or (d) an avulsion fracture
posirion. Repair of the volar plare back ro the meracarpal neck (S-H III) of the ulnar one founh to one third of the epiphysis
resrores anatomy (92,207), bur the value of this procedure must of the proximal phalanx (Fig. 8-104).
be weighed againsr rhe potential of undue stiffness. Ir seldom is
necessary ro repair or reconsrrucr rhe collateral ligaments. An Adolescent Injury. The injury is usually encounrered in
Three weeks of immobilization in a rhumb spica casr is fol- the preadolescent or adolescenr. Clinically, rhe thumb is quite
lowed by a gradual range-of-morion program. Prorecrion during swollen, parricula.rly in the area of the MCP joinr, and ecchymo-
arhletics is also recommended for complere complex disloca- sis often extends out into the skin of the first web. If routine
tions. radiographs show no bony injury, the joinr must be stressed by
370 Upper Extremity

c
FIGURE 8·103. A: A 12-year-old boy sustained a dorsal fracture-dislocation of the metacarpopha-
langeal joint when his thumb was struck by a shotgun bolt. Note that a posteroanterior view of the
thumb metacarpal appears on the same image as a lateral view of the phalanges. B: Closed attempts
to reduce the fracture-dislocation were unsuccessful, and open reduction and internal fixation with
Kirschner wires were performed. C: Four months after surgery, he had only a 10 degree loss of joint
motion.
 Chapter 8: Fractures and DisLocl/tions of the Hand I/nd Carpus in Children 371

often caught over the edge of the extensor aponeurosis when

the joint reduces spontaneously (206,207). The ligament cannot
heal, and chronic lateral instability with a weakened pinch is
likely. A false impression of insrability can result from an SoH
I or II fracture of the proximal phalanx that is undisplaced on
the original radiograph and becomes obvious only on the stress
radiograph (Figs. 8-104D and 8-105). Cast immobilization is
all rhat is required for this injury. Incomplete tears «45 degrees
difference on stress testing) heal in a thumb spica cast worn for
4 weeks.

FIGURE 8-104. Ulnar instability of the thumb metacarpal joint. A: Sim- Operative Indications. If the suess radiograph, made with the
ple sprain. B: Rupture ofthe ligament. C: Avulsion fracture (Salter-Harris
type 111). D: Pseudo-gamekeeper's injury resulting from a Salter-Harris thumb extended, shows that the joint opens 45 degrees more
type I or II fracture of the proximal phalanx. than the normal side, a complete tear has occurred, and open
repair is indicated (Fig. 8-105) (200). An S-H III fracture of
the ulnar corner of rhe epiphysis of the proximal phalanx is
by far the most common childhood gamekeeper's injury. The
applying lateral force with the joint in full extension first, then significantly displaced fracture (fragment rotated and displaced
in full flexion. Preliminary infiltration of the joint with lidocaine > 1.5 mm) requires open reduction and internal fixation to re-
or blocking of rhe median and superficial radial nerves is usually store the integrity of the UCL and ro obtain a congruous joint
necessary. If the ligament is completely rom, there will be no surface (Fig. 8-106).
exact end point on stressing the ligament, particularly in flexion.

Breakdancer's Thumb. Winslet and associates (231) reported Missed Thumb MCP Dislocations. Like some MCP disloca-
on three teenagers with a displaced fracture of the ulnar corner tions in the triphalangeal digits, thumb MCP dislocations also
of the base of the proximal phalanx of the thumb with ulnar can go undetected or neglected (133). Depending on many fac-
instability after breakdancing. All three had open reduction and tOrs (length of time since original injury, age of the parient,
internal fixation. They coined the name breakdancer's thumb for current level of function), the surgeon must decide how aggres-
the injury. sively to treat the problem once recognized.
If detected in the first 6 to 8 weeks, we recommend an at-
T,·eatment. tempt at reduction through a volar or combined appyoach.
Cast Immobilization. Healing in a cast is unlikely because the T ransarticular pinning can be considered. Depending on the
ligament, which is usually avulsed from its distal insertion, is tissue quality, amount of symptoms, and functional status, it is

A B
FIGURE 8·105. A: Even with gentle stress, a complete ulnar collateral ligament incompetence is easily
detected. This 8-year-old girl was treated with early ligament repair, and normal stability resulted. B:
In this 10-year-old boy, a pseudo-gamekeeper's thumb is the result of a Salter-Harris type II fracture of
the proximal phalanx. (B courtesy of James H. Dobyns, M.D.)
372 Upper Extl'emilJI

A B
FIGURE 8·106. A: An ulnar collateral ligament Salter-Harris type III avulsion fracture in a 12-year-old
girl. B: After open reduction and internal fixation.

nor unreasonable co arrempr reduccion up co 4 co 6 momhs after rhe joinr wirh a sepral elevacor in mosr cases. In some parienrs,
Injury. rhe inrerposed volar plare needs co be incised in a longitudinal
Some lare injuries may be besr lefr co remodel co rheir maxi- fashion ro promore its ex.ir from rhe joint. There is no indicarion
mal funcrion, rhen a salvage procedure such as sofr rissue for volar plare repair.
arrhroplasry or fusion (J 99) can be performed. If rhe surgeon is more experienced or more conodell[ wirh
rhe volar approach, it cannor be overemphasized rhar the digiral
nerve is draped over rhe prominenr meracarpal head. U rmosr
• AUTHORS' PREFERRED METHOD care musr be exercised in liberaring rhe incarcerared meracarpal
,~ OF TREATME T from rhe surrounding soft rissues and reducing rhe joint.

Managemem of MCP level dislocarions should be srepwise and

logical. We believe rhar essenrially every Mep dislocarion de-
Dislocations of the Carpometacarpal Joints
serves an arrempr ar closed reducrion. Alter insufflaring rhe joint Dislocarions of rhe CMC joinr, wirh or wirhour small fr;Inure
wirh anesrheric, recrearion of rhe deformiry wirh hyperexrension fragmenrs from rhe meracarpal base, are rare injuries. The deci-
and performing a reducrion maneuver can resulr in reesrablish- sion whether ro open the dislocarion sight is based primarily on
menr of rhe arricular relarionship. This should be performed rhe srabiliry afrer closed reducrion. We suggesr srabilizarion wirh
under oprimized conditions, which may include conscious seda- percuraneous pins in almost all rhese injuries because of rhe
tion and even an operaring room serring. The larrer is advocared procliviry co redislocare.
in case rhe surgeon musr proceed co open reducrion. The fracrures rhar accompany rhe dislocarions can rangc from
We advocare rne dorsal approach for most MCP dislocations small avulsions rhat accompany rhe ligamenr disruprion [Q large
requiring open rrearmenr. The volar plare is rhe rypical rissue fragments comprising a significanr percemage of rhe arricular
blocking reducrion, and ir usually can be removed by sweeping surface (Fig. 8-64). Often rhese fragmenrs are displaced and
 IJrlpter 8: Fractures alld Dis'!ocntion; of the Hand and Cm/JUs in Children 373

rorared. Some large arricular fracrures can rorare 180 degrees weeks afrer closed reducrion and casr immobilizarion, he had a
while rbe fracrure dislocarion is in irs maximum displacemem. normal w[·isr. Ogden (162) published the radiograph of a young
Ir is imporranr ro recognize dur fracrure fragmenrs can block child with a rrans-scaphoid perilunar dislocarion bur gave no
reducrion and be the source of conrinued pain and porential details. Christodoulou and Colton (41) mentioned a 9-year-old
nonuOion. boy who had a [[ans-scaphoid perilunar dislocation, bur no de-
AJrhough isoJared dislocarions ar rhe CMC level do occur, rails were given. Lighr (129) described an 11-year-old child who
rheir parhogenesis and rrearmenr are rhe same as disruprions had open reducrion and Kirschner wire fixarion of a rrans-scaph-
in which fracrures occur. (See previous secrion on meracarpal oid perilunar dislocarion wirh a fracture rhrough rhe lunare.
fracrures.) Pennes er aJ. (167) reponed a 14-year-old girl wirh Mal-fan's
syndrome who had bilateral dorsal perilunate disJocarions, unre-
lared ro rrauma, secondary to ligamentous laxity.
Dislocations of the Carpus
Rare and Often Unrecognized Salvage Treatment Needed
Intercarpal dislocations are uncommon in children. Due ro rhe The principles of rrearment do nor differ from rhose for adulrs
rarity of the injury and the relarive smallness of the child's carpal wirh dislocations of the carpus. Reconsrructive surgery may be
bone, rhis injUly is likely to go umecognized (Figs. 8-90 and 8- required for a chronic dislocation rhar has gone unrecognized
91). A lO-year-old child wirh an acure dorsal rrans-scaphoid (Fig. 8-107). Gerard (81) reponed rhe only child in rhe lirerature
perilunare dislocation was reporred by Peiro er a1. (166). Sixreen wirh a chronic posrrraumaric carpaJ instabiliry. The 7-year-old

A c

FIGURE 8-107. A and B: An 11-year-old girl sustained this injury 7

months previously. She had been radiographed several times, but the
correct diagnosis of volar trans-scaphoid perilunate dislocation was not
made. C: Intercarpal fusion was performed, and 1 year after injury the
range of motion was as follows: dorsiflexion 30 degrees, palmar flexion
30 degrees, radial deviation 10 degrees, and ulnar deviation 25 degrees.
B She had minimal discomfort with strenuous use.
374 Upper Extremity

girl had pain and limitation of wrist motion secondary to a Hypersupination tears the volar radioulnar ligament and trian-
scapholunate dissociation with a palmar flexion collapse defor- gular fibrocartilage, producing a volar dislocation of the distal
mity of the lUl10capitate joint. Open reduction and pin fixation, ulna.
with reconstruerion of the scapholunate ligament with a portion
of extensor carpi radialis longus tendon, correered the instability. Clinical and Radiographic Findings
Ligh t (129) recommended the use of arthrography and MRJ to
If the dislocation is dorsal, there is a marked dorsal prominence
demonstrate scapholunate dissociation in the immature carpus.
of the distal end of the ulna, and any attempt to supinate rhe
One of us (T.].G.) has teported a skeletally immature teenage
pronated forearm is resisted. The AP view shows an abnormal
girl with hemiatrophy who presented with the extremely rare
separation at the distal radioulnar joint, and the ulna is dorsally
pattern of a palmar mid-carpal dislocation (89). Although the
displaced on the true lateral view. If the dislocation is volar, the
patient recalled no antecedent trauma, the wrist had apparently
wrist appears narrower than normal because the normal dorsal
been dislocated for a lengthy period, judging from the radio-
prominence of the distal ulna is missing. The forearm is fixed
graphic and clinical appearance. Symptoms and funcrion Im-
in supination. The ulna and radius are overlapped on the AP
proved after reduction and mid-carpal fusion.
view, and the ulna is volarly displaced on the true lareral view.

Treatment
Dislocation of the Distal Radioulnar Joint
Nonoperative Usually Satisfactory
More Common in the Older Child If the diagnosis is made acutely, closed reduction usually is suc-
Dislocation of the distal radioulnar joint may occur with (148) cessful. A volarly displaced ulna is reduced in full pronation,
or without a fracture of the radius. An isolated dislocation is and a dorsal displacement is corrected by direct pressure over
uncommon in young children, but may occur near the end of the ulna and full supination. A long arm cast in the corrected
the growth period. The dislocation may be in a dorsal or volar position is worn for 4 to 6 weeks. A 4-year-oJd girl with a dorsal
direction and is likely to go unrecognized. dislocation of the distal ulna, successfully treated with a long
arm cast in supination for 4 weeks, was reported by Heiple and
Freehafer (l05). Birch-Jensen (19) reponed a successful result
in a 14-year-old boy with a volar dislocation of the distal ulna
Computed Tomographic Imaging Most Useful
reduced by slight pressure and immobilized for only a week with
Computed tomographic scanning has proved superior to plain a dorsal splint.
radiographs in diagnosing a dislocation or subluxation of the
distal radioulnar joint (61,150,224). The scan is especially useful Operative Indications
in determining through a cast whether the dislocation is reduced. The dislocation is occasionaJly irreducible because of an inter-
posed extensor carpi ulnaris tendon (10,39). Chronic or recur-
rent dislocation is likely to follow an undiagnosed or inade-
quarely treated acute dislocation. Attemprs to restabilize the
Anatomic Considerations
distal radioulnar joint in children using soft tissue procedures
Many clinicians (54,105) have correctly pointed out that the have met with some success. Dameron (54) advised excision of
radiocarpal complex dislocates from the ulna, which, because of the distal end of the ulna if rhe dislocation was unrreated for 2
its fixed proximal articulation with the humerus, cannot dislo- months or longer. Excision of the distal ulna, if indicated, should
cate. Common terminology, however, still refers to the ulna as of course be postponed until growth is complete. Dislocation
being dislocated. of the distal ulna secondary to premature cessation of radial
The head of the ulna articulates with the sigmoid notch of growth is best treated by ulnar shortening.
the radius. The stability of rhe distal radioulnar joint is main-
tained by the triangular fibrocartilage and the dorsal and volar Association with Fractures of the Radius
radioulnar ligaments. The triangular fibrocartilage, extending
Dislocation or disruption of the distal radioulnar joint with a
from the distal margin of the radial sigmoid notch to the base
fracture of the shaft or distal radius is referred to as a Galeazzi
of the sryloid process of the ulna, acts primarily to prevent lateral
fraccure (accually a fracture-dislocation complex). This entity is
displacement of the ulna (100,105). The dorsal and volar radio- discussed in more detail in Chapter 9.
ulnar ligamencs are the prime stabilizers of the distal radioulnar
joint. The dorsal radioulnar ligament becomes taut on prona-
tion, and the volar radioulnar ligament becomes taut on supina- ACKNOWLEDGMENT
tIOn.
We would like to recognize the unparalleled contribution of
Eugene T. "Tom" O'Brien, M.D., to the clinical understanding
and surgical science of trearing children's hand and wrist injuries.
Mechanisms Vary
His experience and insight was brought to us through the first
Hyperpronation results in a tear of the dorsal ligament and trian- four editions of this text, and the influence of his dedication to
gular fibrocartilage and a dorsal dislocation of the distal ulna. this topic guides this and future writings.
 Chi/pter 8: FrllctureJ and DisLocationJ of the Hand and Carpus in ChiLdren 375

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237. Yellin ]A, Towbin RB, Kaufman RA. Stubbed finger osteomyelitis. aged children. Am J Sports Med 1980;8:318-324.
J Trauma 1985;25:808-809. 241. Zook EG, Guy R], Russell RC. A study of nail bed injuries: causes,
238. Yong-Hing K, Wedge ], Bowen CV. Chronic injury to rhe distal treatment, and prognosis. J Hand Surg [Am} 1984;9:247-252.
ulnar and radial growrh plates in an adolescenc gymnast: a case repon. 242. Zook EG, Russell RC. Reconstruction of a functional and estheric
J Bone Joint Surg [Am} 1988;70:1087-1089. nail. Hand Clin 1990;6:59-68.
 DISTAL RADIUS AND ULNA
FRACTURES
PETER M. WATERS

CLASSIFICATIO Casr Immobilizarion

Closed Reducrion and Percutaneous Pinning
ANATOMY External Fixation
Open Reduction
PHYSEAL I JURIES
NondispJaced Fractures
Diagnosis
Minimally Displaced Fractures
Treatmem Options
Bayonet Apposition
Com plications
Cast Treatment
RA IAL PHY EAL STRESS FRACTURES Percutaneous Pin Fixation
Open Reduction
ULNAR PHYSEAL FRACTURES Complications
Treatment PEDIATRIC GALEAZZI FRACTURES
ULNAR STYLOID FRACTURES Anatomy
Diagnosis
Complications
Classification
METAPHYSEAL FRACTURES Trearment
Diagnosis Incomplete Fracwres
Classificarion Complete Fractures
Trearment Irreducible Dislocations
Complications
CaMP ETE FRACTURES
Reduction Techniques

Forearm fl'actures in children are the most common long bone type and displacement. Metaphyseal fracrures are most common,
fractures, comprising about 40% of all pediatric fractures (19, followed by physeal fractures (13,23,32); the disral fragmem in
20,32). The distal aspect of the radius and ulna is the most either usually is extended. Associated fractures of the hand and
common site of fracture in the forearm (5,18,19,26,36) . These elbow regions are rare. Occasionally a direct blow or a fall omo
fractures have been reponed to be three times more common a flexed wrist anel hand causes volar displacemem or angulation
in boys; however, the increased participation in athletics by girls of the diStal fragment.
at a young age may be changing this ratio. Although these frac- Repetitive loading of the wrist can lead to physeal stress inju-
tures occur at any age, they are most frequem during the adoles- ries of the distal radius and, less commonly, the ulna. These
cent growth spurt (2). A direct fall is the usual mechanism of injuries are rare, and occur most frequendy in gymnasts (1,4,6,
injury. With the wrist and hand extended to protect the child, 9,21,27,33). Any patiem with chronic physeal region wrist pain
a fracture occurs if the mechanical force is sufficient. Regardless who parricipatcs in an activity with repetitive axial loading of
of the type, rhese fractures cause pain in the distal forearm,
the wrist, such as gymnasrics or break dancing (15), should be
tenderness directly over the fracture site, and limited morion of
examined for a stress in·ury.
the wrist and hand. Deformity depends on the degree of fracture
The pediatriCC'aleazzi injury usually involves a distal radial
displacement. Standard radiographs are diagnostic of fracture
metaphyseal fracture and a distal ulnar physeal fracrure. These
injuries are rare, but need to be identified acutely for proper
management. The specifics of injuty mechanisms and fracture
Peter M. Waters: Department ofOrrnopcdic Surgery, Children's Hospital, patterns for individual fracture types are discussed in separate
I-brv~rdSchool of Medlcine, Boston. Massochusctts. sections of rhis chapter.
382 Upper Extremity

CLASSIFICATION

Disral radial and ulnar fractures are defined by their anatomic

relationship to the physis. Transphyseal injuries are classified
by the widely accepted Salter-Harris system (88). Metaphyseal
injluries may be torus or buckle fractures, greenstick or incom-
plete fractures, or complete injuries. Pediatric equivalents of
adult GaJeazzi fracture-dislocations involve a distal radial frac-
ture and either a soft tissue disruption of the distal radioulnar
joint D ) or a~nsphyseal fracture of the ulna CTable 9-1)~
In contrast to adults, s <e etaJly immature patients rar~Iy sustain
intraarticular fractures of the distal radius. On occasi;;'n, a Salter-
Harris type III fracture, a cri plane fracture (42), or an adolescent
intraarticuJar Colles' fracture occurs.
Distal radial fracture stability has been more clearly defined
in adults (35) than in chiJdren. At present, an unstable fracture
in a child is often defined as one that cannot be reduced closed.
FIGURE 9-1. Radiographic angulation of the distal radius. The correct
Pediatric classification systems have yet to more precisely define position for a lateral view of the distal radius. The wrist is positioned
fractllre stability, but this issue is critical in determining proper as for the standard lateral radiograph, but the x-ray beam is directed
15 degrees cephalad. (Redrawn from Johnson PG, Szabo RM. Angle
treatment management. measurements of the distal radius: a cadaver study. Skel Radiol 1993;
Fractures also are defined by the degree of displacement and 22' 243; with permission.)
angulation. Static anteroposterior (AP) and lateral radiographs
can be diagnostic of the fracture type and degree of deformity
(rig. 9-1). [n adults, the distal radiaJ articular alignment averages A ATOMY
22 degrees on the AP view and 11 degrees on the lateral view
(17,22,24,28,34). RadiaJ inclination is a goniometric measure- The distal radial epiphysis normally appears between 0.5 and
ment of the angle between the distal radial articular surface and 2.3 years in boys and 0.4 and 1.7 years in girls (12). Initially
a line perpendicular to the radial shaft on the AP radiograph. cransverse in appearance, it rapidly becomes more adulrlike with
PaJmar tilt is measured by a line across the distal articular surface its triangular shape. The contour of the radial styloid progres-
and a line perpendicular to the radial shaft on the lateral view. sively elongates with advancing skeletal maturity. The secondary
center of ossification for the distal ulna ap ears at around age
Pediatric values for radial inclination tend to be less, depending
7. Similar to the radius, the ul~r styloid ;-ppears with the adoles-
on the degree of skeletal maturity of the patient. Palmar tilt
crnt growth spurt. It also becomes more elongated and adulrlike
tends to be more consistent regardJess of the age of the patient.
until physeal closure. On average, the ulnar physis closes at age
Rarely, tomographic views are necessary to assess intraarticu-
16 in girls and age 17 in boys, whereas the .IMlli!Lphysis closes
lar involvement or displacement (Fig. 9-2). This can be by AP
on average 6 monthl.lahe~ than the ulnar physis (16,30). The
and lateral tomograms, computerized tomographic (CT) scans, distal radia1and ulnar p yses contribute approximately 75% to
or magnetic resonance imaging (MRl). Dynamic motion studies 80% of the growth of the forearm and 40% of the growth of
with fluoroscopy can provide important information on fracture the upper extremity (75) (Fig. 9-3).
stability and the success of various treatment options (31). Dy- The distaI radius articulates with the distal ulna at the DRU].
namic fluoroscopy requires adequate pain relief and has been Both the radius and ulna articulate with the carpus, serving as
used more often in adult patients with distal radial fractures. the support for the hand. The radial joint surface has three
concavities for its articulations: the scaphoid and lunate fossi for
the carpus and the sigmoid notch for the uJnar head. These joints
are stabil ized by a complex series of volar and dorsal radiocarpaJ,
ulnocarpal, and radioulnar ligaments. The ,:,~digaments a!:.~
DISTAL FOREARM FRACTURES: the maO or stabilizers. Starting radially at the radial styloid, the
TABLE 9-1.
GENERAL CLASSIFICATION radial cofla[eral, radioscaphocapitare, radiolunotriquerral, and
radioscapholunate ligaments volarly stabilize the radiocarpal
Physeal fractures
joint. The dorsal radioscaphoid and radial triquetra] ligamems
Distal radius
Distal ulna
are less important stabilizers.
Distal metaphyseal (radius or ulna) The triangular fibrocartilage complex (TFCC) is the primary
Torus stabilizer of the ulnocarpal and radioulnar articulations. It ex-
Greenstick tends from the sigmoid notch of the radius across the DRU]
Complete fractures and insertS into the base of the ulnar styloid. It also extends
Galbazzi fracture-dislocations
distally as the ulnolunate, ulnorriquetral, and ulnar collateral
Dorsal displaced
Volar displaced ligaments and insertS into the ulnar carpus and base of the fiftn
metacarpal (10). The interosseous ligament helps stabilize the
radius and ulna more proximally in the diaphysis of the forearm.
 Chapter 9: DistaL Radius and ULna Fractllres 383

A B
FIGURE 9-2. A: Computed tomography scan of displaced Salter-Harris type IV fracture. B: Surgical cor-
rection included external fixation distraction, arthroscopically assisted reduction, and smooth pin fixa-
tion.

r.
c~'11(

/-2 'lID

A
FIGURE 9-3. Ossification of the distal radius. A: Preossification distal radius with transverse ossification
front in a 15-month-old boy. B: The triangular secondary ossification center of the distal radius in a 2-
year-old girl. (Figure continues.)
384 Upper t:wremir)'

FIGURE 9-3. (continued) C: The initial ossification center of the styloid

in this 7-year-old girl progresses radially (arrow). D: Extension of the
ulnar ossification center into the styloid process of an 11-year-old. E:
The styloid is fully ossified and the epiphyses have capped their relative
metaphyses in this 13-year-old boy.

The ulna remains relatively immobile as the radius rotates

around ir. The complex srructure of ligaments stabilize the ra-
dius, ulna, and carpus through the normal wrist motion of 120
degrees of flexion and extension, 50 degrees of radial and ulnar
deviation, and 150 degrees of forearm rotation (l0).
The length relationship berween the distal radius and ulna
is defined as ulnar variance. In adults, this is measured by the
relationship of the radial corner of the distal ulnar articular sur-
face ro the ulnar corner of the radial arricular surface (56). How-
ever, measuremenr of ulnar variance in chiJdren requires modifi-
cations of this technique. Hafner (53) described measuring from
rfte ulnar meraphysis co tfte radial metapftysis co lessen [he mea-
surement inaccuracies relared ro epiphyseal size and shape (Fig.
9-4). If the ulna and radius are of equal lengths, there is a neurral
variance. ]f the ulna is longer, there is a positive variance, and
if the ulna is shorrer, there is a negative variance.
Variance is not dependenr on the length of the ulnar seyloid
FIGURE 9-4. Hafner's technique to measure ulnar variance. A: The dis-
(3), bur the measurement is dependent on forearm positioning tance from the most proximal point ofthe ulnar metaphysis to the most
and radiographic technique (8,11,29). Radiographs of the wrist proximal point of the radial metaphysis. B: The distance from the most
to determine ulnar variance should be standardized wirh the distal point of the ulnar metaphysis to the most distal point of the
radial metaphysis. (From Hafner R, Poznanski AK, Donovan JM. Ulnar
hand and wrist pronated on the cassette, the elbow flexed 90 variance in children. Standard measurements for evaluation of ulnar
degrees, and the shoulder abducted 90 degrees. The importance shortening in childhood. Skel Radial 1989;18' 514; with permission.)
 Chapter 9: Distal Radius and Ulna Fractures 385

of ulnar variance relates to the force transmISSion across the

wrist with axial loading. Normally the radiocarpal joint bears
approximately 80% of the axial load and the ulnocarpal joint
bears 20%. Changes in the length relationship of the radius and
ulna alter respective load bearing. Biomechanical and clinical
studies have shown that this load distribution is important in
fractures, TFCC tears, and Kienbock's disease (9,14,25).

PHYSEAL INJURIES

Distal radial physeal injuries were described more than 100 years
ago (43,85), and these early descriptions raised concerns regard-
ing permanent deformity from this injury. In the 1930s, how-
ever, Aitken (37,38) concluded from his observations at the Bos-
ton City Hospital outpatient clinic that permanem deformity
was rare. Instead, he emphasized the remodeling potential of
distal radial physeal fractures, even when not reduced. The obser-
vations ofAitken have been confirmed throughout the twentieth
century (Fig. 9-5). Most researchers agree that as long as there
is sufficient growth remaining, a distal radial extension deformity
from a malunited fracture has the potential to remodel. Perma-
nem deformity can occur in malunited fractures near the end
of growth or fractures that cause dis cal radial growth arrest.
A
Diagnosis
Distal radial physeal fractures are far more common than distal
ulnar physeaJ fractures (61,71,79,84,91). The nondominant arm
in boys is most commonly injured. The peak incidence is in the
preadolescent growth spurt (36,61). More than 50% of distal
radial physeal fraccures have an associated ulnar fracture. This
usually is an ulnar styloid fracture but can be a diStal ulnar plastic
deformation, greenstick, or complete fracture (40,65,67). The
mechanism of injury generally is a fall on an outstretched hand
and wrist. The distal fragment usually displaces dorsally, creating
an extension deformity char is usually clinically apparent. Pa-
tients have pain and tenderness at the fracrure site, and the range
of motion at the wrist and hand usually is limited by pain.
Neurovascular compromise is uncommon but can occur (95).
When present, it usually consists of median nerve irricability or
dysfunction caused by direct trauma to the nerve at the time
of injuly or ongoing ischemic compression from the displaced
fracture. Thenar muscle function and discriminatoty sensibility
(two-point discrimination) should be tested before reduction in
the emergency setting. Acute carpal runnel syndrome or forearm
compartment syndrome can occur, but more often is caused
by marked volar forearm and wrist swelling that occurs after
reduction and application of a well-molded, tight cast (46,89,
95). Open physeal fractures are rare, but the local skin should
be examined closely for penetration. B
Plain AP and lateral radiographs are diagnostic of the fracture FIGURE 9-5. A: A 13-year-old boy presented 1 month after injury with
type and deformity. Classification is by the Salter-Harris system a displaced and healed Salter-Harris type II distal radius fracture with
for physeaJ fi-acrures (88). Most are Salter-Harris type II frac- obvious clinical deformity. B: Over the next 6 months the patient grew
4 inches and the deformity remodeled without intervention.
tures. The dorsal displacement of the distal fragment of the
epiphysis and dorsal Thurstond-Holland metaphyseal fragment
is evident on the lateral view (Fig. 9-6). Salter-Harris type I
fractures also usually displace dorsally. Volar displacement of
386 Upper Extternit),

-------~

---~---~-~

FIGURE 9-6. Dorsally displaced physeal fracture (type A). The distal
epiphysis with a small metaphyseal fragment is displaced dorsally
(curved arrow) in relation to the proximal metaphyseal fragment.

FIGURE 9-8. Subperiosteal hemorrhage from an occult fracture of the

either a Salter-Harris type I or II fracture is Jess common (Fig. distal radius causes an anterior displacement of the normal pronator
quadratus fat pad (arrows).
9-7). Nondisplaced Salter-Harris type I fractures may be indi-
cated only by a displaced pronator fat pad sign (Figs. 9-8 and
9-9) (90, 100) or tenderness over the involved physis (40,86). A
scaphoid fat pad sign may indicate a scaphoid fracture (Fig.
9-10). If the acute fracture is unrecognized, a late-appearing may be necessary to define rhe fracrure pattern and degree of
periosteal reaction may indicate the fraerure. intraarticular displacement (Fig. 9-2). Suess injuries to the phy-
Salrer-Harris type III fj'acrures are rare and may be caused sis occur mosr commonly in comperirive gymnasts (Fig. 9-12).
by a compression injury or an avulsion of rhe radial origin of
the volar radiocarpal ligaments (39,65) (Fig. 9-11). Triplane
equivaJenr fracrures (81-83), a combination of Salrer-Harris Treatment Options
type II and III fracrures in differenr planes, are rare. CT scans As for most fracrures, rreatmenr options include no reducrion,
closed teduction and cast immobilization, closed reduction and
pin f1xarion, and open reduction. Nondisplaced fracrures are
immobilized until appropriare healing and pain resolution have
been achieved (40,86). If rhere is a question of fracrure srability,
these franures should be treated with a long arm cast and moni-
tored closely during the first 3 weeks of healing to be certain
that there is no loss of alignment. Most displaced Salrer-Harris
type I and II franures can be t1'eared successfully in the acute
care setting with genrle closed reduction and cast immobiliza-
tion. Closed redunion and percutaneous pin fixation are per-
formed in patients with neurovascular compromise and dis-
placed physeal franures (95) to lessen the risk of development
of a compartmenc syndrome in the carp:!1 [LInnel or forearm.
Open reducrion is indicated for irreducible fractures, open frac-
tur'es, displaced Salter-Harris type III and IV fractures, and tri-
plane equivalenr fractures. Irreducible fractures are usually due
ro an entrapped periosteum or pronaror quadratus (70). [nrernal
fixation usually is with smooth pins to lessen the risk of growth
FIGURE 9-7. Volarly displaced physeal fracture (type B). Distal epi- arrest. Plates and screws are rarely used unless the patient is
physis with a large volar metaphyseal fragment is displaced in a volar near skeleral maturity because of concerns about funher physeal
direction (curved arrow). (Reprinted from Wilkins KE, ed. Operative inj ury. In the rarc displaced inrraarticuJar Sal ter-Harris type III
management of upper extremity fractures in children. Rosemont, IL:
American Academy of Orthopaedic Surgeons, 1994:21; with permis- or IV fracture, inrernaJ fixation c:!n be inrraepiphyseal without
sion.) violating the physis. If it is necessary co cross the physis, then
 Chapter 9: Distal Radius and Ulna Fractures 387

c
FIGURE 9-9. (A) A 13-year-old girl with tenderness over the distal radius after a fall. The only radiograph
finding is an anterior displacement of the normal pronator quadratus fat pad (arrow), B: The opposite
normal side (arrow indicates normal fat pad). C: Two weeks later, there is a small area of periosteal
new bone formation (arrow) anteriorly, substantiating that bony injury has occurred.
388 Upper Extremity

Extensor
pollieis brevis

NFS -----~__w.

Radial
eollateral--------'
ligament

Abductor
pollieis --------+-+-\-1 FIGURE 9-12. Stress changes in a female gymnast with widening of
longus the distal radial physis from long-standing high-level performance.

FIGURE 9-10. Anatomic relationships of the navicular fat stripe (NFS).

The NFS, shaded black, is located between the combined tendons of
the abductor pollicis longus and extensor pollicis brevis, and the lateral
surface of the carpal navicular. (Reprinted from Terry DW. Ramen JE
The navicular fat stripe. Ham J Roent Rad Ther Nucl Med 1975; 124: 2S;
with permission.)

AB C
FIGURE 9-13. Acceptable method of closed reduction of distal physeal
fractures of the radius. A: Position of the fracture fragments as finger
trap traction with countertraction is applied (arrows). B: Often with
traction alone the fracture will reduce without external pressure (ar-
FIGURE 9-11. Anteroposterior radiograph of Salter-Harris type III frac- rows). C: If the reduction is incomplete, simply applying direct pressure
ture of the distal radius. over the fracture site in a distal and volar direction with the thumb
often completes the reduction while maintaining traction. This tech-
nique theoretically decreases the shear forces across the physis during
the reduction process.
 Chapter 9: Distal Radius and Ulna Fractures 389

smooth pins should be used ro lessen the risk of iatrogenic phy- periosteum is used as a tension band to aid in reduction and
seal injUlY. Extraarricular external fixation also can be used co stabilization of rhe fracture. Unlike similar fractures in adults,
stabilize and align the fracture. finger trap distracrion with pulley weighrs is often counterpro-
ductive. However, finger traps can help stabilize the hand, wrist,
and arm for manipulative reduction and casring by applying a
Closed Reduction
few pounds of weight for balance. Otherwise an assistant is help-
Most displaced Salter-Harris I and II fractures are (I'eated with ful co support the extremity in the proper position for casting.
dosed reduction and cast stabilization. Closed manipulation of If portable fluoroscopy is available, immediate radiographic
the displaced fracture is performed with appropriate sedation, assessment of the reduction is obtained. Otherwise, a long arm
analgesia, or anesthesia to achieve pain relief and an arraumatic cast is applied and appropriate AP and lateral radiographs are
reduction (40,58,86). Most of these fractures involve dorsal and obtained to assess the reduction. The cast should provide three-
proximal displacement of the epiphysis with an apex-volar ex- point molding over the distal radius co lessen the risk of fracture
tension defotmity. Manipulative reduction is by gende distrac- displacement (Figs. 9-13 and 9-14). The disral dorsal mold
tion and flexion of the distal epiphysis, carpus, and hand over should nor impair venous ourflow from the hand, which can
the proximal metaphysis (Figs. 9-13 and 9-14). The intact dorsal occur if the mold is placed too distal and toO deep so as to

A,B

FIGURE 9-14. A: Lateral radiograph of dorsally dis-

placed Salter-Harris type II fracture. B: Lateral radio-
graph after closed reduction and cast application. C:
Reduction of the volar displaced fracture shown in
Fig. 9-5. The forearm was in supination with three-
point molding anterior over the distal epiphysis and
proximal shaft (white arrows). The third point is
placed dorsally over the distal metaphysis (open
arrow). (The dorsal surface of the cast is oriented to-
ward the bottom of this figure.) (Reprinted from Wil-
kins KE, ed. Operative management of upper extrem-
ity fractures in children. Rosemont, IL: American
Academy of Orthopaedic Surgeons, 1994: 17; with
c permission.)
390 Upper Fxtmnit)'

FIGURE 9-15. A: Anteroposterior and lateral radiographs

of severely displaced Salter-Harris type II fracture of the dis-
tal radius. B: Closed reduction shows marked improvement
but not anatomic reduction. The cast had to be bivalved due
B to excessive swelling. (Figure continues.)

obstrucr rhe dors:ll veins. Posrcasting insrructions for elevation is common if the paticnt has greater rhan 2 years of growth
and close monitoring of swelling and the neurovascular status remaining and rhe deformity is less than 20 degrees (fig. 9-5}.
of the exuerniry are critical.
The fracture also should be monitOred closely with serial
Closed Reduction and Percutaneous Pinning
radiographs for the first 3 weeks to be certain that rhere is no
Joss of anatOmic alignmenr (Fig. 9-15). Generally these fractLJres The indications for percuraneous pinning of distal radial physeal
are stable :lfter closed reduction and cast immobilization. If there fractures are conrroversial. The besr indication is a displaced
is loss of reduction after 7 days, the surgeon should be wary of radial physeaJ fracture with median neuropathy and signitlcanr
rCPC:lt reduction because of the risk of physcal arrest (40,88). volar soft rissue swelling (95) (Fig. 9-16). These patienrs are ar
Fortunately, remodeling of an extension deformiry with growth risk for development of an acute carpal tunnel syndrome or
 Cllttpter 9: Distal Radius and Ulnd FraclUres 391

FIGURE 9-15. (continued) C: Unfortunately, the pa-

tient lost reduction after a new fiberglass cast was
applied. D: Out of cast radiographs show a healed
malunion in a similar position to the prereduction
D radiographs.

forearm comparrmem syndrome with closed reduction and cast Pin fixation can either be single or double (Fig. 9-17). Fluo-
immobilization (46,54,89,95). The torn periosteum volarly al- roscopy is used to guide propet fracture teduction and pin place-
lows tbe fracture bleeding to dissect into tbe volat forearm com- ment. Anesthesia is used fot adequate pain relief and to lessen
partmems and carpal runnel. If a tight cast is applied with a the tisk of further physeal injUlY. The fractute is manipulated
volar mold over that area, compartment pressures can increase into anatomic alignment and the initial, and often only, pin is
dangerously. Percutaneous pin fixation allows the application of placed from the distal epiphysis of the radial styloid obliquely
a loose dtessing, splint, or cast without the tisk of loss of fracture across the physis into the more proximal ulnar aspect of the
reduction (Fig. 9-16). radial metaphysis (Fig. 9-17). A sufficient skin incision should
392 Upper Extrellli~JI

A,B c
FIGURE 9·16. A: Clinical photograph of patient with a displaced Salter-Harris type II fracture of the
distal radius. The patient has marked swelling volarly with hematoma and fracture displacement. The
patient had a median neuropathy upon presentation. B: Lateral radiograph of the displaced fracture. C:
Lateral radiograph in postoperative splint after percutaneous pinning to lessen the risk of neurovascular
compromise in a cast.

be made with pin placement to be certain there is no iatrogenic should be as ;nraumatic as possible, and removal should be exe-
injury to the radial sensory nerve or extensor tendons. Stability cuted as soon as there is sufficient fracture healing for fracture
of the fracture should be evaluated with ~exion/extension and stabiJity in a cast or splinr alone.
rotatory stress under Auoroscopy. Often in children and adoles-
cents a single pin and the reduced periosteum provide sufflcienr
Open Reduction
stability to prevem redisplacement of the fracture. If fracture
stability is questionable with a single pin, a second pin should The main indication for open reduction of a displaced disral
be placed. The second pin can either parallel the first pin or, to radial Salter-Harris type IJ physeaJ fracture is irreducibility (Fig.
create cross-pin stability, can be placed distally from the ulnar 9-18). Most often this is caused by interposed periosteum or,
corner of the radial epiphysis between the fourth and fifth dorsal less likely, pronator quadrarus (57,70,99). Open reduction is
compartments and passed obliquely to the proximal radial por- performed via a volar approach to the distal radial physis. The
tion of the metaphysis (J 0,66,92). Again, the skin incisions for inrerval between the radial artery and the Aexor carpi radialis is
pin placement should be sufflcienr to avoid iatrogenic injury to used. This dissection also can proceed direcrly through the Aexor
the extensor tendons. carpi radialis sheath to protect the artery. The pronator quadra-
The pins arc bent, lefr our of the skin, and covlTed with a rus is isola red and elevated from radial to ulnar. AJthough rhis
sterile dressing. Splint or cast immobilization is used but does muscle can be interposed in [he fracture sire, rhe volar perios-
not need to be tight because fracrure stability is provided by the teum is more commonly interposed. This is evident wirh eleva-
pins. The pins are left in umil there is adequate fracture healing, [ion of the pronator quadratus. The periosteum is extracted from
usually 4 weeks. The pins can be removed in the office withour the physis with care to minimize Further injury to [he physis.
sedation or anesthesia. The fracrure can [hen be easily reduced. Cast immobilization
One of the arguments against pin fixation is the risk of addi- is possible, bur usually a percutaneous smooth pin is used for
tional injury to the physis by a pin (42), bur this has nor been stabilization of rhe reduction. The method of pin insertion is
documented. The risk of physeal arrest is more from the dis- rhe same as aFter closcd reduction.
placed fracture than from a short-term, smooth pin. As a precau- Open physeal Fractures are rare but do require opcn reduc-
tion, smooth, small-diameter pins should be used, insertion tion. The open wound and Fracrure site require irrigarion and
 Chapter 9: Distal Radius and Ulna Fracture; 393

FIGURE 9-17. A: Anteroposterior and lateral radio-

graphs of displaced Salter-Harris type II fracture
pinned with a single pin. B: After reduction and pin-
B ning with parallel pins.

debridement. Care should be taken with mechanical debride- be anatomically reduced closed. The articuJar and physeal align-
menr of the physeaJ cartilage to avoid further risk of growth ment can be evaluated by radiographic tomograms (trispiral or
arrest. CuJtures should be taken at the time of operative debride- CT), MRl scans, or wrist arthroscopy (Fig. 9-2). If anatomic
ment, and appropriate antibiotics are used to lessen the risk of alignment of the physis and articular surface is not present, the
deep space infection. risk of growth arrest, long-term deformity, or limited function
The rare Salter-Harris rype III or IV fracture or triplane frac- is great (Fig. 9-15). Even minimal displacement (> 1 mm)
ture (83) may require open reducrion if the joint or physis cannot should not be accepted in this situation. ArthroscopicalJy assisted
394 Upper Extremity

(Fig. 9-19) is created with closed reduction and percuraneous

pinning. This avoids the increased risk of compartment syn-
drome in rhe carpal canal or volar forearm rhat is presenr if a well-
molded, right casr is applied. In addirion, acure percuraneous
pinning of the fracrme prevents increased swelling, cast splitting,
loss of reducrion, and concerns abom malunion or growth arresr
wirh repeat reduction (Fig. 9-17). Acure pinning of the fracrure
wirh one or rwo smoorh pins rhrough the radial epiphysis pro-
vides fracture srabiJiry wirhour a compressive casr. The risk of
growth arresr from a narrow-diamerer, smooth pin left in place
for 3 ro 4 weeks is exceedingly small.
Open reducrion is reserved for irreducible Salter-Harris rype
I and II fracrures, open fractures, fracrures wirh associared acure
carpal runnel or forearm comparrmenr syndrome, displaced (> 1
mm) Salrer-Harris type III or IV fracrures, or rriplane equivaJenr
fractures. For an irreducible Salrer-Harris rype I or 1I fracture,
exposure is from the side of the rom periosteum. Because rhese
fracrures usually are displaced dorsally, a volar exposure is used.
Smooth pins are used for srabilizarion and are lefr in for 3 ro 4
weeks. Open fractures are exposed through rhe open wound
wirh proximal and disral exrension for adequare debridemenr.
All open debridements are performed in the operaring room
under general anesthesia. Acme compartment syndromes are
rreared with immediare appropriate release of rhe transverse car-
pal ligament or forearm fascia. The transverse carpal ligament
is released in a Z-plasry fashion ro lengrhen the ligamenr and
prevenr volar bow-stringing and scarring of rhe median nerve
FIGURE 9-18. Irreducible fracture. This 13-year-old sustained severe against rhe palmar skin. Displaced intraarticular fractures are
trauma producing widely displaced fracture fragments (arrows). Closed best treared wirh arthroscopically assisred reduction and fixation,
reduction could not be performed because of interposed median nerve bur this is an equipment-intensive operarion requiring arrhro-
and deep flexor tendons: open reduction was required. (Courtesy of
Earl A. Stanley. M.D.) scopic insrrumenrs, camera, and monitOr, along wirh fluoros-
copy. Disrraction across the joinr can be achieved wirh applica-
rion of an external fixaror or finger rraps. Srandard dorsal porrals
(3/4 and 4/5) are used for viewing rhe inrraarricular aspecr of rhe
fracture and alignment of rhe reduction (Geisling). In addirion,
reducrion is helpful ro align and stabilize these rare physeal frac-
direct observarion rhrough rhe anhroscope can aid in safe place-
tures (47,50).
menr of the intraepiphyseal pins. Fluoroscopy is used ro eva!uare
rhe exrraarricular aspecrs of the fracture (rriplane equivalenr and
rype IV fracrures), rhe reduction, and placemenr of fixarion pins
• AUTHOR'S PREFERRED METHOD (Fig. 9-2).
\..~~ OF TREATMENT
Complications
Most Salter-Harris rype I and II fracrures are reduced closed
Malunion
under conscious sedarion wirh the assistance of portable fluoros-
copy. A long arm casr with appropriare three-point molding is Complicarions from physeal fracrures are relarively rare. The
applied. This is changed ro a shorr arm casr when there is suffi- most frequenr problem is malunion. Fortunarely, these fracrures
cient healing for fracture srabiliry, usually afrer 3 ro 4 weeks. ofren occur in children wirh signiflcanr growth remaining. The
Casr immobilizarion is disconrinued when rhere is clinical and deformiry from a Salrer-Harris type lor II fracture is wirh,in the
radiographic evidence of fracrme healing, generally 4 and 6 pbne of marion of rhe wrist joinr and, rherefore, will remodel
weeks after fracture. Range-of-motion and strengthening exer- wirh ensuing growth (40,58,86) (Fig. 9-5). Repear reduction
cises are begun wirh a home program. When rhe child achieves should nor be performed more than 7 days aErer fracrure because
full motion and srrength, he or she can rerum ro full acriviry, of rhe risk of growth arresr. The malunired fracture should be
including comperirive spons. Follow-up radiographs are ob- monitOred over rhe next 6 ro 12 monrhs for remodeling. If rhe
rained ar 6 ro 12 monrhs after fracrure ro be cerrain rhere is no fracrure does not remodel, persisrenr exrension deformiry of the
growrh arresr. disral radial articular surface putS rhe patienr at risk for develop-
A parienr wirh a displaced SaJrer-Harris rype I or 1I physeaJ ing mid-carpal insrabiliry (%) or degenerarive arrhriris of rhe
fracrure, significanr sofr tissue swelling volarly, and median neu- wrist. Corrective osreoromy wirh bone grafring and inrernal fixa-
roparhy (Fig. 9-16) wirh ipsilareraJ elbow and radial fracrures rion is required (49) (Fig. 9-20). An opening-wedge dorsal osre-
 CIJapter 9: Distal Radius and Ulna Fractures 395

FIGURE 9-19. A: Ipsilateral distal radial physeal and supracondylar frac-

tures. This 6-year-old sustained both a dorsally displaced distal radial phy-
seal fracture (closed arrow) and a type II displaced supracondylar fracture
of the humerus (open arrows). B: Similar case treated with percutaneous
B pinning of radial physeal fracture and supracondylar humeral fracture.

FIGURE 9-20. A: Radial metaphyseal fracture that did not remodel in

a now 16-year-old skeletally mature boy. B: Corrective osteotomy with
AB iliac crest bone graft and internal fixation was performed.
396 Upper Extremity

FIGURE 9·21. A: Anteroposterior and lateral radiographs of a 15-year-

old skeletally mature boy with a displaced intraarticular fracture. B: This
fracture needs to be treated like an adult's, with open reduction and
B internal fixation with a volar buttress plate.

otOmy is made, iliac cresr bone of appl"Opriare rrapezoidal shape arricular surface is col1troverslal and risky. However, ir has rhe
ro correcr rhe deFormiry is inseneJ, and eirher plare or external potential of restOring anatOmic alignmenr ro rhe joint and pre-
flxaror is used to mainrain correcrion unril healing. venring serious long-rerm complicarions. This problem forru-
Inrraarricular malunion is more worrisome (Figs. 9-21 and narely is uncommon in children because of rhe rariry of rhe
9-22) because of rhe risk of development of degenerative arthritis injury and this eype of malunion.
iF rhe arricular srep-oFF is more than 2 mm (59). MRl or CT
scans can be useful in preoperarive evaluarions. Arrhl"Oscopy al-
Physeal Arrest
lows direcr examinarion of rhe deFormiry and areas of impinge-
ment or porenrial degeneration. Inrraanicular osrcotOmy wirh Disral radial physeal arresr can occur from eirher the trauma
bone grafring in rhe meraphysis to supporr rhe reconsrrucred of rhe original injury (Fig. 9-23) (55,65,94) or lare (> 7 days)
 Chapter 9: Distal RadittS and Ulna Fractures 397

reduction of a displaced fracture. The exacr incidence of radial dation is for an atraumatic reduction of a displaced physeal frac-
growth arrest is unknown, but has been estimated [0 be 7% of ture less than 7 days after injury.
all displaced radial physeal fracwres. (65). The trauma [0 the When a growth arrest develops, the consequences depend on
physeal cartilage from displacement and compression is a signifl- the severity of the arrest and the amount of growth remaining. A
cant risk factor for growth arrest. However, a correlation berween complete arrest of the distal radial physis in a skeletally immature
the risk of growth arrest and the degree of displacement, type patient can be a serious problem. The continued growth of the
of fracture, or type of reduction has yet to be defined. Similarly, ulna with cessation of radial growth can lead to incongruity of
the risk of further compromising the physis with late reduction the DRU], ulnocarpal impaction, and development of a TFCC
at various time intervals is still unclear. The current recommen- tear (Fig. 9-24). The radial deviation deformity at the wrist can

FIGURE 9-22. A: Anteroposterior and lateral radiographs of a 14-

year-old girl who fell from a height. There is extensive intraarticular
comminution. B: Open reduction, internal fixation, and external
B fixation was performed. (Figure continues.)
398 Upper Extremity

FIGURE 9-22. (continued) C: One year follow-up radiographs

reveal early arthosis. The patient has mild pain and near full
c range of motion.

A B
FIGURE 9-23. Physeal arrest in a Peterson type I fracture. A: Injury film showing what appears to be a
benign metaphyseal fracture. Fracture line extends into the physis (arrows). B: Two years postinjury, a
central arrest (open arrow) has developed, with resultant shortening of the radius. (Reprinted from
Wilkins KE, ed. Operative management of upper extremity fractures in children. Rosemont, IL: American
Academy of Orthopaedic Surgeons, 1994:21; with permission.)
 CiJopter 9: Distal Radius and ULna Fractures 399

A B
FIGURE 9-24. A: Anteroposterior radiograph of ulnar carpal impaction secondary to growth arrest in
the distal radius. B: Anteroposterior and lateral radiographs after Z-shortening of the ulna to a negative
ulnar variance.

be severe enough to cause Ji mitation ofwrist and fotearm motion length is rebalanced; until the radiocarpal, ulnocarpal, and radio-
(Fig. 9-25). Pain and clicking can develop at the ulnocarpal or ulnar joints are resrored; and until the TFCC tear and areas of
radioulnar joints, indicative of ulnocarpal impaction or a TFCC chondromalacia are repaired or debrided (72,77,93).
tear. The deformity will progress until the end of growth. Pain IdeaJJy, physeal arrest of the distal radius will be discovered
and limited motion and function will be present until forearm early before the consequences of unbalanced growth develop.

A B
FIGURE 9-25. A: Anteroposterior radiograph of radial growth arrest and ulnar overgrowth after physeal
fracture. Patient complained of ulnar-sided wrist pain and clicking. B: Clinical photograph of ulnar
overgrowth and radial deviation deformity.
400 Upper Extremity

A B
FIGURE 9-26. A: Anteroposterior radiograph of growth arrest with open ulnar physis. B: Magnetic
resonance imaging scan of large area of growth arrest that was not deemed resectable by mapping.

Radiographic screening 6 to 12 months afrer injury can identi~r or negarive variance. If rhe ulnar physis is srill open, a simulrane-
rhe early arresr. A small area of growrh arresr in a parient near ous arrest should be performed to prevenr recurrenr deformiey.
skeJeral marLlriry may be clinically inconsequentiaJ. However, a If rhe degree of radial deformiey is marked, rhis should be cor-
large area of an'esr in a patient with marked growrh remaining recred by a reaJignment or lengrhening osteotomy. Crireria for
can lead to ulnocarpal impacrion and forearm deformiry if inter- radial correcrion is debarable, bur I have used radial inclinarion
vention is nor performed early. An MRl scan can map rhe area of less rhan II degrees on rhe AP radiograph (Fig. 9-31) (72).
of arrest (80) (Fig. 9-26). If ir is less rhan 45% of the physis, a In the rare case of complere an'esr in a very young parient, radial
bar resecrion can be atrempred (63,64). This may restore radial lengrhening is preferable ro ulnar shorrening.
growth and prevent future problems (Fig. 9-27). If rhe bar is
larger rhan 45% of rhe physis, an ulnar epiphysiodesis will pre-
Triangular Fibrocartilage Complex Tears
venr growrh imbaJance of rhe forearm (72). The growrh discrep-
ancy berween forearms in most parienrs wirh fracrures is minor Triangular fibrocarrilage complex tears should be repaired, The
and does nor require rrearmenr. presence of an ulnar sryloid nonunion is ofren indicarjve of an
associared peripheral rear of rhe TFCC (72,93). The symptom-
atic ulnar seyloid nonunion is excised (44,68,76) and any TfCC
Ulnocarpal Impaction Syndrome
repaired, If physical examinarion or preoperative MRJ scan indi-
The growrh discrepancy berween the radius and ulna can lead cares a TFCC rear in rhe absence of an ulnar sryloid nonunion}
co relative radial shorrening and ulnar overgrowrh (Fig. 9-28). an inirial arrhroscopic examination can define rhe lesion and
The disral ulna can impinge on rhe lunare and triquerrum and appropriare rrearmenr. PeripheraJ rears (Palmer rype B) al'e rhe
cause pain wirh ul nar deviation, exrension, and compression mosr common TfCC rears in chjldren and adolescenrs and can
acriviries (41). Loading rhe ulnocarpal joint in ulnar deviarion be repaired arrhroscopically by an ourside-in surure rechnique.
and compression will recreate rhe pain. Radiographs show rne Central rears (Palmer eype A) are rare in children and can be
radial arrest, ulnar overgrowrh, and disral ulnocarpal impinge- debrided anhroscopically. Tears off rhe sigmoid norch (Palmer
ment. The ulnocarpaJ impaction may be caused by a hyperrro- rype D) can be repaired open or anhroscopicaJly, Distal volar
phic ulnar sryloid fracrure union (fig. 9-29) or an ulnar sryloid rears (Palmer rype C) are repaired open, ar rimes wirh ligamenr
nonunion (44,68) (Fig. 9-30). An MRl scan may reveal chon- reconsrrucrion.
dromalacia of rhe lunare or rriquerrum, a tear of rhe TFCC, and
the extenr of the disraJ radial physeal arresr.
Neuropathy
Trearmenr should correcr all componenrs of rhe problem.
The ulnar overgrowrh is correcred by eirher an ulnar shorrening Median neuroparhy can occur from direcr rrauma from rhe in i-
osreotomy or radial lengthening. Most ohen a marked degree rial displacemenr of rhe fracture, rracrion ischemia from a persis-
of positive ulnar variance requires ulnar shorrening to neurral rendy displaced fracrure} or rhe developmenr of a comparrmenr
 Chaptel' 9: DiJlal RadillS find Ulna Fraa/ll'eJ 401

A B

c D

FIGURE 9-27. Osseous bridge resection. A: This 10-year-old had sustained

a distal radial physeal injury 3 years previously and now complained of
prominence of the distal ulna with decreased supination and pronation.
B: Polytomes revealed a well-defined central osseous bridge involving
about 25% of the total diameter of the physis. C: The bridge was resected.
and autogenous fat was inserted into the defect. Growth resumed with
resumption of the normal ulnar variance. Epiphysiodesis of the distal ulna
was postponed for 6 months. 0: Unfortunately, the radius slowed its
growth, and a symptomatic positive ulnar variance developed. E: This was
treated with an epiphysiodesis (open arrow) and surgical shortening of the
ulna. The clinical appearance and range of motion of the forearm returned
E to essentially normal.
402 Upper Extremity

A B

FIGURE 9-28. A: A markedly displaced Salter-Harris type IV frac-

ture of the distal radius in an 11-year-old boy who fell from a
horse. B: Film taken 3 weeks after closed reduction demonstrates
displacement ofthe comminuted fragments. C: Eighteen months
postinjury, there was 15 mm of radial shortening, and the pa-
c tient had a pronounced radial deviation deformity of the wrist.

FIGURE 9-29. Anteroposterior radiograph reveal-

ing hypertrophic ulnar styloid healing as the source
of the ulnar carpal impaction pain in this patient.
 Chapter 9: DistaL Radius and ULtia Fractures 403

A B
FIGURE 9-30. A: Anteroposterior radiograph of distal radial growth arrest, ulnar overgrowth, and
an ulnar styloid nonunion. Wrist arthroscopy revealed an intact triangular fibrocartilage complex. B:
Anteroposterior and lateral radiographs after ulnar shortening osteotomy.

A B
FIGURE 9-31, A: More severe ulnar overgrowth with dislocation of the distal radioulnar joint and
flattening of the radial articular surface. B: Intraoperative fluoroscopic view of ulnar shortening and
radial osteotomy to corrective deformities.
404 Upper Ev:tremiry

sion in line with the fourrh ray, with care to avoid injuring the
palmar vascular arch and the ulnar nerves exiting Guyon's canal.
The transverse carpal ligament is released with a Z-plasty to
prevenr late bow-stringing of the nerve against the palmar sk.in.
The volar forearm fascia is released in the standard fashion.
Metaphyseal Physis
fracture
fragment
RADIAL PHYSEAL STRESS FRACTURES
Repetitive axial loading of the wrist in dorsiflexion can lead to
physeal Stress injuries (Fig. 9- 12), almost always involving the
radius. Competitive gymnasrics is by far the most common cause
(6,7,21,33,45,69,87). Other acrivities reported ro cause radial
physeal stress fractures include break dancing (15). Factors that
predispose to this injury include excessive training, poor tech-
niques, and attempts to advance roo quickly in competitive level.
Transverse
carpallig.
Proper coaching is imporrant in preventing these injuries.
Hematoma A child with a radial physeal stress fracture has recurring,
activity-related wrist pain, usuaJJy aching and diffuse, in rhe
FIGURE 9-32. Volarforearm anatomy outlining the potential compres-
sion of the median nerve between the metaphysis of the radius and region of rhe distal radial metaphysis and physis. Exrrernes of
dorsally displaced physeal fracture. The taut volar transverse carpalliga- dorsiflexion and palmar flexion reproduce the pain. There is
ment and fracture hematoma are also contributing factors. (Redrawn local renderness over rhe dorsal, distal radial physis. Resistive
from Waters PM, Kolettis GJ, Schwend R. Acute median neuropathy
following physeal fractures of the distal radius. ) Pediatr Orthop 1994; conrractLlre strength testing of the wrist dorsiflexors oEren repro-
14: 173-177; with permission.) duces the pain. There may be fusiform swelJing about the wrist
if there is reactive bone formation. The diffcrenrial diagnosis
includes physeal stress injllly, ganglion, ligamentous or TFCC
injury, tendonitis or muscle-tendon tear, fracture such as a
syndrome in the carpal canal or volar Forearm (Fig. 9-32) (95). scaphoid fracrure, and avascular necrosis of the scaphoid (Preis-
All patienrs with displaced distal radial fracrures should undergo er's disease) or lunate (Kienbock's disease). Radiographs may be
a careful moror-sensOlY examination upon presenration ro an diagnosric. Physeal widening and reactive bone formation are
acute care faciliry. The flexor pollicis longus, index flexor dig- indicative of chronic physcal stress fracture. Premarure physeal
irorum profundus, and abductor pollicis brevis muscles should closure indicates long-standing stress (27,98). In this situarion,
be rested. Light rouch and cwo-poinr discrimination sensibiJiry cominued ulnar growth leads to an ulnar posirive variance and
of the thumb and index finger should be tested in any child pain from ulnocarpaJ impaction or a TFCC tear (1,33). Normal
over 5 years of age wi th a displaced Salter-Harris rype I or II radiographs may not show an early physeal stress fracture. If the
Fracrure. The presence of median neuropathy and marked volar diagnosis is suggested clinically, a bone scan or MRl scan is
soft tissue swelling are indications for percutaneous pin stabiliza- indicated. Bone scans are sensitive but nonspecific. MRI scans
tion of the fracrure co lessen the risk of comparrmenr syndrome usually are diagnosric.
10 a caSL Treatment first and foremost involves rest. This may be diffi-
Median neuroparhy caused by direct rrauma or tracrion is- cult depending on the skiJJ level of the athlete and the desires
chemia generally resolves after fracture reduction. The degree of the child, coach, and parents. Short arm cast immobilization
of neural injury will determine the length of time to recovery. for several weeks may be the only way ro restrin stress to the
RecovelY can be monicored with an advancing Tinel's sign along radial physis in some patients. Splint protection is appropriate
the median nerve. Moror-sensory resting can define progressive in cooperative patients. Protection should continue umil rhere
rerum of neural function. is resolution of pain with examination and acriviry. The athlete
can maintain cardiovascular fitness, strength, and flexibility
while protecting the injured wrist. Once the acute physeal injury
Carpal Tunnel Syndrome
has healed, return to weight-bearing acrivities should be gradual.
Median neuropathy caused by a carpal tunnel syndrome wilJ not This requires the cooperation of the coach and parents. Adjust-
recover unril the carpal tunnel is decompressed. After anaromic menr of techniques and training methods often is necessary to
fracture reduction and pin stabilization, volar forearm and carpal prevellt recurrence. The major concern is development of a radial
wnnel pressures are measured. Gelberman (51) recommended growth arrest in a skeletaJly immature patient. This is an avoid-
waiting 20 minutes or more ro allow for pressure-volume equili- able complicarion with weJl-trained coaches and athletes.
bration before measuring pressures. If rhe pressures are elevated If a radial growth arrest has already occurred upon presenta-
beyond 40 mOl Hg or the difference becween the diastolic pres- tion, treatment depends on the degree of deformiry and the
sure and the compartment pressure is less than 30 mOl Hg (58), patienr's symptoms. Physeal bar resection usually is not possible
an immediate release of the affected comparrmellts should be because rhe arrest is usually roo diffuse in stress injuries. [f there
performed. The carpal wnnel is released through a palmal· inci- is no significanr ulnar overgrowth, a distal ulnar epiphysiodesis
 Chapter 9: Distal Radius and Ulna Fractures 405

will prevem the developmem of an ulnocarpal impacrion syn- volves an ulnar physeal fracture rather than a soft tissue disruption
drome. For ulnar overgrowth and ulnocarpal pain, an ulnar of the distal radioulnar joint. Another ulnar physeal fracture is an
shorrening osteoromy is indicated. Techniques include trans- avulsion fracture off the distal aspect of the ulnar styloid (91). Al-
verse, oblique, and Z-shorrening osteoromies. Transverse osreot- though an ulnar styloid injUJy is an epiphyseal avulsion, it usual Iy
omy has a higher risk of nonunion than either oblique or Z- is associated with soft tissue injuries of the TFCC and ulnocarpal
shortening and should be avoided. The status of the TFCC also joint and does not cause growth-related complications.
should be evaluared by MRl scan or wrist arthroscopy. Jf there Physeal growth arrest is frequent with distal ulnar physeal
is an associated TFCC tear, it should be debrided or repaired fractures. The incidence has been cited from 21% (73) to 55%
as approprtate. (52). Jt is unclear why the distal ulna has a higher incidence of
growth arrest after fracture than does the radius.

ULNAR PHYSEAL FRACTURES

Treatment
Jsolated ulnar physeal fracwres are rare injuries. Most ulnar phy- Treatment options are similar ro those for radial physeal frac-
seal fractures occur in association with radial metaphyseal Ot tures: immobilization alone, closed reduction and cast immobili-
physeal ftactures. Physeal sepatations are classified by the standard zation, closed reduction and percutafleous pinning, and open
Salter-Harris criteria. These injuries include types J, II, 1II, and reduction. Often these fractures are minimally displaced or non-
rarely IV fractures. The rare pediatric GaIeazzi injury usually in- displaced. Immobilization until fracture healing at 3 to 6 weeks

A B

c D
FIGURE 9-33. A and B: A 10-year-old boy sustained a closed Salter-Harris type I separation of the distal
ulnar physis (arrows), combined with a fracture of the distal radial metaphysis. C: An excellent closed
reduction was achieved atraumatically. D: Long-term growth arrest of the distal ulna occurred.
406 Upper Extremity

is standard treatment. Closed reduction is indicated for displaced periosteum. The interposed soft tissue (periosteum, extensor ten-
fractures with more than 50% translation or 20 degrees angula- dons, and flexor tendons (48,60,74)) must be extracted from
tion. Most ulnar physeal fractures reduce to a near anatomic the fracture site. If reduction is not stable, a small-diameter
alignment with reduction of the radial fracture. Failure ta obtain smooth pin can be used to maintain alignment until healing at
a reduction of the ulnar fracture may indicate that there is soft 3 to 4 weeks. Further injury to the physis should be avoided
tissue interposed in the fracture site. This is an indication for during operative exposure and reduction because of the high
open reduction. Exposure should be from the side of the torn risk of growth arrest (Figs. 9-33-9-35).

B c
FIGURE 9-34. A: The appearance of the distal ulna in the patient seen in Fig. 9-21 3 years after injury,
demonstrating premature fusion of the distal ulnar physis with 3.2 cm of shortening. The distal radius
is secondarily deformed, with tilting and translocation toward the ulna. B: In the patient in Fig. 9-21
with distal ulnar physeal arrest, a lengthening of the distal ulna was performed using a small unipolar
distracting device. The ulna was slightly overlengthened to compensate for some subsequent growth
of the distal radius. C: Six months after the lengthening osteotomy, there is some deformity of the distal
ulna, but good restoration of length has been achieved. The distal radial epiphyseal tilt has corrected
somewhat, and the patient has asymptomatic supination and pronation to 75 degrees.
 Chapter 9: Distal Raditts and Ulna Fractures 407

ULNAR STYLOID FRACTURES

Ulnar styloid avulsion fractures are common in association with
radial fracrures (91) and represenr a soft tissue avulsion of the
arrachmenr of the TFCC or ulnocarpal ligamenrs. T rearmenr
consists of immobilizarion and moniroring of long-term our-
come, and most heal wirhour sequelae (62). However, an acute
displaced fracture of the base of the styloid represenrs a disrup-
tion of the TFCC. Most of rhese injuries occur in adolescenrs
wirh high-velocity trauma ar or near skeletal marurity. Trear-
menr should be by tension band reinserrion of the sryloid to rhe
meraphysis and repair of the TFCC (Fig. 9-36). The tension
band wire is removed ar 3 to 6 weeks.
Some ulnar styloid fractures result in nonunion (Fig. 9-30)
or hypertrophic union (Fig. 9-29) (44,68,76,93). Nonunion
may be associated wirh TFCC rears or ulnocarpal impaction.
The hyperrrophic healing represenrs an ulnar positive variance
and ulnocarpal impaction. Borh cause ulnar-sided wrisr pain.
Compression of the lunare or triquetrum on the distal ulna re-
produces the pain. Clicking wirh ulnocarpal compression or
forearm rotation represents either a TFCC tear or chondoma-
FIGURE 9-35. Similar case to Fig. 9-34, but with more progressive distal
lacia of rhe lunate or triquetrum. Surgical excision of the non-
radial deformity treated with corrective osteotomy and epiphysiodesis union or hyperrrophic union with repair of the TFCC to rhe
of the distal radius. base of rhe styloid is the trearment of choice. Postoperative im-
mobilizarion for 4 weeks in a long arm cast followed by 2 weeks
in a shorr arm cast protects the TFCC repair.

Complications
Growth Arrest
The most common complication of distal ulnar physeal fractures
is growth arrest. Golz (52) described 18 such fractures, with

FIGURE 9-36. A: An adolescent with an open, commi-

nuted fracture of the distal radius metaphysis and a
base of ulnar styloid fracture with disruption of the
triangular fibrocartilage complex (TFCC). (Figure con-
A tinues.)
408 Upper Extremity

FIGURE 9-36. (continued) B: After thorough irrigation

and debridement of the radius, internal fixation of the ra·
dius was performed with care taken to not violate the phy-
sis with hardware. The ulna styloid base fracture and TFCC
was repaired with an open tension band technique with a
B "l!! 5 " I suture and smooth wire.

growth arrest in 10%. If the patienr is young enough, continued METAPHYSEAL FRACTURES
growth of the radius will lead to deformity and dysfunction.
The distal ulnar aspect of the radial physis and epiphysis appears The meraphysis of the distal radius is the most common site of
to be tethered by the foreshortened ulna (Figs. 9-34 and 9-35). fotearm fracrure in children and adolescents (19,32,154). They
The radial articular surface develops increased inclination toward occur most commonly in boys in the nondomina.nr arm (168).
the foreshortened ulna. This is similar to the deformity Peinado These fractures have a eeak incidence during the adolescenr
(78) created experimentally with arrest of the distal ulna in rab- growth Spurt, which in girls is age 11 to 12 years and in boys
bits' forelimbs. The distal ulna loses its normal articulation in the is 12 to 13 years (2). During this time ofextensive bone temodel-
sigmoid notch of the distal radius. The metaphyseal-diaphyseal ing, there is _.!"elat~~BQ.J:Q5is of the distal radial metaphysis,
region of the radius often becomes notched from its articulation which makes rhis area more susceptible to fracture with a fall.
with the distal ulna during forearm rotation. Frequently, these
patients have pain and limitation of motion with pronation and
Diagnosis
supinarion (41).
Ideally, this problem is identified beFore the development of The mechanism of injury is generally a fall on an ourstretched
marked ulnar foreshortening and subsequent radial deformity. hand. The usual dorsiflexion position of the wrist leads to ten-
Because it is well known that distal ulnat physeal fractures have sion failure OD rbe volar side. Fracture type and degree of dis-
a high incidence of growth arrest, these patients should have placement depend on rhe heighr and velocity of rhe fall (54).
serial radiographs to identify growth arrest early. Unfortunately, These fractures can be nondisplaced torus or buckle injuries
in the distal ulnar physis, physeal bar rescnion generally is unsuc- (common in younger children with a minimal fall) or dorsally
displaced fractures with apex volar angulation (more commOD
cessful. Surgical arrest of rhe radial physis can prevent radial
in older children with higher velocity injuries) (Fig. 9-37). Dis-
deformity. Usually this occurs late enough in growth that the
placement may be severe enough to cause foreshonening and
forearm length discrepancy is nor a problem.
bayoner apposition (Fig. 9-38). Rarely, a mechanism such as a
Mosr often rhese patiems presem late with established defor-
fall from a height can cause a distal radial fracture associared
mity. Treatment rhen involves rebalancing rhe length of the
wirh a more proximal fracwre of the forearm or elbow (97,143,
radius and ulna. The options include hemiphyseal arrest of the
155) (Fig. 9-39). A fall with a palmar flexed wrisr can produce
radius, corrective closing wedge osteotomy of the radius, ulnar a volarly displaced fracture with apex dorsal angulation (Fig. 9-
lengthening (41,52,73), or a combination of these procedures 38, Table 9-2).
(Figs. 9-34 and 9-35). The painful impingement of rhe radius Children with distal radial fracrures present with pain, swell-
and ulna with forearm rotation can be corrected with reconstitu- ing, and deformity of the distal forearm (Figs. 9-40 and 41).
tion of the DRUj. If the radial physis has significant growth The clinical signs depend on the degree offracwre displacement.
remaining, a radial physeal arrest should be performed at the With a nondisplaced torus fracture in a young child, medical
same time as the surgical rebalancing of the radius and ulna. attention may nor be sought until several days afrer injury, be-
Treatment is individualized depending on rhe age of the parient, cause the intacr periosteum is protective in this situarion, lessen-
degree of deformity, and level of pain and dysfunction. ing pain and the child's restriction of activities. Most disral radius
 Chapter 9: Distal RaditlS find Ulna Fractures 409

~B C

FIGURE 9-37. Metaphyseal biomechanical patterns. A: Torus fracture. Simple bulging of

the thin cortex (arrow). B: Compression greenstick fracture. Angulation of the dorsal cortex
(large curved arrow). The volar cortex is intact but slightly plastically deformed (small
white arrows). C: Tension failure greenstick fracture. The dorsal cortex is plastically de-
formed (white arrow) and the volar cortex is complete and separated (black arrows). 0:
Complete length maintained. Both cortices are completely fractured, but the length of
the radius has been maintained. (Reprinted from Wilkins KE, ed. Operative management
of upper extremity fractures in children. Rosemont, IL: American Academy of Orthopaedic
D Surgeons, 1994.24; with permission.)
410 Upper Extremity

FIGURE 9·38. Complete fractures; bayonet apposi-

B tion. A: Dorsal bayonet. B: Volar bayonet.

Fractures, ho\ovever, will present acutely after the fall with an

obvious defor·miry. Physical examination is limited by the pa-
riem's pain and anxiery. It is imperative w obtain an accurate
examination of rhe mowr and sensory components of the radial,
median, and ulnar nerves before rrearmenr. Median nerve moror
function is evaluated by testing the abducwr pollicis brevis (in-
trinsic) and flexor pollicis longus (exrrinsic) muscles. Ulnar nerve
mawr evaluation includes testing the I1rst dorsal interosseous
(inrrinsic), abducwr digit quinti (intrinsic), and flexor digirorum
profundus to the small finger (extrinsic) muscles. Radial nerve

TABLE 9-2. CLASSIFICATION: DISTAL

METAPHYSEAL FRACTURES
Directional displacement
Dorsal
Vo'lar
Fracture combinations
Isolated radius
Radius with ulna
Ulnar styloid
Ulnar physis
Ulnar metaphysis, incomplete
Ulnar metaphysis, complete
Biomechanical patterns
Torus
Greenstick
One cortex
Two cortices
Complete fracture
Length maintained
FIGURE 9-39. A 10-year-old girl with an innocuous-appearing distal Bayonet apposition
radius fracture associated with an ipsilateral angulated radial neck frac-
ture (arrows).
 Chapter 9: Distttl Radiw find Ulna Fractures 411

FIGURE 9-40. Dorsal bayonet deformity. A: Typical distal

metaphyseal fracture with dorsal bayonet showing a dorsa I
angulation of the distal forearm. B: Usually the periosteum
B is intact on the dorsal side and disrupted on the volar side.

evaluarion involves resring [he common digital extensors for 147,155,160-162) because 3% to 13% of diml radial fractures
metacarpophalangeal joint extension. Sensibijity to light tOuch have associated ipsilateral extremity fractures (Fig. 9-42) (120,
and two-point discrimination should be tested. Normal rwo- 155), increasing the risk of neurovascular compromise and com-
point discrimination is jess than 5 mm but is not present until parrmenr syndrome (Papavasiiious, Staninski, ring).
age 5 to 7 years. Pin-prick sensibility testing will only hurr and Radiographs are diagnostic of the fracture type and degree
scare the already anxious chi1~should be avoided. A recent of displacemenr. Standard AP and lateral radiographs usually
prospective study indicated "n 8% i 'cidence of nerve injury in are sufficient. Complete wrist, forearm, and elbow views are
children with distal radial fractures (168). necessary for high-velocity injuries or when there is clinical ten-
The ipsilateral extremity should be carefully examined for derness. More extensive radiographic studies (eT scan, tOmo-
fractures of the carpus, forearm, or elbow (l 07,128, 129, 133, grams) usually are not necessary unless there is inrraarricular

A
FIGURE 9·41. Reverse bayonet. A: Typical volar bayo-
net fracture. Often the distal end of the proximal frag-
ment is buttonholed through the extensor tendons (ar-

~,..,,====
rows). (Reprinted from Wilkins KE, ed. Operative
management of upper extremity fractures in children.
Rosemont, IL: American Academy of Orthopaedic Sur-
geons, 1994: 27; with permission.) B: Intact volar perios-
teum and disrupted dorsal periosteum (arrows). The ex-
~------- tensor tendons are displaced to either side of the
B proximal fragment.
412 Upper Extremity

B
FIGURE 9-42. Ipsilateral fractures. A: Markedly displaced ipsilateral distal radial and supracondylar
fractures. B: Both fractures were reduced and stabilized with pins placed percutaneously. (Wilkins KE,
ed. Operative management of upper extremity fractures in children. Rosemont, IL: American Academy
of Orthopaedic Surgeons, 1994:29; with permission.)

exrension of rhe meraphyseal fracrure in a skelerally mature ado- The ulnar fracture ofren associated with radial metaphyseal
lescenr. fracrure can be metaphyseal or physeal, or an ulnar sryloid avul-
sion. Similar to radial meraphyseal fracrures, the ulnar fracture
Classification can be complete or incomplere.
Distal radial fracrures also can occur in conjunction with
These fractures are classified by fracrure parrern, type of associ- more proximal forearm fractures (l01), Momcggia fracture-dis-
ared ulnar fracrure, and direcrion of displacemenr. Fracture dis- locations (102), supracondylar distal humeral fractures (Reis,
placement is broadly classified as dorsal or volar. Most disral ri ng, Staninski), or carpal fracrures (l 02, 128, 129,133,161,162).
radial meraphyseal fractures are is laced dorsally with a ex The combination of a displaced supracondylar distal humeral
~lr angulation (32) Volar displacement wIn apex orsal angu- fracture and a displaced disral radial meraphyseal fracture has
lation can occur with palmar flexion injuries. been called the pediatric floating elbow. This injUlY combinarion
Metaphyseal fracture panerns are either torus, incomplere is unstable and bas an increased risk for malunion and neurovas-
or greensrick, or complere fractures. Torus fractures are axial cular compromise.
compression injuries. The sire of corrical failure is rhe _~ransition Pediarric distal radial metaphyseal fractures are nor classified
from meraphysis to diaphysis (138). These injuries are staGle by degree of instability. Unstable fractures have been predomi-
because of the intacr periosreum. On rare occasion, rhey may narely identified rerrospeCtively by the failure w maimain a suc-
exrend into the physis, purring rhem ar risk for growth impair- cessful closed reduction (Fig. 9-43). This occurs in approxi-
ment (80,81). Incomplete or greenstick franures occur with a rnarely 30% of complere disral radial meraphyseal fractures 039,
combinarion of~mpressive and roratory forces, generally a dor- 146,167). This high percemage of loss of alignmem ha.s been
siflexion force and supinatIOn deforming force. This leads to a wlerared because of the remodeling potential of the distal radius.
volar tension side failure and a dorsal compression injury. The Anatomic remodeling is possible because rhe extension defor-
degree of force derermines rhe amount of plasric deformarion, mity is in rhe plane of morion of the wrist joint, the meraphyseal
dorsal comminution, and fracture angularion and rotation. If fracture is juxtaphyseal, and mosr of rhese fractures occur while
rhe force is sufficienr, a complete fracture occurs with disruption there is still significanr growth remaining. However, concern
of both rhe volar and dorsal cortices. Lengrh may be maintained h.as increased about the high failure rate of closed reducrion to
wirh apposirion of the proximal and disral fragmenrs. Fre- maintain anawmic alignmem of these fracrures. F:1Crors rhat
quently, rhe disral fragment lies proximal and dorsal to rhe proxi- h.ave been idemifled as increasing the risk of loss of reduction
mal fragment in bayonet apposition (Table 9-2). with closedmanipularion and casring include poor casring, bayo-
 Chapter 9: Distal Radiw and Ulna Fractures 413

B
FIGURE 9-43. Results of angulation. A: Significant apex volar angulation of the distal fragment. B: The
appearance was not as apparent cosmetically as in another patient with less angulation that was directed
apex dorsally. (Reprinted from Wilkins KE, ed. Operative management of upper extremity fractures in
children. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1994: 27; with permission.)

net apposition, uanslation greater than 50% the diametel' of the begin. Fracrure healing usually occurs in 2 t.'>-4 weeks (20,40,
radius, apex volar angulation greater than 30 degrees, isolated 68,74). Simple torus fractures usually h~~ wlthom long-term
radial fractures, and radial and ulnar metaphyseal fractures at seq~
the same level (139,146,167). These factors define in general icor . at disruption on both the AP and lateral views indi-
terms unstable fracrures. cates a more severe injury than a stable torus fracrure. Splint or
limited immobilization in this situation putS the child at risk
for displacement. More prolonged immobilization, long arm cast
Treatment prorection in a young patient, and closer follow-up are genera y
recommended to lessen the risk of malunion. These fractures
Treatment options are similar to those for radial physeal frac-
generally heal in0to 6 w'&k
tures: immobilization alone, closed reduction and cast immobili- "------
zation, closed reduction and percutaneous pinning, and open
reduction. The fracture rype, degree of fracture instabiliry, asso- Incomplete/Greenstick Fractures
ciated soft tissue or skeletal trauma, and the age of the patient
Immobilization Alone
all influence choice of treatment.
Treatment of incomplete distaJ radial and ulnar fractures de-
pends on the age of the patient, the degree and direction of
fracture displacement and angulation, the surgeon's biases re-
Torus Fractures
garding remodeling, and the surgeon's and community's biases
Torus fracrures are compression injuries with minimal cortical regarding deformity. In younger patients, the remodeling poten-
disruption. If only one cortex is violated, the injury is stable. tial of an acme distal radial malunion is extremely high. Accept-
Treatment should consist of protected immobilization to pre- able sagittal plane angulation of an acute distaJ radial metaphy-
vent further injury and relieve pain. Once the patient is comfort- seal fracture has been reported to be from 10 to 35 degrees in
able, range-oF-motion exercises and nontraumatic activities can patients under 5 years of age (74,103,108,141,145,153,168).
414 Upper Extremity

A,B C

FIGURE 9-44. Extensive remodeling. A: Injury film

of a 7-year-old with a tension failure greenstick
fracture. Band C: Lateral and anteroposterior
views of the same patient taken 1 month later
showing development of 45 degrees angulation in
the sagittal plane and 40 degrees in the coronal
plane. 0 and E: True appearance taken 4 years
later shows only residual angulation of 10 degrees
in the sagittal plane and full correction of radial
angulation in the coronal plane. The patient had
a range of forearm motion equal to that of the
D,E opposite extremity and was asymptomatic.
 Chapter 9: Distal Radius and ULna Fmctures 415

TABLE 9·3. ACCEPTABLE ANGULAR

CORRECTIONS IN DEGREES

Frontal
Saggital Plane Plane

Age (yr) Boys Girls Boys & Girls

4-9 20 15 15
9-11 15 10 5
11-13 10 10 0
>13 5 0 0

Acceptable residual angulation is that which will result in total

radiographic and functional correction.
Courtesy B. deCourtivron, M.D. Centre Hospitalie Universitaire de
Tours. Tours, F,rance. A

Similarly, in patients under 10 years of age, the degree ofaccepr-

able angularion has ranged from 10 ro 25 degrees (74, J 03,] 08,
141,153,168). In patients over 10 years of age, acceprable mal-
union has ranged from 5 co 20 degrees depending on the skeletal
maturity of the patient (74,103,108,112,141,153,]67,168)
(Table 9-3).
The high potential for remodeling of a distal radial meraphy- B
seal malunion has led some researchers to recommend immobili-
zation aJone. As mentioned, the range of accepted malalignment
has been broad as well as age and researcher dependent (Figs.
9-44 and 9-45).
Acceptable frontal plane deformity has been more uniform.
The fracture tends co displace radially with an apex ulnar angula-
tion. This does have the potential to remodel (144), bur less so
than sagirraJ plane deformity. Most researchers agree that only
10 degrees or less of acute maJalignment in the frontal plane
should be accepted. More malalignment than this may not re-
model and may result in loss of forearm rotarion because of the
loss of interosseous space betlveen rhe radius and ulna (169)
(Table 9-3).

Closed Reduction
Most researchers agree thar displaced and malaligned incomplete
fractures should be reduced closed. The areas of controversy are
the degree of acceptable deformity, whether the intact cortex
should be fraerured, and the position of immobilization.
Conrroversies about acceptable angulation of the fracture
after closed reduerion involve the same differences discussed in
the immobilization section. As mentioned, more malalignment
can be accepted in younger patiems, in those with sagittal plane
deformity, and in rhose withour marked cosmeric deformity.
Malaligned apex volar incomplete franures are Jess obvious than
the less common apex dorsaJ fractures. C D
As Evans (115) and Rang (86)emphasized, incomplete fore-
FIGURE 9-45. Bayonet remodeling. A: After numerous attempts at
arm fracrures have a rotatOry componenr ro their malalignment. closed reduction. the best alignment that could be obtained was dorsal
The more common ':flex vQl~fracrures represenr a su ination bayonet apposition in this 8-year-old. B: Three months postfracture,
there is good healing and early remodeling. C and D: Five years after the
deformity, whereas -rne ,esscc;-mmon apex dorsal fi'actures are
injury (age 13), remodeling was complete and the patient had normal
mal rotated in pronation. Correction of the ;;;:Ilrorarion is neces- appearance and forearm motion.
sary to achieve anawmic alignment. Controversy exists regarding
416 Upper Extremity

raeionale is that elbow flexion reduces the muscle forces aoing

co displace the fracrure. ] n addition, a long-arm cast may fureher
restrict the child's aceiviry and therefore decrease ehe risk of
displacemenr. However, Chess (l 04, 105) published reponed re-
displacemenr and reducrion races with well-molded shon arm
casrs similar co rhose wirh long arm casrs. They used a casr index
(sagittal diameter divided by coronal diamerer ar rhe fracrure
sire) of 0.7 or less co indicare a well-molded case. Wilkins
achieved similar resulrs with shore-arm casr erearmenr (168).
However, in mosr centers, rhe srandard is seill long arm case
immobilization (20,40,58,103,158).

COMPLETE FRACTURES
Complere fracrures of ehe distal radius, with or withour an associ-
ated displaced ulnar fracrure, are unsrable fracrures. Generally
these fracrures aredi ·:l.ced_.dorsally, rearing rhe volar perios-
teum and sofr tissues. The israrhagment of epiphysis and me-
raphysis often is in bayonet apposition wirh the proximal frag-
FIGURE 9-46. The brachioradialis is relaxed in supination but may be-
menr (Fig. 9-38). Concomitanr radial and ulnar fracrures ar rhe
come a deforming force in pronation. (Reprinted from Pollen AG. Frac- same level may be more unstable than isolared fracrures (167)
tures and dislocations in children. Baltimore: Williams & Wilkins, 1973; (Fig. 9-47). However, Gibbons reponed loss of reduction in
with permission.)

complerion of greens rick fracrures (18,86,111,118,151). Mosr

researchers advocare complerion of rhe fracrure co reduce rhe
risk of subsequem loss of reducrion from rhe imacr periosreum
and concave deformiry acring as a rension band (157,168) co
redisplace rhe fracture. Complering rhe fracture increases rhe
risk of insrabiliry and malunion.
The posirion and rype of immobilizarion also have been con-
rroversial. Recommendarions for rhe posirion of posrreducrion
immobilizarion include supinarion, neurral, and pronarion. The
rarionale for immobilizarion in pronarion is thar reducrion of
rhe more common apex volar fracrures requires correcrion of
the supinarion deformiry (115). Following this rarionale, apex
dorsal fracrures should be reduced and immobilized in supina-
tion. Pollen (145) believed thar the brachioradialis was a de-
forming force in pronarion and was relaxed in supinarion (Fig. 9-
46) and advocared immobilization in supination for all displaced
disral radial fracrures. Kasser (58) recommended immobilization
in slighr supinarion ro aHow berrer molding of rhe volar distal
radius. Some researchers advocate immobilizarion in a neutral
posirion, believing this is besr ar mainraining the interosseous
space and has the leasr risk of disabling loss of forearm rorarion
in rhe long rerm (113,141,158). Davis and Green (111) and
Ogden (74) advocare thar each fracrure seek irs own preferred
posirion of stabiliry. Gupra and Danielsson (130) randomized
immobilizarion of distal radial meraphyseal greenstick fracrures
in neutral, supinarion, or pronarion ro rry ro determine rhe besr
posirion of immobilizarion. Their srudy showed a srarisrical im-
provemenr in final healing with immobilizarion in supinarion.
Anorher area of conrroversy is wherher long arm or shorr arm FIGURE 9-41. Radial deviation constricts the interosseous space, which
casr immobilizarion is betrer. Most publications on pediatric may decrease forearm rotation. (Reprinted from Wilkins KE, ed. Opera-
tive management of upper extremity fractures in children. Rosemont,
disral radial fracrure rreatmem advocate long arm cast rrearmem IL: American Academy of Orthopaedic Surgeons, 1994: 28; with permis-
for rhe firse 3 co 4 weeks of healing (20,40,58,74,103,158). The sion.)
 Chapter 9: Distal Radius and Ulna Fractures 417

91 % of isolated radial fractures after closed reducrion. Although Cast Immobilization

a rare fracrute wirh bayonet apposition in a very young patient
As discussed earlier there is some disagreement regarding shorr
may remodel (168), the standard treatment for completely dis-
arm or long arm cast immobilization (104,105,168). However,
placed fractures is reducrion and stabilization. The current con-
regardless of the length of the cast, it is imperative to have a well-
troversy is whether cast immobilization alone is adequate stabili-
molded cast over the fracture site (Fig. 9-52). After reducrion of
zation or whether percutaneous pin fixation is more appropriate
a dorsally displaced fracture, three-point fixation is used wirh
for displaced, complete, distal radial metaphyseal fractures.
dorsal pressure proximal and distal to the fracture site and volar
pressure over the reduced fracrure. Excessive swelling should be
Reduction Techniques monitored. If there is any concern regarding impending com-
Techniques of reduction have included initial distraction with partment syndrome, the casr and webril should be immediately
finger traps (111,] 57) followed by manipulation and direct ma- bivalved and the patient's clinical status monitOred closely.
nipulation of the fracture by accemuating the deformity (Figs. The primary problem with closed reduction and cast immo-
9-48 and 9-49). Both Rang (86) and Fernandez (118) expressed bilization is loss of reduction (Fig. 9-53). Mani et al. (139) and
concern about the success of finger trap distraC[ion because the Proctor et al. (]46) described remanipulation rates of 21.3%
intact dorsal periosteum will nor stretch adequately to allow and 23.5%, respectively. Mani et al. (139) concluded that initial
reduction. They advocated sequemial reduction maneuvers: ini- displacement of the radial shaft of over 50% was the single most
tial manipulation of the distal fragmem dorsally to accentuate reliable predictor of fajlure of reduction. ProctOr et al. (J46)
the deformity (Fig. 9-48), thumb pressure on the relaxed dorsal found that complete initial displacement resulted in a 52% inci-
edge of the distal fragment to correct the overriding, and reduc- dence of redisplacement of distal radial fractures in children.
tion of the fracture by forceable application of distal and volar Gibbons et al. (126) noted that completely displaced distal radius
pressure (Fig. 9-49). Anatomic reduction may require repetitive fractures with intact ulnas nad a remanipularion rate of 91 %
"toggling" of the distal fragment volarly. after closed reduction and cast immobilization alone versus a
There is considerable controversy about what constitutes an 0% rate of remanipulation when the same fractures were treated
acceptable reduction (76,110,111,121,123,13],137,148,]49, with closed reducrion, lGrschner wire fixation, and cast immobi-
]63). This is clearly age dependem, because the younger the lization. All three researchers strongly advocated percutaneous
patient, the greater the potential for remodeling (Fig. 9-50). pinning of distal radial fractures at risk of redisplacement (Fig. 9-
~do.rsaL.u lali nment has the greatest otential _re od- 54). Widmann and Waters (J 67) prospectively studied all distal
din because this is in the lane 0 predominant motion of th.e. radial fractures in children requjring reduction over the course
j~ Marked ra ioulnar malalignment is less likely to remodel. of 1 year (POSNA). Of the 86 distal radial metaphyseal fraC[ures,
Malrotation will not remodel (Fig. 9-51). The ranges for accept- 31 % lost reduction and required further intervention with repeat
able reduction according to age are given in the immobilization reduction, casting, or pinning. In patients over 10 years of age
section on incomplete fractures and apply to complete fractures with angulation of more than 30 degrees, the remanipulation
as well. rate was 75%. These findings led to a more recent pwspecrive,

A B
FIGURE 9-48. A and B: Use of the thumb to push the distal fragment hyperdorsiflexed 90 degrees (solid
arrow) until length is reestablished. Countertraction is applied in the opposite direction (open arrows).
418 Upper Extremity

FIGURE 9-49. A and B: Once length has been reestab-

lished. the distal fragment is flexed into the correct
position. Alignment is checked by determining the po-
sition of the fragments with the thumb and forefingers
B of each hand.

FIGURE 9·50. A: Appearance 6 weeks after closed reduction of a distal forearm

fracture in an 8'12 -year-old boy. The radius was reduced, and the ulnar fracture
remained overriding. B: Eighteen months after injury the ulnar fracture had remod-
A eled completely with symmetric distal radioulnar joints.
 Chapter 9: Distal Radius and Ulna Fractures 419

FIGURE 9-51. A: This 7-year-old with bayonet ap-

position was immobilized in a long arm cast in full
pronation. B: One year later, there was still consider-
able angulation with significant loss of forearm ro-
B tation and an unacceptable cosmetic appearance.

randomized study by Waters et al. (166) of distal radial metaphy- thopedic Society of North America with expertise in trauma
seal fractures treated by eirher closed reduction and casr immobi- care. General anesthesia, fluoroscopic control, and a long arm
lizarion or closed reduction and percutaneous pinning. Selecrion cast were used. Despite these optimal conditions, 7 of 18 parients
criteria were a closed metaphyseal fracture angulated more rhan in the cast immobilization group lost reduction and required
30 degrees in a skelerally immature patient over 10 years of age. remanipulation.
To maximize the outcome of the cast immobilization group, The results of all of these studies indicate that distal radial
rhese patients were treated by a member of the Pediatric Or- metaphyseal fractures witl! initial diselacement of more than 3Q.
-.gegrees are inherently unstable. Loss of r~dG'Ctio"~ is common,
with the nskln the 30%" to 40% range. Incomplete reduction
(139,146) and poor casting techniques (104,105,168) increase
the risk of loss of reduction. In addition, the risk of loss of
reduction increases with the age of the patient and the degree
of initial displacement.
Loss of reduction requires repeat manipulation or it will result
in a malunion. Although the rate of malunion is frequent after
these fracrures (40,46,54,58,67,89,104,105,109,111,165), be-
cause of the pOtential for remodeling in skeletally immature
patients, it has not been considered a serious problem (17,37,
38,103,121-124). Distal radial fractures are juxtaphyseal, the
malunion often is in the plane of motion of rhe wrist joint
(dorsal displacement with apex volar angulation), and the disral
radius accounts for 60% to 80% of the growth of the radius.
All these factors favor remodeling of a malunion. However, de-
Courtivron et al. (112) reported that of 602 distal radial frac-
tures, 14% had an initial malunion of more than 5 degrees. Of
these, 78% correered the fromal plane deformity and only 53%
remodeled completely in rhe sagirtal plane. In addition, 37%
FIGURE 9-52. Three-point molding. Top: Three-point molding for dor-
had loss of forearm roration.
sally anguJated (apex volar) fractures, with the proximal and distal
points on the dorsal aspect of the cast and the middle point on the volar Closed Reduction and Percutaneous
aspect just proximal to the fracture site. Bottom: For volar angulated
fractures, where the periosteum is intact volarly and disrupted on the Pinning
dorsal surface, three-point molding is performed with the proximal and
distal points on the volar surface of the cast and the middle point just In the pasr 10 years, closed reducrion and percutaneous pinning
proximal to the fracture site on the dorsal aspect of the cast. have become more common as the primary treatment of distal
420 Upper b:tremity

FIGURE 9-53. Serial radiographs at 3 days (A) and 10

days (B) revealing slow loss of reduction that is com-
monplace after distal radial metaphyseal fracture
B closed reduction.

radial metaphyseal fractures in children and adolescencs (125, menc syndrome (Fig. 9-43) (155,169), and any remanipulation
139,146,166,167). The indicarions cired include fracrure insra- (Fig. 9-55) (167,168).
bility and high risk ofloss of reducrion (125,139,146), excessive Pinning usually is done from disral to proximal under fluoro-
local swelling rhat increases rhe risk of neurovascular compro- scopic guidance. When possible, rhe physis is avoided. Adequate
mise (95,166,168), ipsilateral fractures of the disral radius and exposure should be obtained to avoid radial sensory nerve or
elbow region (floating elbow) thar increase the risk of com parr- extensor tendon injury. Smooth Kirschner or (-wires are lIsed.
 Chapter 9: Distal Radius and Ulna Fractures 421

A B
FIGURE 9-54. Severe swelling. A: An 11-year-old with marked displacement and severe swelling from
a high-energy injury. B: Once reduced, the fragment was secured with an oblique percutaneous pin
across the fracture site. (Reprinted from Wilkins KE, ed. Operative management of upper extremity
fractures in children. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1994: 29, with permis-
sion.)

A B

FIGURE 9-55. Remanipulation. A and B: Two weeks after

what appeared to be initially an undisplaced greenstick frac-
ture, a 14-year-old boy was found to have developed late
angulation of 30 degrees in both the coronal and sagittal
planes. C: Because this was beyond the limits of remodeling,
a remanipulation was performed. To prevent reangulation,
the fracture was secured with a pin placed percutaneously
c obliquely through the dorsal cortex.
422 Upper Extremity

FIGURE 9-56. Different pinning techniques for unstable distal ra-

dius and ulnar metaphyseal fractures. A: A single oblique pin in the
B radius. B: Two parallel pins in the radius. (Figure continues.)

1n younger patients, a single pin with supplemental cast immobi- the skin to allow easy removal in the ambulatOlY serring. A
lization may be adequate fixation. Crossed pins are more stable supplemental, loose-fitting cast is applied. The advantage of pin
(Fig. 9-56). The first pin, or single pin, enters from the radial fixation is that a tight, well-molded cast is not necessary to main-
side distal to the fracture and passes obliquely to the ulnar aspect tain reduction. This lessens the risk of neurovascular compro-
of the radius proximal ro the fracture. The second pin enters mise with associated excessive swelling or ipsilateral fractures.
the radius disral to the fracture between the fourth and fifth Obviously, pin fixation avoids rhe risk of loss of reduction in
compartments and passes obliquely across the fracture into the an unstable fracture. Pinning does have the risk of infection and
proximal radial side of the radius. The pins are left out through concerns regarding growth injury.
 Chapter 9: DiHal Radius and Ulna Fractures 423

FIGURE 9-56. (continued) C: Two parallel pins in the ra-

dius and a single pin in the ulna. D: Crossed pins in the
D radius.

External Fixation also may be necessary for severely comminuted franures co main-
tain length and provide additional stability co pin fixation (Fig.
Unlike distal radial fr;lctures in adults, external rlxation I";lrely is
9-22). Standard appJication of the speciflc fix;lcor chosen is per-
indicated in skeletally immature patients..AJthough it can be
formed with care to avoid injury co the adjacent sensory nerves
used succe'sfully (152,165), the success rates of both closed re-
and extensor tendons.
duction and percutaneous pinning techniques make it unneces-
sary for uncomplicated distal radial fractures in children. The
besr indication is severe associareJ soFt tissu injuries. A severe
crush injury, open fracture, or replantation after amputation that
Open Reduction
requires e. tcnsive sofr tissue cal'e and surgery are all indications Open reduction is indicared for open or irreducible fracrures
for rhe use of external fixation. Supplemental c rcrnal fixation (Figs. 9-36, 9-57, and 9-58). Open fracwres constitute approxi-
424 Upper Extrfmit),

A B
FIGURE 9·57. Open fractures. Radiograph (A) and clinical photo (8) of an open fracture of the distal
radius. This patient needs formal irrigation and debridement in the operating room.

matel)' 1% of all distal radial meraphyseal fractures. All open tures. After thorough irrigarion and debridement, the fracture
fractures, regardless of grade of sofr tissue injury, should be irri- should be anatomically reduced and stabilized, usually with two
gated and debrided in the operating room. The open wound smooth pins. If the soft tissue injury is severe, supplemental
should be enlarged adequately to debride the contaminated and external fixation aJJows for observation and treatment of the
nonviable tissues and protect the adjacent neurovascular suuc- wound without jeopardizing tile fracture reduction. The original

FIGURE 9·58. A 10-year-old girl with a markedly displaced closed fracture of the distal radius with an
angulated ulnar fracture. Note the wide separation between the radial fragments. Dimpling of the skin
was noted when longitudinal traction was applied and reduction was impossible. At open reduction,
the proximal fragment was buttonholed through the forearm fascia and located between the median
nerve and finger flexor tendons. The pronator quadratus muscle was also interposed between the two
fragments.
 ClJflptel' 9: DistaL Radius lind ULna Fmctlt1'es 425

open wound should noc be closed primarily. Appropriare pro- fracrures, ir is imperarive ro reduce rhe ORUJ wirh appropriare
phylacric anribiorics should be used depending on rhe severiry forearm rorarion. For apex volar fracrure.s, rhis usually is wirh
of rhe open fracrure. pronation. If rhe fracrure is apex dorsal with volar displacement,
Irreducible fracrures are rare (Fig. 9-58) and generally are t ere uction forces are rhe opposite. A long arm casr wirh rhree-
secondalY 1'0 inrerposed sofr tissues. Wirh dorsally displaced frac- point molding is used for 3 ro 4 weeks. Radiographs are obtained
rures, rhe inrerposed suucture usually is rhe volar periosreum every 7 ro 10 days unril rhere is sufficient callus formarion. A
or pronaror quadrarus (132) and rarely rhe flexor rendons or shorr arm casr or volar wrisr splinr is used until full healing,
neurovascular suucrures. In volarly displaced fracrures, rhe peri- generally at 4 to 6 weeks after fracrure reduction. The patienr
osreum or exrensor rendons may be interposed. The fracrure is rhen resrricted from conract spons uncil full motion and
should be approached in a srandard fashion opposire rhe side suengrh are regained, which may rake up co 3 weeks afrer casr
of displacemenr (i.e., volar approach for an irreducible dorsal removal. Formal rhcrapy rarely is required. The parient and par-
fracture). The adjacenr neurovascular and rendinous strucrures enrs should be warned ar rhe srarr of treatment of rhe risk of
are prorecred and rhe offending sofe rissue is exrracred from redisplacemenr of the fracrure.
rhe franure site. Pin stabilizarion is recommended ro prevenr
problems with posroperarive swelling or loss of reduction in case.
Bayonet Apposition
Closed reduction rarely fails if rhere is no inrerposed sofe
rissue. However, occasionally mulriple arremprs ar reducrion of Marked displacemenr of disral radial meraphyseal fracrures usu-
a bayoner apposition fracrure can lead ro significanr sweJling ally resulrs in foreshorrening and dorsal overlap of rhe disral
rhar makes closed reducrion impossible. If the patienr is roo old fragment on rhe proximal fragmenr. This ofren is associared wirn
ro remodel bayoner apposirion, open reduction is appropriare. a same-level ulnar metaphyseal fracrure, similarly in bayoner ap-
Pin fixarion withour violating the physis is recommended. position. Rarely, the distal fragment is in volar bayoner apposi-
tion. Borh of rhese siruations require more skill of reducrion
and complete analgesia at rhe fracrure site. At our insrirurion,
~ AUTHOR'S PREFERRED METHOD we reduce rhis fracture in rhe operaring room with general anes-
\...~ OF TREATMENT rhesia or in the emergency room with conscious sedarion and
supplemenrallocal hemaroma block. In eirher siruation, porrable
ondisplaced Fractures fluoroscopy is used. The fracrure usually is reduced in rhe emer-
gency room in young parienrs with minimal swelling and no
Nondisplaced mecaphyseal compression fracrures, includ ing neurovascular compromise, and in whom casr rrearmenr will be
rorus and unicorrical compression greensrick fractures, are inher- sufficient. Reduction with general anesthesia is preferred for
enrly srable. These include rorus and uniconicaJ compression older parienrs and for rhose wirh marked displacemenr, swelling,
greensrick fracrures. Immobilization is used until resolurion of or associared neurovascular compromise in whom percutaneous
pain and radiographic evidence of healing, generally about 3 pin trearmenr is chosen.
weeks. Depending on the acriviry level of rhe parient, a volar
wrist splinr or a short arm cast can be used. Immobilizarion
provides comforr from pain during healing and prorects againsr • AUTHOR'S PREFERRED METHOD
displacemenr wirh secondary injury. Iris imporranr rhar an un- \...~~ 0 F TREATMENT
srable bicorrical fracrure nor be unrecognized on radiograph.
Bicorrical fracrures need more prorecrion, longer resrricrion of The reducrion maneuver is rhe same regardless of anesrhesia rype
acriviry, and closer follow-up ro avoid displacemenr and mal- or srabilizarion merhod. As opposed ro a Colles' fracrure in an
union. A well-molded long arm casr is applied and radiographs adulr, rracrion alone will nor reduce rhe fracrme because rhe
obrained every 7 ro 10 days unril evidence of early radiographic dorsal periosreum acrs as a tension band rhar does not respond
healing. A shorr-arm casr is rhen worn unril clinical and radio- ro increasing linear tracrion wirh weights. Finget· rraps with min-
graphic healing is complere. Any loss of reducrion is rreared wirh imal weigh I' (less than 10 pounds) can be used to balance rhe
repeat reducrion. Rerum ro conran sporrs is resrricted unril rhe hand and help wirh rorationaJ alignment (rhe "steel residenr")
parienr regains full morion and srrengrh. (Fig. 9-59). However, applying progressive weigh l' will only dis-
rracr the carpus and will not alrer rhe fracture alignmene.
After applying preliminary traction wirh eirher light-weighr
Minimally Displaced Fractures
finger traps or hand rracrion, a hyperdorsiflexion maneuver is
Displaced greensrick fracrures rhar are reduced are ~r performed (Fig. 9-48). The initial deformiry is accenruared and
redis lacemene. If left unreduced or poorly immobilized, a mild the distal fragmenr is brought into marked dorsiflexion. The
- Ck-t:;rmiry can become severe during rhe course of healing. dorsum of rhe hand should be broughr more rhan 90 degrees,
Therefore, closed anaromic reduction is performed in all bicorri- and ar rimes parallel to rhe dorsum of rhe forearm to lessen the
cal fracrures with more than 10 degrees of malalignmenr. Gener- tension on rhe dorsal forearm. Thumb pressure is used on rhe
ally these fracrures have apex volar angularion and dorsal dis- disral fragment while still in this deformed posirion (fig. 9-48)
placemenr. Conscious sedarion is used wirh porrable fluoroscopy to restore lengrh by bringing the distal fragmenr beyond rhe
in the emergency care setting. The distal fragmenr and hand are proximal fragmenr. Reducrion is then obtained by flexing rhe
disrracred and rhen reduced volarly. With isolared distal radial distal fragmenr while mainraining lengrh (Fig. 9-49). Ofren this
426 Upper Extremity

FIGURE 9·60. Pin leverage. A: If a bayonet is irreducible, after sterile

preparation, a chisel-point Steinmann pin can be inserted between the
fracture fragments from a dorsal approach. Care must be taken not to
penetrate too deeply past the dorsal cortex of the proximal fragment.
B: Once the chisel is across the fracture site, it is levered into position
and supplementary pressure is placed on the dorsum of the distal frag-
ment (arrow) to slide it down the skid into place. This proredure i,s
usually performed with an image intensifier.

dim·action, or failure ro mainrain elbow flexion ar 90 degrecs

FIGURE 9-59. Once reduced, the fracture is maintained with finger rhat can occur with a human assiSlant. The cast is applied wirh
trap traction and countertraction on the arm. The quality of reduction rhe elbow flexed 90 degrees, rhe wrist in slighr palmar flexion,
is assessed quickly with the image intensifier.
and rhe forearm in the desired rorarion for srability and align-
memo This varies wirh each fracrure ancl each surgeon. My pref-
erence is slighr supinarion (20-30 degrees) unless rhe fracrure
dictares ditTerently. This allows excellem molding against the
inirial reducrion maneuver resrores lengrh and alignmenr, bur
volar aspecr of rhe distal radius at rhe fracrure sire.
rranslarionaJ reducrion is incomplere. The fracrure should be
One of the most importanr elemenrs in a successful long allTl
complerely reduced by roggling rhe disral fragmenr all rhe way
casc for a forearm fraccure is che apf)licacion of che webril. The
volarily by reperirive s'lighr dorsiflexion posirioning of rhe diml
webril should be applied in a continuous roll wich overlap of
fragmenr followed by volar pressure wirh rhe rhumbs. Ir is im-
one chird ro one half ics width. Excra padding is applied over
porranr ro anaromically reduce rhe fracrure. Loss of reduction
che olecranon, along che volar and dorsal forearm where che casc
wirh casr immobilizarion is more likely if rhe fracrure remains
may have ro be splic, and ac che ends of che casc co prevenr
rranslared or malaJigned.
irricacion from fraying. Plascer of paris is used for che caSl co
If rhe parienr presenrs lare wirh marked swelling and rhe
obtain che besc mold possibJe. Inicially a single layer IS applied,
reducrion is difflculr, ir is useful ro rry ro lever rhe proximal
foHowed by spl incs five layers chick along che volar and dorsal
fragmenr distally wirh a percuraneous smoorh wire (Fig. 9-(0).
forearm and che excension region of che elbow. This lessens che
This may prevenr an unnecessary open reducrion. Percuraneous
bulk of che casc and scill allows deep molds. The casc is compleced
pin rixarion is used afrer reduction.
wirh plascer of paris rolls OVe!" che splinrs. A rhree-poinr mold
is applied ac che fracture sice (Fig. 9-(1) as che cast hardens. In
addicion, molds are applied ro maincain a straighc ulnar border,
Cast Treatment
che incerosseous space, and scraighc poscerior humeraJ line. This
If rhe patienr is under 10 years of age, has no prereduction creaces che classic "box" long arm casc I·acher chan the all roo
signs or symproms of neurovascular impairmenr, or has minimal frequent "banana" cast chac allows for displacemenr. Final radio-
swelling, then casr immobilization is used (Figs. 9-61 and 9- graphs are obtained, and if che redllccioll is anaromic, che casr is
(2). I use a long arm cast. The casr is applied with the aiel either overwrapped with tiberglass to lessen che weighc, increase palicnc
of an assistanr or finger traps and balancing counrer weights on sacisfacrion, and prevenc casc breakdown chac could lead co loss
the upper arm (Fig. 9-59). The advanrage of the finger trap of reduction.
sreel residenr is thar there is no risk of muscle farigue, menral Pacients are eicher discharged or admicced co che hospical
 Chapter 9: Distal Radius and UIlla Frfl[{Um' 427

A B
FIGURE 9-61. A: Lateral radiograph of displaced metaphyseal radius and ulna fractures. B: Anteropos-
terior and lateral healed radiographs with anatomic alignment after closed reduction.

depending on the degree of concern regarding risk of excessive

swelling, neurovascular compromise, and patienr and parental
reliability. If there is any doubt, the patient is admirred for obser-
vation. The cast is split anytime there are signs of neurovascular
compromise. The patient is instructed to maintain elevation for
at least 48 ro 72 hours after discharge and rerum immediately
if excessive swelling or neurovascular compromise occurs. The
patienr and family are warned of the risk of loss of reducrion
and the need for close follow-up. We inform our patients and
parents that the risk of return ro rhe day surgery unit for repear
reduction is approximately 30% during the first 3 weeks.
FolJow-up examinations and radiographs are obtained every 7
to 10 days for 3 weeks. If rhere is loss of reduction, I individualize
treatment depending on the patient's age, degree of deformity,
time since fracture, and remodeling potemial (Fig. 9-53). If res-
toration of aJignment with growth occurs, I reassure the family
that the child should achieve anaromic alignment over time with
growth. If the child is older, there is risk offurther displacement,
or the deformiry is marked, repeat reduction in the day surgery
unir with fluoroscopy is performed. Most often, a percutaneous
pin is used for the second reduction (Fig. 9-55).
Cast immobilization usually is for 4 to 6 weeks. The long
arm CaSt is changed ro a shorr arm cast at 3 to 4 weeks. With
clinical and radiographic healing (Figs. 9-61 and 9-62), a protec-
tive volar splint is used and activities are restricted until the
patient regains full motion and strength, usually in 1 to 3 weeks
FIGURE 9-62. Anteroposterior and lateral radiographs of anatomic after cast removal. As with other distal radial fractures, formal
alignment with closed reduction of a distal radius metaphyseal fracture. physical therapy is rarely required.
428 Upper Extremity

Percutaneous Pin Fixation Complications

Percuraneous pinning of disra! radial meraphyseal fractures is Disral radial meraphyseal fracrures have complicarions similar
mosr ofren used in parients wirh excessive swelling or signs of co physeal fracrures but with differenr frequencies. Loss of reduc-
neurologic injury. In rhese siruations, rhe parienr is ar risk for rion and malunion are the mosr common problems, and growrh-
development of a forearm or carpal runnel comparrmene syn- relared complications are infrequenr. Neurovascular compro-
drome with a well-molded, right-firring casr. Similatly, concur- mise does occur and should be considered in rhe acure manage-
rem displaced supracondylar and distal radial fracrures are menr of rhis fracrure.
neared with percutaneous fixation of borh fracrures co lessen rhe
risk of neurovascular compromise. Older patiems near the end Malunion
of growrh wirh bayonet apposition fracrures also are treared wirh
Loss of reducrion is a common complication of disral radial
percuraneous pin fixarion because they have less abiliry co re-
mcraphyseal fracrures treared with cast immobilization. Because
model and rheir fracrures are very unsrable wirh a high risk of
rhis complicarion occurs in ar leasr 30% of bayoner apposirion
displacemenr. Finally, open fraceures usually are rreared wirh pin
fracrures (126,139,146,166,167), many surgeons trear rhis frac-
fixation. rure primarily wirh pin fixation co avoid rhe problems thar can
The pinning rechnique for the radius is eirher a single radial- occur wirh malunion (Fig. 9-51). Orherwise ir is clear rhar pa-
sided pin or crossed radial- and ulnar-sided pins. Fixarion of rhe rienrs treared wirh cast immobilizarion need ro be monitored
ulna rarely is necessary (Fig. 9-56). Srabiliry wirh a single pin closely (172).
is checked wirh fluoroscopy, and if further fixarion is needed, a Forrunarely, many angular mal unions of the distal radius will
second pin is added. The physis is avoided if possible. A small remodel (13,74,76,103,111,121-123,137,144,149), probably
incision is made for rhe inserrion of each pin co prorect rhe because of asymmetric physcal growrh (136,137). The younger
radial sensory nerve and adjacenr extensor tendons. Smoorh pins the patienr, [he less rhe deformity, and the closer rhe fracrure is ro
are used and are removed in rhe office as soon as rhere is sufficienr the physis, the grearer the porenrial for remodeling. Ir is unclear
healing co make the fracrure stable in a casr or spline, usually ar 4 wherher rhere is any capaciry for rorational malunion remodeling
weeks. Rehabiliration is similar co that for casr-treated fractures. (124,150). Angular and rotational malunion rhar does nor re-
model can lead to loss of morion. The degree and plane of loss
of morion, as well as the individual affected, derermine if this
Open Reduction is Funcrionally significanr (172). Cadaveric srudies indicate that
residual malangulation of more rhan 20 degrees of rhe radius or
The twO mosr common indications for open reduction are an ulna will lead to loss of forearm rotarion (140,158,159). Less
open fracrure (Haasbeck) and an irreducible fracture. All open than 10 degrees of malangularjon did not alter forearm rOfation
fractures are irrigated and debrided in rhe operating room. The significantly in eirher srudy. Distal rhird malunion affected rora-
inirial open wound is extended adequarely co inspect and cleanse tion less rhan middle or proximal third malunion. Radioulnar
rhe open fracture site. After rhorough irrigarion and debride- malunion affected forearm rorarion more rhan volar-dorsal mal-
ment, rhe fracrme is reduced and stabilized. A cast is rarely union. Malangularion may lead co a loss of rorarion at a 1: 2
applied in rhis siruarion because of concern about fracrure stabil- degree ratio, whereas malroration may lead co rorarional loss at
iry, sofr tissue care, and excessive swelling. Crossed pin fixarion only a 1: 1 degree loss (86). The funcrional loss associated with
ofren is used wirh Gustib grade 1 or 2 open fracrures. More rorarional morion loss is difficulr to predict. This has led some
severe sofr tissue injmies usually require external fixarion with clinicians ro recommend no trearmenr (110,111), arguing thar
a unilateral frame, with care raken co avoid soft rissue impinge- mosr of these fracrures will remodel, and rhose rhat do not re-
menr during pin placemenr. [f flap coverage is necessary for the model will not cause a funcrional problem (134). However, a
sofr tissue wounds, the fixacor pins should be placed in consulra- significanr functional problem is presenr if shoulder motion can-
tion with rhe microvascular surgeon planning the soft rissue not compensate for loss of supinarion.
coverage. ] prefer co reduce these fracrures as anaromically as possible
Irreducible fracrures are usually secondary ro soft rissue en- and lessen the risk of malunion. No elemenr of malrotation is
accepted in rhe reducrion. As indicared in rhe trearmenr secrions,
trapment. Wirh dorsal displacemenr, rhis is most often either
fracrures ar high risk of loss of reducrion and malunion are
the volar periosreum or pronacor quadrarus, and open reducrion
treared wirh anatomic reducrion and pin fixarion. Fracrures
through a volar approach is necessalY co extracr rhe interposed
treared in a cast are followed closely and re-reduced for any loss
sofr rissues and reduce rhe fracture (Fig. 9-63). Percuraneous
of alignment of more than 10 degrees. Although loss of roration
pin fixarion usually is used co stabilize rhe fracrure in patients
can occur with anacomic reducrion (32,142,168), ir is less likely
with open physes. If plare fixarion is used, jr should avoid viola-
rhan with mal unions.
rion of rhe physis (Fig. 9-36). Displaced inrraarricular injuries
in skeletally immature patients are adulrlike and require standard
Nonunion
rrearmenr such as open reducrion and inrernal fixarion (Fig. 9-
21) or combinarion trearmenr with internal and external fixation Nonunion of a closed radial or ulnar fracrure is rare. In children,
(Fig. 9-22). nonunion has been universally relared to a pathologic condirion
 Chapter 9: Distal Radim and Ulna Fractures 429

FD.S. FC.U.

E.D.C. E.P.L.

FIGURE 9-63. A: Volar approach through the interval be-

tween the digital flexors and ulnar neurovascular bundle. FOS,
flexor digitorum superficial is; FCU, flexor carpi ulnaris. B: Dor-
sal approach between the third and fourth dorsal compart-
ments. EOC, extensor digitorum communis; EPL, extensor pol-
licis longus. (Reprinted from Holmes JR, Luis OS. Entrapment
of pronator quadratus in pediatric distal-radius fractures: rec-
ognition and treatment. J Pediatr Orthop 1994; 14' 498--500;
B with permission.)

of rhe bone or vasculariry (68). Congenital pseudarrhrosis or of a single-bone forearm are surgical options. The best choice
neuroflbromarosis (35) (Fig. 9-64) should be suspecred in a depends on the individual parient.
parienr wirh a nonunion afrer a benign fracture. This occurs
mosr ofren in an isola red ulnar fracture. The distal bone is ofren
narrowed, sclerotic, and plasrically deformed. These fracrures Cross-Union
rarely heal wirh immobilization. Vascularized fibular bone grafr-
ing usually is necessary for healing of a nonunion associared wirh Cross-union is a rare complicarion of pediarric distal radial and
neuroflbromarosis or congeniral pseudarrhrosis. If the patienr is ulnar fracrmes. Ir has been described afrer high-energy rrauma
velY young, this may include a vascularized epiphyseal rransfer and internal f1xarion (164). A single pin crossing borh bones
ro resrorc disral growrh. increases rhe risk of cross-union (164). Synosrosis rake-down
Vascular impairment also can lead ro nonunion. Distal radial can be performed, bur rhe resulrs usually are less rhan full resrora-
nonunion has been reponed in a child with an ipsilateral supra- tion of morion. It is importanr ro derermine if rhere is an element
condylar fracrure wirh brachial artery occlusion. Revasculariza- of rorarional malunion wirh rhe cross-union because rhis will
rion of rhe limb led ro eveneua.! union of the fracwre. Nonunion affecr rhe surgical ourcome.
also can occur wirh osreomyeliris and bone loss (44). Debride- Sofr rissue conrracrion across borh bones also has heen de-
menr of rhe necroric bone and eirher rraditionaJ bone grafring, scribed (16). Contracrure release resulred in resrorarion offore-
osreoclasis lengthening, vascularized bone grafting, or crearion arm monon.
430 Uppa Extremity

the physis. This coincides wirh a Peterson type I fracrure (81,

82) (Fig. 9-65) and in essence is a physeal fracture. These frac-
rures should be monitOred for growrh arreSL
Both undergrowrh and overgrowth of the distal radius aher
fracrure has been described by DePablos (114). The average
difference in growrh was 3 mm, a range of - 5 ro +]0 mm
of growrh disrurbance compared with rhe contraJareral radius.
Maximal overgrowth occurred in rhe 9- to ] 2-year-old age
group. As long as the patienr is asympromatic, under- or over-
growrh is nor a problem. If ulnocarpal impaction or DRUJ dis-
ruprion occurs, rhen surgical rebalancing of the radius and ulna
may be necessary.

Neurovascular Injuries
Borh rhe median and ulnar (106,163) nerves arc less commonly
injured in meraphyseal fracrures than in physeal fracrmes. The
mechanisms of neural injury in a meraphyseal fracrure include
direct contusion from rhe displaced fragmenr, rracrion ischemia
from renring of rhe nerve over rhe proximal fragmenr (144),
entrapmenr of rhe nerve in rhe fracture sire (40,170), rare
laceration of rhe nerve (Fig. 9-66), and rhe developmenr of
an acure comparrmenr syndrome. If signs or symproms of
neuroparhy are presenr, a prompt closed reducrion should be
performed. Exueme posirions of immobilizarion should be
avoided because rhis can lead to persisrenr tracrion or compres-
sion ischemia and increase rhe risk of compartmenr syndrome.
If rhere is marked swelling, ir is bener ro percutaneously pin
FIGURE 9·64. This 3-year-old presented to the emergency room with rhe fracrure rhan ro apply a constrictive caSL If rhere is concern
pain aher an acute fall on his arm. The ulna is clearly pathologic with abour comparrmenr syndrome, rhe forearm and carpal canal
thinning and deformity prior to this injury. This represents neurofibro- pressures should be measured immediarely. If pressures are
matosis.
markedly eleva red , appropriare fascioromies and comparrmenr
releases should be performed immediareJy. Finally, if rhe nerve
was inracr before reducrion and is our afrer reducrion, neural
enrrapmenr should be considered, and surgical explora[ion
Refracture and decompression may be required. Forrunarely, mosr median
and ulnar nerve injuries recover afrer anaromic reducrion of
Fonunarely, refracrures afrer meraphyseaJ radial fracrures al'e rare
rhe fracrure.
and much less common than after diaphyseal level radial and
ulnar fracrures. Mosr commonly, refracture occurs with prema-
rure disconrinuation of immobiJizarion or early rerurn ro poren-
rially traumatic acrivities. Ir is advisable ro protecrively immobi- Infection
lize rhe wrist unril full radiographic and clinical healing (usually Infecrion afrer disral radial fracrures is rare and is associared wirh
6 weeks) and to resrricr acriviries unril full morion and strength open fracrures or surgical intervenrion. Fee e[ al. (117) described
are regained (usually an additional 1-3 weeks). Individuals in- rhe developmenr of gas gangrene in four children atrer minor
volved in high-risk activities, such as downhill sk.i racing, snow- puncture wounds or lacerarions associared wirh disral radial frac-
boarding, or skareboarding, should be prorecred wirh a splinr rures. Trearmenr involved only local cleansing of rhe wound
during those acriviries for much longer.
in all four and wound closure in one. All four developed life-
rhrearening closrridial infecrions. Three of rhe four required
upper limb ampUra[lOnS, and rhe fourth underwent mulriple
Growth Disturbance sofr rissue and bony procedures for coverage and rrearInL:nr of
Growrh arresr of the disral radius afrer meraphyseal fracrure is osreomyeliris.
rare. Abram and Connolly each reponed one parient wirh phy- !nfecrions relared ro surgical inrervemion also are rare. Super-
seal arresr afrer nondisplaced rorus fracrures. Two addirional ficial pin sire infecrions can occur and should be rrea[ed wirh
parienrs were reponed in a series of 150 disral radial meraphyseal pin removal and anribiorics. Deep-space infecrions from percu-
fracrures (119). Wil kins and O'Brien (168) proposed rhar rhese raneous pinning of rhe radius has nor been described, bur ir is
arrests may be in fracrures that extend from the metaphysis to only reasonable ro rhink rhar jr will occur ar some poinL All
 Chapter 9: Distal Radius find Ulna Fracwtes 431

A B
FIGURE 9-65. Peterson type I physeal injury. A: A comminuted distal metaphyseal fracture that extends
to the physis (open arrow). B: Six weeks after the fracture, the callus also extends up to the physis (open
arrow).

A B
FIGURE 9-66. A grade III open fracture of the radius resulted in complete disruption of the ulnar nerve.
Intraoperative photographs of the nerve deficit between the operative jeweler's forceps (A) and sural
nerve grafting (B) after the wound was clean enough to allow for nerve reconstruction.
432 Upper Extremity

deep-space lnfecrions should be treated with appropriate surgical

debridement, antibiotics, and wound management.

PEDIATRIC GALEAZZI FRACTURES -

fractures of the distal radius associated with DRUj disruption
have been called Galeazzi fracture-dislocations. AJthough Sir
Ashley Cooper is credited with the first description of this injury
in 1824, Riccardo Galeazzi (177,188) (Fig. 9-67) gave this frac-
ture-dislocation its name with his 1934 report of 18 such inju-
ries. In children, this injury may involve either disruption of
the DRUj ligaments or, more commonly, a distal ulnar physeal
fracture. The former is called a true Galeazzi lesion and the latter
is a GaJeazzi equivalent lesion (Fig. 9-68) (60,181,182,187,188).

Anatomy
The radius normally rotates around the relatively stationary ulna.
The two bones of the forearm articulate at the proximal and
distal radioulnar joints. In addition, proximally the radius and FIGURE 9-68. Galeazzi fracture-dislocation variant. Interposed perios-
teum can block reduction of the distal ulnar physis (arrow). This destabi-
ulna articulate with the distal humerus and distally with the lizes the distal radial metaphyseal fracture. (Reprinted from Lanfried
carpus. These articulations ate responsible for forearm pronation MJ, Stenciik M, Susi JG. Variant of Galeazzi fracture-dislocation in chil-
and supination, as well as elbow and wrist flexion and extension. dren. J Pediatr Orthop 1991;11: 333; with permission.)

At the DRUj, the concave sigmoid notch of the radius incom-

pletely matches the convex, asymmetric, semicylindrical shape

of the distal ulnar head (Fig. 9-69) (3). This allows some transla-
tion at the DRUj with rotatory movements. The ligamentous
strucrures are critical in stabilizing the radius as it rotates about
the ulna.
The DRUj includes multiple soft tissue attachments, the
most important of which is the TFCC. The TFCC includes the
volar and dorsal ligamentous attachments of the distal ulna to
the radial sigmoid notch, as well as the distal extension to the
ulnar sryloid, carpus, and base of the fifth metacarpal. The volar
ulnocarpal ligaments (V ligament) from the ulna to the lunare
and triquetrum are important ulnocarpal stabilizers (3,190,196).
The central portion of the TFCC is the articular disk (Fig. 9-
70). The interaction between the bony articulation and the soft

Dorsal

; Distal

FIGURE 9-67. Riccardo Galeazzi, 1866-1952. (Reprinted from J Bone FIGURE 9-69. (Redrawn from Bowers WHo Green's Operative Hand
Joint Surg fBr] 1953;35' 680; with permission.) Surgery. New York: Churchill-Livingstone, 1993: 98B.)
 Chapfer 9: Distal Radius and Ulna Fractures 433

tissue attachments accounts for stability of the DRUJ duting

pronation and supination. At the extremes of rotation, the joint
is most stable. The compression loads between the radius and
v ulna are aided by the tensile loads of the TFCC to maintain
stability throughout rotation (Fig. 9-71).
Throughout the mid-forearm, the interosseous ligament (Fig.
9-72) connects the radius to the ulna. It passes obliquely from
the proximal tadius to the distal ulna. However, the interosseous
ligament is nor present in the distal radius. Moore et aI. found
that injuries to the TFCC and interosseous ligament were re-
sponsible for progressive shortening of the radius with fra<:;ture
in a cadaveric study. The soft tissue component to the injury is
a major factor in the deformity· and instability in a Galeazzi
fracru re-dislocation. .

Diagnosis

J) I
Galeazzi fracture-dislocations are relatively rare injuries in chil-
dren. Walsh and Mclaren (194) cited an incidence of 3% of
pediatric distal radial fractures in their study. Most series of
GaJeazzi fracture contain a relatively small number of pediatric
patients (81,182,183,194).
The mechanism of injury is axial loading in combination
with extremes offorearm rotation (175,187,189,191). In adults,

III/! the mechanism of injury usuaJly is an axially loading fall with

hyperpronation. This results in a distal radius fracture with a
dorsal ulnar dislocation. However, in children, both supination
FIGURE 9-70. Diagrammatic drawing of the meniscal reflection and
the prestyloid recess. The meniscal reflection runs from the dorsoulnar (apex volar) and pronation (apex dorsal) deforming forces have
radius to the ulnovolar carpus. The arrow denotes access under the been described (181,182,194). The mechanism of injury is most
reflection to the tip of the styloid-the so-called prestyloid recess. (Re- obvious when the radial fracture is an incomplete fracture. With
drawn from Bowers WHo Green's Operative Hand Surgery. New York:
Churchill-Livingstone, 1993.) an apex volar (supination) radial fracture, the distal ulna is dis-
placed volarly, whereas with an apex dorsal (pronation) radial
fracture, the distal ulna is displaced dorsaJly (Figs. 9-68 and 9-

Dorsal
Dorsal

Dorsal

Pronation Midrotation Supination

FIGURE 9-71. Distal radioulnar joint stability in pronation (left) is dependent on (1) tension developed
in the volar margin of the triangular fibrocartilage (TFC, small arrows) and (2) compression between
the contact areas of the radius and ulna (volar surface of ulnar articular head and dorsal margin of the
sigmoid notch, large arrows). Disruption of the volar TFC would therefore allow dorsal displacement of
the ulna in pronation. The reverse is true in supination, where disruption ·of the dorsal margin of the
TFC would allow volar displacement of the ulna relative to the radius as this rotational extreme is
reached. The dark area of the TFC emphasizes the portion of the TFC that is notsupported by the ulnar
dome. The dotted circle is the arc of load transmission (lunate to TFC) in that position. (Redrawn from
Bowers WHo Green's Operative Hand Surgery. New York: Churchill-Livingstone, 1993.)
434 Upper Extremity

Interosseous membrane

FIGURE 9-72. The attachment and the fibers of the interosseous membrane are such that there is no
attachment to the distal radius. (Redrawn from Kraus B, Horne G. Galeazzi fractures. J Trauma 1985;
25.1094; with permission.)

69). This is evidenc borh on clinical and radiographic examina- ment of rhe disral radial fracture. Dorsal displacemenr (apex
rions. In addirion, rhe radius is foreshorrened in a complere volar) fracrures were more common than volar displacement
fracrure, causing more radial deviarion of rhe hand and wrist (apex dorsal) fracrures in rheir series (Fig. 9-73). Wilkins and
(Fig. 9-70). A child with a Galeazzi injury has pain and limitation O'Brien (168) modified the Walsh and McLaren merhod by
offorearm rotarion and wrist flexion and extension. Neurovascu- classifying radial fractures as incomplete and complere fracrures
lar jmpairmem is rare. and ulnar injuries as true dislocarions and physeal fracrures
The radial fracture is evidem on radiographs, and concurrent (Table 9-4). DRUj dislocarions are called [fue GaJeazzi lesions
injuries to the ulna or ORUj should be idencified. A rrue lareral and distal ulnar physeal fracrures are called Galeazzi equivalenr
view is necessary ro identify rhe direction of displacemem, which lesions (60,178,18],182).
is imperarive to determine the method of reducrion. Rarely are
special radiographs, such as a CT scan, necessary.
Treatment
Pediarric Galeazzi fracwres have a higher success rare wirh non-
Classificatio n
operarive trearmenr rhan similar injuries in adults (J 83, 187). In
Galeazzi fracrure-dislocarions are mosr commonly described by adulrs, ir is imperative ro anaromically reduce and internally fix
direcrion of displacement of eirher the disral ulnar dislocarion rhe disral radial fracrure (l80, 183, 184,185, 187). Generally rhe
or rhe radial fracrure. Lens (181,182) preferred ro describe rhe DRUJ is reduced wirh reducrion and fixation of the radius. In
direcrion of the ulna: volar or dorsal. Walsh and McLaren (194) pediarric patients, the distal radial fracture ofren is a greensrick
classified pediatric Galeazzi injuries by the direction of displace- type char is scable afcer reducrion and casr immobilizacion is

A B
FIGURE 9-73. Walsh's classification. A: The most common pattern, in which there is dorsal displacement
with supination of the distal radius (open arrow). The distal ulna (black arrow) lies volar to the dorsally
displaced distal radius. B: The least common pronation pattern. There is volar or anterior displacement
of the distal radius (open arrow), and the distal ulna lies dorsal (black arrow). (Reprinted from Walsh HPJ,
McLaren CANP. Galeazzi fractures in children. J Bone Joint Surg [Br) 1987;69:730-733; with permission.)
 CiJf1ptrr 9: DiJta{ Radius alld Ulna FractureJ 435

should align the fracrure and reduce the DRUJ (Fig. 9-74).
TABLE 9-4. CLASSIFICATION: GALEAZZI
Similarly, if the incomplete radial fracture is an apex dorsal volar
FRACTURES IN CHILDREN
displaced fracture, the rotatory deformity is pronation (Fig. 9-
Type I: Dorsal (apex volar) displacement of distal.radius 75). Supinating the forearm and applying volar-to-dorsal force
Radius fracture pattern should reduce the incomplete fracture of the radius and the
Greenstick
Complete
DRUJ dislocation (168,181,182,193). In both these situations,
Dista I ulna physis pOl·table fluoroscopy can be used to evaluate the fracture-dislo-
Intact cation reducrion and to test the srability of the distal ulna. If
Disrupted (equivalent) anacomically reduced and stable, a long arm cast is applied with
Type II: Volar (apex dorsal) displacement of distal radius appropriate rotation and three-point molds. The cast is left in
Radius fracture pattern
Greenstick
place for 6 weeks to a]Jow the soft tissue injuries to heal.
Complete In a Galeazzi equivalent injury with a radial fracrure and an
Distal ulna physis ulnar physeal fracture, both bones should be reduced. Usually
Intact this can be accomplished with the same methods of reduction
Disrupted
if the radial fracture is incomplete. The distal ulnar physis can
remodel a nonanatomic reduction if there is sufficient growth
Reprinted from Walsl HPJ, McLaren CAN, Owen R. Galeazzi
fractures ,in children. J Bone Joint Surg (Bri 1987 698:730-733.
remaining and the ulnar physis continues to grow normally.
Unfortunately, the risk of ulnar growth arrest after a Galeazzi
equivalent has been reponed to be as high as 55% (52).
Complete fractures of the diStal radius have a higher rate of
loss of reducrion after closed treatment (168). If not monitored
closely and re-reduced if necessary, loss of reduction can lead to
malunion with Joss of motion and function. These injuries may
sufficient (183,194). However, adolescents with complete frac-
be best treated with open reducrion as in adults.
tures should be treated with internal fixation similar to adults.

Open Reduction
Closed Reduction
The indication for open reducrion of the radial fracrure is failure
The method of reduction for greenstick radial fractures depends to obtain or maintain fracrure reduction. This most often occurs
on the type of displacement. With apex volar dorsally displaced with unstable complete fractures (Fig. 9-76). Open reduction
ftactures of rhe radius, the rotacory deformity is supination. Pro- and internal fixation of the radius are performed via an anterior
nating the radius and applying dorsal-to-volar redUCtion force approach (Fig. 9-77). Standard compression plating is preferred

A B
fiGURE 9-74. Supination-type Galeazzi fracture. A: View of the entire forearm of an ll-year-old boy
with a Galeazzi fracture-dislocation. B: Close-up of the distal forearm shows that there has been disrup-
tion of the distal radioulnar joint (arrows). The distal radial fragment is dorsally displaced (apex volar),
making this a supination type of mechanism. Note that the distal ulna is volar to the distal radius. (Figure
continues.)
436 Upper Extremity

c D
FIGURE 9-74. (continued) C and D: The fracture was reduced by pronating the distal fragment. Because
the distal radius was partially intact by its greenstick nature, the length was easily maintained, reestab-
lishing the congruity of the distal radioulnar joint. The patient was immobilized in supination for 6
weeks, after which full forearm rotation and function returned.

FIGURE 9-75. Pronation Galeazzi. This 8-year-old sustained a pronation Gal-

eazzi fracture. A: The anteroposterior view shows some shortening of the distal
radius (arrow) in relation to the distal ulna, which has a small greenstick compo-
nent. B: The pronation component (arrow) is better appreciated on this lateral
A view. The distal ulna lies dorsal to the distal radius (open arrow).
 Chapter 9: Dista! Radius and Ulna Fractures 437

ro imramedullary or cross-pinning techniques. Stable. anaromic

reducrion of rhe radius almosr always leads ro stable reducrion
of rhe ORUj dislocation. A long arm cast is used for 6 weeks
ro allow fracture and sofr tissue healing.
Occasionally, rhe ORUj dislocarion cannot be reduced (Fig.
9-78) because of interposed soft rissues, mosr commonly the
periosteum, extensor tendons (exrensor carpi ulnaris, extensor
digit quimi), TFCC, or orher ligamenrous srrucrures (173,174,
179,182). The easiest approach for open reducrion of the ORU]
Long forearm is an extended ulnar approach. Care should be raken ro avoid
muscles injury to the ulnar sensory nerve. This approach allows for expo-
Pronator
sure both volarly and dorsaJly to extract rhe imerposed sofr tis-
sues and repair the torn srructures. Smooth pin fixation of rhe
~~!1~WJ quadratus ORUj can be used to maintain reduction and allow application
of a loose-fitting cast. The pin is removed in rhe office ar four
weeks wirh continuarion of rhe casr for 6 weeks.
Similarly, rhe ulnar physeal fracture can be irreducible in a
Galeazzi equivalent injUlY. This also has been reported ro be
FIGURE 9-76. Fractures of the distal radius are angulated toward the
ulna due to the pull of the long forearm muscles and the pronator secondary to interposed periosteum (60,187), exrensor rendons
quadratus. (Redrawn from Cruess RL. The management of forearm inju- (48,57,103), or joint capsule (176). Open reducrion musr be
ries. Orthop C1in North Am 1973;4:969-982; with permission.)
executed wirh care to avoid further violaring the physis.

A B
FIGURE 9·77. A: The patient with the pronation injury shown in Fig. 9-69 had a closed reduction and
attempted fixation with pins placed percutaneously across the fracture site. However, this was inade-
quate in maintaining the alignment and length of the fracture of the distal radius. B: The length of the
radius and the distal radioulnar relationship were best reestablished after internal fixation of the distal
radius with a plate placed on the volar surface. The true amount of shortening present on the original
injury film (see Fig. 9-69A) is not really appreciated until the fracture of the distal radius is fully reduced.
(Reprinted from Wilkins KE, ed. Operative management of upper extremity fractures in children. Rosem-
ont, IL: American Academy of Orthopaedic Surgeons, 1994: 34; with permission.)
438 Upper I::.Xmmity

A B
FIGURE 9-78. An adolescent girl presented 4 weeks postinjury with a painful, stiff wrist. A: By examina-
tion, she was noted to have a volar distal radioulnar dislocation that was irreducible even under general
anesthesia. B: At the time of surgery the distal ulna was noted to have buttonholed out of the capsule,
and there was entrapped triangular fibrocartilage and periosteum in the joint.

• AUTHOR'S PREFERRED METHOD Complete Fractures

\...~ 0 F TREATMENT Open reducrion and internal fixation with an anterior plate and
screws are used for complete Galeazzi fractures of the radius.
Incomplete Fractures The ORU] usually reduces anaromically and is stable with reduc-
Incomplete fractures of the distal radius with either a true dislo- tion and fixation of the radius. The patient is immobilized in a
cation of the ORU] or an ulnar physeal fracture are treated with long arm cast for 4 weeks and a short arm cast for 2 more
closed reJuction and long arm cast immobilization. This can be weeks. Rerurn to unrestricted activities and SpOrts depends on
performed in the emergency setting with conscious sedation or restoration of full motion and strength.
in the operating room with general anesthesia. Porrable fluoros-
copy is used. If the fracture is apex volar with dorsal displacement
Irreducible Dislocations
of the radius and volar dislocation of the DRU], then pronation
and volar-to-dorsal force on the radial fracture is used for reduc- Irreducible dislocations are treated with open reduction. Exten-
tion. If the fracture is apex dorsal with volar displacement of sile exposure is necessary to define the pathologic anatomy and
the radius and dorsal dislocation of the ORU], then supination carefully reduce the DRU]. The interposed soft tissues are ex-
and dorsal-to-volar force is applied to the distal radius for reduc- tracted and repaired. Depending on the stabiliry of the reduction
tion. The reduction and stability of the hacture and ORU] dislo- and tepair, a supplemental smooth pin may be used across the
cation are checked on dynamic fluoroscopy before long arm cast ORU] for 4 weeks to maintain the joint reduction. This is parric-
immobilization. Ifboth are anatomically reduced and stable, the ularly true if the patient presents late.
cast is used for 6 weeks ro allow soft tissue and fracture healing.
[n a Galeazzi equivalent injury, there is potential for remodeling Complications
of the physeal fracture if sufficient growth remains. As long as
the DRU] is reduced, malalignment of less than 10 degrees can Malunion and DRUJ Subluxation
remodel in a young child. The risk of physeal growth arrest is Malunion of the radius can lead to subluxation of the ORU],
high with this physeal injury, and operative exposute may in- limited forearm rotation, and pain, usually secondary to persis-
crease the of growth impairment. If the fracture is severely mal- tent shortening and malrOtation of the radial fracture. Most
aligned, the ORU] cannot be reduced, or the patient is older often this occurs when complete fractures are treated with closed
and remodeling is unlikely, open reduction and smooth pin redUCtion and there is failure to either obtain or maintain reduc-
fixation are indicated (168). tion of the radial fracture. The ulna remains subluxed and heals
 Chapter 9: Distal Radius and Ulna Fractures 439

with an incongruent joint. Treatmem for this requires proper 5. Cheng JC, Shell WY. Limb fracrure pattern in different pediatric age
groups: a study of 3,350 children. j Orthop Trauma 1993;7:15.
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 INJURIES TO THE SHAFTS OF THE
RADIUS AND ULNA
CHARLES T. PRICE
GREGORY A. MENCIO

FRACTURES OF THE SHAFTS OF THE RADIUS Surgical Anatomy

A D UI A Mechanism of Injury
Diagnosis Classification
Classifica tion Signs and Symptoms
Anatomy Radiographic Findings
Treatmem Principles Treatmem
Treatment Options Prognosis
PLASTIC DEFORMA~ ION OF THE RADIUS A D Complications
UL A

FRACTURES OF THE SHAFTS OF THE placed. He advocated pronation or supination of greenstick,

RADIUS AND ULNA Monteggia, and Galeazzi fracrures based on the mechanism of
injury (29,30). For complete fractures, Evans recommended de-
Fractures of the radius and ulna shafts account for only 3% to termining the position of the bicipital tuberosity of the radius
6% of all children's fractures (64,65) (Fig. 10-1). In boys, there on an ameroposterior (AP) radiograph, then placing the distal
is a bimodal peak, the first at approximately age 9 years and the fragment in the same amount of rotation to effeer reduction
second at approximately 13 or 14 years of age. Girls show a (Fig. 10-2). He found that all such fractures usuaJly needed to
single peak at approximately age 5 or 6 years (65). Approximately be immobilized in some degree of supination (Fig. 10-3).
75% of fractures of the shafts of the radius and ulna are in the
distal third, 15% in the middle third, and 5% in the proximal
Diagnosis
third. Momeggia fraerure-dislocations and complex injuries ac-
coum for the remaining 5% (25,38,123). Mechanism of Injuries
Tradirional teaching (30,42) developed a concepr of postre-
Because conical bone is strong, it ofren requires greater trauma
ducrion positioning based on which third of the radial and ulnar
to produce failure of the diaphysis than the metaphysis. As is
shafts was fractured:
typical of most fractures in the upper extremity, fractures of the
1. If the fracture of the shafts was proximaL to the insenion of radial and ulnar shafts usually are caused by indirect forces, such
the pronator teres, the forearm should be held in supination. as landing on the outstretched upper extremity (Fig. 10-4).
2. If the fracture was in the middLe third, mid-position was ad- When the child falls, the main deforming force is transmitted
vised. to the radius. The radius usually fails first, followed by the ulna
3. If the fracture was in the distaL third, pronation was the posi- (128). Shaft fractures are more common in younger children
tion of choice. because the conical bone is more porous and the transirion from
diaphysis to metaphysis is less distinct than in older children
This concept was challenged by Evans, who recognized two (128).
groups of fractures: those in which rhe shaft of the radius re-
mained in continuity and those in which it was completely dis-
Signs and Symptoms
Pain, swelling, crepitus, and deformity make the diagnosis ob-
vious. However, plastic deformation injuries present primarily
Charles T. Price: Department of Pediatric Orthopaedics, Orlando Re-
with deformity, mild tenderness, and limited forearm rotation.
gional Healthcare System, Orlando, Florida.
Gregory A. Mencio: Department of Onhopaedics and Rehabiliraraion, Pain and swelling may be minimal and crepitus is absent in
Vanderbilr University Medical Cenrer, Nashville, Tennessee. pJastic deformation injuries and minor greenstick fractures.
444 Upper .Extremity

25 ...- Boys
0--0 Girls
20

15
.-
10 \
.:
5 Level of
Fracture

o 5 10 15
Age
FIGURE 10-1. The annual incidence per 10,000 children of fractures of
the shaft of the radius and ulna for the various age groups. Note the
bimodal peaks for boys and single peak for girls. (From Landin LA. Frac-
ture patterns in children: analysis of 8,682 fractures with special refer-
ence to incidence, etiology and secular changes in a Swedish urban
80· 90· 100·110·,20·130.140·,50·160.170.180.
population, 1950-1979. Acta Orthop Scand Suppl 1983;202:65; with
permission.)

FIGURE 10-3. The rotational position of the upper radial fragment in

50 cases, plotted against the level of fracture. Each case is represented
by a black dot. (Redrawn from Evans E. M. Fractures of the radius and
Radiographic Findings ulna. J Bone Joint Surg Br 1951 ;33: 548; with permission.)

Rotational Alignment
Anteroposterior and lateral radiographs that include both the
proximal and distal radioulnar joints are essential for an accurate ment may be in any position, but the position of the proximal
analysis of rotation of the fracture fragments. The radius is a fragment is determined by muscle pull.
curved bone and malrotation can be recognized by a break in For complete fractures, it is necessary to determine the posi-
the smooth curve of the radius and a sudden change in the width tion of the proximal fragment so that the distal fragment can
of rhe cortex (17,68,76,82). Radiographs should also reveal be positioned to align with the same amount of rotation as the
whether fracrures are complete or incomplete. Incomplete, or proximal fragment. This can be derermined by the position of
greenstick, fractures with angulation usually have a rotational the bicipital ruberosity in the fl'actured radius. The bicipital ru-
deformity (Fig. 10-5). If the fracture is complete, the distal frag- berosity is medial when the forearm is supinated, posterior when
in mid-position, and lateral when pronated (Fig. 10-2). If in
doubr, radiographs of the opposite normal forearm should be
obrained in supinarion, mid-posirion, and pronarion to compare
rhe posirion of rhe bicipital tuberosity.
Milch proposed the following anatOmic criteria to determine
proper torsional alignment of rhe forearm bones. regardless of
rhe degree of rotation (76):

1. The coronoid process of rhe ulna points anreriorly and the

styloid process of the ulna points posreriorly in the lateral
projection. The radial styloid is nor seen in the normal lateral
projection with the forearm supinared.
2. In the normal AP view wirh the forearm supinated, the coro-
noid and styloid processes of the ulna are hidden bur rhe
radial styloid and bicipiral ruberosity are seen. For example,
in a completely supinated normal forearm, an AP view shows
both rhe bicipitaJ tuberosity and the radial styloid, bm neirher
the coronoid process nor rhe ulnar styloid is seen. The lateral
O·
view shows both rhe coronoid process and rhe ulnar styloid,
FIGURE 10-2. The normal bicipital tuberosity from full supination (90 bur neither prominence of the radius is seen. Thus, if the
degrees) to mid-position (0 degrees). In children, these characteristics
are less clearly defined. (Redrawn from Evans EM. Fractures of the ra- styloid process of rhe ulna is seen on the AP view and is
dius and ulna. J Bone Joint Surg Br 1951;33' 548; with permission.) absent on the lateral view, a torsional deformity of the ulna
 Chapter / (): f njl/ries to the Shafts of the Radius lind Ulna 445

Monteggia Fracture c

Galeazzi Fracture
o

A. B Torus Fracture Complete Fracture

FIGURE 10-4. A fallon the outstretched hand can produce any of these shaft fractures: torus fracture
(A); complete fracture (B); Monteggia fracture-dislocation (C); Galeazzi fracture-dislocation (D).

B
FIGURE 10-5. Angulation plus rotation. A and B: Forced supination of the forearm produces a fracture
pattern with apex volar angulation in addition to dorsal displacement with supination of the distal
fragment. (Figure continues.)
446 Upper EWl'emity

FIGURE 10-5. (continued) C and D: Forced pronation of the forearm can

result in a fracture pattern with apex dorsal angulation, in addition to prona-
tion and volar displacement of the distal fragment. E: Clinically, the apex
E dorsal angulation (arrow) in pronation injuries is much more prominent.

is presenc. If the bicipital ruberosiry of the radius projects fracrures are "B," and complex fractures are "C" (Fig. 10-6).
medially in the AP view and rhe radial sryloid is not seen, Wedge and complex fracrures are uncommon in children, so
torsional deformiry of rhe radius is preseO(. most pediatric shafr Fracrures are designated 22-A. W'hen only
3. In the mid-position no bony prominences are seen in rhe AP the ulna is fractured, rhis is identified with an additional numeral
projection, but all four prominences are seen on the lateral "1" (22-Al). An isolated simple radial fracrure is idenrified with
view. Angulation usually is associared with rorarion (Fig. lO- an additional "2" (22-A2). The mosr common fracrure is a sim-
S). ple Fracrure of both bones. Simple borh-bone shaft fractures
are identified by adding rhe numeral "3" (22-A3) (Fig. 10-7).
Subgroups are identified by placing a decimal and using addi-
tional numerals. For example, a simple franure of the ulnar shafr
Classification
with radial head dislocation, Monteggia fracture-dislocation, is
The Orrhopaedic Trauma Associarion (OTA) has classified Frac- identified as 22-B1.3 (Fig. 10-8). More complex fracrures have
tures of rhe radi,us and ulna with rhe numeric designarion of additional alphanumeric classifications to allow for srandardiza-
"2." Diaphyseal fracrurcs are classified with a second number rion of research and communication (92).
"2." Thus, all shaft fractures of rhe radius and ulna are desig- The OTA Classificarion System has some deficiencies when
nared "22." Simple fractures are given the letrer "A," wedge applied to pediarric and adolescenr Forearm Fractures. Greensrick
 Chapter J 0: jnjuries to the Shafts of the Radius and Ulna 447

Bone: Location: Types:

Radius/ulna (2) Diaphyseal (22) A. Simple (22-A)

I \ '\
, \r' I
~ .... _ ... __ .... 1

B. Wedge (22-B)

C. Complex (22-c)

FIGURE 10-6. Orthopedic Trauma Association Classifica-

tion. Fractures of the radius and ulna are designated by
the numeral "2." Diaphyseal fractures are identified by a
second numeral "2." Simple fractures are given the letter
"A," wedge fractures are "8," and complex fractures are
"c." (Redrawn from Orthopaedic Trauma Association
Committee for Coding and Classification. Fracture and
dislocation compendium. J Orthop Trauma 1996;10[Suppl
1): 1; with permission.)

fracrures and plasric deformarion are nor classified separately. identified as either apex volar (supinarion injury) or apex dorsal
Comminution is rare in children and oFren has litrle clinical (pronarion injury). This disrincrion is particularly imporranr For
significance. Treatmeor decisions in the pediarric age group managemenr of greensrick fracrures.
rarely depend on specific classification. Closed reductions are Level offracture: The level of fracture is iden tifled as occurri ng
common in rhe pediarric age group and clinical decisions are in the proximal, middle, or distaJ third.
based on degree of completion and level of the Fracture, com-
bined with severity and direction of deFormity.
The rraditional classification of shaft fractures of the radius Joints Disrupted
and ulna is ourlined in rhe following secrions. These types of forearm shaft fracrures include Monreggia Frac-
rure-dislocarion, when rhe ulnar shaFt fracrure is associared with
radial head dislocarion proximally, and Galcazzi fracrure-dislo-
Joints Intact
cation, when rhe radial shaFt Fracrure is associared wirh disloca-
Shah fractures in which rhe proximal and disral radioulnar joints rion of rhe disral radioulnar joinr. Mooreggia and Caleani hac-
remain ioraer can be subcategorized by their degree of comple- rures are discussed elsewhere in this rextbook, bur rhe clinician
tion, direcrion of deformiry, or level of fracrure (Table 10-1): musr always be cognizanr of rhe possibility of occult or missed
joinr disruprion whenever a Forearm fracture is identified.
Degree of completion: The degree of completion usually is
defined as plasric deformarion, greensrick, or complete. Proper
Unusual Fracture Patterns
identificarion is important because each of these types is man-
aged differenrly. Plascic deformation inj mies also may be difflculc co derecr and
Direction ofdeformity The direcrion of the deFormity can be require special managemenr techniques.
448 Upper Lx/remit)'

RADIUS/ULNA

Groups:
Radius/ulna, diaphyseal, simple Radius/ulna, diaphyseal, wedge Radius/ulna, diaphyseal, complex
(22-A) fracture (22-8) (22-C)
1.Ulna simple, radius intact 1.Ulna simple, radius intact 1.Complex of ulna (22-C1)
(22-A1) (22-81)

2.Radius simple, ulna intact 2.Radius fracture, ulna intact 2.Complex of radius (22-C2)
(22-A2) (22-82)

3.Simple fracture both bones 3.Wedge fracture, simple or 1.Complex of both bones (22-C3) FIGURE 10-7. Orthopedic Trauma As-
(22-A3) wedge of other bone (22-83) sociation Classification. When only the
ulna is fractured, this is identified by
the additional numeral "1." Isolated
radius fracture is identified with an
additional "2." Both bone fractures
are identified by adding the numeral
"3." (Redrawn from Orthopaedic
Trauma Association Committee for
Coding and Classification. Fracture
and dislocation compendium. J Or-
thop Trauma 1996;10[SuppI1]:1; with
A B C permission.)

3.With dislocation of radial head

(Monteggia) (22-81.3)

TABLE 10·1. CLASSIFICATION: SHAFT

FRACTURES

Radioulnar Joint Intact

Degree of completeness
Plastic deformation
Greenstick fracture
Complete disruption
Direction of deformity (greenstick)
Apex volar (supination injury)
Apex dorsal (pronation injury)
Level of fracture
Proximal third
Middle third
Distal third
FIGURE 10-8. Orthopedic Trauma Association Classification. Radioulnar joints disrupted
Subgroups of forearm fractures are identified by the use of a decimal Proximal-Monteggia fracture-dislocation complex
and additional numerals. Monteggia fracture dislocation is classified
Distal-Galeazzi fracture
22-B 1.3. (Redrawn from Orthopaedic Trauma Association Committee
for Coding and Classification. Fracture and dislocation compendium. J
Orthop Trauma 1996;10[Suppl 1]:1; with permission.)
 ChajJtfr J 0: Injuries tli the Shrifrs of the Radius and Ulna 449

FIGURE 10-9. "Floating elbow" injury. A and B: A 5-year-old with ipsi-

lateral grade II open fracture of the radius and ulna and a type III, closed
supracondylar humerus fracture. C and 0: Irrigation and debridement of
the forearm wound followed by intramedullary stabilization of the ulna.
The supracondylar fracture was treated by open reduction and pinning.
(Figure continues.)

A B

c D

The so-called floating elbow (Fig. 10-9) is a special variant with closed reduction and plaster immobilization if the forearm
that combines a ftacture of the humerus with a forearm fracture. fracture is stable or minimally displaced (99,119,149). However,
Ipsilateral forearm fractures are seen in 3% to 13% of supracon- when the forearm Fracture is unstable or open, or jf there is exten-
dylar fractures (99,119,149). The supracondylar fracrure usually sive soft tissue injury, plate or inrramedullaty fixation may be a
is displaced and requires closed reduction with pinning before more appropriate method to maintain reduction (Fig. 10-10).
the forearm fracrure can be treated. Nondisplaced supracondylar Segmental, comminuted, or open forearm Fractures usually
fractures may not require pinning (149). Afrer stabilization of indicate high-energy trauma. More aggressive managemenr usu-
the supracondylar fracture, the forearm fracture can be treated aJly is warranted for these types of injuries.
450 Upper Ev:tremit)'

FIGURE 10-9. (continued) E and F: All fractures healed at 4 weeks after surgery before
pin removal in the office. G and H: Forearm and elbow at 1 year aher surgery are virtually
anatomic.

G H
 Chilpter 10: Injuries 10 the Shafts of the Radius and ULlin 451

B
FIGURE 10·10. Ipsilateral supracondylar fractures. A: A 1O-year-old with grade I open fractures of the
radius and ulna (open arrows). An ipsilateral supracondylar fracture is manifest by considerable swelling
at the elbow (large black arrows). B: The supracondylar fracture was first manipulated and reduced and
then secured with pins placed percutaneously. The forearm fracture was then cleaned and debrided,
and secured with intramedullary pins inserted distally.

Anatomy deformity. Delayed unions and nonunions are rare in children.

Thus, closed reduction and cast immobilization is often success-
The radius bows laterally immediately distal to the bicipital tu-
ful and should be arrempted in most fractures.
berosity. The bicipital tuberosity is distal to the neck on the
Cadaver studies (76, J 22) have demonstrared that 10 degrees
medial aspect of the shaft and slightly anrerior. The radius has
of residual fixed angular deformity in the middle or distal third
one distinct border for the attachment of the interosseous mem-
of rhe radius or ulna does not cause functional loss of forearm
brane. The proximal radius is cylindrical, changing to a triangu-
rotation. ROtatOl-Y deformities produced losses of pronarion and
lar shape at the junction of the proximal and middle thirds and
supination equal to the degree of rotational deformity (J 22).
flattening at its lower end. The radius, like the ulna, is a thick-
Sarmiento et a1. compared experimental results from cadaver
wa.lled bone throughout the greater part of the shaft.
studies with clinical radiographic findings in 105 patients wi th
The radius is bound to the ulna by the inrerosseous mem-
residual deformities and concluded that limitation of rotation
brane and annular ligament at the proximal radioulnar joint.
is within c1inicaJly acceptable ranges with residual angulation of
The triangular articular disk binds the radius to the ulna at the
10 degrees or less (J 13).
distal radioulnar joint. These structures allow pronation and
Spontaneous correction of residual angulation can occur in
supination movemenrs of the forearm. The interosseous distance
children. The amount of correction depends on age, the distance
is greater disraJly than proximaJly because of rhe curve of the
from the physis, the severity of deformity, and the direction of
radius. In pronation, the radius totates diagonally across the ulna
angulation. Grearer degrees of correction can be expected in
and the palm faces posteriorly. The crossover poinr of the twO
younger children and in more distal fractures (J 1,24,38,54,89,
bones is in the proximal forearm. Walker demonstrated that
139,153). Onne and Sandblom observed that during the first
longitudinal forces of Jess than 9.8 kg are rransmj[[ed by the decade of life, the shafts of the forearms have an excellent capac-
interosseous membrane to the ulnohumeral joint and loads of ity of correcting angulation up to 20 degrees spontaneously (89).
greater magnitude are transmi[[ed to the radiohumeral joint Others have confirmed this remodeling porencial (38,50,79,95,
(142). 96,J23,J39). The capacity for remodeling diminishes aner the
age of J0 years. Angulation of more tnan 10 degrees after the
age of 10 years is unlikely to remodel (35,50,54,89,95,96,139).
Treatment Principles
Malrotation is difficult to measure and mayor may not re-
The objecrive of successful treatment of greenstick or complete model (2 ],35,42,95,96). Fuller and McCullough observed that
fractures is fuJI recovery of forearm rotation without cosmetic malrotarion of the fracture limited movement co the same degree
452 Upper Extremit),

as the rotational deformity (35). Gram and Weiss observed that with the apex of the angle towatd the interosseous space, resul ted
malrotation does nor conect with growth, but noted that 30 in loss of motion. Roberts (104) confirmed this finding, but
degrees of malrotation may be accepted without functional defI- Price et a1. (95,96) stated that interosseous encroachment is an
cit (42). unpredictable indicator of loss of motion.
Determining acceptable limits for angulation at the time of Location of the fracture is another facror that influences out-
reduction is complicated by Ihe fan that malunion does not come. Numerous researchers have noted that proximal shaft frac-
always com:I:Hc with loss of forearm rotation. Daruwalla ob- rures have a worse prognosis than distal shaft fractures (10,21,
served that it is difflcull ro predict the cxtenr of limitation of 24,38,95,96,123,130,153).
fotearm movement with varying degrees of angulation (24). Recommendations for acceptable teduction vary. Moesner
Hagstrom et al. observed that the correlation between final an- and Ostergaard (79) stated that children younger than 9 years
gulation and range of pronation and supination is weak (50). of age with angulation of less than 20 degrees will regain full
This observation has been confirmed by others (42,51,84,95, range of motion and 90% remodel iog. This conclusion has been
%,15.3). supported by Carey et al. (15) and others (54,89,39). However,
From a functional standpoint, Carey et aJ. (15) noted that Blount (10) cautioned, "fracrures of the middle third of rhe
patienrs older than 10 years of age might have residual changes forearm should not be allowed to remain angulated ro any appre-
on radiographs without a commensurate loss in range of motion. ciable degree except in velY young childten." Daruwalla (24)
They reponed on nine patients, 11 ro 15 years of age, with an concluded that after age 6 years, remodeling is unlikely ro correct
average angulation of 13 degrees (range, 5-30 degrees). Five of a deformity of more than 10 degrees. Daruwalla believed that
the nine patienrs lost forearm rotation ranglng from 20 to 35 angulation of 15 degrees is acceptable in children younger than
degrees, bur none had functional deficits. They concluded that 5 yeats. Hogstrom et al. (50) noted that young children have a
none of these patienrs would have been better off with open good chance of achieving correction of angular deformity, but
reduction. Thomas et al. (123) reviewed 65 malunions in chil- concluded that all deformities exceeding 10 degrees should be
dren up ro age 15 years and concluded that up ro 15 degrees con'ected because it is impossible ro predict remodeling. Price
of angular deformity is acceptable because the final loss of func- et al. (95,96) concluded thaI 10 degrees of angulation, complete
tion is negligible. When tJ'eating forearm fractures, the clinician displacement, and loss of radial bow can be accepted rather than
should consider the statement by Hey Groves that "art should resorting ro open reduction (Table 10-2).
secure supination and nature be trusted ro secure pronation"
(48). A supination Joss cannot be compensated well by adduction
at the .shoulder, but a pronation loss can be masked by abduction Treatment Options
at the shoulder.
Closed Management
Nilsson and Obrant examined J8 adults who had sustalned
displaced forearm fractures as children (84). All had been re- Greenstick Fractures
duced and maintained in good position withour displacement Skillful closed management usually is successful for rhis injury.
or angulation. The average loss of pronation-supination motion Greenstick fractures may appear ro be angulated and may also
was 19 degrees, even in the absence of malunion. Thus, factors have a rotational element. Holdsworth and Sloan compared this
olher than residual angulation may also be responsible for loss fracrure with a cardboard rube that, when twisted, tends ro bend;
of forearm rotation (84,122). unbending it is possible only if it is untwisted (51). When the
Another difficulty in predicting functional outcome is that apex is roward the dorsum of the hand (apex dorsal-pronation
some younger patients Jose forearm roration rega.rdless of remod- injury), the forearm should be supinated to achieve reduction
eling (95,%). Younger et al. noted that the mean age of patients (Fig. 10-12). When the apex is roward the palm of the hand
with resrricted movement was 7.2 years (153). Holdsworth and (apex volar-supination injury), a pronation fotce must be applied
Sloan noted that functional improvemem is complete by 3 years ro secure reduction (Fig. 10-13).
:tftcr injury, but radiographic appearances may continue ro im- Should greenstick fractures be made complete? There appears
prove beyond that time (51). As a rule, older patients me at ro be no unanimity ofopinion. Advocates for breaking the intact
greater risk for loss of pronation-supination motion, but this is cortex believe thar angulation will recur if it is nOt done (11,
not always the case (24,35,105). 43,53,98,146). Others believe it is unnecessary ro break the in-
Lel1b'th discrepancy between the radius and ulna is uncom- tact cortex (1,25,30,33,123). Instead, the intact cortex is used
mon after shaft fracture of one or both bones (21,27,95,96,139). as an aid ro reduction. Advocates for leaving the hinged cortex
Limb overgrowth or shortening does not occur if the physis is intact emphasize the need for full pronation for apex volar (supi-
undamaged (15,27). This sugge.sts that remodeling can occur nation) greenstick fractures and full supination for apex dorsal
with regard ro length as well as angulation. (pronation) greenstick fractures (1,2'1,33) (Figs. J 0-12 and 10-
Overriding of fracture fragments is another consideration. 13).
Blounr and Johnson stated that overriding with bayonet apposi- Another reason ro break the intact cortex was proposed by
tion is acceptable if the angular alignmenr is satisfactOlY (11) Gruber (43), who noted that greenstick forearm fracrures have
(Fig. 10-11). This observation has been confirmed by others the highest risk of I'efractute of all pediatric fractures. He posru-
(41,95,96,98). lated that the intact cortex heals by primalY bone healing with
The direction of al1gulation may influence loss of foreatm little callus. Simultaneously, a resorption zone develops on the
rotation. Daruwalla (24) observed rhat angulation of both bones, side of the broken cortex. Thus, the weakne.s.s of the bone per.sists
 Chapter 10: Injuries to the Shafts of the Radius and ULna 453

D
FIGURE 10·11. Bayonet apposition. A: An 11-year-old sustained a fracture of the radial and ulnar shafts
with bayonet apposition but excellent alignment. B: Four weeks after the fracture, there is early callus
with maintenance of the bayonet apposition but satisfactory linear alignment. C and D: Five years
postinjury (age 16 years), there is excellent linear alignment and full supination and pronation.

TABLE 10-2. LIMITS OF ALIGNMENT

Loss of Radical
Age Angulation Malrotation Displacement Bow

Age <9 yr 15 degrees 45 degrees Complete Yes

Age 2:9 yr 10 degrees 30 degrees Complete Partial
454 Upper ExtremitJl

c B
FIGURE 10-12. A: Greenstick fracture of both shafts of the forearm at the distal third with pronation
of the distal forearm and apex dorsal angulation at the fracture site. Band C: The fracture was manipu-
lated into supination and placed in a long arm cast. correcting the angular and rotational malalignment.

A B
FIGURE 10-13. A: Greenstick fracture of the proximal third of the radius and ulna, with apex volar
angulation of the radius. B: Postreduction view in long arm cast shows 40-degree angulation of the
radius. This original reduction was in neutral but should have been in full pronation. As a result, there
is some residual angulation at the fracture site. (Figure continues.)
 Chapter 10: Injuries to the Shafts o/the Radius and Ulna 455

c D
FIGURE 10-13. (continued) C: At 1 month, there was 15-degree residual angulation of the proximal
radius, which was thought would remodel to some degree. D: At 8 months postinjury, angulation of
the radius persisted, with supination of 45 degrees and pronation to 70 degrees. Despite the residual
angulation, the patient does not complain of any functional impairment.

beyond the initial healing phase. He recommended initial frac- intentionally fracture the opposite cortex, but a crack often is
turing of the intact cortex to reduce the risk of fracture recur- heard as the reduction is completed. Full pronation or full supi-
rence. nation maintains tbe reduction if the opposite cortex remains
intact. A sugar-tong splint is then applied, with the elbow flexed
to a right angle.
. . AUTHORS' PREFERRED METHOD Approximately 1 week later, the splint is removed and a well-
\..~ OF TREATMENT molded long arm cast is applied. Radiographs should be made
at that time to determine whether reduction has been main-
Even with minimally angulated greenstick fractures, the elbow tained. Cast immobilization is continued for 6 weeks. I recom-
should be evaluated carefully to ensure that a Monteggia type mend a Velcro splint for an additional 6 weeks because of the
IV lesion with an ipsilateral radial head dislocation is not present. high incidence of refracture with this injury.
Minimal angulation can be accompanied by significant rota-
tional deformity. Any angulation should be reduced if a family Complete Fractures
member or other observer has made specific comments that the If the fracture is complete, an entirely different situation exists.
forearm appears deformed. The deformity presenr immediately The distal fragment may be in any position, but muscle pull
after injury often is the final posirion into which rhe fracture determines the position of the proximal fragment (Fig. 10-14).
tends to drift when the swelling has subsided. Thus, it becomes necessary to determine the position of the
Pain relief for fracture reduction may be achieved by a variety proximal fragment so that the distal ftagment can be aligned
of methods (5,20,31,46,55,57,72,88,133,145,147). The Ameri- with it.
can Academy of Pediatrics has published guidelines for the moni- If both fractures are complete and overriding, Davis and
toring and management of children during and after sedation Gteen (25) advocated flngertrap traction of 10 to 15 pounds to
(2) (see also Chapter 3). For greenstick fractures, I prefer a mini- bring out to length and to let the fracture seek its own correct
dose Bier block as described by Juliano (57), or intravenous rotational alignment. Traction through flngertraps with coun-
sedation as described by Varela er al. (133). Inrravenous sedarion tertraction on the arm rends to stretch an intact periosteum to
provides adequate analgesia for one reduction attempt, which allow bone ends to oppose (Fig. 10-15).
usually is sufficient. A Bier block provides more prolonged anal- Alternatively, it is possible to increase the deformity and tog-
gesia. gle one bone at a time by thumb pressure, and then immobilize
Supinating and extending the wrist while gently correcting in a long arm cast in correct rotation with the elbow flexed to
the angulation (Fig. 10-12) reduces apex dorsal angulated green- 90 degrees (Fig. 10-16). The cast should be molded into an oval
stick fractures (pronation injuries). Volar angulated greenstick (Fig. 10-17). If the reduction is unsatisfactory, temanipulation
fractures (supination injuries) are reduced by pronating and flex- IS necessary.
ing the wrist while gently correcting the angulation. 1 do not The proper position for immobilization depends on the frac-
456 Upper Extremity

Biceps (supinator)

Supinator

Pronator
teres

Pronator
quadratus

FIGURE 10-14. Muscle forces that deform fractures of the radius above FIGURE 10-15. Application of traction-countertraction using fin-
the level of the insertion of the pronator teres. The proximal fragment gertraps. (Redrawn from Weber BG, Brunner C, Freuler F. Treatment of
supinates because of the unopposed pull of the supinator and biceps fractures in children and adolescents. New York: Springer-Verlag, 1980;
muscles. (Redrawn from Cruess RL. The management of forearm inju- with permission.)
ries. Orthop Clin North Am 1973;4:969; with permission.)

extension was originally described in the 1940s by Thorndike

and Dimmler (126). It was also advocated by Watson-Jones
ture. Evans recommended that all complete both-bone fractures
(144) in the 1950s. In a series of 130 pediatric forearm fractures,
should be immobilized in some degree of supination (29). Carey
Gainor and Hardy (37) found it necessary to treat eight patients
et al. (15) advocated immobilization of all fractures in neutral
in elbow extension because reduction was unstable in flexion.
position without extremes of pronation or supination. Proximal
Walker and Rang (142) reporred satisfactolY results in 15 pa-
fractures are more likely to require supination for maintenance tients who required management with the elbow in extension.
of reduction (11,29,30). They noted that most forearm fractures, which are stable in
One of the major difficulties in treating fracrures of the shafrs flexion, should still be treated in a conventional cast, but unstable
of the radius and ulna is the development of late angulation fractures can safely be treated with the elbow in extension (Figs.
because of slippage of the forearm proximally in the long arm 10-19 and 10-20).
cast when the elbow is flexed to 90 degrees (Fig. 10-18). In an Radiographs should be made at intervals for up ro 3 weeks
efforr to prevent this, Rang (98) originally placed a ring proxi- after reduction. Minor loss of alignment at this time is observed.
mally on the casr to counteract this migration (Fig. 10-18). An- Major loss of alignment requires remanipulation under anesthe-
orher option is ro immobilize the forearm with the elbow in sia. Yoro et al. (140) noted that 7% of their pediatric forearm
extenSIOn. fractures required remanipulation. Jones and Weiner (56) advo-
The elbow usually is immobilized in flexion, bur this is not cate dosed management with pins and plaster technique as a
always necessary or desirable. The use of a long arm cast in salvage technique when casting alone is insufficient.
 Chapter 12: Monteggia haetllre-Dislocation in Children 545

A B

FIGURE 12-22. Type II fracture-dislocation. The typical radio-

graphic findings include (A) a posterior dislocation of the radial
head (arrows) and (B) a proximal metaphyseal fracture, which
may extend into the olecranon (arrows). In addition to being
posterior, the head may be lateral as well (arrows) (C). (Courtesy
of Dr. Gail S. Chorney, MD, Hospital for Joint Diseases, New York,
New York.) c

oblique midshaft fracture parrern, suggesting possibly two differ- elbow bent (Q 60 degrees of flexion. He showed that the rype
ent mechanisms of injury. II lesion occurred consisrently if the anterior cortex of the ulna
The mechanism proposed and experimentally demonstrated was weakened; otherwise, a posterior elbow dislocation was pro-
by Penrose (84) shows the rype II lesion occurring when the duced (Fig. 12-23). The difference in bony integriry of the ulna
forearm is suddenly loaded in a longirudinal direction wirh the suggested a reason for the high incidence of type II Momeggia
546 Upper £xtremty

;,1,
--------------
----
FIGURE 12-24. Reduction of type II lesion. The elbow is held at 60
degrees of flexion; traction is applied in line with the forearm and the
elbow is extended. It may be necessary to apply pressure over the radial
head to complete the reduction.

B c
8exion. The radial nead may reduce spontaneously Ot may re-
FIGURE 12-23. Mechanism of injury for type II fracture-dislocation.
A: The elbow is flexed approximately 60 degrees; a force is applied quire gentle, anteriorly directed pressure applied to its posterior
longitudinally, parallel to the long axis of the forearm. B: A posterior aspect. The elbow is extended once the radial head is reduced
elbow dislocation may occur. C: If the integrity of the anterior cortex and is immobilized in that position to stabilize the radial head
of the ulna is compromised, a type II fracture-dislocation occurs.
and allow molding posteriorly to maintain the ulnar reduction
(28,56,82,123) (Fig. 12-24).

fracwres in older adults and its rariry in children. Penrose funher Operative
noted that the rotational position of the forearm did nOt seem Because of the rariry of the lesion, therc are no established indica-
to affect rhe rype of fracrure produced. tions for operative treatment. Treatment goals are stable concen-
Haddad er al. (42) described rype II Monceggia injuries tric reduction of the radial head and alignment of the ulnar
caused by low-velociry injuries in six adults, five of whom were fracwre. Tne radial head should be reduced by open technique
on long-term corticosteroid tnerapy. They suggested that this if there is interposed tissue or ifit is accompanied by a fracwred
supports the theory that the rype II (posterior) Monteggia injury capitellum or radial head. The ulnar fracwre is exposed along
is a variant of posterior elbow dislocation, in that it occurs when its subcutaneous border if necessary and tLxed internally. Fixa-
the ulna is weaker than the ligamcnrs surrounding the elbow tion can be accomplished by plating or intramedullary fixation.
joint, resulting in an ulnar fracrure before the ligament disrup- Because of children's abiliry to heal rapidly, jnrramedullary fixa-
tion associated with dislocation occurs. tion is adequate and sometimes can be done percutaneousl)' afrer
a closed reduction of the ulna (80,85).
Treatment
~ AUTHORS' PREFERRED METHOD
Nonoperative . . . . ~ OF TREATMENT
As with type I injuries, rype II lesions usually have a satisfactory
result after closed reducrion (61,77,82,89,127). The ulnar frac- The goals of treatment in the type II Monteggia lesion are [0
rure is reduced by longirudinal traction in line wirh the long obtain a stable concentric reducrion of the radial head, with
axis of the forearm while the elbow is held at 60 degrees of adequate alignment of tne ulna.
 Chapter 12: Monteggia Fracture-Dislocation in Children 547

First, ulnar length is reestablished by applying longitudinal

traction and straightening the angular deformity. The radial
head may reduce spontaneously or with gentle, anteriorly di-

,
rected force directly over the radial head. Once reduced, the
position of the head can be stabilized by holding the elbow in
extension. The alignment of the ulnar fracture can be maintained
by applying a cast with the elbow in extension or by using percu-
raneous inrramedullary fixation. If intramedullary pinning is
used, the elbow may be flexed ro 80 degrees and a cast applied. VARUS
FORCE
Radiographs should be taken after casr application and approxi-
mately every 7 ro 10 days ro confirm conrinued reducrion of LONGITUDINAL
the radial head. FORCE
The Boyd approach can be used ro obtain reduction of the FIGURE 12-25. Mechanism of injury for type III lesions. A forced varus
radial head ifit cannot be obtained through closed manipulation. stress causes a greenstick fracture of the proximal ulna and a true lateral
Management of the annular ligament is the same as described or anterolateral radial head dislocation.

previously in type I Monteggia lesions.

The cast, either in fuJI extension or flexed ro 80 degrees ar
the elbow, is maintained for 3 ro 4 weeks, then changed ro a
removable splinr. This allows early intermitrenr range of motion elbow, in combination with an ourstretched hand planted firmly
in a protected manner for 3 ro 4 more weeks. At 6 ro 8 weeks against a fixed surface (Fig. 12-25). This usually produces a
after injury, the patient may be released to full activities. This greenstick ulnar fracture with tension failure radially and
prorocol may avoid the nece~sity for formal physical rherapy compression medially. The radial head dislocates larerally, rup-
(82). turing the annular ligamenr. Hume (46) suggested that the in-
jury may be the result of hyperextension of rhe elbow combined
with pronation of the forearm. Other authots confirmed the
Type III Lesions mechanism of varus force at the elbow as the cause of rhese
Clinical Findings injuries (8,28,72,82,115). The direction of the radial nead dislo-
cation is probably determined by the rotarion and angubtion
Later;)1 swelling and varus deformity of rhe elbow and significant force applied simuJraneously with the varus moment at the elbow
limitation of morion, especially supinarion, are the hallmarks of (72).
lateral Monteggia fracture-dislocations, or rype III Monteggia
lesions.
Treatment
Incidence Nonoperative
Nonoperarive trearment is effective in nearly all patients (8,11,
Type 111 lesions are common in children, occurring second in
28,46,61,72,77,82,115,127, (29), although rhe rate of operative
frequency ro anrerior Monteggia fracrure-dislocarions (8,72,77,
treatmenr has been reporred to be as high as 12% (77).
82,127). Injuries to the radial nerve, panicularly the posterior
interosseous branch, occur frequently wirh this lesion (11,105).
Open reduction of the radial head ofren is necessary because of Focus on Ulnar Reduction. Reduction is carried out by revers-
interposirion of soEr rissue berween it and the ulna or capitellum ing rhe mechanism of injury (28,72,82,116). The elbow is held
01,46,114,128,129). in extension with longitudinal traction. Valgus stress is placed
on the ulna at the site of the fracture, producing clinical realign-
ment. The radial head may spontaneously reduce or need assis-
Radiographic Evaluation tance with gentle pressure applied laterally (Fig. 12-26). Reduc-
The radial head may be displaced larerally or anrerolaterally (80, tion is sometimes heralded by a palpable click (L 16).
82). The ulnar fracture often is in the meraphyseal region (8,
11,46,82,128,129), bur ir can occur more distally (77,127,128). Confirm Radial Head Reduction. Radiographs are obtained
Radial angularion ar rhe ftacture site is common to all lesions, in the standard views (69). The position of the radial head is
regardless of rhe level. Radiographs of rhe emire forearm should imporranr. Any malalignmcnt in either view implies the possibil-
be ohrained because of rhe ,lssociation of disral radial and ulnar iry of inrerposed tissue or persistenr malalignmenr of the ulna.
fracwres wirh rhis elbow injury complex (lIS). The angular alignmenr of the ulna must be as straight as possible
ro allow and mainrain reduction of rhe radial head (36).

Mechanism of Injury
Maintenance ofReduction.
Wrighr (129) srudied fracwres of the proximal ulna with law'al Degree of Flexion. Reduction is maintained by a long arm cast
and anterolateral dislocations of the radial nead and concluded with the elbow in flexion. The degree of flexion varies depending
thar rhe mechanism of injury was varus stress at the level of the on the direction of the radial head dislocation. When the radius
548 Upper E-ctremty

FIGURE 12-26. Reduction of type III lesion. Valgus stress is placed on

the ulna at the fracture site (arrow), producing clinical realignment.
The radial head may spontaneously reduce or need an assistive push.

IS IDa straight lateral or anterolateral position, flexion to 110

to 120 degrees improves stability (28,72,89,J 27). If there is a
posterolateral component to the dislocation, a position of only
70 to 80 degrees of flexion has been recommended (1 J 6).

Forearm Rotation. Forearm rotation usually is in supination,

which tightens the interosseous membrane and further stabilizes
the reducrion (8,28.72,127). Over rhe years, one researcher has
changed the suggested posirion of immobilization from prona-
rion (115) to semisupinarion (I J 6). Ramsey and Pedersen (89)
recommended neutral as the best position of rotation to avoid
loss of morion; their patients demonsuated no loss of reducrion
using thar position.
B
Operative FIGURE 12-27. Irreducible type III lesion. A: Injury films showing typi-
Surgical intervenrion has rwo goals: reducrion and stabilizarion cal greenstick olecranon fracture and lateral dislocation of a type III
Monteggia lesion. B: After manipulation and correction of the ulnar
of rhe radial head and the ulnar fracrute. deformity, the radial head still was not reduced. (Figure continues.)

Radial Head Reduction. The radial head is reduced through

a Boyd approach (16, J 28). This allows removal of rhe interposed
tissues (76,12J,J28) and repair or reconstrucrion of the annular
ligament if necessary (12,20,36,38, J02, 114) (Fig. J 2-27). The
 Chapter 12: Monteggia Fracture-DisLocation in ChiLdren 549

surgical rechnique is essentially rhe same as previously described

for rhe type I Monteggia Fracrure-dislocation.

Ulnar Stabilization. Srabilizarion of rhe ulna is necessary to

prevent recurrent lateral dislocarion of the radial head. Varus
alignment or radial bow, particularly wirh oblique fractures, may
lead ro subluxarion of rhe radius (36,77) (Fig. 12-28). Fixation
wirh plates (36) and Kirschner wires (6) has been performed
with sarisfactolY results. Up ro 25 degrees of varus angulation
is consistent with normal alignment and funcrion (77), and any
residual deFormity decreases with rime (89).

~ AUTHORS' PREFERRED METHOD

,~ OF TREATMENT

We concur with Cunningham (25), who believed that reducrion

of rhe dislocated radial head is an im ponant part of the manage-
ment of the Monteggia fracrure-dislocation. Our merhod of
c rreatment is aimed primarily ar obtaining and maintaining re-
FIGURE 12-27. (continued) C: Open reduction was performed to ex- duction of the radial head, either by open or closed technique.
tract the interposed torn orbicular ligament. (From Wilkins KE, ed. Op- The type of treatment of the ulnar fracture we choose is deter-
erative management of upper extremity fractures in children. American
mined by its efFect on the primary goal, radial head reduction.
Academy of Orthopaedic Surgeons Monograph Series. Rosemont, IL:
American Academy of Orthopaedic Surgeons, 1994: 50; with permis-
sion.) Nonopecative
The results of nonoperative reduction of a type III lesion are
shown in Fig. 12-29.

A B
FIGURE 12-28. Radial bow of the ulna. A: Anteroposterior views of both elbows showing residual radial
bow of the proximal ulna after an incompletely reduced Monteggia type III lesion. B: This bow has
produced a symptomatic lateral subluxation of the radial head. (From Wilkins KE, ed. Operative manage-
ment of upper extremity fractures in children. American Academy of Orthopaedic Surgeons Monograph
Series. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1994.51; with permission.)
 550 Upper Extmnty

depending on the age of the child. It is replaced by a removable

splint for an additional 3 to 4 weeks while early ranging of the
elbow has begun. Restoration of rotation is particularly impor-
tant ar this time. Before application of rhe splint 3 [Q 4 weeks
postinjury and at discontinuation at 6 to 8 weeks postfracture,
radiographs are taken to assess the (·eduction. At 6 to 8 weeks
after injury, sufficient healing has occurred to allow gradual re-
rurn ro full activities.

Operative
Similar [Q our goals for closed reducrion, our operative indica-
tions are failure to obrain and maintain reduction of rhe radial
head and aJignmem of the ulnar fracrure.

Reducing the Radial Head. Failed closed reduction of the ra-

dial head implies interposirion of soft tissue, which we remove
through a Boyd approach (Fig. 12-20). If possible, the annular
ligamenr is repaired, bur we find that formal reconstruction usu-
ally is unnecessaty if the radiocapitellar relation is restored and
stable. If stability is in question, we reconstrucr the annulaJ liga-
ment as described for the rype I Monteggia lesion.

AS
Ulnar Realignment. Before a formal annular ligament recon-
FIGURE 12-29. Type III lesion, nonoperative treatment. A: Injury film
showing lateral dislocation of the radial head. B: Radiograph taken struction, ulnar a1 ignment must be evaluated critically. If inade-
after closed reduction showing reduction of the radial head and heal- quare, the ulnar alignment may prevent relocation of the radial
ing of the ulna by nonoperative methods. 11ead. The ulnar fracture can usually be reduced closed, but open
realignmenr may be necessary due to interposed tissue. Once
reduced, the ulna can be mainrained by the insertion of intra-
medullary pins, either in a retrograde fashion or percutaneously.
Reduction Technique. We hold the elbow in extension [Q con- The ends of rhe pins can be buried subcuraneously and removed
trol the proximal fragment by locking the olecranon into the larer with minimal surgery.
humerus. We tnen can apply longitudinal [['action in line with
the forearm with valgus suess applied at the ulnar fracture site
After Care. Postoperative care is rhe same as for a fracrure
(Fig. 12-26). This usually allows the radial head to become reap-
rreated nonoperatively, wirh emphasis on early morion.
posed [Q the capitellum, bur ptessure laterally over rne promi-
nence of the radial head may be necessaty.
Type IV Lesions
Radiographic Evaluation. Radiographs are raken in the AP
Clinical Findings
and lateral planes to confirm the reduction of the radial head
and assess rhe ulnar alignment. Up to 10 degrees of ulnar angula- The appearance of the patient and limb with a rype IV lesion
tion is acceptable in younger children, provided the radial head is similar to rhat of the eype I lesion. More swelling and pain
reducrion is concentric and stable. would be expected because of the magnitude of force required
to create this complex injury. Particular artention should be
Immobilization. A long arm cast is applied in [wo portions. given to the neurovascular status of the limb, anticipating rhe
First, a Muenster eype of shorr arm cast is applied with the possible increased risk for a compa(-rment syndrome. AJrhough
forearm in neuuaJ rotation. This allows careful molding of the rhis injury is uncommon in general and rare in children, rhe
cast to maimain the alignment of the ulnar fracture. The elbow radiocapirellar joint should be examined in all midshaft forearm
is rhen flexed to approximarely 110 degrees in lateral or antero- fractLIres to avoid missing this injury complex (Fig. 12-30). Fail-
lareral dislocations, and the cast is complered to the axilla. In ure to recognize rhe radial head dislocation is rhe major compli-
younger children, where rhe casr may be hard to mold, a loop carion of rhis fracrure (10).
sling is incorporated into rhe cast to prevent it from migrating
discally. Although we have no experience with the method, treat-
ment of a posterolateral dislocation witn an extended elbow cast Radiographic Evaluation
with valgus molding seems logical. The pattern of radial head dislocation is similar to thar in a rype
I Monteggia lesion-rhar is, ir is direcred anrcriorly (Fig. 12-
After Care. Radiographs should be taken in the completed cast 31). The radial and ulnar fracrures usually are seen at any level
to confirm cominued reduction of the radial head and satisfac- in the middle third (30), with the radial fracture usually distal
tory ulnar alignmem. The cast is left in place for 3 to 4 weeks, to the ulnar injury. They may be complcre or greenstick.
 Chapter /2: Monteggia Fraeture-Dis/oClltion in C/Jildren 551

A B
FIGURE 12-30. Type IV Monteggia lesion. A: Anterior dislocation of the head of the radius with fracture
of the upper third of the radial shaft with the ulna angulated anteriorly. The dislocation of the radial
head was not recognized. B: Five years later, the radial head was still dislocated, misshapen, and promi-
nent. A full range of motion was present, with the exception of a loss of 10 degrees of full supination.
The patient had no pain, but generalized weakness was noted in this extremity, especially in throwing
motions. (Courtesy of Fred C. Tucker, MD.)

Mechanism of Injury using flexible pins. This allowed closed reduction of the radial
head. One of the authors of this chapter has reponed on four
Bado proposed that the type TV lesion is caused by hyperprona-
type IV Monteggia lesions in children, treated by both operative
tion (6). Two case repom discuss the mechanism of injury. One
and nonoperative techniques. He recommends plating of the
implies that the injury is due to the hyperpronation mechanism
radius in older children.
of Evans (39), and the other demonsuates a type IV lesion caused
by a direer blow (96). Olney and Menelaus (77) repon a single
type IV lesion in their series but do not discuss the mechanism.
Our preferred mechanism for this type of lesion was described ~ AUTHORS' PREFERRED METHOD
in the section on type I lesions. \..~ OF TREATMENT
The goals of treatment for a type IV Monteggia lesion are similar
Treatment
to those of the other Bado rypes. The presence of the free-floati ng
This complex lesion has been treated by both closed (77) and proximal radial fragment hampers the abiliry to reduce the radial
open (8) techniques. Two clinicians (39,96) treated the radial head. Stabilization of the radial fracture converts the type IV
and ulnar fractures with percutaneous intramedullary fixation lesion to a eype I lesion, greatly facilitating treatment. The goals

FIGURE 12-31. Type IV lesion. There is an anterior dis-

location of the radial head. The radius and ulna frac-
tures are usually in the middle third of the shaft, with
the radial fracture distal to the ulnar fracture.
552 Upper Extmncy

FIGURE 12-32. Type IV closed reduction. A: Injury film

in a 7-year-old with fractures of the shafts of the radius
and ulna and associated dislocation of the radial head.
B: Initial closed reduction with some residual posterior
angulation. C: At 3 weeks postinjury, the forearm was
remanipuiated to correct the posterior angulation. D:
Appearance 8 weeks postreduction, still with slight pos-
terior angulation. E: Six months later, there has been
considerable remodeling. (From Wilkins KE, ed. Opera-
tive management of upper extremity fractures in chil-
dren. American Academy of Orthopaedic Surgeons
Monograph Series. Rosemont, IL: American Academy of
E Orthopaedic Surgeons, 1994: 51-52; with permission.)
 Chapter /2: MOI·/teggin Fracture-Di,Location in Children 553

FIGURE 12-33. Operative treatment, type IV lesion.

The initial goal is to stabilize the radius. In older
children, a plate may be indicated. Intramedullary
pinning usually is adequate. (See Fig. 12-31 for injury
film.)

for rreatment of a type IV lesion are, therefore, stabilizarion Mechanism of Injury

of the radial fracture, resroration of the ulnar alignment, and
The mechanism of injury by which the fracture occurs helps
concenrric reduction of the radial head.
define its equivalent type and is discussed in the sections on the
relevant Bado type.
Nonoperative. Closed reducrion should be attempted initially,
especialJy if the radial and ulnar fractures have greenstick pat-
rerns. Use of the image intensifler facilitates treatment by allow- Treatment
ing immediate confirmation of reducrion of the elements of the
As with the other Bado types, rreatment addresses (\VO general
injury complex, especially the radial head. Closed treatment of
components of the lesion: ulnar fracture and associated injury.
unstable lesions may be attempted, bur it is our experience that
multiple remanipulations are required ro obtain a satisfacrory
outcome (Fig. 12-32). Ulnar Fracture
This fracture is treated as for the other Bado types. The method
is dictated by the fracture pattern and location and its srability
Operative. If the fractures are unstable, we reduce the fracrures
after reducrion.
closed and fix rhem percutaneously with intramedullary pins.
In children 12 years of age or older, plating the radius through
Associated Injury
Henry's extensile approach (43) provides more rigid stabilization
These associated fractures and dislocations are evaluated and
(Fig. 12-33). Once stability is achieved, a closed reduction of
treated using principles based on the particular injury. They are
the radial head is attempted. This is usually successful, but any
discussed thoroughly in orher sections of this chapter.
inrraarricular obstruction can be removed using the Boyd ap-
proach, which is more direct than extending HenlY'S approach.
Complications (All Lesions)
After Care. The elbow is immobilized for 4 weeks in 110 to
120 degrees of flexion with the forearm in neurral rotation. The
Old Undetected Fracture-Dislocations
cast is reduced ro a short arm cast for an additional 4 weeks An undetccted dislocarion of rhe radial head is uncommon (28,
while beginning early range of motion at the elbow and forearm. 36, I 00, I 13). Isolared radial head dislocations with no apparent
Forearm rOtarion, within the limits of cast resrrictions, is specifi- lesion of the ulna caused by remote trauma have been mistal,en
cally encouraged ro avoid permanent loss of rotation. At 8 weeks for radia.l head dislocations of congenital etiology (29,66). Subse-
pOStinjuly, rhere is gradual return ro full activities. quent authors have refuted the exisrence of a unilateral congeni-
tal dislocation of the radial head (64). Observations of the shape
of the ulna in parients with an isolated dislocarion of the radial
Bado's Equivalent Lesions head have indicated the existence of persistent plastic deforma-
Clinical Findings tion of the ulna associated with this radial lesion (63) (Figs. 12-
34 and 12-35). The diagnosis of a dislocated radial head has
Clinical findings are similar to those for the corresponding Bado been aided by the acceptance of the veracity of the radiocapitellar
lesion, with the common triad of pain, swelling, and deformity. line (69,100,109) (Fig. 12-9).

Natural History
Radiographic Evaluation
The ability to diagnose the dislocated radial head at the rime of
As with the Bado types, careful radiographic study should be injury has helped prevent the difficult problem of persistent
made with at least rwo orthogonal views. Special views such as radial head dislocation. When a previously undetected disloca-
obliques should be obtained ro delineate the associated injuries tion is encountered, the natural histOry of the untreated lesion
(e.g., radial head or neck fracrures, lateral humeral condyle frac- should be considered in determining rhe method of rrcatment.
tures) clearly to allow adequate pretreatment planning. The belief rhat many children wirh persisrenr dislocation of the
554 Upper Extremty

["adial head do well has been supported by several investigators

(73,87,98,107). Fahey (34) believed thar although in the shorr

E--d
term persistent dislocations do well, they present problems later.
At that time, the problem can be treared by resecrion of rhe
radial head.
Orher reportS, however, suggested thar rhe natural hiscoly of
persistent dislocation is not benign and is associated with re-
stricred morion, deformity, functional impairment (weakness,

E---~~
instability), pain, degenerative arthritis, and late neuropathy (5,
13,14,22,38,40,46,47,50,52,63). KaJamchi (50) reported pain,
instability, and restricted motion, especially loss of pronation
and supination. He also noted [hat children have a valgus defor-
mity and a prominence on the anterior aspect of [he elbow.
Tardy nerve palsies have been reponed as developing subsequent
co an unrecognized Momeggia lesion of long-standing duration
FIGURE 12-34. The ulnar bow line. This line, drawn between the distal
(1,5,45,62).
ulna and the olecranon, defines the ulna bow. The "ulnar bow sign"
is defined as deviation of the ulnar border from the reference line of
more than 1 mm. (From Lincoln TL, Mubarak 5J. "Isolated" traumatic Indications for Treatment
radial head dislocation. J Pediatr Orthop 1994; 14: 455; with permission.)
As experience has developed with reconstrllcrive relocation of
the radial head in Monteggia lesions, the indications have be-
come clear. Bloum (15), in his classic monograph, and Fowles
er al. (36), in their analysis, suggested thar reconstrucrion pro-

FIGURE 12-35. Ulnar bow line. A: The injury film of an

8-year-old girl who fell, spraining her arm. Note ante-
rior bow ofthe ulna (black arrows) and loss ofthe radio-
capitellar relation (open arrow). B: Film at time of diag-
nosis. Note persistent ulnar bow and overgrowth of
radius. (Courtesy of David Mann, MD, VW Hospital and
B Clinics, Madison, Wisconsin.)
 Chapter /2: JvJonteggia Fracture-DisLocation in Children 555

vides rhe besr resulrs in patients who have had a dislocarion for 3 Roberrs (64) used the Bell-Tawse procedure bur modified ir by
or 6 months or less, respectively. Fowles et aJ., however, reponed changing the sire of procurement of the ligament to rhe lareral
successful relocarions up ra 3 years after injury, and Freedman ponion of rhe triceps rendon. They found rhar immobilizing
et aJ. (38) up ra 6 years after injury. Throughour the literature, the elbow in flexion and using a transcapitellar pin ro establish
the appropriare age seems ra be younger than 10 years (108). stability worked well, avoiding the inconvenience of a long arm
Hirayama er al. (44) suggested that the procedure nor be per- cast in extension. Hurst and Dubrow (47) used the central por-
formed if rhere is significant deformity of the radial head, flarten- tion of the triceps rendon. Disrally, rheir dissection of perios-
ing of rhe capitellum, or valgus deformity of the neck of the teum was carried along the ulna to the level of the radial neck,
radius. providing more stable fixation rhan the rechnique of stopping
In a mOte recent reporr, however, Seel and Peterson (99) at the olecranon described by Bell-Tawse. Furrher, a periosteal
suggested that rhe age of the patient and the duration of the runnel was used rarher rhan a drill hole to establish flXarion for
dislocation are unimportant. Their criteria for surgical repair the tendinous strip of the ulna. Thompson and Lipscomb (117)
were (a) normal concave radial head articular surface and (b) have used a fascia lara grafr passed through a drill hole in the
notmal shape and conraur of the ulna and radius (deformity of ulna to stabilize an unstable radial head.
either waS corrected by osteotomy). They treated seven patients
(all girls) ranging in age from 5 to 13 years for chronic disloca- Osteotomy
tions that had been present from 3 months ra 7 years. All seven In a Monteggia lesion with a mildly displaced ulnar fracrure bur
were fully active with no elbow pain or instability at an average persistent dislocation of the radial head, an osteotomy of rhe
of 4 years after surgery. ulna usually is not indicared (64). However, various types of
Although they recommended surgical treatment of chronic osteotomies have been used to facilitate reduction of the radial
Monteggia lesions in children because of the long-term sequelae, head, as well as ro prevent recurrent subluxarion afrer annular
Rodgers et al. (97) cautioned that the results of reconstructive ligament reconstruction (Fig. 12-36). Kalamchi (50) rep0Ired
procedures are unpredictable and associated with a number of using a drill osteotomy and allowing it to floar, thus facilirating
serious complications. Fourteen complications occurred in their reduction of the radial head. He stared thar this afforded the
seven patients (11 months to 12 years of age) treated from 5 advantages of minimal periosteal stripping, allowing rhe osteot-
weeks to 39 months after injury, including malunion of the omy to heal rapidly. Hirayama et al. (44) and Mehta (67,68)
ulnar shaft, residual radiocapitellar sublu;"ation, radiocapitellar used ulnar osreoromies to facilirare and srabilize rhe reduction
dislocation, transient ulnar nerve palsy, partial laceration of the of rhe radial head. Hirayama did a l-cm dim'action osreotomy
radial nerve, loss of fixation, nonunion of the ulnar osteotomy, approximately 5 cm disral to the tip of the olecranon. Internal
compartment syndrome, conversion reaction, and possible fi- fixation in rhe form of plare and screws was used, but there were
brous synostosis. significant complicarions wirh loosening and plare breakage.
Mehra used an osteotOmy of the proximal ulna in which a bone
Historical Development of Surgical Repair grafr was used to stabilize rhe osreoroffiY. In neirher series was
The technique for delayed reduction of the radial head in a an annular ligament repair performed. Oner and Diepstraten
Monteggia fracture is attributed to Bell-Tawse (12). He used (78) suggested avoiding radial osteoromies because of the restric-
the sutgical approach described by Boyd (16). Other surgical rion of morion thought to occur owing to adhesions, as well as
approaches have been developed subsequent to Boyd, but are ulnar osreoromies because of the high rate of complicarions.
not as adaptable to annular ligament reconsrruction (41,110). Although rhey did not perform rourine ulnar osteotomy, they
poinred out rhar in eype III lesions in which osreotomies were
Annular Ligament Reconstruction not performed, there was recurrenr sublLlXarion because of rhe
Once the capsule has been debrided from the joint, considera- persisrent ulnar angularion (Fig. 12-28). Freedman et al. (38)
tion is given as to whether the annular ligament needs to be reduced a delayed type I Monreggia lesion using open reducrion
reconstructed. Kalamchi (50) restored stability after open reduc-
tion and osteoramy by reefing the remnants of the annular liga-
ment.
Various authors have considered it necessary to reconstruct
the annular ligament, probably because of insufficiency of the
natural scructure. Although Bell-Tawse (12) used a strip of tri-
ceps tendon, other authors have tried other mareriaJ. Corberr
(24) reponed srabilizing an open reduction of rhe radial head
using rhe lacenus flbrosus through an anterior approach. Speed
and Boyd (102) used a scrip of the forearm fascia to esrablish
srability of the radial neck. Warson-Jones (124) used a srrip of
palmaris longus tendon. May and Mauck (65) used chromic FIGURE 12-36. Ulnar osteotomies. Left: Floating open osteotomy
ligature. Bell-Tawse (12) used the central portion of the triceps without fixation or bone graft. Center: Hirayama distraction osteot-
rendon passed through a drill hole and around the radial neck omy, grafted and fixed with a plate and screws. Mehta's osteotomy is
similar but is held with a bone graft only. Right: Valgus osteotomy for
to stabilize the reducrion. This was aided by immobilizing rhe a type III lesion: floating osteotomy with bone graft. This osteotomy
elbow in a long arm cast in exrension. Bucknill (20) and L1oyd- may be easily stabilized with an intramedullary pin.
556 Upper Extremty

of rhe head wirhour annular ligamenr reconsrrucrion, ulnar osre- cannor be reduced, rhe ulna is osreoromized. The osreoromy is
oramy combined wirh radial shorrening, and deepening of rhe formed at rhe sire of maximum deformiry rhrough a small inci-
radial norch of rhe ulna. sion, leaving the periosteum as undisrurbed as possible. If reduc-
Inoue and Shionoya (48) compared rhe results of simple cor- rion of the radial head still cannor be achieved, radial shorrening
recrive ulnar osreoramy in six parienrs wirh rhose of posrerior can be considered, bur we have no experience with this proce-
angular (overcorrected) osreoromy in six others and found that dure.
better clinical ourcomes were obtained with the angular osreot- AIrer ligamenr reconsrrucrion, rhe ulnar osreoromy can be
omy. Tajima and Yoshizu (I12), in a series of 23 neglecred stabilized or lefr ro floar. Stabilization can be performed by sev-
Monreggia fracrures, found rhar the besr rcsulrs were obrained by eral rechniques, including plating, bone graft, or intramedullary
opening wedge osreoramy of rhe proximal ulna wirhour ligamenr fixarion. Percuraneous inrramedullary fixarion wirh flexible
reconstrucrJOn. Kirschner wires allows self-adjusrmenr bur adds srabiliry ro rhe
entire reconsrrucrion; ir is our preferred rreatmenr.

~ AUTHORS' PREFERRED METHOD Annular Ligament Reconstruction. Ar rhe rime of exposure,

,'~ OF TREATMENT rhe rriceps aponeurosis and rendon are examined for rheir rhick-
est portion. A 1- X 6-cm strip is developed and carried distally,
Indications. If a patienr younger rhan 12 years of age presenrs carefully elevating rhe periosteum from the proximal ulna down
with delayed diagnosis of a Monreggia lesion, the radial head to the level of the radial neck. In the Bell-Hawse technique, a
should be replaced in irs appropriate relarion wirh rhe capi- drill hole slightly larger than rhe strip of tendon is made in the
tellum. The child does weU in the shorr term, but problems ulna. The strip of tendon is then passed around the radial neck
develop later. As rhe child marures to aduldlOod, there is a slgnif- and through the drill hole in the ulna. The ligament is then
icant chance of progressive instabiliry, pain, weakness of the brought back and surured to itself (Fig. 12-37).
forearm, and resrriction of motion. There is also a risk of rardy More recently, Seel and Peterson (99) described the use of
radial nerve or ulnar nerve palsies. There should be no radiocapi- twO holes drilled in the proximal ulna. The holes are placed at
rellar incongruity due ra radial head deformity after reduction. the original attachments of the annular ligament and thereby
allow repair of the annular ligament (frequently avulsed from
Surgical Approach. The skin incision begins approximately one attachment and trapped within the joint) or reconstruction
halfway ben-veen rhe cenrral porrion of lhe triceps and the lareral of the annular ligament with whatever tissue or material is de-
border, beginning proximal enough ro obrain 6 ra 7 cm of rendi- sired (they suggesred triceps tendon). It secures the radial head
no us srrip. The incision conrinues disrally along the [areral bor- in irs normal position from any dislocated positions and allows
der of rhe ulna JUSt pasr the level of rhe radial neck. Dissection osreotomy for correction of any accompanying deformiry of tbe
is carried deep, lifting rhe anconeus off rhe ulna sharply in an ulna or radius. Seel and Peterson noted that the Bell-Tawse
extraperiosreal manner. The capsule is enrered and any inrer- procedure tends to pull the radius posterolaterally (Fig.12-38,
posed capsule, old ligamenr, or osteochondral fragment is re- left) and possibly constricts the neck of the radius, thereby poten-
moved from the joint. The radial notch of the ulna is also cleaned rially limiting the growth of the radial neck ("notching") and
ro allow rhe radial head ro fall inro place once reduced. Capsular reducing forearm rOlation. They suggested that although this
adhesions are removed from rhe radial head ro allow ir ro fall repair mighl be satisfactoty for anteromedial dislocations, it may
away from rhe anrerior capsule. not be optimal for anterior, anterolateral, lateral, and posterolat-
eral dislocations. Initially, Seel and Peterson placed a single drill
Radial Head Reduction. Radial head reduction is then at- hole obliquely across the ulna to exit medially at the site of
rempred. If ir is accomplished, it is scrutinized for congruity the medial attachment of the annular ligament on the coronoid
between rhe radial head and rhe capitellum. If this is satisfacrory, process of rhe ulna (Fig. 12-38, center). The tendon was routed
a ligamemous reconsrrucrion can be performed. If the radius through the tunnel, brought around the neck, and sutured to

FIGURE 12-37. The central slip of the triceps is used to reconstruct an annular ligament. (Redrawn
from Bell-Tawse AJS. The treatment of malunited anterior Monteggia fractures in children. J Bone Joint
Surg Br 1965;47: 718; with permission.)
 CI?flpter 12: Monteggia Fractll re-Di$/ocation in Children 557

FIGURE 12-38. Drawings of transverse cuts ofthe proximal right radius

and ulna (viewed distally) at the level of the radial head. Left: Route
of the triceps tendon in Bell-Tawse reconstruction. The direction of
stability is posterior (large arrow). Center: Drill hole placed obliquely
to exit the ulna at the site of the medial annular ligament attachment.
The direction of stability is posteromedial (large arrow). Right: Two
drill holes exit the ulna at sites of medial and lateral annular ligament
attachments. The direction of stability is anatomic (arrow). (From Seel
MJ, Peterson HA. Management of chronic posttraumatic radial head
dislocation in children. J Pediatr Orthop 1999; 19.306-312; with permis-
sion.)

FIGURE 12-40. Radiograph showing a broken transcapitellarwire with

subsequent dislocation of the radial head. A pin of sufficient size is
rhe lareral side of rhe ulna. With this construct, the direction mandatory to avoid pin failure.
of stability was posteromedial. The LIse of cwo drill holes to
secure rhe annular ligament or orher reconstructive tendon at
both normal attachments of the annular ligament on the ulna
achieved a more normal posteromedial holding force on the neck
of sufflcienr size is mandatoty to avoid pin failure (55); a small
of the radius (Fig. 12-38, right).
pin will fatigue (Fig. 12-40). AJrernarive rechniques to secure the
An alternarive to the drill hole is to use a small bone staple
reducrion of the radius include transversely pinning the radius to
or bone-anchoring device (Fig. 12-39).
the ulna (61) and immobilizing the elbow in exrension (12).

Stabilizing the Radial Head. Once concentric reduction is After Care. After wound closure, a long arm cast is applied
achieved, the radiocapitellar relation is secured by passing a with the forearm in 60 to 90 degrees of supination. The position
transcapirelbr Steinmann pin rhrough rhe posrerior aspect of of the elbow is predetermined by the transcapitellar Sreinmann
the capirellum into rhe radial head and neck wirh the elbow at pin. This position relaxes the biceps and maintains rhe ulna in
90 degrees and the forearm in supination (Fig. 12-39). A pin neutral position. The casr is maintained for 6 weeks, afrer which
rhe cast and pin are removed and acrive motion is begun, espe-
cially pronation and supinarion. Elbow flexion and exrension
return rapidly bur rorary morion of rhe forearm may take 6 [Q
9 monrhs [Q improve, wirh pronation possibly being Jimired
permanently (96).

Nerve Injuries
Radial Nerve
The Jirerarure reflects a 10% ro 20% incidence of radial nerve
injury, making ir the mosr common complicarion associared
wirh Monreggia fracrures (49). Ir is mosr commonly associared
wirh rype [ and III injuries, wirh the larrer being more frequenr
(11,73,100). The posrerior inrerosseous nerve is mosr commonly
injured because of irs proximiry ro rhe radial head and its inri-
mate relarion ro rhe arcade of Frohse (Fig. 12-7). The arcade
may be rhinner and rherefore more pliable in children (103).
This may accounr in pan for rhe rapid resolmion of the nerve
injury in children.
FIGURE 12-39. Fixation of radial head. After the ligament is recon-
structed, the radial head is stabilized using a transcapitellar pin. Note Such a lesion in a child is rreared expecramly. Nerve funcrion
the use of a bone anchor as an alternative to the drill hole. usually rerurns by approximarely 9 weeks afrer reducrion, if nor
558 Upper ExtremfJ

sooner (l 04, 106). Ir has been recommended that the nerve be Stein et at. (l06), in their report specifically examining nerve
explored if there is no clinical or electromyographic return of injuries in Monteggia lesions, reponed no median nerve deficits.
neurologic function by 12 weeks (104,106). These recommen- Watson and Si nger (l25) reporced enrrapmenr of the main trunk
dations are drawn from series of adult patients and may be pre- of the median nerve in a greensrick ulnar fracture in a 6-year-
mature and unnecessary in children. A review of a series of chil- old girl. Compbion of the fracture was necessary for release of
dren's Monteggia lesions (77) recommends waiting 6 months the nerve. At 6 months after surgery, there was full moror recov-
before intervention in a posterior interosseous nerve injUly. Most ery but sensation was slightly reduced in the tips of the index
series repon 100% resolution barh in fractures treated promptly finger and rhumb.
and in those treated remotely from the date of injury (l,5,62).
Spinner (103) reporced three posterior interosseous nerve in- Tardy Nerve Palsy
juries in children. All function recurned spontaneously, but he The literature highlights seven cases of tardy radial nerve injury
recommended that if 110 clinical or electromyographic return associated with radial head dislocation (1,5.45,62,130). The eype
occurs in approximately 6 weeks, exploration and neurolysis of of treatment has varied. Usually, excision of the radial head
the nerve should be performed. There are cwo reports (71, I 01) is included with exploration and neurolysis of me nerve, with
of irred ucible Monteggia fractures caused by interposition of the uniformly good results (1,5). Other surgeons have explored the
radial nerve posterior co the radial head. After the nerve was nerve alone, with good but variable results (45,62). Yamamoto
replaced to its normal anatomic position and the head reduced, and associates (130) combined radial head resection and nerve
function returned in approximately 4 months. Morris (71), in exploration with tendon transfers, producing good results in twO
cadaveric studies, demonstrated that significant anterior disloca- patients.
tion of the radial head and varus angulation of the elbow allowed One patient, who had a combination of radial head disloca-
the radial nerve to slide posterior co the radial head and, wirh tion and a malunited distal humerus fracture, presented with
subsequent reduction of the radial head, become entrapped. combined rardy radial and ulnar nerve palsies (I). The ulnar
nerve lesion was treared with anterior uansposition, which pro-
Ulnar Nerve vided resolution of the paresis. The radial nerve was treared by
Bryan (19) reporced one adult with an ulnar nerve lesion associ- resection of the radial head and exploration of the nerve.
ared with a rype II Monteggia lesion, with spontaneous resolu-
tion. Stein and colleagues (106) reporced three combined radial
nerve and ulnar nerve injuries, cwo of which required exploration Associated Fractures and Unusual Lesions
for functional return of the nerve. Monteggia lesions have been associated with fractures of rhe
wrist and the distal forearm (8), Distal radial and ulnar joint
Median Nerve dislocation or sprain and fracture of the distal ('ad ius through
The association of median nerve injuries with Monreggia frac- the physis or distal metaphysis are most frequently reponed (8,
tures is low. Injury ro the anterior interosseous nerve has been 14,51,96) (Fig. 12-4]). Galeazzi fractures may also occur con-
reported in cwo series (124,] 27). In one case, exploration was currently with Monteggia lesions (8,75). Radial head and neck
necessary co release the entrapped nerve from the ulna (124). fractures are commonly associated with type II fractures (8,32),
Both cases had complete resolution of the neurologic deficit. but may occur with others (35,37,51). With a type II lesion,

FIGURE 12·41. Associated injuries. An a-year-old

child with a high-velocity injury to the entire fore-
arm. A: Radiograph of a type III Monteggia fracture
and associated lateral condyle (black arrow) and dis-
tal radial physeal (white arrow) fractures. B: Postop-
erative management with percutaneous pin fixa-
B tion.
 Chapter 12: Monteggia Fracture-Dislocatio/l in Children 559

FIGURE 12-42. Periarticular ossification. Persistent dislo-

cations of the radial head are frequently accompanied by
a thin cap of bone and other areas resembling sesamoid
bones.

the radiaJ head may fracture, usually on its ancerior rim (32). ficarion around the radial head and neck (12,46,62,64,107,109).
Strong et al. (111) reponed twO cases of a type I equivalent It appears as a thin ridge of bone in a caplike distribution and
lesion consisting of a fractured radial neck and midshaft ulnar may be accompanied by other areas resembling sesamoid bones
fracture. This equivalenc was unique in having signiflcanc medial (Fig. 12-42); they resorb with treatment and time. Ossification
displacemenc of the distal radial fragmen£. They had signiflcanc may also occur in the area of the annular ligamenc (31). Although
difficulry in obtaining and maincaining reduction of the radius noting thei r appearance, none of the authors detailed elbow
through closed technique in this fracture panern. function after the formation of these lesions (12,46,64,107,109).
Fracrures of the lateral condyle have been associated with The other form of ossification is [['ue myositis ossiflcans. This
Monceggia fracrures (82). Ravessoud (90) reponed an ipsilateral occurred in approximarely 3% of elbow injuries and 7% of
ulnar shaft lesion and a lateral condyle fracture without Joss Monteggia lesions in a series of adults and children (120). Myosi-
of the radiocapitellar relation, suggesting a Monceggia rype II tis ossificans h.as a good prognosis in patiencs younger than 15
equivalent. years of age, appearing at 3 to 4 weeks postinjury and resolving
in 6 to 8 months (Fig. 12-43). Its occurrence is related to the
severiry of the initial injury, association with a fractured radial
Periarticular Ossification
head, the number of remanipulations during treatment, and pas-
Two patterns of ossification have been noted radiographically. sive motion of the elbow during the postoperative period (74,
Various investigators have commenced on the formation of ossi- 120).

A B
FIGURE 12-43. Periarticular ossification. A: Lateral radiograph of an old anterior dislocated radial head.
B: Two months after treatment, with resolution of ossification.
560 Upper ExtremfJl

SUMMARY 17. Boyd HB, Boals JC The Monteggia lesion: a review of 159 cases.
Clin Ortbop 1l)W;66:lJ4.
18. Bruce !-il', Harvey JP, Wilson ]C Monteggia fi·acrure.] Bone Joint
Adherence w several fundamental principles helps ensure good Surg Am 1974;56:1563-1576.
ourcomes afrer Monteggia fractures in childl'en: 19. Bryan RS. Monteggia fracture of rhe forearm. ] Trauma 1971; 11:
992-998.
• If, in a radiograph of rhe forearm, one bone overlaps or angu- 20. Bucknill TM. The elbow joint. Proc R Soc Med 1977;70:620.
lares, subluxarion of either radioulnar joinr should be consid- 21. Campbell WC A textbook on orthopedic sulgery. Philadelphia: \x/B
ered. Saunders, 1930.
• Evaluation of the radial head locarion requires an AP view of 22. Caravias DE. Some observarions on congenital dislocation of the head
of the radius.] Bone Joint SUlg Br 1957;39:86-90.
the proximal forearm and a true lateral view of the elbow.
23. Cooper A. Dislocations and fi'actures ofthe joints. Boston: TR Marvin,
• The radiocapirellar line musr be inracr in both views. 1844:391-400.
• Achievement of concentric, congruent radial head reduction 24. Corbett CH, Anterior dislocation of the radius and irs recurrence. Br
is of primary imporrance, wherher by open or closed means. .I Surg 1931;19:155.
• In type IV injuries, the radial fracture must be srabilized before 25. Cunningham SR. Fracture of the ulna head with dislocation of the
head of the radius . .I Bone Joint Surg 1934;16:351-354.
radial head reduction.
26. CUrlY GJ. Monteggia fracture. Am] StIlg 1947;123:613-617.
• Stability of rhe ulnar reducrion is required whelp mainrain 27. Denuce A. Men-wire sun les ltlxations du coude. These de Paris, 1854.
reducrion of rhe radial head. Srability may be inherenr to rhe 28. Dot'Jnans JP, Rang M. The problem of Monteggia fracture-disloc-
fracrure pa[[ern or achieved by inrernal frxarion. ations io children. Orthop Clin North Am 1990;21 :251.
• If addirional srability of rhe radial head reducrion is necessary, 29. Dm'crney JG. haite des maladies de os. Paris: De Bure l'Aire, 1751.
30. Eady JL Acure Monteggia lesions in children . .I S C Med Assoc 1975;
ir can be achieved by reconsrrucrion of rhe annular ligamenr.
71:107-112.
• Immobilizarion should be in rhe posirion rhar besr achieves 31. Lmvaker J. Post-traumatic calcification of the annular ligament of
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ulna. 32. Edwards EG. The post.erior Momcggia fracrure. Am Surg 1952;18:
• Early mobilizarion, especially rmarion, is imporranr w avoid 323-337.
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sriffness.
1949;31:578-588.
• Frequenr radiographic evaluarion is necessary w monitor the 34. Fahey JJ. Fractures of the elbow in children: Monteggia's fracrure-cUs-
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35. Fahmy NRM. UnusuaJ Monteggia lesions in kids. InjlllY 1980;12:
399-404.
36. Fowles JV, Sliman N, Kassah MT. The Monteggia lesion in c1lildren.
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92. Reckling FW, Cordell LD. Unstable fracture-dislocations of the fore-
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81. Pavel A, Pitman J, Lance E, et al. The posterior Monteggia fracture: 111. Strong M, Kopp M, Gillespie R. Fracrure of the radial neck and
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I
562 Upper Extremty

114. Thakore HKO. Lareral Monteggia fracture in children. Int j Orthop 122. Versrreken LG. Shaft forearm fractures in children. inrramedullary
Trauma 1983:55. nailing with immediate motion: a preliminary reporr.j Pediatr Orthop
115. Theodorou SO. Dislocation of the head of the radius associated with 1988;8:450-453.
fracrure of the upper end of ulna in children. j Bone joint Surg Br 123. Walker J, Rang M. Forearm fractures in children. j Bone joint Surg
1969;51 :700-706. Br 1991 ;73:299.
116. Theodorou SO, Ierodiaconou MD, Rousis K Fracture of the upper 124. Watson-Jones R. Fracture and joint injury, 4th ed. Edinburgh: ES
end of the ulna associated with dislocation of the head of the radius Livingsrone, 1956.
in children. Clin Orthop 1988;228:240-249. 125. WatsonJAS, Singer Gc. Irreducible Monteggia fracture: beware nerve
117. Thompson 0, Lipscomb B. Recurrent radial head subluxation treated entrapmenr. Injury 1994;25:325-327.
with annular ligament reconstruction. Clin Orthop 1989;246: 126. Weitbrechr ]. Syndesmologia sive historia ligamentorum corporis hu-
mani. Petropoli Typographia Academiae Sclantiarum, Brecht, 1742.
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127. Wiley JJ, Galey JP. Monteggia injuries in children. j Bone joint Surg
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128. Wise RA. Lateral dislocation of rhe head of radius with fracture of
119. Thompson HA, Hamilron AT. Monteggia fracture: internal fixation rhe ulna. j Bone joint Surg 1941;23:379.
of fractured ulna with I.M. Steinmann pin. Am j Surg 1950;79: 129. Wright PRo Greenstick fracture of the upper end of the ulna with
579-584. dislocation of the radio-humeral joint or displacemenr of the superior
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injuries. Clin Orthop 1967;50:129-134. 130. Yamamoro K, Yoshiaki Y, Tomihara M. Posterior interosseous nerve
121. Tompkins DG. The anterior Monteggia fracture. j Bone joint Surg palsy as a complication of Monteggia fractures. Arch jpn Chin 1977;
Am 1971;53:1109-1114. 46:46-56.
 THE ELBOW REGION: GENERAL
CONCEPTS IN THE PEDIATRIC
PATIENT
JAMES H. BEATY
JAMES R. KASSER

Capsule
I ClDE CE
Fat Pads
Vulnerabilicy of Upper Extremities
Ligaments
Specific Percentages
Higher in 5- to 10-Year-Old Boys
RADIO RAPHIC Fr s
ANATOMY Standard View
The Ossification Process Jones View
The Fusion Process Anteroposterior Landmarks
Blood Supply Lareral Landmarks

We thank Kaye Wilkins for his contribution to this chapter and exrremities to fractures. In the three major series reviewing large
previous editions. Much of this chapter is his effort. numbers of fractures sustained by children (3,24,35), the upper
At me turn of the century, Sir Robert Jones (30) echoed extremicy consistenrly accounted for 65% to 75% of all the
the opinion of that era about elbow injuries: "The difficulties fractures sustained. The most common area of the upper extrem-
experienced by surgeons in making an accurate diagnosis; the icy injured is the distal forearm (3,36). In these and other series,
facilicy with which serious blunders can be made in prognosis again the incidence of fractures about the elbow was consistent,
and treatment; and the fear shared by so many of the subsequem ranging from 7% to 9% (3,24,35,36,43).
limitation of function, serve to render injuries in the neighbor-
hood of the elbow less arrractive than they might otherwise have
proved." These concerns are applicable even today. The presen- Specific Percentages
tation of a child with a swollen, injured elbow still brings some
anxiety [Q the [I'eating orthopaedic surgeon. Fracrures in other Considerable data are available relating the specific percentages of
regions of the body can often be managed with minimal treat- the various fractures in the elbow region to the tOtal number of
mem to obtain uniformly good results. In the region of the elbow injuries. The distal humerus accounts for 86.4% of the frac-
elbow, however, there are often more indications for aggressive tures about the elbow region. In a combined series of5,228 frac-
treatment, including operative management. Due to the high tures (3,4,7,8,15,16,21,27,34,36-38,45,49) of me distal hume-
incidence of injuries and complications in children's elbow inju- rus, 79.8% involved the supracondylar area, 16.9% involved the
ries, the orthopaedic surgeon must devote much time to learning lateral condyle, and 12.5% represented avulsion ofthe medial epi-
the basic principles. condyle. Both T -condylar fractures and fractures of (he medial
condyle had an incidence ofless (han 1%. In this large series, (here
I CIDENCE was no mention of any fracture of the lateral epicondyle.

Vulnerability of Upper Extremities

Children tend to protect themselves with their outstretched anns Higher in 5- to lO-Year-Old Boys
when they fall, thus accounting fot the vulnerabilicy of the upper
Elbow injuries are much more common in the skeletally imma-
ture than in older people (11,53). The peak for fractures in (he
James H. Beary: Deparrment of Orrhopaedic Surgery, University of distal humerus is in the first decade of life, with most of the
Tennessee, C<tmpbell Clinic, and LeBonheur Children's Medical Center,
injuries occurring between ages 5 and 10 years (27). Elbow inju-
Memphis, Tennes.<ee.
James R. Kasser: Dq,arrmenr of Orthopaedic Surge.)', Harvard School of ries are more common in boys. In the Northern Hemisphere,
Medicine, and Children's Hospital Medical Ccnrer, BostOn, Massachuserrs. the seasonal peak is during the summer, (he low point during
564 Upper Extremity

the winter (27,34). Thus, the most likely candidate for an elbow
injulY is a boy 5 to 10 years of age playing during summer
vacation.
The peak incidence of physeal (epiphyseal plate) injuries in
most parts of the body is toward the termination of skeletal
maturity. The Petersons (42) found that the incidence of physeal
injuries in all parts of the body peaked between ages 10 and 13
years. However, the peak age for injuries to the distal humeral
physes was 4 to 5 years in girls and 5 to 8 years in boys. In most
physeal injuries, the increased incidence with advanced age is
said to be due to weakening of the perichondrial ring as it ma-
tures (see Chapter 5). Thus, some different biomechanical forces
and conditions must exist about the elbow to make the physis
more vulnerable to injuries at an earlier age. (For more data on
the relationship of fractures about the elbow to all rypes of frac-
tures, see Chapter 1).

ANATOMY
The elbow is a complex joint composed of three individual joints
conrained within a common arricular cavity. This chapter em-
phasizes anatomic concepts unique to the growing elbow.

FIGURE 13-1. During the first 6 months, the advancing ossifying bor-
The Ossification Process der of the distal humerus is symmetric.

Central-Distal Process
The process of differentiation and martll'ation begins at the cen-
ter of the long bones and progresses distally. The ossification
Distal Humerus
process begins in the diaphysis of the humerus, radius, and ulna
at the same time. By term, ossification of the humerus has ex- Sex Variation
tended distally to the condyles. In the ulna, it extends to greater Ossification of the distal humerus proceeds at a predictable rate.
than half the distance between the coronoid process and the tip In general, the rate of ossification in girls exceeds that of boys
of the olecranon. The radius is ossified proximally to the level (20,22,25). In some areas, such as the olecranon and lateral
of the neck. The bicipital ruberosiry remains largely unossifled epicondyle, the difference between boys and girls in ossiflcarion
(Table 13-1) (23). Brodeur et al. compiled a complete arias of age may be as great as 2 years (22).
ossification of the Structures about the elbow (9), and their work
is an excellent reference source for finer details of the ossification Initial Symmetry
process about the elbow. During the first 6 months, the border of ossification of the distal
humerus is symmetric (Fig. 13-1).

Lateral Condyle
TABLE 13·1. SEQUENCE AND TIMING OF
OSSIFICATION IN THE ELBOW The ossification center of the lateral condyle, on average, appears
Girls (yr)' Boys (yr) just before 1 year of age but may be delayed as late as 18 to 24
months (II).
Capitellum 1.0 1.0 When the ossific nucleus of the lateral condyle first appears,
Radial head 5.0 6.0 the distal humeral metaphyseal border becomes asymmetric. The
Medial epicondyle 5.0 7.5
Olecranon 8.7 10.5 lateral border slants and becomes straight to conform with the
Trochlea 9.0 10.7 ossificHion cenrer of the lateral condyle (Fig. 13-2). By the end
Lateral epicondyle ;0.0 12.0 of the second year, this border becomes well defined, possibly
even slightly concave. This ossification center is usually spherical
Data from Cheng !'c, Wing-Man K. Shen WY, et al. A new look at when it first appears. It becomes more hemispherical as the distal
the sequential development of elbow-ossification centers in
children. J Pediatr Orthop 1998;18':161-167.
humerus matures (IO). This ossific nucleus is now exrending
intO the lateral ridge of the trochlea (Fig. 13-3). On the lateral
view, the ph)'sis of rhe capitellum is wider posteriorly. Thjs is a
 Chapta 13: Gmeral ConceptJ in the Pediatric Patient 565

FIGURE 13-2. Ossification at 12 months. As the ossification center of

the lateral condyle develops (arrow), the lateral border of the metaphy-
FIGURE 13-4. At about 5 or 6 years of age, a secondary center develops
sis becomes straighter.
in the medial epicondylar apophysis (white arrows). At this same time,
the ossification center of the radial head also develops (open arrow).
Note that the physis of the proximal radius is widened laterally (curved
arrow).

normal variation and should nor be confused wirh a fracrure

(10).

Medial Epicondyle
Ar about 5 to 6 years of age, a small concavity develops on rhe
medial aspect of rhe meraphyseal ossificarion border. In rhis area,
a medial epicondyle begins ro ossify (Fig. 13-4).

Trochlea
Ar abour 9 to 10 years of age, rhe trochlea begins to ossify.
Inirially, ir may be irregular wirh mulriple centers (Fig. 13-5).

Lateral Epicondyle
The lareral epicondyle is lasr ro ossify and is nor always visible
(Fig. 13-6). Ar about 10 years of age, ir may begin as a small,
separare oblong center, rapidly fusing with the lareral condyle
(10).

The Fusion Process

Jusr before complerion of growth, rhe capitellum, lateral epicon-
dyle, and trochlea fuse ro form one epiphyseal center. Meraphy-
seal bone separares the extraarricular medial epicondyle from this
common humeral epiphyseal center (Fig. 13-7). The common
FIGURE 13-3. At 24 months, the oval-shaped secondary ossification epiphyseal center ultimarely fuses with the disral humeral me-
center of the lateral condyle extends into the lateral crista of the troch-
lea. The lateral border ofthe neck (metaphysis) of the radius is normally raphysis. The medial epicondyle may nor fuse wirh rhe meraphy-
angulated both anteriorly and laterally. sis until rhe late reens.
566 Upper Extremity

FIGURE 13-S. At about 9 years of age, the ossification of the medial

crista of the trochlea may begin as two well-defined centers (arrows).
These multiple centers can give the trochlea a fragmented appear-
ance.

FIGURE 13-7. The secondary ossification centers of the lateral condyle,

trochlea, and lateral epicondylar apophysis fuse to form one center
Proximal Radius (white arrows). This common center is separated from the medial epi-
condylar apophysis by advancing metaphyseal bone (black arrows).
The head of the radius begins to ossify at about the same time
as the medial epicondyle (Fig. 13-4). The ossification center is
present in at least 50% of girls by 3.8 years of age but may not
be present in the same proportion of boys until around 4.5 years
metaphysis. The ossification center flattens as it matures. At
(20). Initially, the ossification center is elliptical and the physis
about age 12, it develops a concavity opposite the capitellum
is widened laterally because of the obliquity of the proximal
(J 0).
Ossification of the radial head may be bipartite or may pro-
duce an irregularity of the second center. These secondary or
irregular ossification centers should not be interpreted as fracture
fragments.

Olecranon
There is a gradual proximal progression of the proximal ulnar
metaphysis. At birth, the ossification margin lies halfway be-
tween the coronoid process and the tip of the olecranon. By
about 6 or 7 years of age, it appears to envelop about 66% to
75% of the capitellar surface. The final portion of the olecranon
ossifies from a secondary ossification center that appears around
6.8 years of age in girls and 8.8 years in boys (Fig. 13-8A).
Porteous (43) described two separate centers, one arricular and
the other a traction type (Fig. 13-8B). This secondary ossifica-
tion center of the olecranon may persist late into adult life (41).

Fusion of the Ossification Centers

The epiphyseal ossification centers of the distal humerus fuse
as one unit and then fuse later to the metaphysis. The medial
FIGURE 13-6. The apophysis ofthe lateral epicondyle ossifies as either epicondyle is the last to fuse to the metaphysis. The ranges of
an oblong or a triangular center (arrows). The wide separation of this
center from the metaphyseal and epiphyseal borders of the lateral con- onset of ossification of the various centers and their fusion to
dyle is normal. other centers or the metaphysis are summarized in Fig. 13-9.
 Chapter 13: General Concepts in the Pediatric Patient 567

A B
FIGURE 13-8. Ossification of the olecranon. A: Secondary ossification begins as an oblique oblong
center at about 6 to 8 years of age. B: It may progress as two separate ossification centers: articular
(open arrow) and traction (closed arrows).

9 8-11 yrs ?,..

5-8yrs
d 9-13yrs u 7-9yrs

k 2- 14+yrs
2-1m-11m & 7-11yrs . " u 17+yrs

A
u 1m-26m u 8-13yrs tY

c B
FIGURE 13-9. Ossification and fusion of the secondary centers of the distal humerus. A: The average
ages for the onset of ossification of the various ossification centers are shown for both boys and girls.
B: The ages at which these centers fuse with each other are shown for both boys and girls. (Redrawn
from Haraldsson 5. On osteochondrosis deformans juvenilis capituii humeri including investigation of
the intra-osseous vasculature in the distal humerus. Acta Orthop Scand SuppI1959;38; with permission.)
c: The contribution of each secondary center to the overall architecture of the distal humerus is repre-
sented by the stippled areas.
568 Upper E'xtremit.y

Each center contributes to the overall architecture of the distal Three structural components govern the location of the en-
humerus (Fig. 13-9C). trance of the vessels into rhe developing epiphysis. First, thete
Fusion of the proximal radial and olecranon epiphyseal cen- is no communicarion between the intraosseous metaphyseal vas-
ters with their respective metaphyses occurs at around the same culature and the ossification centers. Second, vessels do not pene-
time that the common distal humeral epiphysis fuses with its trate the articulat surfaces. The lateral condyle is nonarticular
metaphysis (i.e., between 14 and 16 years of age) (5,9,47). only at the origin of the muscles and collateral ligaments. Third,
Noting that the pattern and sequence of ossification of the the vessels do not penetrate the articular capsule except at the
six secondary ossification centers around the elbow were mainly interface with the surface of the bo~e. Thus, only a small portion
derived from studies conducted more than 30 years ago, Cheng of the lateral condyle posteriorly is both nonarticular and extra-
et al. evaluated elbow radiographs of 1,577 Chinese children capsular (Fig. 13-11) (26).
(14). They found that the sequence of ossification was the same
in boys and girls-capitellum, radial head, medial epicondyle,
Intraosseous
olecranon, trochlea, and lateral epicondyle-bur ossification was
delayed by about 2 years in boys in all ossification centers except Posterior End Vessels
the capitellum (Table 13-1). The most extensive study of the intraosseous blood supply of
the developing distal humerus was conducted by Hataldsson
Blood Supply (Fig. 13-12) (25,26). He demonstrated that twO types of vessels
exist in the developing lateral condyle. These vessels entet the
Extraosseous
posterior portion of the condyle just lateral to the origin of the
There is a rich arterial network around the elbow (Fig. 13-10) capsule and proximal to the articular cartilage near the origin
(55). The major artetial trunk, the brachial artery, lies anteriorly of the anconeus muscle. They penetrate the nonossified cartilage
in the antecubital fossa. Most of the intraosseous blood supply and traverse it to the developing ossific nucleus. In the young
of the distal humerus comes from the anastomotic vessels that child, this is a relatively long course (Fig. 13-12A). These vessels
coutse posteriorly. communicate with one another within the ossific nucleus bur .

_---Brachial artery
Profunda brachii artery-----;\

fIr
"

"' ~

1 + - - - - Superior ulnar
collateral artery
Radial collateral artery---I
Middle collateral branch Inferior ulnar
Profunda brachii artery-- ~-\----collateral artery

Radial recurrent artery--(i,,-I Ulnar recurrent artery

""+----Anterior
Ao------Posterior
Posterior interosseous
recurrent artery - - - - - - - I i - +- Common. interosseous artery
Interosseous artery
------Anterior
------Posterior
I------Ulnar artery
Radial artery

FIGURE 13·10. The major arteries about the anterior elbow.

 ChtlJltl'r 13: General Concepts in the Pediatric Patient 569

Two Separate Trochlear Vessels

Haraldsson's (26) studies have shown twO sources of blood sup-
ply to the ossific nucleus of the medial portion of the trochlea
(Fig. 13-12B). The lateral vessel, on the posterior surface of the
distal humeral metaphysis, penetrates the periphery of the physis
and terminates in the rrochlear nucleus. Because this vessel sup-
plying the trochlea is an end vessel, it is especially vulnerable to
injury by a fracture that courses through either the physis or the
very distal portion of the humetal metaphysis. Injury to this
vessel can markedly decrease the nourishment to the developing
lateral ossific nucleus of the trochlea. The medial vessel pene-
trates the nonarticulating portion of the medial crista of the
trochlea. This multiple vascular source may account for the de-
FIGURE 13-11. The vessels supplying the lateral condylar epiphysis
enter the posterior aspect of the condyle, which is extraarticular. (Re- velopment of multiple ossification centers in the maturing troch-
drawn from Haraldsson S. On osteochondrosis deformans juvenilis capi- lea, giving it a fragmented appearance (Fig. 13-5).
tuli humeri including investigation of the intra-osseous vasculature in
the distal humerus. Acta Orthop Scand SuppI1959;38; with permission.)
Final Anastomosis
When growth is complete, meraphyseal and epiphyseal vessels
anastomose freely. The blood supply from the central nutrient
do not communicate with vessels in either the metaphysis or vessel of the shaft reaches the epicondylar regions in the skeletally
nonossifled chondroepiphysis. Thus, for practical purposes, they mature distal humerus (33).
are end vessels.

Lateral Crista Is Part of Lateral Condyle Capsule

The ossification center of the lateral condyle extends into the
Intraarticular Structures
lateral portion of the trochlea. Thus, the lateral crista or ridge
of the trochlea derives its blood supply from these condylar The articular surface lies within the confines of the capsule, but
vessels. The medial ridge or crista remains unossified for a longer nonarticulating areas involving the coronoid and radial fossae
period of time. anteriorly and the olecranon fossa posteriorly are also within the
confines of the articular cavity (54). The capsule attaches JUSt
Trochlear Vessels Traverse Physis distal to the coronoid and olecranon processes. Thus, these pro-
The trochlea is covered entirely by articular cartilage and lies cesses are intraarricular (29). The entire radial head is inrraarricu-
totally within the confines of the articular capsule. The vessels lar, with a recess or diverticulum of the articular cavity of the
that supply the nucleus of the ossific ceorers of the trochlea elbow extending distally under the margin of the orbicular liga-
must therefore traverse the periphery of the physis to enter the ment. The medial and lateral epicondyles are extraarricular.
epiphysis.

Anterior Portion Strongest

The anterior capsule is thickened anteriorly. These longitudi-
nally directed fibers are very strong and become taut with the
elbow in extension. In hyperextension, the tight anterior bands
of the capsule force the ulna firmly into contact with the hume-
rus. Thus, the fulcrum of rotation becomes uansmitted proxi-
mally into the tip of the olecranon in the supracondylar area.
This is an important factor in the etiology of supracondylar
fractures.

A B Fat Pads
FIGURE 13-12. Intraosseous blood supply of the distal humerus. A: The
vessels supplying the lateral condylar epiphysis enter on the posterior At the proximal portion of the capsule, between it and the syno-
aspect and course for a considerable distance before reaching the ossific viallayer, are twO large fat pads (Fig. 13-13). The posterior fat
nucleus. B: Two definite vessels supply the ossification center of the
medial crista of the trochlea. The lateral one enters by crossing the pad lies totally within the depths of the olecranon fossa when
physis. The medial one enters by way of the nonarticular edge of the the elbow is flexed. The anterior fat pad extends anteriorly out
medial crista. (Redrawn from Haraldsson S. On osteochondrosis de- of rhe margins of the coronoid fossa. The significance of these
formans juvenilis capituli humeri including investigation of the intra-
osseous vasculature in the distal humerus. Acta Orthop Scand Suppl fat pads in the interpretation of radiographs of the elbow is
1959;38; with permission.) discussed larer.
570 Upper Extremity

Anterior fat pad

Fat pad in
olecranon fossa

FIGURE 13-13. The elbow fat pads. Some of the coronoid fat pad lies
anterior to the shallow coronoid fossa. The olecranon fat pad lies totally
within the deeper olecranon fossa.

FIGURE 13-14. Jones axial radiographic view of the elbow.

Ligaments
The pertinent ligameorous anatomy involving the orbicular and
collateral ligaments is discussed in the sections on the specific rhe disral humeral meraphysis. The ossificarion center of the
injuries involving the radial neck, medial epicondyle, and elbow lateral condyle exrends into rhe radial or lareral crista of the
dislocations. trochlea (Fig. 13-9C). This physealline forms an angle with the
long axis of the humerus. The angle formed by rhis physealline
and the long axis of the humerus is termed Baumann's angle
RADIOGRAPHIC FINDINGS (Fig. 13-15A) (1). Baumann's angle is not equal to rhe carrying
angle of rhe elbow in the older child (10). This is a consisrent
Because of the ever-changing ossification pattern, identification angle when both sides are compared and rhe x-ray beam is di-
and delineation of fractures abour the elbow in the immarure recred perpendicular to rhe long axis of rhe humerus.
skeleton may be subjecr to misinrerprerarion. The variables of
ossifJcarion of rhe epiphyses should be well known to the ortho-
paedic surgeon who [('ears these injuries. Effects of Angulation
Caudad-cephalad angularion of rhe x-ray rube or righr or lefr
Standard View angularion of the rube by as much as 30 degrees changes Bau-
mann's angle by less rhan 5 degrees. If, however, rhe rube be-
The srandard radiographs of rhe elbow include an anreroposter- comes angulared in a cephalad-caudad direction by greater than
ior view with rhe elbow extended and a lateral view wirh rhe 20 degrees, the angle is changed significantly and the meaSl1l'e-
elbow flexed to 90 degrees and rhe forearm neutral. ment is Inaccurare.

Jones View Effects of Rotation

In rhe injured elbow, ir is ofren difficult to exrend the elbow. Camp et al. (J 2) found in their cadaver srudies rhar rorarion of
In these cases, an axial view of rhe elbow, rhe Jones view, may rhe distal fragment or the eorire reduced humerus aJso can airel'
be helpful (Fig. 13-14). The distal humerus is often difficult to rhe projecrion of Baumann's angle. They found char to be accu-
iorerpret because of rhe superimposed proximal radius and ulna. rate, rhe humerus muse be parallel to rhe x-ray plate. wirh the
Ofrcn rhere is a high index of suspicion for a fracrure, bur none beam direcred perpendicular to rhe film as well.
is visualized on rhe rourine anteroposrcrior and lareral radio- Thus, in the routine anreroposrerior radiographs of rhe distal
graphs. In rhis case, inrernal and external oblique views may be humerus including rhe Jones view, Baumann's angle is a good
helpful. This is especially true in visualizing fracrures of rhe radial measuremenr of any deviarion of rhe angularion of the disral
head and coronoid process. humerus (16).

Anteroposterior Landmarks
Other Angles
Baumann's Angle
Two orher angles are commonly used in anreroposrerior radio-
In the srandard anteroposterior view, rhe major landmark is tl1e graphs to derermine the proper alignment of the distal humerus
angulation of rhe physeal line berween rhe lareral condyle and or cal'lying angle. The humeral-ulnar angle is derermined by
 Chapter J3: GeneraL Concepts ill the Pediatric Patient 571

Baumann's
Angle

A
90 - a

c------- t
B

Humeral-Ulnar
Angle

B c
FIGURE 13-15. Anteroposterior radiograph angles of the elbow. A: Baumann's angle (a). B: The hu-
meral-ulnar angle. C: The metaphyseal-diaphyseal angle. (Reproduced from O'Brien WR, Eilert RE, Chang
FM, et al. The metaphyseal-diaphyseal angle as a guide to treating supracondylar fractures of the hume-
rus in children. Unpublished data; with permission.)

lines longirudinally bisecting the shaft of the humerus with the with other cemers. The metaphyseal-diaphyseal angle is the least
shaft of the ulna (Fig. 13-15B) (2,28,41). The metaphyseal- accurate of the three (50).
diaphyseal angle is determined by a line that longirudinally bi-
sects the shaft of the humerus with a line that connects the
widest poims of the metaphysis of the distal humerus (see Fig. Lateral Landmarks
13-15C) (40). The humeral-ulnar angle is the most accurate in
Teardrop
determining the true carrying angle of the elbow. Baumann's
angle also has a good correlation with the clinical carrying angle. The lateral projection of the distal humerus presents a teardrop-
However, it may be difficult to measute in the adolescem when like shadow above the capitellum (47). The amerior dense line
the ossification cemet of the lateral condyle is beginning to fuse malcing up the teardrop represents the posterior margin of the
572 Upper bxtremity

f
\
I

A,B C,D
FIGURE 13-16. Lateral radiographic lines of the distal humerus. A: The teardrop of the distal humerus.
B: The angulation of the lateral condyle with the shaft of the humerus. C: The anterior humeral line.
D: The coronoid line.

coronoid fossa. The posterior dense line represents the anterior ance (Fig. 13-5). This fragmentation can be misinterpreted, es-
margin of the olecranon fossa. The inferior portion of the tear- pecially if the disral humerus is slightly oblique or tilted. These
drop is the ossification center of the capitellum. On a true lateral secondary ossification centers may be mistaken for fracture frag-
projection, this teardrop should be well defined (Fig. 13-16A). meors lying bervv'een the semilunar notch and lateraJ condyJe
(Fig. 13-17).
On the IareraJ projecrion, the physealline berween the lateraJ
Shaft-Condylar Angle
condyle and the distaJ humeral meraphysis is wider posteriorly.
On the lateral radiograph, there is an angulation of 40 degrees This may give a misinterpretation that the lateral condyle is
berween the long axis of the humerus and the long axis of the fractured and tilted (0).
lateral condyle (Fig. 13-16B). This also can be measured by In the anteroposterior projection before the radial head ossi-
the flexion angle of the distaJ humerus, which is calculated by fies, there is normally some lateral angulation to the radial border
measuring the angle of the lateral condylar physealline with the of the neck of the radius that may give the appearance of subluxa-
long axis of the shaft of the humerus (18). tion (Fig. 13-3). The true position of the radiaJ head can be
confirmed by noting the relationship of the proximal radius co
the ossification center of the lateral condyle on the lateral projec-
Anterior Humeral Line tion (46).
If a line is drawn along the anterior border of the distal humeral
shaft, it should pass through the middle third of the ossification
center of the capitellum. This is referred to as the anterior hu-
meral line (Fig. 13-16C). Passage of the anterior humeral line
through the anterior portion of the lateral condylar ossification
center or anterior to it indicates the presence of posterior angula-
tion of the distal humerus. In a large study of minimaJly dis-
placed supracondylar fractures, Rogers et at. (44) found that this
anterior humeral line was the most reliable factOr in detecting
the presence or absence of occulr fractures.

Coronoid Line
A line directed proximally aJong the anterior border of the coro-
noid process should barely tOuch the anterior porrion of the
lateral condyle (Fig. 13-160). Posrerior displacement of the lat-
eral condyle projects the ossiflcarion center posrerior to this coro-
noid line (47).

Pseudofracture
Some vagaries of the ossification process about the elbow may
FIGURE 13-17. Pseudofracture of the elbow. The trochlea with its mul-
be interpreted as a fracture (47). For example, the ossification tiple ossification centers may be misinterpreted as fracture fragments
of the trochlea may be irregular, producing a fragmented appear- lying between the joint surfaces (arrow).
 Chapter /3: Ceneral Concepts in the Pediatric Patient 573

Fat Pad Signs of the Elbow the fat pad in this area projects anterior to the bony margins
and can be seen normally as a triangular radiolucency anterior
Three Fat Accumulations
to the distal humerus. AJthough displacement of the classic
There are three areas in which fat pads overlie major structures
elbow fat pads is a reliable indication of an intraarricular effusion,
of the elbow. Displacement of any of the fat pads can indicate
there may be instances in which only one of the fat pads is
the presence of an occult fracture. The first cwo are the fat pads
displaced. Brodeur and colleagues (IO) and Kohn (32) have
that overlie the capsule in the coronoid fossa anteriorly and the
shown that the coronoid fat pad is more sensitive to small effu-
olecranon fossa posteriorly. Displacement of either or both of
sions. It can be displaced without a coexistent displacement of
these fat pads is usually referred to as the classic elbow fat pad
the olecranon fat pad (Fig. 13-18C).
sign. A third accumulation of fat overlies the supinator muscle
as it wraps around the proximal radius.
Supinator Fat Pad
Olecranon (Posterior) Fat Pad A layer of fat on rhe anterior aspect of the supinator muscle
Because the olecranon fossa is deep, the fat pad here is totally wraps around the proximal radius. This layer of fat or far pad
colltained within the fossa. It is not visualized on a normal lateral may normally bow anteriorly to some degree. Brodeur et al.
x-ray of the el bow flexed to 90 degrees (Fig. 13-18A). Distention (10) stared displacement may indicate the presence of an occulr
of the capsule with an effusion, as occurs with an occult intraar- fraceure of the radial neck. Displacemenr of the fat line or pad
ticular fracture, a spontaneously reduced dislocation, or even an is often difficult to interpret; in a review of fractures involving
infection, can cause the dorsal or olecranon fat pad to be visual- rhe proximal radius, Schunk er al. (47) found ir to be posirive
ized (56). only 50% of the time.

Coronoid (Anterior) Fat Pad Fat Pad Variations

Likewise, the ventral or coronoid fat pad may be displaced anteri- For the fat pads to be displaced, rhe capsule musr be iorace. This
orly (Fig. 13-18B) (6). Because the coronoid fossa is shallow, can explain why there may be no displacemenr of the fat pads

A-C D,E

F'IGURE 13-18. Radiographic variations of the elbow fat pads. A: Normal relationships of the two fat
pads. B: Displacement of both fat pads (arrows) with an intraarticular effusion. C: In some cases, the
effusion may displace only the anterior fat pad (arrows). D: In extension, the posterior fat pad is
normally displaced by the olecranon. E: An extraarticular fracture may lift the distal periosteum and
displace the proximal portion of the posterior fat pad. (Redrawn from Murphy WA, Siegel MJ. Elbow
fat pads with new signs and extended differential diagnosis. Radiology 1977; 124: 656-659; with per-
F mission.) F: An x-ray showing displacement of both fat pads (arrows) from an intraarticular effusion.
574 Upper Extremit),

with an elbow dislocation that has spontaneously reduced be- 7. Boyd HB, AJrenberg AR. Ftacrures about the elbow in children. Arch
cause of rupture of the capsule. Murphy and Siegel (39) have 5111g 1944;49:213-224.
8. Brewster AH, Karp M. Fracmres aboUl the elbow in children. An end-
shown other variations of displacement of the classic fat pads. result srudy. Surg Gynecol Obstet 1940;71 :643-649.
If the elbow is extended, the fat pad is normally displaced from 9. Brodeur AE, Silberstein JJ, Graviss ER. Radiology ofthe Pediatric Elb01l1.
the olecranon fossa by the olecranon (Fig. 13-180). Disral hu- Bosran: GK Hall, 1981.
meral fractures may cause subperiosteal bleeding and may lift 10. Brodeur AE, Silbersrein JJ, Graviss UZ, et al. The basic tenets for
appropriate evaluation of the elbow in pediatrics. In: Currmt problem_,
the proximal portion of the olecranon fat pad wirhout the pres-
ill diagnostic radiology. Chicago: Ye~r Book Medical, 191:D.
ence of an effusion (Fig. 13-18E). These false-negative and false- II. Buhr AJ, Cooke AM. Fracrure Patterns. Lrmat 19'59;1:531-'536.
posirive findings must be kept in mind when interpreting the 12. Camp J, lshiZlle K, Gomez M. ct a1. Alter~tion of lhum~nn's angle by
presence or absence of a fat pad with an elbow injury. humeral position: implications for [\'(:atI1lCIH of supracondylar huJUcTus
fracrures. j Pediatr Orthop 1~~3;13:521-555.
13. Chacon D, Kissoon N, Brown T, et al. Use of comparison radiographs
Posterior Fat Pad Is Most Reliable
in rhe diagnosis of rraumatic injuries of the elbow. Ann Emerg /V/ed
Corberr's (16) review of elbow injuries indicated that if a dis- 1992;21 :8~'5-899.
placement of the posteriot far pad existed, a fracture was almost 14. Cheng JC, Wing-Man K, Shen WY, et al. A ncw look at thc scquemiaJ
always presenc. Displacement of the anterior fat pad alone, how- development of elbow-ossification cemetS in children. j Pnliatr Orthop
ever, could occur without a fracrure. Corbett also determined 1998; 18: 161-167.
15. Conn JJr, Wade PA.1njllfies of I' he elbow: a ten year review.] Trauma
rhat the degree of displacement bore no relation to the size of
1961;1:248-268.
the fracture. Skaggs and Mirzayan (48) reponed thaI' 34 of 45 16. Corberr RH. Displaced far pads in trauma ra the elbow. IrUury 1978;
children (76%) with a history of elbow trauma and an elevated 9:297-298.
posterior fat pad had radiographic evidence of elbow fractures 17. Oai L. Radiogr~phic evaluation of Baumann angle in Chinese children
at an average of 3 weeks after injulY, although anteroposterior, and its e1inical relevance. j Pediatr Orthop 1999;8: 197-199.
18. D'Arienzo M, Innocenti M, Pennisi M. The ueatment of supracondy-
lateral, and oblique radiographs at the time of injUlY showed no
lar ftacrures of the humerus in childhood (cases and results). Arch Putti
orher evidence of fracture. They recommended that a child with ChiI' Olgrwi Mov 1983;33:261-269.
a history of elbow trauma and an elevated far pad be treared as 19. Donnelly LF, l<JostcrmcierTT, Klostcrman LA. Traumatic dbow effu-
if a nondisplaced elbow fracture were presenc. Donnelly et aJ. sions in pediauic patients: are occult fracrures the rule~ AjR 1998; 171:
(9), however, found evidence of fracture in only 9 of 54 chil- 243-245.
dren (17%) who had a hisrory of trauma and elbow joint effusion 20. Elgenmark O. The normal devclopmem of the ossifrc cenrers during
infancy and childhood. Acta Paediatr Seal'lll Suppl 1946;33.
bur no identifiable fracrure on initial radiographs. They con-
21. Fahey JJ. Fracrures of the elbow in children. /mtr Course Lect 1960;
cluded that joint effusion without a visible fracture on inirial 17:13-46.
radiographs does not correlate with rhe presence of occult frac- 22. Francis Cc. The appearance of centers of ossificarion from 6-15 vcom.
ture in most patients (83%). Persistent effusion did correlate Am} Phys I1I11/1ropo/1940;27:127-138.
with occulr fracture: 78% of those with occulr fractures had 23. Gray OJ, Gardner E. 1're,,"tal developmem of the humaJ1 elbow joint.
Am J Anat 1951 ;88:429-469.
persistent effusions, compared with 16% of those without frac-
24. Hanlon CR, Estes WL. Fr~ctllres in childhood: ~ statistical ~nalysis.
tures. Am} SlIIg 1954;87:312-323.
25. H3raldsson S. The inrraosseous v~scularure of the distal end of the
Comparison Radiographs humerus wirh special reference to capirulum. ACia Ol'lhop Scand 1957;
Often it is tempting to order comparison radiographs in a child 27:81-93.
26. Haraldsson S. On osteochondrosis deformans juvenilis c~pituli humeri
with an injured elbow because of the difficulty evaluating rhe
including investigation of inn'a-osseous vascularure in disr~1 humerus.
irregularity of the ossification process. However, the indications Acta Orthop SCiwd Suppl 1959;38.
for ordering comparison radiographs are rare. Kjssoon et al. 03, 27. Henrikson 13. Supracondylar fracrure of th~ humerus in children. Acta
31) found that the use of routine comparison radiographs in ChiI' Scand SuppI1966;369.
children with injured elbows did not significantly increase the 28. Ippoliro E, Catcrini R, Scola E. Supracondylar fracrures of the humerus
accuracy of diagnosis, regardless of the inrerpreter's training. in children. AJl<llysis at marurity of 53 patierm treated conservatively.
j Bone joint 5111;'< [Am) 1986;68:333-344.
29. Jenkins F. The functional anaromy and evolmion of the mammalian
humeroulnar ~niCllbtion. Am} Anat 1973;137:281-298.
REFERENCES 30. Johansson O. Capsular and ligament injuries of the elbow joint. Acta
ChiI' Scand Suppll962;287.
1. Baumann E. Tleirrage zur Kenntnis clur Frackturen am Ellbogengelenk. :) I. Jones R. A note on the rrcann<:ll[ of injuries about rhe elbow. Provincial
Bruns Beitr F Klin ChiI' 1929;146:1-50. Meet J 1895; I :28-30.
2. Beals RK. The normal carrying angle of the elbow. Clin Orthop 1976; 32. Kissoon N, Galpin R, Gayle M, er al. Evaluation of rhe role of compari-
19:194-196. son r~diographs in the diagnosis of rraumatic elbow injuries. j Pet/ian
3. Beekman F, Sullivan JE. Some observations on fracrures of long bones Orthop 199'5; 15:449-453.
in children. Am j SUlg 1941 ;51:722-738. 33. Kohn AM. Soft tissue alterations in elbow rrauma. AjR J 959;82:
4. Blount WI'. Fractures in children. BaJrimore: Williams & Wilkins, 867-874.
1955. 34. Laing PG. The ar(erial supply of the adult humerus.} Bone joint SUlg
5. Blount WP, Cassidy RH. Fractures of the Elbow in Children. }AMA [Alii) 1956;38:1105-1116.
1951; 146:699-704. 35. L~ndin I A. Fracture patrerns in children. Analysis of 8682 fracrures
6. Bohrer SP. The fat pad sign following elbow uauma. its usd:ulness with special reference ro incidence, etiology and secular ch~ngcs in a
and reliability in suspecting "invisible" fracllllTs. Gill RadioI1970;21: Swedish urban pupulation, 1950-1979. Acta Orthop Scand SIIP/'/1983;
90-94. 54.
 Chapter 13: General Concepts in the Pediatric Patient 575

36. Landin LA, Danielsson LG. Elbow fractures in children: an epidemiol- 48. Silberstein JJ, Brodeur AE, Graviss ER. Some vagaries of the capitellum.
ogical analysis of 589 cases. Acta Orthop Scand 1986;57:309. ] Bone Joint Surg [Am} 1979;61:244-247.
37. Lichtenberg RP. A study of2532 fractures in children. Am] Surg 1954; 49. Skaggs DL, Mirzayan R. The posterior fat pad sign in association with
87:330-338. occult fracture of the elbow in children. ] Bone Joint Surg [Am} 1999;
38. Marion J, Lagrange J, Faysse R, et al. Les fractures de l'exuemite in- 81: 1429-1433.
ferieure de l'humerus chez l'enfant. Rev Chir Orthop 1962;48:337- 50. Smith L. Deformity following supracondylar fractures of the humerus.
413. ] Bone Joint Surg [Am} 1960;42:235-252.
39. Maylahn OJ, Fahey JJ. Fractures of the elbow in children.]AMA 1958; 51. Webb AJ, Sherman Fe. Supracondylar fracrures of the humerus in
166:220-228. children.] Pediatr Orthop 1989;9:315-325.
40. Murphy WA, Siegel MJ. Elbow fat pad with new signs and extended 52. Wilkins KE. Fractures and dislocarions of the elbow region. In: Rock-
differential diagnosis. Radiology 1977; 124:659-665. wood CA Jr, Wilkins KE, King RE, eds. Fractures in children, 3rd ed.
41. O'Brien WR, Eilert RE, Chang FM, et al. The metaphyseal diaphyseal
Philadelphia: JB Lippincott, 1991:509-828. .
angle as a guide ro treating supracondylar fractures of the humerus in
53. Wilkins KE. Fractures and dislocations of the elbow region. In: Rock-
children. (Unpublished.)
wood CA Jr, Wilkins KE, Beaty JH, eds. Fractures in children, 4th ed.
42. O'Donoghue DH, Stanley L. Persistent olecranon epiphyses in adults.
] Bone Joint Surg 1942;24:677-680. Philadelphia: Lippincott-Raven, 1996:653-904.
43. Peterson CA, Peterson HA. Analysis of the incidence of injuries ro the 54. William PL, Warwick R. Gray's anatomy. Philadelphia: \X'B Saunders,
epiphyseal growth plate.] Trauma 1972; 12:275-281. 1980.
44. Porteous CJ. The olecranon epiphyses. ] Anat 1960;94:286. 55. Wilson PD. Fractures and dislocations in the region of the elbow. Surg
45. Rogers LF, Malave S Jr, White H, et al. Plastic bowing, rorus, and Gynecol Obstet 1933;56:335-359.
greenstick fractures of the humerus. Radiology 1978;128:145-150. 56. Yang Z, Wang Y, Gilula LA, et al. Microcirculation of the distal hu-
46. Sandegrad E. Ftacture of the lower end of the humerus in children: meral epiphyseal cartilage: implications for post-traumatic growth de-
treatment and end results. Acta Chir Scand 1944;89: 1-16. formities. ] Hand Surg [Am} 1998;23: 165-172.
47. Schunk VK, Grossholz M, Schild H. Der Supinarorfertkorper bei 57. Zanella FE. Injuries of the elbow and forearm in children. Rontgenbku-
Frakturen des Ellbogengelenkes. ROFO 1989; 150:294-296. ter 1984;37: Ill.
 SUPRACONDYLAR FRACTURES OF
THE DISTAL HUMERUS
JAMES R. KASSER
JAMES H. BEATY

ClOE CE AND GE ERAL CONSIDERATIO S Neurologic Deficir

Elbow Stiffness
EXTE SiaN-TYPE SUPRACONDYLAR FRACTURES Myositis Ossificans
Mechanism of Injury Nonunion
Posteromedial versus Posterolateral Displacemenr of Extension- Avascular Necrosis
Type Supracondylar-Type Fracrures Angular Deformiry
Signs and Symproms FLEXIG -TYPE SUPRACONDYLAI FRACTURE
Radiologic Evaluation Etiology and Pathology
Trearmenr Radiographic Findings
Vascular Injury Treatment

We thank Kaye Wilkins for his contribution to this chapter and incidence of rhis fracture than girls. Combining 61 repons of
previous editions. Much of th.is chapter is his effore. supracondylar fractures toraling 7,212 displaced fractures of the
distal humerus yields a consistent pattern, as shown in Table
Between the mid-20th centUlY. when eady reports of pinning
14-1. Boys have ournumbered girls by about 3 to 2. The average
of fractures of the distal humerus fifSl appeared, and now, treat-
age at fracture is 6.7 years. The left or nondominanr side pre-
ment of supracondylar fractures has evolved tremendously.
dominates in almost all studies. Two thirds of children hospital-
Blount's caution against operative management (26) has given
ized with elbow injuries have supracondylar fractures. Nerve
way to modern concepts of treatment involving skeletal stabiliza-
injL1lY occurs in at least 7%. The radial nerve has been the most
tion and soft tissue managemenr, which have greatly improved
frequently involved nerve in older studies; however, the median
OutCOme (29,48,69,147,181).
nerve is much more commonly injured, particularly the anterior
Both COSt and clinical result have been significantly affected
interosseous nerve (AIN), in more recent studies (49.174). The
over the past 25 years (76). Problems of vascular compromise.
Volkmann ischemic conuacrure. and neurovascular entrapment ulnar nerve is most commonly injured iarrogenicalJy during pin-
in the fracture callus have been greatly decreased, but not elimi- ning or in a flexion-type of supracondylar fracrure. It is possible
nated. thaI' there has been a change in rhe panern of displacement of
rhese fractures, accounring for the change in frequency of median
nerve injuries, bur it is more likely tnat the subtle loss of thumb
INCIDENCE AND GENERAL and finger flexion that indicates an AlN injury is more frequently
CONSIDERATIONS recognized.
Increased ligamentous laxity (Fig. 14-1) has been correlated
The peak age at which supracondylar fracwres occur is between with the occurrence of supracondylar fractures (25,139) and
5 and 7 years. The rare of occurrence incn:ases steadi I)' in the with ulnar nerve subluxation (98). Supracondylar fracrures are
first 5 years of life, and rradirionally boys have had a higher more likely in children with ulnar nerve subluxation. which
makes the nerve vulnerable in medial pinning techniques:
Almost all supracondylar fractures are caused by accidental
trauma. A fall from a height accounts for 70% of all supracondy-
James R. Kasser: Deparrment of Orrhopaedic Surgery, Harvard School of lar fractures (64). In children under 3 years of age, the fracture
Medicine, Children's Hospital Medical Center, Boston, MassachusetTs. usually occurs in a fall from a bed, from furniture, or down
James H. Beaty: Department of Orthopaedic Surgery, University of
Tennessee, Campbell Clinic, and LeBonheur Children's Medical Center, stairs. In children over 3 years of age, the fracture generally
Memphis, Tennessee. results from a fall from monkey bars, swings, or other play-
578 Upper Extremity

TABLE 14-1. EFFICIENCE OF SUPRACONDYLAR FRACTURES

Percentage of Total Paran:rtage of

Number of Nerve .Total Nerve
Incidence Fractures (%) Involved Injuries (%)a

Side involved Radial 41.2

Right 39.2 Median 36.0
Left 60.8 Ufnar 22.8
Sex incidence
Male 62.8
Female 37.2
Ipsilateral fractures 1.0
Open fractures 1.0
Volkmann contracture 0.5
Flexion type 2.0
Fractures with nerve injuries 7.7

Data were compiled from 7212 fractures occurring in 61 major series.

Data from References, 3, 5, 13, 15, 17,18,22,23,27,29,34,41,45,47,51,53,59,60-63,66,68, 82, 84,
85,91; 93, 94, 97,103,107,109,116,117,118,124,130,132,134,136,137, 144,145, 148, 150;155, 156,
167, 168, 173, 180, 183, 184, 186, 187, 188, 195, 197.
a Average age was 6.7 years.

ground equipmem. In one srudy of 99 patiems with supracon- humeral supracondylar fractures are displaced in extension, bur
dylar fractures seen over a 15-momh period, only 1 was flexion-eype injuries do occur.
secondary ro abuse (I75). When a child under 15 momhs
of age has a supracondylar fracture of the distal humerus,
abuse should be considered; with a reasonable history, however, EXTENSION-TYPE SUPRACONDYLAR
such a cause is unlikely. FRACTURES
The most commonly associated fractures are distal radial frac-
Mechanism of Injury
tures, but fractures of the scaphoid and proximal humerus do
occur. Pulse is absent at presentation in [2% ro 15% of patiems, Supracondylar fractures generaJJy occur as a result of a fall onro
but vascular insufficiency requiring operative imervemion is rela- the outstretched hand with the elbow in fuIJ extension (40)
tively rare (32,36,44,162) (2%-4%). Volkmann ischemic con- (Fig. 14-2). The flexed elbow may be stabilized by the biceps,
tracrure is rare, occurring in about 0.5% of patients. Most distal brachiaJis, and triceps muscles, but once extended beyond neLi-

FIGURE 14-1. Hyperflexibility. At the peak age for supracon-

dylar fractures there is a naturally occurring hyperextension of
the elbow, which predisposes the distal humerus to this type
of fracture. (Reprinted from Wilkins KE. The operative man-
agement of supracondylar fractures. Orthop Gin North Am
1990;21:269-289; with permission.)
 Chapter 14: Supracondylar Fractures of the Distal Humerw 579

D
Li:
I ,

FIGURE 14-2. Hyperextension Forces. A: Most young children attempt to break their falls with the
upper extremity extended. Because of the laxity of the ligaments, the elbow becomes locked into hyper-
extension. B: This converts the linear applied force (large arrow) to an anterior tension force. Posteriorly,
the olecranon is forced into the depths of the olecranon fossa (small arrow). C: As the bending force
continues, the distal humerus fails anteriorly in the supracondylar area. D: When the fracture is complete,
the distal fragment becomes posteriorly displaced. The strong action of the triceps (large arrow) pro-
duces proximal displacement of the distal fragment.

tral, the elbow flexor muscles are at a poor mechanical advantage lateral columns of the distal humerus at the level of the middle
and there is little resistance to injury. The olecranon in its fossa of the olecranon fossa.
in the dista.l humerus acts as a fulcrum, whereas the capsule
transmits an extension force to the dista.l humerus just proximal
Role of the Periosteum
to the physis as the elbow hyperextends. The capsular insertion,
distal to the olecranon fossa and proxima.l to the physis, is critical As the supracondylar fracture displaces posteriorly, the anterior
in producing a consistent failute patrern of a transcondylar frac- periosteum fails and tears away from the displaced distal frag-
ture in children. In full extension the elbow becomes tightly ment. The anterior loss of periosteal integrity leads to frequent
inrerlocked, concentrating bending forces in. the distal humerus failure of anterior callus formation in early fracture healing,
(133). which is of little significance clinically (Fig. 14-4). Further frac-
Posterior displacement of the distal fragmenr occurs, with ture displacement is accompanied by corresponding increased
the proximal or metaphyseal fragment impaling the anterior soft periosteal disruption with decreased fracrure stabiliry.
tissue Strucrures. The fracture in the sagitral plane was classically Intact medial or lareral periosteum, the periosteal hinge, has
described by Kocher (l06) as extending obliquely from anterior been said to provide stabiliry after fracture reduction (81, t03,
and distal to posterior and proxima.l. However, clinical studies 161). Pronation of the forearm (J 3, 104) after reduction of a
by Holmberg (91) and Nand (J 37) have demonstrated that the posteromedially displaced supracondylar fracture is said to stabi-
ftacture pattern is transverse on lateral radiographs in more than lize reduction by closing the fracture gap laterally, tensioni ng
80% of patients (Fig. 14-3). The fracture line in the anteropos- the medial periosteal hinge, and tightening the lateral ligaments
terior (AP) view extends transversely across both the medial and of the elbow (Fig. 14-5). Conversely, a laterally displaced supra-
 580 Upper £xtremity

FIGURE 14-3. Orientation of fracture lines. A: Thetypi-

cal transverse fracture line originates just above the epi-
condyles and courses through the supracondylar area
(arrows). B: In the lateral projection, the fracture line is
A,S usually also transverse.

condylar fracture is more stable in supination. Experimental data Posteromedial versus Posterolateral
by Abraham (2) questioned this generally accepted concept, sug- Displacement of Extension-Type
gesting that little stabiliry resuJts from an intact periosteal hinge. Supracondylar-Type Fractures
If the periosteum is intact medially and laterally in a supracondy-
Generally, medial displacement of the distal fragment is more
lar fracture wirh pure posterior displacement, it may yield a very
common rhan lateral displacement, occurring in approximately
stable reducrion .

...
...

FIGURE 14-5. lntraarticular stabilizing forces. A: Supination of the

forearm (1) creates a downward lateral tilt of the distal fragment (3).
This produces compressive forces between the articulating surface of
the ulna and the medial border of the trochlea (A 1, stippled area),
which in turn generates clockwise forces (2) about the medial side of
the fracture. B: Pronation of the forearm (1) creates an upward tilt of
FIGURE 14-4. Periosteal changes. Radiographs taken 2 months after the distal fragment (3) because of the compressive forces between the
fracture. Lateral view demonstrates a persistent gap (white arrow) in articulating surface of the ulna and the lateral border of the trochlea
the anterior cortical margin where interposed periosteum prevented (Bl, stippled area), which in turn generates counterclockwise forces (2)
anatomic reduction. Note the absence of periosteal new bone anteri- about the medial side of the fracture. (Reprinted from Abraham E,
orly on the proximal fragment, although there is abundant periosteal Powers T, Witt P, et al. Experimental hyperextension supracondylarfrac-
new bone (black arrows) on the posterior surface. tures in monkeys. Clin Orthop 1982;171:309-318; with permission.)
 Chapter 14: Supracondylar Fractures of the Distal Humerus 581

t:l-\------Brachial artery
- - - - - - M e d i a n nerve

Radial nerve

FIGURE 14·6. Neurovascular relations. Left: If the distal spike penetrates the brachialis muscle laterally
(posteromedial fractures), the radial nerve may be tethered. Right: If the spike penetrates medially
(posterolateral fractures), both the median nerve and brachial artery can be tethered.

75% of patients in most series (191). However, in one series teum first and displace the fragment posterolaterally. Conversely,
with a high preponderance of median nerve and brachial artery if a patienr falls with the arm pronated, the disral fragment tends
injuries, 47% of patients had posterolateral displacement of the to become displaced posteromedially. Whether the displacemenr
distal humeral fragment (36). The biceps tendon insertion and is medial or lateral is importanr because it determines which soft
axis of muscle pull lies medial to the shaft of the humerus, and tissue structures are at risk From the penetrating injury of rhe
Holmberg (91) suggested that this anatomic location of muscle proximal metaphyseal fragment. Medial displacemenr of the dis-
pull created a force that tended to displace the distal humeral tal fragment places the radial nerve at risk, and lateral displace-
fragment medially. ment of the distaJ fragment places the median nerve and brachial
The position of the hand and forearm at the time of injury artery at risk (Fig. 14-6). The brachial artery and median nerve
plays a role in the direction of displacement of the distal humeral may become entrapped in the fracture site with lateral displace-
fragment. In a patient who falls onto an outstretched supinated ment, but they are highly unlikely to become entrapped with
arm, the forces applied tend to disrupt the posteromedial perios- the distal fragment displaced medially. The brachial artery is
placed further ar risk by the ulnar-sided tether of the supratroch-
lear artery (Fig. 14-7).
The Gartland classification of supracondylar fracrures is cur-
rently the most commonly used system based on its prevalence
/~~"",,~---Brachial artery in the literature and use in pediatric fracture rexts. It is easy to
/"'~+------Mediannerve use and facilitates treatment decisions and communication. The
Gartland (74) c1assiflcarion (Table 14-2) is based on the radio-
graphic appearance of fracture displacement. A rype I or nondis-
placed fracture (Fig. 14-8) has an anterior humeral line that
intersects the capitellum, an intact olecranon fossa, no medial
or lateral displacement, no medial column collapse, and a normal
JW""iIlt-t-f------Supratroch lear artery

)V"'---+------Anterior ulnar
recurrent artery

TABLE 14-2. CLASSIFICATION OF

SUPRACONDYLAR FRACTURES
Type I Undisplaced
Type II Displaced (with intact posterior cortex)
Type III Displaced (no cortical contact)
FIGURE 14-7. Arterial pathology. The supratrochlear branch that
arises from the anterior ulnar recurrent artery may bind the main trunk Posteromedial
of the brachial artery against the sharp end of the proximal fragment. Posterolateral
(Redrawn from Rowell PJW. Arterial occlusion in juvenile humeral su-
pracondylar fracture. Injury 1974;6:254-256; with permission.)
582 Upper Extremity

A B

c D
FIGURE 14-8. Types of supracondylar fractures. A: Type I fracture, where the anterior humeral line (long
arrows) crosses through the ossification center of the capitellum. There is also posterior displacement of
the olecranon fat pad (large arrows). B: Three weeks postinjury, there is evidence of new periosteal
bone formation from both the anterior and posterior cortices (arrows). Because a definite fracture line
was not seen in the original radiographs, this new bone formation confirms the original suspicion of a
fracture. C: Type 11. Lateral view of a displaced supracondylar fracture with the posterior cortex intact.
There is both rotation and angulation of the distal fragment. D: Type III. Totally displaced fracture.
There is no contact between the fragments.

Baumann angle. A eype J[ fracrure is exrended bur nor rranslated graphic appearance of rhe disral fragmenc may be highly variable
wirh an inracr posrerior correx. The anterior humeral line does depending on (a) the degree of ossification of rhe disral humeral
nor inrersecr rhe capirellum. Some rorarionaJ displacemenr and epiphysis, (b) size of rhe ossified meraphyseaJ fragmenr, and (c)
rilr inco varus, as derermined by rhe Baumann angle, may be position of flexion and roration of rhe disral humeral fragment.
presenr. A eype III fracrure has a circumferenriaJ break in rhe
correx wirh displacemenr of rhe fracrure fragmenrs. In the com-
mon exrellsi,on rype supracondylar fracrure, rhe disral fragmenr
Signs and Symptoms
is displaced posreriorly wirh rhe meraphyseal fragmenr impaled An elbow or forearm fracrure should be suspecred in a child
inco rhe br:J.chialis muscle and anrerior sofr tissues. The radio- wirh elbow pain or failure ro use the upper eXEremiry afrer a fall.
 Chapter /4: Supracondylar Fractures of the Distal Humerus 583

FIGURE 14-9. Clinical appearance. The S-shaped configuration is

created by the prominence of the spike of the proximal fragment
(A), flexion of the distal fragment (8), and the posterior promi-
nence of the olecranon (C).

Initial radiographs should include the entire extremiry, because III fractures, gross displacement (Fig. 14-9) of rhe elbow is evi-
multiple fracrures may be present even with what seems like dent. An anterior pucker sign (191) may be presenr if rhe proxi-
minor trauma. In children with elbow pain and failure ro use mal fragmenr has penetrated rhe brachialis and rhe anrerior fascia
the upper extremiry, the differential diagnosis should include of the elbow (Fig. 14-10). When rhe proximal fragmenr is disen-
occulr fracrure, nursemaid's elbow, and infecrion. Wirh a clear gaged from irs pucker in rhe skin, rhere is sometimes bleeding
hiscory of a "pulling rype" of injury, manipularion for a nurse- with signs of a grade I open fracture. Careful motor, sensory,
maid's elbow may be performed before a radiograph is obtained. and vascular examinations should be performed in all patiems.
In general, if rhe hiswry is nor clear or there is any question of This may be quire difficult in a young child bur should be ar-
a fall OntO an outstretched hand as rhe mechanism of injury, a tempted. Sensation should be tested in discrete sensory areas of
radiograph should always be obtained before elbow manipula- the radial netve (dorsal first web space), medial nerve (palmar
tion. Wirh a rype I supracondylar fracture, rhere may be disral index finger), and ulnar nerve (palmar little finger). Mowr exam-
humeral tenderness, lack of the anconeus sofr spar (elbow effu- ination should include finger, wrist, and thumb extension (radial
sion), restricrion of morion, and evidence of bruising. In rype nerve), index distal interphalangeal and thumb inrerphalangeal

FIGURE 14-10. The pucker sign. This patient had penetration

of the spike of the proximal fragment into the subcutaneous
tissue. In the anteroposterior view (A), there is a large puckering
or defect in the skin where the distal fragment has pulled the
skin inward. Laterally (B), there is puckering ofthe skin (arrow) in
the area where the spike has penetrated into the subcutaneous
A,S tissue.
584 Uppe1' Extremity

flexion (AIN), and thenar (median) and imerossei (ulnar nerve) evaluation of the olecranon fossa as an indication of injuty in
muscle function. The vascular examination should include deter- the distal humerus. The lateral film should be taken as a true
mining the presence of pulse, as well as warmth, capillary refill, lateral with the humerus held in the anatomic position and not
and color of the hand. Tenseness of the volar compartment externally rotated (Fig. 14-12). Oblique views of the distal hu-
should be evaluated, and me amounr of swelling about the elbow merus (Fig. 14-13) occasionally may be helpful when a supracon-
should be noted. Passive finger extension and flexion should be dylar fracture or occult lateral condylar fracture is suspected bur
tested and findings accurately recol'ded. In the initial examina- not seen on standard AP and lateral views, but should not be
tion of a child with a severe supracondylar ftacture with high routinely ordered in the evaluation of an elbow injury.
parental and paticnr anxiety, ir is easy to overlook vital informa- If the AP and lateral views show a displaced type II or III
tion. However, because further decision making is clependenr supracondylar fracture but do not show full detail of the distal
on an accurate initial examination, care should always be f:1kcn humeral fragment, we usually obtain further radiologic evalua-
to obtain all of the above informarion as accurately as possible. tion in the operating room with the patient anesthetized. Repeat
When rhe elbow injUlY is obvious, its examination should be trips for radiologic evaluation in the emergency setting generally
delayed until rhe proximal humerus and disral radius have been result in increased pain without significant improvement in ra-
fully examined for associated or occult fractures. diograph quality. Detailed radiographs need ro be obtained at
some point, however, to define the fracture anatomy with partic-
Radiologic Evaluation ular emphasis on (a) impaction of the medial column, (b) supra-
condylar comminution, and (c) vertical split of the epiphyseal
All parients with a history of a fall onto an outstretched hand fragment. T-condylar fractures (Fig. 14-14) can initially appeat
and pain and inability to use the exrtemity should undergo a to be supracondylar fractures, but these generally occur in chil-
thorough radiologic evaluation. This may include obraining AP dren 8 to 10 years of age, in whom supracondylar fractures are
views of the enrire upper extremity (Fig. 14-1 n.
Comparison less likely, although T-condylar fractures have been reported in
views rarely are required by an experienced physician, but occa- young children.
sionally may be needed in the evaluation of an ossifying epi- In a young child, an epiphyseal separation (55,56,200) can
physis. The AP radiograph should always be taken as an AP of mimic an elbow dislocation. In an epiphyseal separation, the
the distal humerus rather than an AP of the elbow in which the fraerure propagates through the physis without a metaphyseal
elbow is held in flexion. This allows more accurate evaluation fragment. This fracture occurs in very young children with pri-
of the distal humerus and decreases the error in determining marily chondral epiphyses. On physical examination, the patient
angular malalignment in the distal humerus. It also allows better appears to have a supracondylar fracture with gross swelling

FIGURE 14-11. Occult ipsilateral fractures. A: Type II supracondylar fracture (open

arrow) with an occult distal radial fracture (solid arrows). B: Type II supracondylar fracture
(open arrows) with an occult proximal humeral fracture (solid arrows). B
 Chapter 14: Supracondylar Fractures of the Distal Humerus 585

Incorrect

FIGURE 14-12. Radiographic positioning. The correct method of tak-

ing a lateral view is with the upper extremity directed anteriorly rather
than externally rotated.

about the elbow and marked discomfort. The key to making

the diagnosis and differentiating this injury from an elbow dislo-
cation is seeing thar rhe capitellum moves with the radial head.
B
Sometimes a supracondylar fracture with a small metaphyseal
FIGURE 14-13. Oblique views. Often, the fracture line is not visualized
fragment can mimic a lateral condylar fracture (Fig. 14-15).
on any of the lateral or anteroposterior views (A). An oblique view (8)
In such cases, more data are required to initiate treatment. An of the distal humerus may demonstrate the extent of the fracture line
arthrogram may be helpful to determine the extent of the elbow (arrows)
injury. In selected patients, magnetic resonance imaging or ultra-
sonography (200) also may aid in evaluation of injury to the
unossifled epiphysis.
neurovascular sr<!ws and other injuries, including but nor limired
to head injUlY and general cardiorespiratory status. Excessive
Treatment flexion or forced extension should be avoided, because both may
lead to vascular compromise.
General Principles
Initial management of all patients suspected of having an elbow
Type I (Nondisplaced)
injury is splinting in a comfortable position, generally 20 to 30
degrees of elbow flexion, pending careful physical examination The disral humeral injury may nor be the prima,y problem:
and radiologic evaluation. The initial responder to a child with neurologic compromise has been reported with nondisplaced
an elbow injUJY and polytrauma should make an assessment of supracondylar fractures (160). Radiographs of rhe emire extrem-
586 Upper Extremity

A B
FIGURE 14-14. Occult T-condylar. A: Original radiographs appear to show a type III posteromedial
supracondylar fracture. B: After manipulation, the vertical intercondylar fracture Iine (arrows) was visual-
ized.

A B
FIGURE 14-15. This 1.2-year-old girl sustained a fracture that on the anteroposterior view (A) appears
like an elbow dislocation and on the lateral view (B) has the appearance of a lateral condyle fracture.
(Figure continues.)
 Chapter 14: Supracondylar Fractures of the Distal Humems 587

C
FIGURE 14-15. (continued) (C) Arthrography showed the outline of
the entire cartilaginous epiphysis. This is an epiphyseal separation with
a metaphyseal fragment (Salter II).

FIGURE 14-16. Because the weight of the cast can produce an exten-
ity should be reviewed to be sure that there is no injulY in other sion movement about the distal humerus, a sling to support the weight
partS of the humerus or in the fotearm bones. On radiography, of the cast is necessary.
a type I supracondylar fracture has a visible fracture line travers-
ing rhe medial and lateral columns at the level of the oJecranon
fossa without displacement. The anterior humeral line transects
the capitellum. In general, in a type I fracture, the periosteum An acceptable position is determined by the anterior humeral
is intact with significant inherenr stability of the fracture. line rransecting the capitellum, a Baumann angle of 70 ro 78
Simple immobilization with a posterior splinr applied in 90 degrees or equal to the other side, and an intact olecranon fossa.
degrees with side supportS or simple collar and cuff is all that Medial column collapse can lead (Q varus deformiry in an other-
wise minimally displaced and normally healing distal humeral
is necessary (40,193). This allows swelling to occur and does
rracture. The duration of immobilization for supracondylar frac-
not put the brachial artery at risk of compression. Mapes and
tures is about 3 weeks, whether type 1, II or llI. In general, no
Hennrikus (121), using Doppler examinarion of the brachial
physical therapy is required after this injury. Patients are seen
artelY after supracondylar fractures, found that flow was de-
at 2 to 4 weeks after immobilization is removed to be sure that
creased in the brachial artery in positions of pronation and in-
range of motion and strength are returning normally.
creased flexion. A simple splint with the forearm in neutral posi-
tion and the elbow flexed no more than 90 degrees should be
used initially. Before the splint is applied, it should be confirmed Type /I Fracture (Displaced with an Intact Posterior
that the pulse is intact and that there is good capillaLY refill. A Cortex)
circumferenrial cast may be applied if additional fractures require
This fracture category encompasses a broad army or distal hu-
treatment, but careful observation is necessary (Q avoid any risk
meral hyperextension injuries, depending on the degtee of rota-
of compartment syndrome.
tion. Even greater than the variation in fracture stability is the
Radiographs are obtained 3 to 7 days after fracture ro docu-
spectrum of soft tissue injuries with rype II supracondylar rrac-
menr lack of displacement, and a long arm cast can be applied
tures. Cal'eful assessment of the soft tissue injury is critical in
with a ring over the distal ponion of tl1e cast and a sling around
rreatmenr decision making. Radiologic definition of this injury
the neck to suppOrt the weight of the cast (Fig. 14-16). Without demonstrates an incomplete osseous separation with some poste-
suppOrt, the weight of the cast applies an cxtcnsion tOrque about rior cortical contacts. Therefore, good stability should be ob-
the distal humerus, leading to fracture displacement. If thete is tained with dosed reduction. Medial column collapse (Fig. 14-
any evidence of extension of the distal fragmenr, as judged by 17) or buckling must be identified because a varus deformity
lack of intersection of the anterior humeral line with the capi- may result from a simple closed reduction without stabilization
tellum, the fracture should be reduced with hyperflexion of the when these an.: present. For closed reduction, traction is applied
elbow ro 120 degrees with pinning. The most common cause first, followed by correction of rotational deformity. The exten-
of cubitus varus deformiry is inadequate treatmenr of types I sion deformity is corrected with pressure by the surgeon's thumb
and II fractures, rather than the deformity complicating rype III over the olecranon and posterior humeral condyles. The align-
fractures. menr of the distal humeral fragmem is verified in AP and lateral
588 Upper Ewremity

A B
FIGURE 14-17. Greenstick medial collapse. A: An anteroposterior view of a type II fracture showing
greater collapse of the weaker medial column (arrows). B: Lateral view showing the posterior cortex is
still partially intact. (Reprinted from Wilkins KE. The management of severely displaced supracondylar
fractures of the humerus. Techniques Orthop 1989;4:12-24; with permission.)

views. With the elbow held in hyperflexion, Jones' views, rotat- An alternative method of closed management is the use of a
ing the arm slightly to expose the medial and lateral column of collar and cuff (40) (Fig. 14-21). The advantages of this ueat-
the distal humerus, are valuable to document reduction. ment are a lack of circumferential rigid casting and the avoidance
Millis (132), as well as others (13,26,86,94,147,161), have of the weight of the cast, which may produce an extension mo-
shown the necessiey of elbow hyperflexion to more than 120 ment. In this technique, the elbow is held in hyperflexion by
degrees to maintain reduC[ion of an extension-type supracondy- the collar and cuff, bur not in a rigid manner, which decreases
lar fracture without pinning (Fig. 14-18). Therefore, the decision the risk of vascular compromise. After 3 weeks of immobiliza-
must be made to either place Kirschner wires in the distal hume- tion, the patient is allowed to begin active motion Out of the
rus to stabilize the fracture, allowing immobilization in a com- collat and cuff.
fortable position of less than 90 degrees of elbow flexion, or to
place the child in a cast with the elbow in 120 degrees of flexion.
Type "' Extension Supracondylar Fracture
The presence of significant swelling, obliteration of pLJse wirh
flexion, neurovascular injuries, and other injuries in the same In this fracture the periosteum is torn, there is no cortical contact
extremiey are indications for pin stabilization ofa eype II fracture. between the fragments, and soft tissue injury may accompany
If pinning is chosen, two lateral pins (42,181) through the diml the fracture. Careful preoperative evaluation is mandatory. If
humeral fragment, engaging the opposite conex of the proximal circulatory compromise is indicated by absenr pulse and a pale
fragmenr, are generally sufficient to maintain fracrure alignment hand, or jf compartment syndrome is suspected, immediare re-
(Fig. 14-19). Some degree of inherent stabiliey is provided by duction and skeletal srabilization are mandarory. AJternative
the posterior cortex and the intact periosteum. Cross pinning methods of management, including traction and closed reduc-
of rhis fracrure rarely is needed. The techniques for crossed and tion wirh collar and cuff or casring can be used in rhe absence
lateral pinning are described later on in this chapter. If pin stabi- of acme vascular insufficiency. Thcre are twO viable alternatives
lization is used, the pins are left protruding through the skin for achieving fracture alignmcnt: acme manipulative reduction
and are removed at 3 to 4 weeks after fixation, generally without and traction.
the need for sedation or anesthesia.
If cast immobilization is chosen, the cast should be a figure-
Technique of Reduction
of-eight (Fig. 14-20) cast sparing the antecubital fossa. We gen-
erally make this with fIberglass to allow better radiographic eval- Whether a fracture is held in place with pins or a cast, realign-
uation with the cast in place. Hadlow (83) reported that closed ment of the humerus is necessary and rhe technique of manipula-
reduction and casting were satisfactory without pinning in 37 tive reduction is the same (Fig. 14-22). The patient is anesthe-
of his 48 patients. tized and the affected arm is extended over the screen of the
 Chapter 14: Stlpracondylar Fractures oj the Distal Humerus 589

A B

FIGURE 14-18. Necessity for hyperflexion. A: Injury film. B:

Hyperflexion of the elbow adequately reduced the fracture.
C: When the elbow is extended to only 90 degrees, the reduc-
tion is lost. (Reprinted from Wilkins KE. The management of
severely displaced supracondylar fractures of the humerus.
Techniques Orthop 1989;4: 12-24; with permission.) c
590 Upper Extremity

A B

FIGURE 14-19_ This type II supracondylar fracture (A) is stable after

closed reduction and is ideal for pinning with two lateral pins (B and
c C) placed parallel and engaging the opposite cortex.
 Chapter /4: Supracondylar FmCfttres of the Distal Humems 591

FIGURE 14-20. Figure-of-eight wrap. In the figure-of-eight cast, both

the padding and the plaster are wrapped in a figure-of-eight manner
(arrows). (Reprinted from Wilkins KE. The management of severely dis-
placed supracondylar fractures of the humerus. Techniques Orthop
1989;4:5-24; with permission.)

FIGURE 14-21. A collar and cuff is a safe treatment that can be used
to maintain reduction in hyperflexion.

t
c

(
A

o
FIGURE 14·22. Manipulative closed reduction. A: Traction is applied with the elbow in extension and
the forearm in supination. The assistant stabilizes the proximal fragment. After traction has been applied
and the length regained, the fracture is hyperextended to obtain' appqsition of the fragments. B: With
traction being maintained, the varus or valgus angulation along with the rotation of the distal fragment
is corrected, C: Once the length and alignment have been corrected, the elbow is flexed. Pressure is
applied over the posterior aspect of the olecranon to facilitate reduction of the distal fragment. D: The
distal fragment is finally secured to the proximal fragment by pronating the forearm.
592 Upper Extremity

C-arm fluoroscopic unic. Longitudinal traction is applied first rected, because of the effect of the surrounding soft tissue. f:.
to dislodge the proximal fragment, which may be entrapped in flexion reduction maneuver is then performed with pressure of
the brachialis muscle, the antecubital fascia, or the superficial the thumb over the olecranon and to a variable degree over the
fat and skin. If traction does not restOre length and alignment, distal condyles of the humerus. Genera'lly the fracture reduction
a "milking maneuver" has been described by Archibeck (11) can be felt, and the elbow is then held in hyperflexion and
and Peters (145) to disengage the proximal fragment from the pronation to achieve a stabJe reduction.
soft tissue. This is done by manipulating the soft tissue over the Anteroposterior and lateral views are obtained using ~he
fracture to pull the soft tissue away from the proximal fragment image intensifier. With the elbow flexed, a pure AP view is nearly
rather than simply applying traction on rhe bones, which may impossible to interpret, so the actual AP view is taken by rotating
not aJlow reduction of a buttonholed proximal fragmenc. Once tl1e arm slightly medially and laterally to view the columns of
length is restOred, medial or lateral translation is corrected. The the distal humerus and the reduction of the fracture (Fig. 14-
image intensifier is helpful for this because the medial and lateral 23). The arm is then extcmally rotated to obtain a lateral view
columns should be realigned on the AP image. Rotation is cor- of the distal humerus. The surgeon rotates the entire arm by
rected simultaneously, but in general, malrotation resolves as placing one hand on the proximal humerus and the other hold-
traction is applied and the medial and lateral alignment cor- ing the wrist pronated with the elbow hyperflexed. This is gener-

u /

A B

I
I /
\\ 30°
I
I
I
I

~I
I
I
I
I

c
D
FIGURE 14-23. Jones view. A: The proper elbow position and tube direction for the Jones view. S:
radiograph of an elbow taken with the tube 90 degrees to the film. C: Cephalad angulation of the tube
distorts the image of the distal humerus. D: Radiograph of the same elbow with the tube angulated
cephalad.
 Chapter 14: Suprawndylm' Fractm'es of the Distal Humerus 593

A B
FIGURE 14-24. Stability in external rotation. A: The stability of type II fractures is tested by taking a
lateral radiograph with the extremity fully externally rotated. B: If there is sufficient intrinsic stability,
the fracture will remain reduced on the radiograph.

ally a stable position that will allow rotation of a reduced supra-

condylar fracture. The lateral image is then evaluated for
restoration of the conical contour of the distal humerus, reduc-
tion of the fracture gap, and presence of the amerior humeral
line intersecting the capitellum.
Rotating the arm with the fracture reduced and held in a
srable position is possible in nearly all posreromedially displaced
supracondylar fractures (Fig. 14-24). In posterolaterally dis-
placed supracondylar fractures, however, the reduction is fre-
quently unstable in hyperAexion and may be less stable in prona-
tion. If the fracture reduction is unstable, the C-arm should be
rotated to obtain AP and lateral views rather than anempting
to rotate rhe arm and losing a tenuous reduction. An anatomic
or nearly anatomic reduction is a prerequisite for skeletal stabili-
zation. If this cannot be achieved by closed reduction, traction
or open reduction can be used.

Cast Immobilization Technique

Because type III fractures are intrinsically unstable, the elbow
must be held in extreme flexion to prevent the distal fragment
from rotating; these fractures tend to rotate wirh flexion of less
than 120 degrees (32). Usually, however, severe swelling pre-
vents the elbow from being kept in hyperflexion. When the
swelling subsides, the distal fragment tends to rotate horizon-
rally, mal<ing ir susceprible to varus angulation, particularly if
the fracture line is angulated (Fig. 14-25). In most series (48,
110,147,186) the results of type III fractures treated with closed
reduction and cast immobilization are not as good as those B
creared with pinning. However, Hadlow er aI. (83) suggested
that selective use of casring is beneficial, reporting that in their FIGURE 14·25. Effects of obliquity of the fracture line. If the fracture
line is transverse (A), pure rotation does not produce angulation. If the
series, 61 % of type III and 77% of type II fractures were success- fracture line is oblique (B), rotation of the distal fragment produces a
fully treated without pinning. secondary distal angulation.
594 Upper Extremity

A flgure-of-eight cast is used ro maintain flexion of ar least their value. Present controversy includes (a) crossed pins (Fig.
120 degrees. If the arm can be flexed ro 120 degrees with all 14-26) or two lateral pins; (b) burying pins or leaving them out
inracr pulse, casting can be used as primary treatmenr. Alburger through the skin; (c) timing of pinning, that is, emergent, ur-
et ai. (4) reponed that using skin traction initially unril swelling genr, or elective; and (d) the role of open reduction. Absorbable
decreases allowed successful use of casting without pinning. Al- polyglycolide pins have not been found suitable for fixation of
though a number of hisroric series used casting as primalY rreat- supracondylar fractures (28).
menr, most recenr reports favor pinning of this fracruce. Whefl Zionrs (199) evaluated the rorsional srrength of pin configu-
a cast is used as primary rreatmenr, it should be worn for 3 [0 rations in an adult humeral cadaver model. The maximal
4 weeks. After cast removal, motion is encouraged and the pa- srrength was gained by using two crossed pins with one placed
tienr is placed in a sling umil comforcable, which may vary from through the medial condyle and one through the lateral condyle,
hours ro days. Physical therapy usually is not required, because extending up the corresponding columns and engaging the op-
simple active motion is encouraged and usually is sufficient. posite cortex. The [Orque required to produce 10 degrees of
rotation averaged 37% less with two lateral pins parallel and
80% less with two lateral pins crossed than with medial and
Technique of Pin Fixation
lateral crossed pins. Thus, lateral pinning required significandy
Pin fixation of supracondylar fracrure of the humerus has been less force to produce 10 degrees of displacement than did crossed
performed for over 50 yeats (131). Jones (99) and Swenson pinning (Fig. 14-27). The question, however, is whether the
(178) were early advocates of this technique. Before the develop- resistance [0 torque provided by lateral pinning is sufficienr to
menr of the fluoroscopic uflit, blind pinning (9 1) was performed; allow fracture healing without displacement, if supplemented
Jones noted that this could be done without complications by by cast immobilization in the clinical setting. In addition, the
even the "average surgeon." Modern imaging techniques and experimental models have no inract periosteum, which will pro-
improved power equipment have made percutaneous pinning vide further fracture stability, nor do they have pediatric cancel-
the standard rreatmenr for this difficult fracture. Flynn (66,67), lous bone, which may be quite different in terms of pin fixation
and later Wilkins (190,191), among others (29,127,128,147, III ecna nics.
148) popularized modern pinning techniques and documented Onwuanyi (141), in a clinical series, also concluded that there

FIGURE 14-26. Crossed pinning is a more stable configuration than two lateral pins. The lateral pin is
placed at the border of the ossified lateral condyle. The medial pin enters the medial epicondyle and
is generally more transverse than the lateral pin.
 Chapter 14: Supracondylar Fractures of the Distal Humerus 595

A B

FIGURE 14-27. Lateral pin constructs. A: Three lateral

pins. B: Two parallel pins. C: Late displacement in a pa-
tient with two small lateral pins that crossed at the frac-
ture site. (Reprinted from Wilkins KE. The management
of severely displaced supracondylar fractures of the hu-
merus. Techniques Orthop 1989;4:212-224; with permis-
c sion.)

was greater stability or ability to maincalO reduction with the reported series ranges form 0 to 5% (33,93,153,157). Because
crossed pinning technique. Cheng (42) reported 180 type III the ulnar nerve may sublux anteriorly when the elbow is hyper-
supracondylar fractUres neared wich lateral pinning as primary flexed in as many as 30% of patients (198), it is at significant
treatmenc in nearly all. He reported very low incidences of cubi- risk in the crossed pinning technique. Locating the ulnar nerve
tUS varus deformity and loss of reduction and concluded that in wirh a nerve stimulator has been suggesred (129). Making a
acwal practice there was no difference between two lateral pins small 1.5-cm incision over the medial epicondyle for placemenc
and crossed pins. He recommended lateral pins as [he treatmenc of the medial pin also has been proposed as a way to locate and
of choice because there is less risk of ulnar nerve injury with protect rhe ulnar nerve. This technique works well and may
this technique. avert the problem of iatrogenic ulnar nerve injury when crossed
The primary risk with crossed pinning is injury to the ulnar pinning is required for vety unstable fracwres. Also, placing the
nerve by a medial pin. The frequency of ulnar nerve injury in lateral side pin first with the elbow hyperflexed and then placing
 596 Upper Extremity

the medial pin with the elbow In only 90 degrees of flexion ulnar groove. The medial pin is generally more horizolHaJ than
lessens this risk. the lateral pin and should traverse the medial column and engage
the opposite lareral cortex.
Variations in the crossed pinning technique include: (a) no
Technique of Pinning: Crossed Pins medial incision (Fig. 14-29); (b) maintenance of reducrion by
strapping the arm in a position of hyperflexion before pinning
Steel pins 0.062 Ot 0.075 mm (5/64th inches) in diameter are
(Wilkins; Fig. 14-30) (191); (c) using a bar as a fulcrum ro
used. (Fig. 14-28). Aftet reduction of the fracrure and with the
facilitate reduction, as described by Flynn (66); and (d) pinning
C-arm screen used as an operaring rabie, rhe arm is held wirh
the medial side first with the elbow in hyperflexion. If no medial
the elbow hyperflexed and the forearm pronared ro mainrain
incision is used, the ulnar nerve is palpated and pushed poste-
rhe reducrion. Anaromic reduction is confirmed wirh rhe image
riorly as the pin is inserted. Pinning medially with the elbow in
intensifier before pinning. The lateral pin is inserted first. The
hyperflexion, as described by Wilkins, has the benefir of holding
insertion site is made so rhar the pin will traverse the lateral
rhe fracrure in betrer position while pinning, but does place the
portion of the ossified capitellum, cross rhe physis, proceed up
ulnar nerve at higher risk.
rhe lateral column, and engage the opposite medial cortex proxi-
mally. Using a Kirschner wire or radiodense objecr, the position
for insertion of the pin is documented. A small incision is made
Two Lateral Pins
in the skin. The pin is placed using a power drill and sharp
Kirschner wire or Steinmann pin. Provisional stabiliry is Two lateral pins (12,42,141) (0.062 or 0.75 mm) provide less
achieved with the first pin. Then the elbow is gently extended stability than crossed pins, but there is no risk to the ulnar nerve,
ro about 45 degrees of flexion ro allow a perfect AP radiograph which is a significanr benefit of rhis rechnique. The operaring
of the distal humerus ro ensure anaromic alignmelH. The elbow room set up for two lateral pins is exactly the same as rhar for
is then flexed ro 120 degrees and externally rotated and a lareral crossed pins. After achieving closed reduction and confirming
image is obtained wirh fluoroscopy. A second pin is rhen placed the position on AP and lateral views, rhe first pin site should
medially. A smaJi 1.5-cm incision is made over rhe medial epi- be chosen wirh rhe second pin in mind. The goal is to have two
condyle and dissection is performed down to the level of rhe pins thar are parallel on the AP and lateral views. If the pins are
medial epicondyle. If the ulnar nerve has subluxed over the me- placed so thar rhey cross well proximal ro the fracture, this may
dial epicondyle, sometimes bJum dissection stimulates the nerve be satisfactOry, bur is nor as secure as parallel pins. Two pins
and the fingers will move slighdy. If rhe ulnar nerve is found, crossing ar rhe fracrure is unsatisfactOry because rorquc will not
it should be rerracted posteriorly and a pin placed through rhe be sarisfacrorily resisred and a rotational deformity may result.
medial epicondyle under direct vision. The posirion of the In choosing a sire for the first pin, we generally place ir up
Kirschner wire from the medial side is confirmed with fluoros- through rhe cemer of the ossified capitellum. It engages the edge
copy. The pin should emer the medial epicondyle and not the of the olecranon fossa, giving jt grearer srability, and rhen further

A B
FIGURE 14-28. Lateral pin placement. A: The lateral pin is placed first using the (-arm screen as an
operating room table. The elbow is held in hyperflexion for the placement of the lateral pin. B: The
lateral view is obtained by externally rotating the arm, holding the elbow in hyperflexion for stability.
 Chapter J 4: Supracondylm' Fractures of the Distal Humerus 597

B c
FIGURE 14-29, Medial pin placement. A: The medial epicondyle is posteromedial (arrow). B: The medial
pin is placed directly through the medial epicondyle, using the opposite thumb to pull posterior the
soft tissues, thus protecting the ulnar nerve. C: The relationship of vital structures during medial pin
placement. The pin is directed from posteromedial to anterolateral directly through the center of the
medial epicondyle under control of the image intensifier, with the upper extremity fully externally
rotated.

penetrates the opposite correx. A second pin is placed through splint or bivalved long arm cast with the forearm in neutral and
the distal humeral epiphysis latetal to the capitellum but clearly the elbow flexed slightly less than 90 degrees. Although this
within the epiphysis. It proceeds parallel to the first pin up the position of flexion is chosen as a general rule, it is imperative
lateral column and engages the opposite cortex. If the fitst pin that the elbow be placed in a position that is most favorable for
is placed centrally in the lateral column, the second pin will neurovascular structures. If the pulse becomes weak or obliter-
nearly always cross the first just above the ftacture, and this will ated at 80 degrees of flexion, the arm should be pur ina position
be a less satisfactOlY lateral pinning. Maximal pin separation and whete the pulse is strongest. The study by Mapes and Hennrikus
parallel alignment increase the stability with this technique. (121), using Doppler evaluation of the brachial artery, showed
The "shal<e test" can be used to test the stability of fWO lateral rhat with progressive flexion and pronation, the pulse pressure
pins. If the arm can be grasped by the proximal humerus and and therefore flow was incrementally diminished. Fracture sta-
shaken mildly without displacement of the fracture, the fixation bility is gained by skeletal stabilization, and the splint or cast is
is satisfactoly. If displacement occurs, it is generally rotational simply placed to protect the patient. If a circular cast is used, it
with loss of reduction of the medial column. We simply reduce should be bivalved and spread to prevent constriction. In no case
the fracture to an anatomic position and place a medial pin as should a child be in a circular cast with the elbow hyperflexed
described in the technique for crossed pinning. A third lateral following this procedure.
pin will increase stability slightly, but is rarely necessary. Iyengat et aL compared early and delayed pinning to detet-
After pinning by any technique, the patient is placed in a mine whether fractures treated more than 8 hours after trauma
598 Upper fxtremity

A B

FIGURE 14·30. Temporary stabilization. Once re-

duced, the elbow is taped into hyperflexion (A).
This allows the elbow to be manipulated into full
external (B) and internal (C) rotation, providing di-
rect lateral visualization of the respective medial
and lateral condyles. (Reprinted from Wilkins KE.
The operative management of supracondylar frac-
tures. Orthop Clin North Am 1990;21 :269-289;
c with permission.)

had higher incidences of open reductions and complicarions and lareral pins demonsrrared that proximally placed pins diverg-
(96). Thcy concluded rhar rhere was no difference. However, ing in the distal fragmenr were more srable rhan orher methods
rhis was a rerrospecrjve review and it is possible rhar severe frac- of percuraneous pin fixarion.
rures were treared emergenrly, which would bias the conclusion.
In general, these fracrures are [I'eated emergently. With smoorh , . AUTHORS' PREFERRED METHOD
pins left out rhrough rhe skin, there is rarely a need for anesthesia \...~ OF TREATMENT
for pin removal. A very low infection rare accompanies pinning
(less than 1%) because they are in place only 3 to 4 weeks. When possible, we prefer closed reduction and pinning of rypc
2 and rype 3 supracondylar fracrures. Two lateral pins are chosen
Intramedullary Pin Fixation for a "srable" fracture, and crossed pins are used for very unstable
fractures. We always make a small incision over the medial epi-
Prevot et al. (149) reported their experience wirh inrramedullalY
condyle ro prorecr the ulnar nerve when using crossed pins.
fixarjon of supracondylar fracrures in children. Afrer closed re-
duc[ion, the pins were inserted proximally ar the junction of
Open Reduction
rhe middle and proximal [hird and passed dis[ally in rhe shafr,
diverging in each of the supracondylar colum ns. Their laborawry Closed reducrion may nor be possible because of inrerrosed
experimenrs comparing rhis rype of f1xarion wirh medial-lateral sofr rissuc, especially in posrerolaterally displaced supracondylar
 Chapter J 4: upracondylar Fractures of the Distal Humerus 599

fracrures. Open reduction should be considered co obtain align-

menr if there is vascular compromise or neural enrrapmenr, as
judged by soft tissue interposition. An open reduction is also
indicated if there is an open fracture that requires irrigation and
debridement or simply if a satisfaccory closed reduction cannot
be performed.
During the early part of this century there was a reluctance
to recommend open reduction of supracondylar fracrures. With :-'Tt--+-Brachial a.
improvement in operative techniques and more experience with f-+~c- Median n.

surgical inrervenrion, open reduction of acute supracondylar

fractures has now become widely accepted.
Fleuriau-Chateau er al. (65) reporred excellenr results with
Distal
open reductions of irreducible fractures. The range of motion
humerus
was satisfaccory in 94% of patienrs, and none had myositis or
cubitus varus deformity. Fifteen of the 25 children with irreduci-
ble fractures had enrrapment of neurovascular structures pre-
venting reduction. The high incidence of enrrapment of neuro-
vascular srructures in individuals skilled in closed reduction
supports the use of open reduction in irreducible fracrures. The
approach for open reduction has been somewhar conrroversial.
Anterior, medial, lateral, and posrerior approaches have all been
recommended. Those who advocare medial and lateral ap-
proaches (189) operate through the side in which the periosteal
hinge is torn; that is, a lateral approach is used for posteromedial
displacement or a medial approach is used for posterolateral
displacement. The posterior approach (166) co the elbow
through the triceps muscle and tendon has been used with excel-
lent results. OUf preference is the direct anterior approach (52,
77) through a transverse anterior incision in the antecubital FIGURE 14-31. Tenting of neurovascular bundle. With posterolateral
fractures, the neurovascular structures often are tented overthe medial
fossa, extending proximally, medially as needed. The brachialis spike of the proximal fragment. This fragment can be "buttonholed"
muscle is generally transected by the proximal humeral fragment. through the brachialis muscle.
The Structures remaining intact anteriorly are the biceps tendon
and neurovascular bundle (Fig. 14-31). The anteromediaJ ap-
proach gives easy access to an enrrapped neurovascular bundle
and allows anatomic reduction of the humeral fracture under The most frequent complication of surgical management ap-
direct vision by simply placing a retractor on the remaining pears to be a loss of range of motion. One of the reasons given
ponion of the brachialis muscle. in the past for loss of motion was rhe use of a posterior approach.
Pins are then placed either medially and laterally or two lateral Ir has been stated that approaching the fracture through the
pins are used, as described above, to provide stable flxation. Mrer relatively uninvolved posterior tissues, induces added scar lead-
open reduction, pins may be left in place slightly longer than ing to stiffness. In earlier reponed series using a posterior ap-
after closed reduction, but there are no firm data on this. Good proach, loss of range of mOtion was significanr. However, in
caJlus should be observed at the fracture before pin removal, rhe past decade, use of a posterior approach with no significant
generally 3 co 4 weeks after injury. Prolonged pin fixation is not increase in postoperarive elbow stiffness has been reponed. Re-
necessary. sidual cubitus varus occurred in as many as 33% of patients in
some of the earlier series (7,51,79,189), most due to inadequate
surgical reduction. When good reducrion was accomplished, the
Incidence of Complications Lessened
incidence of cubitus varus was low. Surgical intervention does
One of the reasons for an increase in open reductions has been not guarantee an anatomic reduction; it is rhe qualiry of the
the recognition that complications are relatively few. The fears reduction achieved at the rime of surgery that is imponanr.
of infecrion, myosiris ossificans, and neurovascular injury (74, La! and Bahn (112) reported that delayed open reducrion,
163,170,187) have been dispelled by surgical experience (10,14, 11 to 17 days afrer injuly, did not increase rhe frequency of
39,48,65,71,76). In a combined series of 470 fractures treated myositis ossificans. If a supracondylar fracture is unreduced or
by open reduction, the incidence of infection was 2.5%, all of poorly reduced, delayed open reduction and pin fixation appear
which resolved (5,21,37,52,75,79,82,85,103,108,138,147,151, ro be jusrified.
165,186,189). The incidence of neurovascular complications Open supracondylar fractures generally have an anterior
from the procedure itself was essentially zero. Four patients with puncrure wound where the metaphyseal spike penetrates the
myositis ossificans (1.4%) were reported, all in a single series skin. Even if the open wound is only a small puncture in the
(79). center of an anterior pucker, open irrigation and debridement
600 Upper Extremity

are indicared. The anterior approach, using a rransverse incision

wirh medial or lareral exrension as needed, is recommended.
The neurovascular bundle is direcrly under the skin and rented
over rhe metaphyseal fragmenr, so care should be taken in ap-
proaching this fracrure surgically. Whereas the skin incision can
be exrended medially proximally and larerally distaJly, often only
rhe rransverse portion of rhe incision is required, which gives a
bener cosmeric result. The brachialis muscle usually is tran-
secred, because ir is a muscle belly ro irs insenion on rhe coronoid
attachment and is highly vulnerable ro rrauma from rhe proximal
metaphyseal fragmenr. The fracrure surfaces are examined and
washed, and a curer is used ro remove any din or entrapped soft
rissue. Once rhe debridemenr and washing are complere, rhe
fracture is srabilized wirh Kirschner wires. All parienrs wirh open
fracrures are also treared wirh ancibiorics: cephalothin for Gustilo
rypes 1, 2, and 3A injuries, with the addirion of an aminoglyco-
side For rypes 3B and C fracrures.
FIGURE 14-32. The olecranon wing nut is a simple skeletal traction
device. Varying the insertion point of the rope alters torque about the
Traction Management of Type III Supracondylar distal fragment.
Fractures
Traerion can be used in rwo ways in rhe management of rype
III supracondylar fracrures: ro allow swelling to decrease and ro
facilirate closed reducrion, as described by AJburger er at. (4) pinning and would certainly collapse wirh simple casring afrer
and orhers (17l, 197). I n this technique, patienrs are placed in reducrion. The durarion of rracrion usually is abour 14 days
sidearm or overhead skin rraction for 3 ro 5 days uncil elbow before casr immobilization in [his rapidly healing fracrure. Pro-
hyperf1exion can be tolerared for closed reduerion. Alburger er longed traction may be necessary if poor reducrion is obrained
a1. reported 92% good or excellenr results in 39 patients neared in tracrion, because signiflcanr callus musr be presenr for fracrure
in this manner. stabiliry before casring.
Definirive nearment of rhe fracrure with 14 days of rracrion
or until healing has occurred hisroricaJ Iy has Jed ro a velY low
incidence of cubirus varus deformiry, as documented by Smirh
(111,172). D'Ambrosia (51) in a series of supracondylar frac-
tures ([eared wirh overhead skeleral rracrion, found no cubitus
varus deformiries; wirh sidearm or skin ([acrion for deflnirive
trearment, rhe rare of vaJUS deformiry was 3YYo. Piggor (146)
documented rhe efficacy of srraighr lareral skin rracrion with a
reporr of only 4% cubirus varus deformiries and no vascular
compJicarions. A comparison by Prierro (I50) of pinning and
Dunlop's rraerion demonstrared rhe relarive beneflrs of pinning
in decreased com and shoner nospiral srays in addirion ro a
lower cubirus varus rare. He reported a 5% rare of cubirus varus
deformiry in rhe pinning group and 53% in the Dunlop's trac-
rion group. Skeleral tracrion overhead wirh use of an olecranon
wing nur (Fig. 14-32) has been advocared by Palmer (144),
Worlock (I 97), and Badhe (I G). Overhead traerion was superior
ro sidearm rracrion and had a Jow incidence of cubirus varus
(2%-9%) in rnese series. Tne olecranon wing nur is a simple
device thar can be placed in rhe proximal ulna wirnour risk of
injury ro rhe ulnar nerve, as mighr occur in placing a rransversc
rracrion pin. The wing nut offers rhe advantage of applying a
rorque about me disral humeral fragment by changing the posi-
tion of rhe ([acrion rope into rhe holes in rhe wing nuts.
The indications for rracrion as rhe definitive management of FIGURE 14-33. Overhead olecranon pin traction. The arm is suspended
a supracondylar fracture are (a) an unsrable fracrure reducrion by a pin through the olecranon (short arrow). The forces maintaining
the reduction (long arrows) are exerted upward through the pin and
or parrern rhar cannor be pinned, and (b) supracondylar commi- sideways through a counter-sling against the arm. The forearm is sup-
nurion or medial column comminurion that is nor suirable for ported with a small sling (double arrow).
 Chapter 14: Supracondylar Fractures of the Distal Humerus 601

Technique of Traction Wing Nut Insertion of choice. Anatomic reduction of the fracture is not critical with
traction, but maintenance of alignment is. Callus formation is
With the arm prepped in a sterile manner, a hole is drilled in
rapid in the area of the fracture, and the distal fragment should
the COl·tex opposite the coronoid process of the ulna. A 3.2-mm
be confirmed to be neither hyperextended nor rotated into varus
drill bit is used and a hole is made through both corrices JUSt
or valgus malalignment, based on radiographic evaluation while
distal to the coronoid process. A wing nut is then placed through
in traction. After good callus formation (generally after about
the small incision. The wing nut engages the opposite cortex
14 days), the patient can be removed from traction and placed
but does not penetrate it. A sterile dressing is placed around the
in a long arm cast.
interface berween the wing nut and skin. A traction rope and
weights are applied (Fig. 14-33). A sling is used to suppOrt the
hand and forearm. Initially, traction of abollt 5 pounds is ap- Vascular Injury
plied, depending on the size of the patient. The shoulder should
Type III supracondylar fractures have significant incidences of
be lifted JUSt off the bed (144). AP and lam'al radiographs should
brachial artery injury, vascular insufficiency, and compartment
be taken in traction to judge the adequacy of reduction. After
syndrome, each of which should be evaluated separately in a
there is good callus formation (generally after 10 to 15 days),
patienr with a severe elbow injury.
the patient is removed from traction and placed in a long arm
cast, which is worn for about 2 weeks.
Brachial Artery Injuries and Vascular Insufficiency
About 10% to 20% of patients with rype III supracondylar frac-
, . AUTHORS' PREFERRED METHOD tures presenr with an absent pulse (44,58,164). In the emergency
\...~ OF TREATMENT management of a patient with a rype III supracondylar fractute,
the arm should be splinted with the elbow in about 30 degrees
For supracondylar comminution (Fig. 14-34) where stable pin- of flexion. This will facilitate rransporr of the patient to the
ning is impossible to achieve, we have uniformly chosen traction. appropriate facility for care and radiographic evaluation. The
Although these fractures are telatively rare, they do occur, and presence of a pulse and perfusion of the hand should be docu-
orthopaedic surgeons should be familiar with the use of traction memed. Perfusion is estimated by color, warmth, and capillary
as a technique of management of this fracture. We use a traction refill. The question sometimes raised in the emergency room
wing nut rather than a transverse traction pin, but this is a matter evaluation of a patiem with supracondylar fracture and poor

A B
FIGURE 14-34. A: Because of supracondylar comminution, stable pinning could not be achieved and
traction was chosen. B: Remodeling occurred over 1 year, and the patient regained full motion with
normal alignment.
602 Upper Extremity

blood flow to the hand is whether an arteriogram should be What is the relationship between compartment syndrome and
performed as part of the preoperative evaluation. The answer is perfusion? Is there a way to determine when flow is insufficient
an emphatic "no" (164). The initial approach to management of in a more objective way?
a patient with vascular compromise secondary to a supracondylar Several investigators have attempted to provide criteria for
fracture should be immediate closed reduction and stabilization repair in addition to warmth and color in the patient with ab-
with Kirschner wires. If an anatomic reduction cannot be ob- sence of a palpable pulse. The use of simple Doppler ultrasonog-
tained closed, open reduction through an anterior approach (14, raphy in the operating room has been studied by two groups
65) with medial extension allows evaluation of the brachial artery (162,164). In the absence of a palpable pulse, a Doppler device
and removal of the neurovascular bundle entrapped within the can be used to measure lower flow states with small pulse ampli-
fracture si teo tude. Shaw (164) found no false-positive explorations when pa-
After closed reduction and stabilization, the pulse and perfu- tients with pulses that could not be palpated but were identified
sion of the hand should be evaluated. Most extension type supra- on Doppler evaluation were observed and exploration was per-
condylar fractures are reduced and pinned with the elbow in formed in those in whom no pulse was found with either palpa-
hyperflexion. With more than 120 degrees of elbow flexion, the tion or Doppler. The brachial artery was either transected or
radial pulse generally is lost, even in patients with an initially entrapped in all patients with surgical exploration, and none
intact pulse. After pinning when the arm is extended, the pulse with "spasm" had surgery. Schoenecker et al. (162), using the
frequently does not return immediately. This is presumably sec- same criteria, identified six patients for exploration. Three had
ondary to arterial spasm, aggravated by swelling about the artery a damaged or transected brachial artery with no flow, and three
and decreased peripheral perfusion in the anesthetized, some- had an artery kinked or trapped in the fracture. At follow-up,
what cool intraoperative patient. all patients with vascular repair had a radial pulse. One patient
Because of this phenomenon, 10 to 15 minures should be wi th more than 24 hours ofvascular insufficiency had an unsatis-
allowed for recovery of perfusion in the operating room before factory outcome. Copley et al. (44) reported that of 17 patients
any decision is made about the need for exploration of the bra- with type III supracondylar fractures and no palpable pulse at
chial artery and restoration of flow to the distal portion of the presentation, 14 recovered pulse after reduction. The three ex-
extremity. Because most patients without a palpable pulse main- plorations identified significant vascular injury, and the brachial
tain adequate distal perfusion, the absence of a palpable pulse artery was repaired. In addition to Doppler evaluation, pulse
alone is not an indication for exploration of a brachia! artery. oximetry (104,154) has been recommended. Our experience
Gillingham and Rang (78) recommended observation of patients with the use of a Nelkor system for this technique is that when
with absent pulse, because most pulses returned within 10 days. used in the operating room, it often underestimates perfusion.
The decision to explore a brachial artery needs to be based on We believe this is secondary to its use in an anesthetized person
objective criteria, if possible. with low blood pressure and peripheral vasoconstriction. As a
Traditionally, the decision has been based only on whether patient is waking up and pulse pressure and peripheral circula-
the hand was warm and pink. The following case indicates the tion are increased, pulse oximetry becomes a valid way to deter-
difficulry with this. A 2-year-old girl was injured in a fall from mine perfusion. We have found it useful for evaluating patients
a couch (Fig. 14-35). A type III supracondylar fracture and a after vascular repair or pinning but not for intraoperative deci-
pale, cool hand were documented on presentation to a local sion making. Copley and Dormans, (44) reported that some
emergency department. Two hours later, the patient was brought patients who initially had good perfusion and an intact pulse
to the operating room, where a cool, pale hand with poor capil- lost both in the postoperative period. Two of 14 patients showed
lary refill and an absent pulse was noted. Immediate closed re- signs of increased vascular insufficiency over a 48-hour period
duction and pinning was performed with nearly anatomic reduc- and required subsequent reconstruction. Data such as this sup-
tion. The hand felt warmer and capillary refill was present. The ports in-hospital observation of patients with supracondylar frac-
pulse was not palpable, but because of the improved state of tures, especially those with evidence of vascular compromise.
the hand, no exploration of the brachial artery was performed. Obliteration of the radial pulse after closed reduction and
During the next 4 hours the patient was observed closely with pinning is a strong indication for brachial artery exploration.
increasing fussiness, a nonpalpable pulse, and slow capillary re- After 10 to 15 minutes is allowed for resolution of arterial spasm
fill. At this point an arteriogram was performed, showing bra- as a cause for loss of pulse, the brachial artery should be explored.
chial artery obstruction. Compartment pressures were measured, Either direct arterial entrapment at the fracture or arterial
and increased pressure was noted in the volar compartment. A compression by a fascial band pulling across the artery may cause
decision was made to return to the operating room for explora- loss of pulse after fracture reduction. As described above, the
tion and repair of the brachial artery and forearm fasciotomy. other indication for brachial artery exploration is persistent vas-
Whereas the outcome in this case was satisfactory with no long- cular insufficiency after reduction and pinning.
term sequelae, other than scarring, the question is whether the
low perfusion with subsequent ischemia and compartment syn-
Exploration of the Brachial Artery
drome could have been identified at the time of the closed reduc-
tion and immediate repair done. The orthopaedic surgeon and vasculat surgeon need to work
What would happen if no repair had been performed in the together in the management of this problem. Often release of
above case? Had a repair been performed immediately, could a fascial band or adventitial tether resolves the problem of ob-
the development ofa compartment syndrome have been averted? structed flow. This is a simple procedure performed at the time
 Chapter 14: SUjJrilcond),lar Fractures of the Distal Humerus 603

A B

c D
FIGURE 14-35. A: This 2-year-old patient sustained a type III supracondylar fracture with vascular com-
promise. B: Pinning was performed in a nearly anatomic position. C and D: Six hours postoperatively,
increasing pain, a pale hand, and evolving compartment syndrome prompted arteriography, showing
brachial artery occlusion.
604 Upper Extremity

Bicipital aponeurosis

Brachlahs
(musculocutaneous nerve)

Pronator teres
(median nerve)

B
FIGURE 14-36. Brachial artery exploration through anteromedial approach. (Figure continues.)

of exploration of the antecubital fossa and identification of the brachialis muscle. This occurs when the arrery is tethered by a
brachial artery. In some patients, however, a formal vascular fascial band or aterial adventitia attached to the proximal me-
repair and vein graft are required. The brachial artery should be taphyseal spike pulling the artery in the fracture site. Dissection
approached through a transverse incision across the antecubital should occur proximally to distally, along the brachial artery,
fossa, with a medial extension (LIming proximally at about the identifying both the artery and the median nerve. Arterial injUlY
level of the medial epicondyle (Fig. 14-36). Care must be taken generally is at the level of the supratrochlear artery (Fig. 14-7),
because the neurovascular bundle may be difficult to identify which provides a tether, making the artery vulnerable at this
when it is surrounded by hematoma, but it may lie in a velY location. Arterial transection or direct arterial injury can be iden-
superficial position. At the level of the fracture, the arteIy may tified at this level. Entrapment of the neurovascular bundle in
seem to disappear inro the fracture site, covered with shredded the fracture is best identified by proximal to distal dissection.
 Chapter 14: Supracoru0,lar Fractures of the Distal Humerus 605

Lateral antebrachial
cutaneous nerve

Fascia
Fascia over over biceps
brachioradialis

Brachial artery

Median nerve

Pronator teres

Bicipital aponeurosis
(Lacertus fibrosus)

c Cutaneous veins

Biceps
Bicipital
aponeurosis (cut)

Biceps tendon

Radial artery

Brachioradialis

Brachial artery

Brachialis

Median
nerve

Superficial head
D of pronator teres

FIGURE 14-36. (continued)

The decision ro repair a damaged arrelY or lise a vein graft the injured ponion of the vessel is excised and a vein graft is
is generally made by the vascular surgeon. If spasm is the cause inserted. When flow is rescored, the wound is closed and the
of arterial insufficiency, several techniques have been recom- patient is placed in a splint with the eJbow flexed Jess than 90
mended. If arrerial spasm is the cause of inadequate flow, and degrees and the forearm supinated. Posroperative monitoring
collateral flow is not sufficient to maintain the hand, attempts should include temperature, pulse oximetry, and frequent exami-
ro relieve the spasm may be tried. Both stellate ganglion block nations for signs of compartment syndrome Ot ischemia. Injec-
and application of Paverin or local anesthetic ro the arrelY have tion of urokinase has been suggested co increase flow (35); we
been found ro be beneficial in this situation. If spasm is not have had no experience with tl1is technique.
relieved by these techniques and collateral flow is insufficient, Sabhalwal et al. (159) documented that 3.2% of patients
606 Upper Extremity

with type III suptacondylat ftactures have an absent pulse at significantly increases the likelihood of compartment syndrome.
presentation, for which they recommended noninvasive moni- An arterial injury in association with multiple injuries or crush
toring. Magnetic resonance angiography and color flow duplex injury further diminishes blood flow to the forearm musculature
Doppler were helpful in deciding whether or not to explore the and increases the probabiliry of a compartment syndrome.
brachial artery. Although repair is technically feasible, Sabharwal Even ifdistal pulse is found by palpation or Doppler examina-
et al. cautioned that high rates of reocclusion and residual tion, an evolving compartment syndrome may be present. In-
stenosis argued against early revascularization if not absolutely creased swelling over the compartment, increased pain, and de-
necessary. Early reocclusion, however, was not reported by creased finger mobiliry are cardinal signs of an evolving
Schoenecker et al. (162) or Shaw et al. (164). compartment syndrome. Evaluation of possible compartment
The necessity of early treatment of vascular compromise was syndrome cannot be based on the presence or absence of a radial
emphasized by Ottolenghi (143), who found no Volkmann is- pulse alone. If a compartment syndrome does appear to be evolv-
chemic contractures (135) in patients in whom vascular compro- ing, initial management includes removal of all circumferential
mise was treated within 12 hours. The frequency of this compli- dressings. The volar compartment should be palpated and the
cation increased steadily with repair between 12 and 24 hours: elbow should be extended. We believe that the fracmre should
after 24 hours of delay in treatmem, outcomes were uniformly be immediately stabilized with Kirschner wires to allow proper
poor. This series presents convincing evidence that prompt ex- management of the soft tissues.
ploration of arterial insufficiency markedly decreases the inci- Another factor that contributes to the development of com-
dence of Volkmann ischemic contracture. However, it should parrment syndrome is warm ischemic time after injury. When
be understood that brachial artery obstruction and compartment blood flow is compromised and the hand is pale with no arterial
syndrome, although related, are not equivalent, and both are flow, muscle ischemia is possible, depending on the time of
fortunately rare problems. Ischemia will lead to a compartment oxygen deprivation. Mter fracture reduction and restoration of
syndrome, but the presence of a radial pulse does nor preclude flow, the warm ischemic time should be nored. If this time is
it. more than 6 hours, comparrment syndrome secondary to is-
chemic muscle injury is likely. Prophylactic volar comparrment
fasciotomy can be performed at the time of arterial reconstruc-
Compartment Syndrome
tion. The exact indication for prophylactic fasciotomy in the
In acute compartment syndrome (90,135), increased pressure absence of an operative revascularization is uncertain. Even when
in a closed fascial space causes muscle ischemia. With untreated the diagnosis is delayed or the compartment syndrome is
ischemia, muscle edema increases, further increasing pressure, chronic, fasciotomy has been shown to be of some value.
decreasing flow, and leading to muscle necrosis, fibrosis, and
death of involved muscles. Forearm compartment syndrome oc-
Technique for Volar Fasciotomy
curs after 1% or fewer supracondylar fractures. A compartment
syndrome of the forearm may occur with or without brachial The volar compartment of the forearm can be approached
artery injury and in the presence or absence of a radial pulse. through the classic Henry approach or the ulnar approach (Fig.
The diagnosis of a compartment syndrome is based on resistance 14-37). If the compartment syndrome is associated with a bra-
to passive movement of the fingers and dramatically increasing chial artery and median nerve injuries, We generally use the
pain after fracmre. The classic five "P's" for the diagnosis of Henry approach as an extension of the vascular repair. The ad-
compartment syndrome-pain, pallor, pulselessness, paresthe- vantage of the ulnar approach, as described by Willis and Rora-
sias, and paralysis-are poor indicators of a compartment syn- beck (194) is that it produces a more cosmetically pleasing scar.
drome. A volar fasciotomy involves opening the volar compartment
Mubarak and Caroll (135) recommended forearm fasciotomy from the carpal runnel distally to the lacertus fibrosa and antecu-
if clinical signs of compartment syndrome are present or if intra- bital fascia proximally. The fascia over the deep flexors is opened,
compartmental pressure is greater than 30 mm Hg. Heppenstal as is the superficial fascia, to decompress the deep volar compart-
et al. (88) suggested that a difference of 30 mm Hg between ment of the forearm. Failure to release the deep volar fascia may
diastolic blood pressure and compartment pressure should be cause contracmre of the deep finger flexors. Generally only the
the threshold for release. Ifpain is increasing and finger extension volar compartment is released, with an associated decrease in
is decreasing, fasciotomy is clearly indicated. Measuring com- pressure in the dorsal or extensor compartment. If the volar
partment pressures in a terrified, crying child is difficult, and if Henry approach is used, the interval between the brachioradialis
clinical signs of compartment syndrome are present, a trip to and flexor carpi radialis and radial artery are retracted ulnarward.
the operating room for evaluation and possible fasciotomy is The deep volat compartment is exposed. The flexor digitorum
often a better course of action than pressure measurement and profundus and flexor pollicis longus are exposed along with the
observation. pronator teres proximally and the pronator quadratus distally.
Clinical conditions that contribute to the development of If the ulnar approach is used, as described by Willis and
compartment syndrome are direct muscle trauma at the time of Rorabeck (194), the release is performed from the carpal canal
injury, swelling with intracompartmemal fractures (associated to the antecubital fossa, as with the Henry approach. The skin
forearm fracmre), decreased arterial inflow, and restricted venous incision begins above the elbow crease, medial to the biceps
outflow. The mechanism of injury of the supracondylar fracture tendon (Fig. 14-37); it crosses the elbow crease and extends
is critical. An associated forearm fracture or forearm crush injury distally along the ulnar border to the volar wrist, where it courses
 Chapur 14: Supracondylar Fractures oj'the Distal Humerus 607

FDS -------- __"

"

D
FIGURE 14-37. Surgical approach for forearm fasciotomy. A: Ulnar approach, skin incision. B: Ulnar
approach, intermuscular interval (FOS, flexor digitorum sublimis; FCU, flexor carpi ulnaris). C: Henry
approach, skin incision. D: Henry approach, FCR, flexor carpi radialis interval (BR, brachioradialis; ECRB,
extensor carpi radialis brevis). (Reprinted from Willis RB, Rorabeck CH. Treatment of compartment syn-
drome in children. Orthop C1in North Am 1990;21 :407-408; with permission.)

radially across the carpal canal. The fascia ovet the flexor carpi jured. In modern series, the AIN appears to be the most com-
ulnaris is incised, and the interval between the flexor carpi ulnaris monly injured (49,58,126), with. loss of motot power to the
and the flexor digitOrum sublimis is identified. The ulnar nerve flexor pollicis longus and the deep flexor to the index finger as
and anelY are retracted, exposing the deep flexor compartment first described by Spinner in 1969 (174). The direction of the
of the forearm. The deep flexor fascia is incised. The ulnar nerve displacement of the fracture determines the nerve most likely to
and artelY, as well as the CJrpal tunnel, are decompressed distally. be injured. If the distal fragment is displaced posteromedially,
After fasciotOmy the wound gener311y is left open. An effective the radial nerve is more likely to be injured. Conversely, if the
way to manage the wound is with a criss-crossed rubber band displacement of rhe distal fragment is posterolateral, the neuro-
technique, securing the tubber bands in place with skin staples. vascular bundle is stretched over the proximal fragment, injuring
An alternative is to simply place a sterile dressing over the open the median nerve or AIN or both. In a flexion type of supracon-
wound, bur this makes wound closure difficult and probably dylar fracture, which is rare, the ulnar nerve is the most likely
increases the need for skin grafting. Definitive closure or skin nerve to be injured.
grafting generally is performed within 5 to 7 days. Skeletal stabi- In general, if the nerve deficit is present when the patient
lization of the supracondylar and forearm fractures is nccessa,y alTives in the emergency department and if the fracture is reduci-
for proper management of compartment syndrome. ble, open reduction of the fracture and explotation of the injured
nerve are not indicated. In most series, nerve recovery, whether
radial, median, or ulnar, generally occurs at an average of 2 to
Neurologic Deficit 2 1/2 months. Culp et a1. (50) reported identification of eight
In most modern series, the incidence of neurologic deficit with injured nerves in 5 patients in which spontaneous recovery did
supracondylar fractures is 10% to 20% (J 27, 160), with an inci- not occur by 5 months following injUiY. Neurolysis was success-
dence as high as 49% in one series (36). Reports differ as to ful in reswring nerve funcrion in all but one. Nerve grafting
whcrher the radial or median nerve is the most frequently in- may be indicated for nerves not in continuity at the time of
608 Upper £>:tremiIJ

explorarion. Neurolysis for perineural fibrosis is generally suc- ulnar nerve funcrion in rhree parients. One nerve rhar was ex-
cessful in resroring nerve funcrion. There is no indicarion for plored had direcr penerrarion of the ncrve, and rhe pin was
early elecrromyographic analysis or rrearmenr orher than obser- replaced in proper posirion. Two parients had lare-onser ulnar
varion for nerve deficit unci I 5 to 6 months afrer fracture. nerve palsies, discovered during healing, and rhe medial pin was
In rheir series of radial nerve injuries wirh humeral fracrures, removed.
Amillo er al. (8) reported that of 12 injuries thar did not sponta- If a postoperarive neural injury is documemed, we prefer to
neously recover wirhin 6 months of injury, only 1 was associared explore the ulnar nerve and replace rhe pin in proper posirion.
with a supracondylar fracture. Perineural fibrosis was present in If an ulnar nerve lesion is documented lare in rhe course of
4 patients, 3 nerves were enrrapped in callus, and 5 were eirher fracture healing, we remove rhe pin bur do nor explore the nerve.
panially or rorally rransected. Prevention of ulnar nerve injury is obviously more desirable
ln rhe supracondylar area, perineural fibrosis appears ro be rhan treatmem of ulnar neuroparhy. Because of rhe frequency
rhe mosr common cause of prolonged nerve deficit. AJrhough of ulnar nerve injulY wirh crossed pinning, mosr surgeons prefer
nerve injury is related ro fracrure displacemenr, a neural deficir to use twO lareral pins if possible and no medial pin. Neverrhe-
can exisr wirh even minimally displaced fractures. Sairyo er a1. less, ir should be recognized rhat two lateral pins are about 30%
(160) reported one patient in whom radial nerve palsy occurred less resistant to wrque rhan crossed pins. However, successful
wirh a slighdy angulated fracture that appeared ro be a purely mainrenance of alignment of rype III supracondylar fracrures
exrcnsion type fracture on inirial radiographs. Even in parients wirh cwo lateral pins has been reponed (42). lf cross-pinning is
wirh mild injuries, a complere neurologic examinarion should be to be used, nerve penerrarion and indirecr rrauma to the nerve
performed before rrearment. An irreducible fracrure wirh nerve can be prevemed by making a 1.5-cm incision over the medial
deficit is an indicarion for open reduction of the fracture ro be epicondyle and being certain rhar rhe ulnar nerve is protecred
sure that there is no nerve entrapment. Chronic nerve entrap- when rhe medial pin is placed. Another alternarive for prorecrion
ment in healed callus can give the appearance of a hole in rhe of rhe ulnar nerve was described by Michael and Stanislas, who
bone, Metev's sign. Nerve transecrion is rare, and almost always auached a nerve srimulator to a needle, which was lIsed for
involves rhe radial nerve (19,30,50,123,126). localizarion of the ulnar nerve (129). Once the ulnar nerve was
Iatrogenic injury to the ulnar nerve has been reported (0 identified, a standard pinning rechnique was used, placing rhe
occur in 1% ro 5% of patients with supracondylar fractures (33, medial pin 0.5 to 0.75 mm anterior ro rhe nerve. We have no
93,153,157). In a large series of rype III supracondylar fracwres, experience wirh rhis technique. The concralareral elbow should
the rate of iatrogenic injury ro the radial nerve was less rhan always be examined for ulnar nerve subluxarion in flexion be-
1%. The course of rhe ulnar nerve through rhe cubital tunnel, cause ir usually is bilareral and associared wirh ligamentous laxiry.
between rhe medial epicondyle and rhe olecranon, makes it vul- Some surgeons palpate rhe ulnar nerve and push ir posreriorly
nerable when a medial pin is placed. The ulnar nerve generally (Fig. 14-29).
is injured by diI"(~cr trauma from rhe medial pin, with or withom Radial nerve injuries are rare complications of pinning of
actual penetration of the nerve. If rhe pin is placed in the ulnar supracondylar fractures. The mosr common cause is probably a
groove rarher than in rhe medial epicondyle, injury is Jikely. The direcr piercing injlllY ro rhe radial nerve, as rhe medial pin exits
ulnar nerve may sublux over the medial epicondyle in as many rhe anterolareral correx of the humerus. This injury can be besr
as 30% of parients; rhis usually is bilareral and associared wirh prevented by ensuring rhat pin penerrarion in rhe opposire cortex
ligamentous laxiry. Ulnar nerve subluxarion occurs mosr com- is limired to 1 to 2 mm. The medial pin should be backed our
monly wirh hyperflexion of rhe elbow and injury ro the nerve slightly if ir prorrudes significantly beyond the cortex. Sponta-
is most likely when a medial pin is placed with the elbow in neous recovery of radial nerve function generally occurs.
hyperflexion.
lf an ulnar neuropathy is documenred posroperarively when
Elbow Stiffness
one was nor present preoperarively and a medial pin has been
placed, what is appropriare trearment? Brown and Zinar (33) Loss of motion after extension-rype supracondylar fracwres is
reporred four ulnar nerve injuries associared wirh pinning of rare in children. Two series analyzed rhis complicarion in derail
supracondylar fractures, all of which resolved spontaneously 2 (47,87) and found rhar fracrures rreared closed had an average
(Q 4 months after pinning. Lyons et aJ. (118) documented ulnar loss of morion of 4 degrees and a residual flexion contracrure
nerve injuries associated with pinning in 19 of375 parients who of 4 degrees. In those rreared with open reducrion, rhe loss of
had cross-pinning of supracondylar fracwres. In only 4 was rhe flexion was 6.5 degrees and rhe flexion conrracwrc was 5 degrees
medial pin removed. Two had explorarions, which found no or 1.2 degrees of hyperextension. Loss of morion has been re-
nerve rransecrion. These researchers recommended leaving rhe ported with rhe posrerior triceps spliuing incision for open re-
medial pin in place until rhe fracwre heals. Rasool (153) reported ducrion (79,82,122).
six patients wich ulnar nerve injuries in whom early expJoration AJthough loss of motion usually is minimal, significant loss
was performed. In cwo rhe nerve was penerrared, and in three of flexion can occur. This is generally caused by eirher posrerior
ir was consrricred by a rerinaculum over rhe carpal tunnel, aggra- angularion of rhe disral fragment, posrerior rranslarion of rhe
vared by rhe pin. In one patiem, rhe nerve was subluxed and disral fragment wirh anrerior impingemenr, or medial roration
was fixed amerior ro rhe cubical tunnel by rhe pin. Full recovery of rhe distal fragment wirh a prorruding medial meraphyseal
occurred in rhree parients, parrial recovery in cwo, and no recov- spike proximally (r:;ig. 14-38). In young children wirh significanr
ery in cwo. Royce er al. (157) reponed sponraneous recovery of growth potenrial, there may be significant remodeling of anrerior
 Chapter /4: SupracondJ'lar Fractures ofthe Distal Humerus 609

t
A B

c
FIGURE 14-38. Distal fragment rotation. A: Posterior angulation only of the distal fragment. B: Pure
horizontal rotation without angulation. C: Pure posterior translocation without rotation or angulation.
D: Horizontal rotation with coronal tilting, producing a cubitus varus deformity. There is a positive
crescent sign. (Redrawn from Marion J, LaGrange J, Faysse R, et al. Les fractures de I'extremite inferieure
de I'humerus chez I'enfant. Rev Chir Orthop 1962;48:337-413; with permission.)

impingement, and any corrective surgery should be delayed at

least 1 year. Although anterior impingement can significantly
remodel, there is lirrle remodeling to persistent posterior angula-
tion or hyperextension.

Myositis Ossificans
Myositis ossificans is often mentioned as a possible complication
(79,169) of supracondylar fractures, but it is remarkably rare
(Fig. l4-39). This complication has been described after open
reduction, but vigorous postoperative manipulation or physical
therapy is believed ro be rhe mosr commonly associated facror
(6,107,147,i67).
In a repon of rwo patients with myositis ossificans after closed
reduction of supracondylar fractures, Airken (3) noted thar limi-
tation of motion and calcification disappeared after 2 years. Post-
operative myositis ossificans can be observed with rhe expecta-
tion of spontaneous resolution of both restricted motion and
the myositis ossificans. There is no indication for early excision.

Nonunion
The disral humeral meraphysis is a well-vascularized area with
remarkably rapid healing, and nonunion of a supracondylar frac-
FIGURE 14-39. Myositis ossificans. Ossification of the brachialis muscle
ture is rare, with only a single case described by Wilkins and developed in this 8-year-old who had undergone multiple attempts at
Beary (I 91). We have not seen nonunion of this fracture. With reduction. (Courtesy of John Schaeffer, M.D.)
610 Upper Extremity

infection, devasculatization, and soft tissue loss, the risk of non- roms of avascular necrosis of the trochlea do not occur for
unIon II1creases. months or years. Healing is normal and motion is regained,
but mild pain and occasional locking develop with characteristic
Avascular Necrosis radiologic findings. Romine follow-up radiographs of supracon-
dylar fractures are nor necessary because this complication is
Avascular necrosis of the trochlea after supracondylar fracture
highly unusual and the fishtail deformiry of the distal humerus
has been reported. The blood supply of the ossification center
does not compromise function.
of the trochlea is fragile, with r'I'IO sepal'ate sources. One small
artery is latera'i and courses directly thtough the physis of the
Angular Deformity
medial condyle. It provides blood to the medial crista of the
trochlea. If the fracture line is very distal, this artery can be Angular deformities of the distal humerus after supracondylar
injured, producing avascular necrosis of the ossification center fractures are much Jess common since the development of mod-
and resulting in a classic fishtail deFormiry (Fig. J4-40). Symp- ern techniques of skeletal stabilization. In the past, the incidence

A B

D
FIGURE 14-40. Avascular necrosis of the trochlea. A: Anteroposterior injury film of an 8-year-old with
a distal type III supracondylar fracture. B: The distal extension of the fracture (arrow) is best appreciated
on the lateral reduction film. Postfracture, the patient was asymptomatic until 2 years later, when elbow
stiffness developed. C: Repeat radiographs at that time showed atrophy of the trochlea (arrows). D:
Three·dimensional computed tomographic reconstruction demonstrates atrophy of the trochlea.
 Chapter 14: SupracondyLar Fractures of the DistaL Humerus 611

Horizontal rotation (59,191) in a mediaJ di renion or internal

rotation of the distal Fragment is believed to predispose to distal
fragment varus angulation (Fig. 14-38). Eccentric position of
the biceps has been suggested as a cause of varus tilting by the
distaJ fragment. Chess et al. (43) evaluated the clinical appear-
ance of cubirus varus in an anatomic srudy of256 combinations
of varus angulation, inrernal rotation, and posterior angulation.
They found that the major componenr of cubirus varus defor-
mity was true varus angulation in the coronal plane. Internal
rotation did appear to worsen the deformity. In a clinical study
019,120), the true distal humeral rotation was measured on
wedges removed from osteoromies of the distaJ humerus; the
horizontaJ rotation of the distal humerus did not correlate with
the severity of cubirus varus (85). Horizontal rotation may
accentuate the clinical varus deformity, but it is not the primary
cause. CoronaJ plane deformity and hyperextension are the fac-
rors in cubitus varus deformity and are important in planning
surgicaJ correction.
Some researchers have suggested that cubitus varus deformity
may produce weakness, but most believe that the effeers are
primarily cosmetic. An increased risk of fracture (54), especiaJly
of the lateral condyle, has been linked with cubitus varus defor-
FIGURE 14-41. Cosmetic effects. A combination of varus coronal rota-
tion and medial horizontal rotation of the distal fragment causes the mity (Fig. 14-42). Vat us angulation may complicate throwing.
lateral condyle to be unduly prominent (arrow). This accentuates the However, the functional effects of cubitus varus deformity are
unpleasant appearance of the cubitus varus deformity. (Reprinted from minimal and, other than decreasing fracture risk, the main indi-
Wilkins KE. Residuals of elbow trauma in children. Orthop C1in North
Am 1990;21:291-314; with permission.) cation for correction of a varus deformity is to improve the
appearance of the elbow rather than to improve function.

of cubims varus deformity after supracondylar fracrures ranged

from 9% ro 58% (60,92,122). Pirone et al. (47) reponed cubi-
rus varus deformities in 14% of patienrs treated with cast immo-
bilization compated with 3% in patients with percutaneous pin
fixation. A decrease in frequency of cubitus varus deformity after
the use of percutaneous pin fixation has been reflected in other
recent series (28,29,66,67,101,128,147,148). The usuaJ etiology
of cubims varus deformity is malunion of the distaJ humeral
fragmenr rather than growth arrest. Distal humeral varus is gen-
erally believed to be a tesult of residual coronaJ angulation aggra-
vated by malrotation and hyperextension.
Malunion of the distal humerus usually creates a static defor-
mity (Fig. 14-41), which becomes evidenr as the patient gains
Full motion. A flexion deformity obscures the true varus defor-
mity, which is generally associated with hyperextension. Al-
though some investigators have proposed that unequal growth
in the distal humerus causes varus deformity (17,31,91,92,144,
167), this is unlikely ro cause a signiflcanr varus deformity in
the first few months after fracrure. The growth of the distaJ
humerus is 20% of that of the overall length of the humerus.
In a 5-ycar-old, therefore, the amount of distal humeral growth
in 1 year is approximately 2 mm, making it unlikely that growth
asymmetry is a significant cause of varus deformity that occurs
within the first 6 to 12 months after fracture. However, avascular
necrosis of the trochlea or medial portion of the distal humeraJ
fragment can result in progressive varus deformity. Ina series FIGURE 14·42. Predisposition to lateral condyle fracture. This 5-year-
of 36 varus deformities reported by Voss et a1. (I85), four pa- old sustained a supracondylar fracture of this extremity 1 year before
this acute stage II fracture of the lateral condyle (arrows). It was thought
tients had medial growth disturbance and distal humeral avascu- that the cubitus varus deformity predisposed the patient to this second
lar necrosis as a cause of progressive varus deformity. fracture. (Courtesy of Kenneth P. Butters, M.D.)
612 Upper Extremity

will lead ro lateral overgrowth and progressive deformiry. Lareral

epiphysiodesis will not correcr rhe deformiry, bur will prevenr
ir from increasing. Voss er a1. (185) used hemiepiphysiodesis
wirh osreoromy in (VIIO patienrs wirh growth an'est and varus
deformiry. The humerus varies in length by a few cenrimerers
from one individual CO another, bur in general is about 30 cm
long at skeletal maruriry_ Approximately 65% of the lengrh of
rhe humerus is achieved by age 6 years. A 6-year-old child has
approximarely 10 cm of growrh left in rhe enrire humerus, wirh
only approximarely 2 cm provided by rhe disral physis. Growrh
an'est, in the absence of avascular necrosis or collapse, will be a
velY slowly evolving phenomenon, and epiphysiodesis in a child
older than 6 years will have little effeer on longitudinal growrh.
In general, prevention of increasing deformiry from medial
growth arresr is the only role for lateral epiphysiodesis. Because
of rhe sJow rate of growth in the distal humerus, we do not
believe there is any role for lateral epiphysiodesis in correction
of a varus deformiry in a child with otherwise normal physis.

Osteotomy
Osteoromy is the only way 1'0 correcr a cubitus varus deformiry
with a high probabiliry of success. A variery ofcorrective osreotO-
FIGURE 14-43. A patient with cubitus varus shows overlapping of the
distal humerus, with the olecranon (arrow) producing the typical cres- mies have been described, almost all with significant complica-
cent sign. tions (Table 14-3). Stiffness, nerve injury, and recurrenr deform-
iries are the mosr commonly reported complications. An overall
complication rate approaching 25% in many series has led to
some conrroversy about the value of a distal humeral corrective
The radiologic appearance of cubirus varus deformiry is dis- osreotOmy for cubitus varus deformiry.
rincrive. On rhe AP view, rhe angle of rhe physis of rhe lareral To choose an appropriare osteotOmy, the exacr location of
condyle (Baumann angle) is more horizonral rhan normal. On rhe deformity musr be determined. Because malunion is rhe
rhe Lueral view, a crescenr sign is produced by rhe superimposi- cause of most cubitus varus deformities, the angular deformiry
rion of rhe capirellum on rhe olecranon (Fig. 14-43). usually occurs ar the level of the fracfLIre. If rhe deformity is
Cubirus varus deformiry also is associated with a significanr caused by growth arrest, the actual deformiry will be cenrered
increase in lare ulnar nerve palsies, as reponed in rhe Japanese at rhe site of the growth arrest. Rotation and hyperrension con-
lirerature (1,24,182). Wirh a cubirus varus deformiry, rhe olecra- tribute ro the deformiry, bur varus is rhe mosr significanr f.lctor
non fossa moves co rhe ulnar side of rhe disral humerus (140), (43). Hyperexrension can produce a severe deformiry in some
and the rriceps shifrs a bit ulnalward. Investigacors rheorized parients. After derermining rhe locarion and cause of rhe defor-
rhat this ulnar shift may compress rhe ulnar nerve againsr rhe miry, the appropriate osteotOmy can be chosen. In general, a
medial epicondyle, narrowing the cubiral tunnel and resulring lateral closing wedge osreotOmy with a medial hinge will correct
in chronic neuroparhy. In a recent repon (1), a fibrous band rhe varus deformiry, with some minor correction of hyperexren-
running be(Vlleen the heads of rhe flexor carpi ulnaris was sian (9,20,46,70,72,80,98,100,111,177,185,196).
thoughr co cause ulnar nerve compression. An oblique configuration (Fig. 14-45) places the center of
rorarion of rhe correcrive osteotomy as close to rhe acrual level
of rhe deformiry as possible. Oppenheim er a1. recommended
Treatment of Cubitus Varus Deformity
osreotOmy at a higher level, emphasizing that the length of the
As for the rrearmenr of any posrtraumaric malalignmenr, oprions curs should be equal (Fig. 14-46) (142). The higher the osteot-
include (a) observ<lrion wirh expecred remodeling, (b) hemiepi- omy, rhe more rranslation is produced in correering rhe angular
physiodesis and growrh alrerarion, and (c) correcrive osteoromy. deformiry. Proper preoperative planning places the apex of the
Bracing of rhis deformity is not cffecrive for improving align- osreoromy close ro the level of the deformiry and obrains the
menr or prevenring increasing varus. Observation generally is besr anaromic result. On an AI' radiograph of rhe humerus with
not appropriare because a1rhough hyperextension may remodel rhe forearm in full supination, rhe size of rhe wedge and rhe
co some degree in a young child (Fig. 14-44), in an older child, angular correcrion needed are determined. An "incomplere" lar-
lirrle remodeling occurs even in the plane of motion of rhe joinr. eral closing wedge osreoromy is performed, leaving a small me-
Hemiepiphysiodesis of the disral humerus may occasionally dial hinge of bone inracr. The osteotomy usually is fixed wirh
be of value, particularly co prevenr cubirus varus deformiry from (VIIO Kirschner wires placed larnally. In rhe absence of an inrac[

developing in a parienr wirh clear medial growrh an'esr or rroch- medial hinge, two lateral wires probably are nor suHicicnr to
lear avascular necrosis. If unrreared, medial growth disturbance secure this osteotomy (185).
 Chapter /4: Supracondylar Fractures of the Distal Humerus 613

B c
FIGURE 14-44. A hyperextension deformity in the distal humerus may remodel somewhat, whereas
varus and valgus deformity do not. Hyperextension deformity in the distal humerus following fracture
(A). Four years later (B), a more normal distal humeral anatomy is seen with remodeling of the hyperex-
tension deformity; 2 years later, (e), a normal distal humeral anatomy is reconstituted.
614 Upper Extremity

TABLE 14-3. RESULTS OF SEVERAL STUDIES USING VARIOUS OSTEOTOMIES

Study (Ref.) Type Fixation Complications

Incomplete Osteotomies
Ring and 5ecor (105), 15 cases MOW, Riedel clamp, tibial graft Tlhree neutral
Three ulnar palsies
Ra ng (152), 20 cases LCW, K-wires One aneurysm
One skin slough
One nerve palsy
5ix varus
Two stiff
Carlson et al. (37), 12 cases LCW, staple None
Betlemore et al. (120) 27 cases LCW, K-wire, French technique Four infections
Four loss of fixation
Three varus
Four poor scars
Five prominent condyles
Gao (73), 15 cases LCW, suture Three undercorrected
McCoy and Piggot (175), 20 cases LCW, French technique Four neutral
Two varus
Two stiff
One poor scar
Graham et al. (80), 16 cases LCW, cast Two varus
Danielsson et al. (52), 11 cases LCW, staple None
Mixed Osteotomies
Oppenheim et al. (142), 14 incomplete, 31 complete LCW, K-wires, French technique Five nerve palsies
Three infections
Twelve varus
One stiff
Two poor scars
Unspecified Osteotomies
5weeney (177), 15 cases lCW, K-wires Five varus
Complete osteotomies
Langenskiold and Kivilaakso (114), 11 cases LCW, unicortical plate, rot. Two varus
Two neutral
Two reoperations
Labelle et al. (111), 15 cases LCW, K-wires, rot. Three loss of fixation
Three nerve palsies
DeRosa and Grazi.ano (157), 11 cases 5C, screw One loss of fixation, varus
Kanaujia et al. (102), 11 cases Dome K wires Two stiff
Laupaltarakasem et al. (115), 57 cases 5C, screws Three loss of fixation
Two reoperations
Two prominent condyles
Uchida et al. (182), 12 cases 5C, screws None
Voss and Kasser (185),34 cases K-wires No nerve palsies, One loss
of fixation

MOW, medial opening wedge; LCW, lateral closing wedge; rot., rotational correction; Sc. step-cut osteotomy.
 Chapter /4: Supracondylar Fractures oJthe Distal Hllmems 615

B FIGURE 14·47. The step-cut osteotomy. The distal fragment can be

FIGURE 14·45. A: By moving the apex of the closing wedge distally, rotated in the horizontal plane (circular arrow) to correct that part
the center of rotation of the osteotomy is moved closer to the defor- of the deformity. (Reprinted from De Rosa GP, Graziano CPo A new
mity. B: Upon closing a distally based wedge osteotomy, there is less osteotomy for cubitus varus. Clin Orthop 1988;236: 160-165; with per-
translational effect than in a more proximally based osteotomy. mission.)

Wilkins and Beary (191) recommended crossed wires in this

situarion. With rhis incomplere osreoromy, rorarion cannot be
correcred, bur rorarional deformiry was nor found ro be a signifl-
canr problem in srudies by Voss (185) and Oppenheim (142).
A dome osreoromy has been described by Japanese surgeons
(89) in which a curved osteoromy is made in the supracondylar
area. Proponenrs of this osreoromy suggest rhar mulriplane cor-
recrion is possible wirhour inducing translarion in rhe disral frag-
menr and thar roration can be correcred. This osreoromy is ofren
performed rhrough a posrerior approach.
DeRosa and Graziano (57) described a srep cur osreoromy
(Fig. 14-47) in which rhe disral fragment is slorred inro rhe
proximal fragmenr and rhe osreoromy is secured wirh a single
screw. Mulriple osreoromies wirh varying degrees of complexiry
have been recommended. In general, incn.::tsing complexiry
means increasing complicarions. No series of osteoromies has
been reported wirhour some significant complicarions.

Results of Osteotomy
Funcrional ourcomes are generally good, bur rhe preoperative
funcrional deflcir is nearly always minor in patients with cubitus
varus deformiries. Complications of humeral osreoromy include
sriffness, nerve injUly, and persistent deformiry (Table 14-3);
however, wirh a properly performed osreoromy, complicarions
are relarively few. Ippoliro er al. (95) reporred long-term follow-
up of parienrs wirh supracondylar oSteoromies, 50% of whom
had poor resulrs. Increasing deflcir has been reporred afrer osreor-
FIGURE 14-46. Technique ofthe lateral closing wedge osteotomy. The
omy in young children, bur rhis did nor occur in rhe series
limbs should be of equal length, and the medial cortex should remain
intact. (Reprinted from Oppenheim WL, Clader TJ. Smith C, et al. Supra- reporred by Voss er al. (185), in which four patienrs had growth
condylar humeral osteotomy for traumatic childhood cubitus varus de- arrest and avascular necrosis; laren·t! epiphysiodesis was per-
formity. Clin Orthop 1984; 188:36; with permission.)
formed ro prevenr recurrent deformiry in twO of rhese parienrs.
Hyperextension deformity may remodel over time (Fig. 14-
44), but correcrion is slow and inconsisrent. In the series from
616 Upper Extremity

Children's Hospital (I85), hyperextension deformities remod- deformiry or neurologic abnormality, anatomy of neurovascular
eled as much as 30 degrees in young children, but in child ren srrucrures is unlikeJy w be normal.
facing mawtiry, rhere was no significanr remodeling in the flex- Wilkins recommended combining dome and lateral closing
ion/exrension plane. If hyperextension appears ro be a major wedge osteowmies through a posterior approach for multiplanar
problem, osteoromy also should be direcred at this deformiry correction. This procedure is performed with the patient prone.
rather rhan simple correcrion of the varus deformiry; this requires For patients wirh significanr hyperexrension deformiry, we
a mulrip'lane osreowmy. would choose this procedure For multiplanar correcrion.

• AUTHORS' PREFERRED METHOD FLEXIO -TYPE SUPRACONDYLAR

,~ 0 F TREATMENT FRACTURE

J prefer an incomplete lareral closing wedge osreoromy for cor- Flexion-rype supracondylar humeral frac[Lltes account For about
rection of mosr cubirus varus deformities. It is a simple procedure 2% of humeral fractures. A flexion parrern of injury may not
and in our hands has had a very low complication rate. A simple be recognized unril reduction is attempted because inirial radio-
latera.! approach is used rarher than a posterior approach, and it graphs are inadequate. A key to the recognition of a flexion-rype
is a muscle-preserving osteoromy that allows rapid rehabilitation supracondyla.r fracture is that it is unstable in flexion, whereas
afrer hea.!ing. Sriffness and nerve injury are rare complications exrension-rype fracrures generally are stable in hyperflexion. A
of this procedure. Performing rhe procedure with rhe patient laterally displaced supracondylar fracrure may actua.lly be a flex-
supine allows easy observation of the correction achieved. ion-rype injury.
Kirschner wire fixarion can be used in the juvenile age group
and scrcw fixation in adolescenrs.
Etiology and Pathology
There is no reason ro mobilize the ulnar nerve, but care is
taken nor ro penetrate the medial COrteX with a saw. The posirion The mechanism of injury is generally believed ro be a fall directly
of the radia.! nerve limits proximaJ lateral dissecrion. Symeonides onro the el bow rather than a fall onto the outstretched hand with
er al. (179) reported finding a radial nerve entrapped within hyperextcnsion of the elbow (Fig. 14-48). The distal fragment is
fracture callus in rhe lareral aspect of the metaphysis. With severe displaced anteriorly and may migrare proximaJly in a rotally

FIGURE 14-48. Flexion mechanism. Flexion-type

fractures usually result from a blow to the poste-
rior aspect of the elbow. The obliquity of the frac-
ture line may be opposite that of an extension
type. The large black arrows demonstrate the
usual direction of displacement of the fragments.
 Chapter 14: Supracondylar Fractures of the Distal Humems 617

A B

FIGURE 14-49. Flexion valgus deformity. Lateral (A) and anteroposter-

ior views (B) of a flexion-type supracondylar fracture. The distal frag-
ment (arrow) is laterally displaced in the coronal plane as well. Despite
aggressive treatment, there was mild residual cubitus valgus plus a flex-
ion contracture when the fracture healed (C). (Reprinted from Wilkins
KE. Residuals of elbow trauma in children. Orthop Gin North Am 1990;
c 21:291-314; with permission.)

displaced fracture. The ulnar nerve is vulnerable in this fracture upper extremity. Fracture classification is the same as for exten-
parrern (3,68,84,158), and it may be emrapped in the fracture sion-type supracondylar fractures (Gaetland): type I, nondis-
or in the healing caJlus (l ] 3). placed fracture; type II, minimally angulated greenstick fracture;
and type III, tOtally unstable displaced distal fracture fragmem.

Radiographic Findings
The radiographic appearance of the distal fragment varies from
Treatment
mild angular deformity to complete anterior displacement. Ante- In general, type I flexion-type supracondylar fractures are stable
rior displacement often is accompanied by medial or lateral nondisplaced fractures that can simply be protected in a long
translarion (Fig. 14-49). Associated fracrures of the proximaJ arm cast (62,137,152). If mild angulation, as in a type II fracture,
humerus and radius mandate full radiographic evaluation of the requires some reduction in extension, the arm can be immobi-
618 Upper Extremity

A problem with rype III flexion supracondylar fracrures is

(hat reduc(ion is difficult to achieve and when achieved (he
elbow usually is in extension, making smbilization of the dis(al
fragmenr with pins qui(e difficulr.
Type I and II fracrures (Figs. 14-50 and 14-51) generally
are reduced if any angular displacement is seen on fluoroscopic
imraopera(ive evalua60n. Type II fracrures can be immobilized
in an extension cast with the elbow fully extended (Fig. 14-51).
A ring is applied so tha( (he weigh( of (he cas( can be supponed
by a sling around the neck. The cast is removed at 3 weeks.
If closed reduction is performed withom skeletal stabilization,
follow-up radiographs usually are taken at 1 week and then when
the cast is removed at 3 weeks.
For unstable rype II and III flexion supracondylar frac[ures,
pinning is generally required. The pinning technique described
for extension-rype supracondylar fractures is not appropriate for
this fracture, because its instability in flexion precludes pinning
wi[h the elbow hyperflexed. Pinning should be performed after
closed reduction with the elbow in mild flexion or full extension.
In a flexion-type supracondylar fractllre, if reduction can be
FIGURE 14-50. Type I flexion injury. A type I flexion supracondylar obtained in extension, it is rarely if ever stable in flexion. In
fracture pattern (arrows) in a 6-year-old below-the-elbow amputee.
There is only about a 10 degree increase in the shaft condylar angle. general, a slightly less than anatomic reduction can be accepted as
He was treated with a simple posterior splint. long as (here is no soft tissue interposition of tissue, the Baumann
angle is close to the other side, and neither flexion nor extension
is seen on the lateral view. Altnougn rotation of the arm is often
possible for a lateral view of extension supracondylar fracture,
lized wi(h (he elbow fully ex(ended. Radiologic evalua(ion wi(h the C-arm must be moved to get satisf:1crory radiographs when
[he elbow ex[ended is easily obrained and accura[e in de[ermin- pinning a flexion-type supracondylar fracrure, because they usu-
ing (he adequacy of reduc[ion. Reduc[ion is assessed byevalua[- ally are rotationally unstable even when reduced.
ing [he olecranon fossa. Baumann angle, and (he amerior hu- Pinning is generally performed with the elbow in about 30
meral line imersening the la[eral condyle. If redunion cannot degrees of flexion, holding the elbow in a reduced position (Fig.
be obtained, as is often the case, or if ro[ation persis(s, soft (issue 14-52). If closed reduction can be obtained, pinning can be
imerposition, possibly (he ulnar nerve, should be suspected. accomplished in this position. Reduction may be facilitated by

A B
FIGURE 14-51. Closed reduction, extension cast. A: A 5-year-old girl sustained a type II flexion pattern.
B: She was manipulated into extension and found to be stable, and thus was maintained in a long-arm
cast in extension.
 Chapter 14: Supr'lcondylar F,"actures of the Distal Humerus 619

A B

C D
FIGURE 14-52. Closed reduction, pin fixation. A: Injury film of a 9-year-old with a type II flexion injury.
B: A satisfactory reduction was achieved by fully extending the elbow. C: The elbow was then gradually
flexed to full flexion, maintaining pressure proximally through the forearm (arrows) to keep the distal
humeral fragment extended. 0: The distal fragment was then secured with three pins placed laterally.
620 Upper Exrremil)'

placing a rracrion rype of olecranon wing nur rhrough rhe proxi- humeral fracrure and good callus formation, the arm is immobi-
mal ulna ro give a berrer grip on rhe disral fragmenr. lized in a cast with rhe elbow in extension, and radiographs are
The larel'al pin is generally placed frrsr rhrough rhe lareral obtained. We prefer wing nur-type tracrion for rhis co apply
condyle, exrending rhrough rhe proximal fragmenr and engaging skeletal rraction with rhe elbow flexed 30 co 40 degrees for com-
rhe opposire correx. The medial pin is rhen placed rhrough rhe fort. This may require some sling suspension, as well as a skeleral
medial epicondyle. \'(/t;; make a -,mall incision over rhe medial rracrion pin or wing nur. If an ulnar neuroparhy develops in
epicondyle ro ensme rhar rhe ulnar nerve is nO[ enrrapped in rracrion, rhe nerve is probably rrapped in the fracture and open
rhe fracru reo reducrion and ulnar nerve explorarion are indicared.
Afrer pinning of a flexion-rype supracondylar fracrure, rhe
arm should be placed in a case. If rhe fracrure is held in anaromic
posirion wirh pins, a flexed-arm casr can be used ro provide
~ AUTHORS' PREFERRED METHOD
bean paricnt comfort, but a casr wirh the elbow in maximal
,~ OF TREATMENT
exrension is acceprable.
Open reduction frequenrly is required for flexion-rype supra-
In general, we rrear rype I flexion supracondylar fraerures wirh
condylar fractures. Open reducrion is besr performed through
a splint or cast wirh the elbow flexed for comforc. Minimally
an anceromedial approach, rarher rhan an ancerior approach, as
displaced rype II fractures rhar reduce in extension are treated
is used for exrension-rype supracondylar fracrures. Wirh flexion-
in an exrension easr. Unsrable rypes II and III fracrures are
rype fracrures, brachialis remains inracr and musr be rerracted
pinned. We make a small incision over the medial epicondyle
in order to expose the frac(Llre, necessiraring a medial exrension
if a medial pin is placed. Open reduction is used if an anaromic
ro rhe ancerior approach. To be sure rhar rhe ulnar nerve is not
closed reducrion can nor be obtained.
enrrapped in the fracwre sire, explorarion of rhe ulnar nerve or
ar Ieasr idencificarion is probably advisable with rhis fracture.
Fracrure reducrion should be obtained under direcr vision of
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I. Abe M, lshim T, Shirai H, er al. Tardy ulnar nerve palsy caused by
cubitus ,'MuS deformity.] Hand SUlg [Am] 1995;20:5-9.
Anteromedial Open Reduction of Flexion- Type 2. Abral1am E, Powers T, Win P, et al. Experimenral hyperextension
Supracondylar Fractures supracondylar fractures in monkeys. Clin Grthop 1982; 17l:309-318.
3. Aitkcn AP, Smirh L, Blackene CWo Supracondylar fracrures in chjl-
A rransverse incision is made across the antecubital fossa, curving dren. Am) Surg 1943;59:161-171.
proximally posrnior co rhe neuromuscular bundle. Dissection 4. Alhurger PO, Weidner PL, Randal RB. Supracond}'lar fractures of
the humerus in children.] Pediatr Grthop 1992;12:16-19.
is carried down co rhe level of me superflcial fascia of rhe forearm
5. Alcon WH, Bowden I:lW, Miller PRo Displaced supracondylar fr.1c-
and antecuhiral fossa. The neurovascular bundle is identified tures of d1e humerus in children: long-term follow-up of 69 parielHs.
and rerracred media.lly. The brachiaJis and biceps tendons are } Am GSlt"Opath Assoe 1977;76:910-915.
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Wound closure is performed wirh inrerrupred srirches, eirher 9. Amspacher], Mcrss"nbaugh J. Supracondylar osteoromy of the hume-
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for 3 or 4 weeks uncil good callus fOI'marion is presene. Pins 10. Archibald OM, RoberrsJA, Smith MGH. Transarricular fixation for
gencrally are lefr our rhrough the skin and removed in rhe office severely displaced supr:1Condylar fractures in children. } Bant' }uillf
wirhour need for anesthetic. No immediare rehabilirarion is Surg [Br] 1991;73:147-149.
given, bur rhe parienr is encouraged ro begin gende acriviries 11. Archibeck M, Scon S, Peters C. Brachialis muscle enrrapmenr in
displaced supracondylar humerus fractures: a techniquc of c10scd re-
wirh rhe arm and co begin regaining morion withom a stressful
duction and report of initial results. ] Pediatr Grthap 1997: 17:
exercise program. 298-302.
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Traction (Am) 1977;59:914-9 I6.
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Tracrion can be used for this fracture, but the elbow generally merus.} Bone }oint Surg (/111'1] 1~)77;')9:,)8t)-595.
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for the patient in rracrion. AJrhoLlgh overhead tracrion works supracondylar humeral fractures in children: resulrs of open reducrion
best For extension-eype supracondylar fracrures, we rhink rhat via a ventral approach in comparison with closed treatment. Injury
side arm tracrion migh r be berter for rh is fractu rei however, 1t)')3;24: 179-181.
[5. Aronson DO, Prager PI. Supracondylar fractures of the humerus in
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reducrion. Afrer 14 days or so in traction, with a srable disral 16. Badhe N, Howard P. Olecranon screw tracriun for displaced supra-
 Chapter 14: Supracondylar Fractures of the Distal Humerus 621

condylar fractures of the humerus in children. Injury 1998:29: 43. Chess DG, Leahey JL, Hyndman Jc. Cubirus varus: significant fac-
457-460. tors. J Pediatr Grthop 1994; 14: 190-192.
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192. Wilkins KE. Fractures and dislocations of the elbow region. In: Rock-
in the callus of a supracondylar fracture. J Bone Joint Surg [Br} 1975;
wood CA Jr, Wilkins KE, King RE, eds. Fractures in children, 3rd
57:523-524.
180. Te Slaa RL, Faber FWM, Nollen AJG, et al. Supracondylar fractures ed. Vol. 3. Philadelphia: JB Lippincott, 1991:509-828.
of rhe humerus in children: a long-term follow-up study. Neth J Surg 193. Williamson OM, Cole WG. Treatment of selected extension supra-
1988;40: 100-103. condylar fractures of the humerus by manipulation and scrapping in
181. Topping RE, Blanco JS, David TJ. Clinical evaluation of crossed-pin flexion. Injury 1993;24:249-252.
versus later-pin fixation in displaced supracondylar humerus fracrures. 194. Willis RB, Rorabeck CH. Treatment of compartment syndrome in
J Pediatr Grthop 1995; 15:435-439. children. Grthop Clin North Am 1990;21 :40 1-412.
182. Uchida Y, Sugioka Y. Ulnar nerve palsy after supracondylar humerus 195. Wilson PD. Fractures and dislocations in the region of the elbow.
fracture. Acta Grthop Scand 1990;61:118-119. Surg Gynecol Gbstet 1933;56:335-359.
183. Vahvanen V, Aalro K. Supracondylar fractures of the humerus. Acta 196. Wong HK, Balasubramaniam P. Humeral torsional deformity after
Grthop Scand 1978;49:225-233. supracondylar osteotomy for cubitus varus: irs influence on rhe postos-
184. Van Egmond DB, Tavenier 0, Meeuwis JD. Anatomical and func- reocomy cartying angle. J Pediatr Grthop 1992; 12:490-493.
tional results after treatmenr of dislocated supracondylar fractures of 197. Worlock PH, Colton e. Severely displaced supracondylar fracrures
the humerus in children. Neth J Surg 1985;37:45-49. of the humerus in children: a simple merhod of rreatment. J Pediatr
185. Voss FR, Kasser JR, Trepman E, et al. Uniplanar supracondylar hu- Grthop 1987;7:49-53.
meral osteocomywith preser Kirschner wires for posttraumaric cubitus
198. Zaltz I, Waters P, Kasser J. Ulnar nerve insrability in children. j
varus. J Pediatr Grthop 1994;14:471-478.
Pediatr Grthop 1996:16:567-569.
186. Walloe W, Egund N, Eikelund L. Supracondylar fracrure of the hu-
merus in children: review of closed and open reducrion leading to a 199. Zionts LE, McKellop HA, Hathaway R. Torsional strength of pin
proposal for treatment. Injury 1985; 16:296-299. configurarions used co fix supracondylar fractures of the humerus in
187. Watson-Jones R. Fractures and joint injuries. Edinburgh: ES living- children. J Bone Joint Surg [Am} 1994;76:253-256.
scone, 1956. 200. Ziv N, Litwin A, Karz K, et al. Definirive diagnosis offracture-separa-
188. Webb AJ, Sherman Fe. Supracondylar fractures of rhe humerus in tion of rhe c\istal humeral epiphysis in neonates by ultrasonography.
children. J Pediatr Grthop 1989;9:315-325. Pediatr RadioI1996;26:493-496.
 THE ELBOW: PHYSEAL
FRACTURES, APOPHYSEAL
INJURIES OF THE DISTAL
HUMERUS, AVASCULAR NECROSIS
OF THE TROCHLEA, AND
T -CONDYLAR FRACTURES
JAMES H. BEATY
JAMES R. KASSER

PJ-IYSEAL FRACTURES Complications

Fractures Involving the Lueral Condylar Physis Fractures Involving the Lateral Epicondylar Apophysis
1m mobil ization Chronic Tension Stress Injuries (Li((le League Elbow)
Percutaneous Pins
Open Reduction AVASCULAR NECROSIS OF THE TROCHLEA
Fractures of the Capitellum Definition
Fraccures Involving the Medial Condylar Physis HistOrical Perspeccive
Fractures of the Trochlea Incidence
Fractures Involving the Entire Distal Humeral Physis Etiology
Patterns of Necrosis
APOPHY EAL INJURIES OF THE or TAL Clinical Signs and SymptOms
HUMERUS Sequelae
Fractures Involving the Medial Epicondylar Apophysis Treatmem
Basically a Nonoperative Fracwre
Early Motion Essential T -CONDYLAR l~RACTURES
Avoid Early Aggressive Physical Therapy Incidence
Operative Indjcations Mechanism of lnjUlY
Acute Incarceration in the Joint Pathology
Prevention of Valgus Instability Diagnosis
Operative Technique Treatment
Fragmented Apophysis Complications

We thank Kaye Wilkens for his contribution to this chapter various physes to injury is altered by t\'vo major factors: age and
and previous editions. Much of this chapter is his effort. mechanism of injury. Next to those of the distal radius, injuries
to the distal humeral physes are the most common physeaJ inju-
ries. The peak age incidences of these physeal injuries vary con-
PHYSEAL FRACTURES
siderably. In general, the physes of the major long bones are
All the physl:s of the distal humerus are vulnerable to injury, most vulnerable to fracture just before puberty, when rhe peri-
each with a distinct fracture pattern. This vulnerability of the chondral ring is weakest (l,II). Fractures involving the medial
epicondylar apophysis are most common in preadolescenrs, with
the peak ages 11 ro 15 years. This is probably because many
James H. Beaty: Deparrmenr of Orthopaedic Surger)" University of avulsions of rhis apophysis are associated with posrerolateral dis-
Tennessee, Campbell Clinic, and Le[lonheur Children's Medical Center, locations, which also are common in this age group. Fractures
Memphis. Tennessee.
James R. Kasser: Deparrmenr of Orthopaedic Surgery, Harv;'lI'll School of involving the lateral condylar physis occur early, wich the average
Mnlicine, Children's Hospiral Medical Cemer, Bosron, Massachuserrs. age around 6 years (2,4,7,9-12). Fractures involving the medial
626 Upper Extremity

condylar physis are rare and occur most often in children 8 to type II) exirs through the rrochlea, Cotton (29) around the same
12 years of age (3,6,8). Fractures involving the total distal hu- time described more of rhe derails of the various subluxarions
meral physis may occur in neonates or within the flrsr 2 to 3 of borh the fragment and elbow joinr thar occurred wirh rhis
years of liFe ('5). type of Fracrure. He noted rhat because me fragment usually was
The specific fracture patterns, incidence, and mechanism of still attached to rhe proximal radius, borh th.e radius and ulna
injury are discussed in detail in the following sections dealing were subluxed. The mosr common displacemenr was "ourward
wi th these speci flc fractures. and backward"; "inward and forward" displacement was rare.
Corron also noted that rhe main parhology was associated wirh
Fractures Involving the Lateral Condylar the roration of the condylar fragment. He observed rhar rhis
Physis fracture ofren resulted in limited exrension, had some 10caiiareraJ
outgrowth ar the fracture site, and ['are!y resulted in axial devia-
Incidence and Outcome
tion of the elbow unless rhere was a resultanr nonunion. Lirtle
Fractures involving the lateral condylar region in the immature has been added to his description of rhe pathology of [his lesion
skclcron either cross the physis or follow it for a shorr distance by more recent investigarors.
into the trochlea. FraCtures of the lateral condylar physis consti-
tute ]6.9% of fractures of the distal humerus. Fracture Anatomy and Classification
FrJCtures of the lateral condylar physis are only occasionally ClassiFication of lareral condylar physeal fractures can be de-
associated with injuries outside the elbow region. Within the scribed by eirher the anaromic location of rhe fracture line or
elbow region, the associated injuries that can occur with this rhe stage of displacement. An understanding of both of rhese
Fractllre include dislocarion of the elbow (which may be a result classifications is essential in the management of rhese fractures.
of the injury to the lateral condyhr physis rather than a separare Anatomic Location. Salter and Harris classified lateral condylar
injury), fraCtures of the radial head, and fractures of the oleCI'a- physeal injuries as rype IV injuries in their c1assificarion of phy-
non, which are ofren greenstick in nature. True acure fracrures seal fractures (83). A true Salrer-Harris rype IV injury tnrough
involving only the anaromic capitellum are rare in the immature the ossific nucleus of rhe lateral condyle is rare. AJthough lateral
skeleron. condylar fractures are similar to Salter-Harris type II and IV
The diagnosis of lateral condylar physeal injuries may be less fractures, rrearmenr guidelines follow those of a type IV injury:
obvious both clinically and radiographically than that of supra- open reduction and inrernal fixation of displaced inrraarricular
condylar fracrures, especially if the fracture is minimaJJy dis- fractures, wirh the porential for mild growrh disrurbance of rhe
placed. The incidence of a funcrional loss of range of motion distal humeral physis. There is no conract between the ossifica-
in the elbow is much greater with fractures of the lateral condylar tion center of the epiphysis and the exposed bone in the meraph-
physis because rhe fracture line ofren exrends inro rhe articular yseal f[·agment.
surface. A difficult supracondylar fracture with cubitus varus, The Milch c1assiflcarion is based on rhe locarion of rhe frac-
barring the immediate neurovascular complications, is likely ro ture line through the epiphysis of the distal humerus.
resulr in a surgically correctable cosmetic deformity with an es-
sentially normal range of morion in the elbow. A poorly rreated Milch Type I. In rhis type, rhe fracture line originares in the
lateral condylar physeal injulY, however, is likely ro result in a metaphysis, crosses rhe physis more or less obliquely, and linaJJy
signi flcant loss of range of motion that is nor as responsive ro rraverses rhe ossiflcarion cenrer of rhe lateral condylar epiphysis
surgical correction. The complications of supracondylar frac- ro exir in rhe area of rhe capirulorrochlear groove (Fig, 15-1).
tures are usually evident in the immediate postinjury period. There can be conrau between the bony ossification cenrer of
The poor outcome of a lateral condylar physeal fracture may rhe epiphysjs and rhe bony metaphysis, leading to growrh arresr
not be obvious until months or even years later. IppolitO et al. due ro an osseous bridge~Cispecially in very young children. For-
(54) evaluated 49 individuals wirh humeral condylar fractures tunately, less tha~ 20% ,f rhe g~Lthehumerus~ccurs
18 ro 45 years after the injury, Twenty fractures with displace- rh rou h the disra \, 1!JJlfr-h1 physis.
--~
ment of 2 ro 10 mm wirh no tilting of the osreochondral frag-
menr had been treated without reduction and 16 fractures wirh
Milch Type II. This more common fracture line originares in
the posterolateral metaphysis, where there is a fragment of vari-
marked displacemenr and rilring of the Fragment had been
able size (Fig. ] 5-2). The fracture then usually courses within
rre:ued surgically; all 36 had good resulrs. AJI 13 parients (I'eared
the physis down to rhe deprhs of the trochlea. The fracture line
operatively or nonoperariveJy for old, displaced fractures had
does nor traverse rhe lareral condylar epiphysis or ossi f1carion
poor results, Nonunion developed in 4 and osreonecrosis in 6.
cen ter. The ossification center of the lareral condyle extends to
Arthrosis of rhe elbow was found in fractures complicared by
the lareral crisra of the trochlea, Thus, rhe terminal porrion of
osteonecrosis and nonunion, and in old fractures when rhe hu-
the Fracrure line courses through rhe physeal cartilage rhat lies
meral condyle was resecred, bur ir was nor observed in uncompli-
between the ossification centers of the lateral condyle and rhe
ca red fracrures.
medial condyle. In rhe age group in which mosr of rhese fractures
occur, there is lirtle ossification of rhe medial crista of the
Pathology
trochlea.
Early Descriptions Because rhe fracrure line srans in rhe mcr:tphysis and rhen
Milch (66,67) defined rhe fracrure rhar exited through rhe troch- courses along rhe physeal cartilage, ir has some of rhe ch:tracteris-
leocapirellar groove as a rype I (Milch type I). Tne type II (Milch rics oFborh rype II and IV injuries according to the Salter-Hanis
 Chapter 15: The ELbow 627

A B
FIGURE 15-1. A: Injury film of a 7-year-old with an undisplaced fracture of the lateral condyle (small
arrows). Attention was drawn to the location of the fracture because of extensive soft tissue swelling
on the lateral aspect (white arrows). B: Because of the extensive soft tissue injury, there was little intrinsic
stability, allowing the fracture to become displaced at 7 days (arrows).

classiflcarion. This fracture classiflcarion is debarable, because Stage of Displacement

the fracrure exirs the joinr in the nor-yet-ossifled cartilage of the Displacement has been described as occurring in three stages
trochlea. (Fig. 15-3) (55,61,99). In the firsr srage, the fracture is relatively
Mirsky, Karas, and Weiner (71) compared intraoperative undisplaced and the articular surface is intact (Fig. 15-3A and
findings ro preoperative radiographic classification in 25 dis- B). Because rhe trochlea is inract, there is no lateral shift: of the
placed fractures of the lateral condyle and found that in 13 olecranon.
(52%) the Milch classification did not correlate wirh intraopera- In rhe second stage, the fracture ex rends complerely through
tive findings. Eight of 17 fractures (47%) classified preopera- the articulal· surface (Fig. 15-3C and D). This ailows the proxi-
tively as Milch rype [ fraCtures were unstable, and 5 of 8 fractures mal fragmenr ro become more displaced and can allow lateral
classified preoperatively as Milch rype II fractures were extraar- displacemenr of the olecranon. In the thitd stage, the condylar
ricular, extending across the distal humeral physis medially. Mir- fragment is rotated and totally displaced larerally and proximalJy,
sky et al. idenrifled three distinct fracture patterns: 9 fractures which allows translocation of both rhe olecranon and the radial
exited the disral humeral epiphysis just medial ro the capirelJum, head (Fig. 15-3£ and F)
11 exited through the trochlear epiphysis, and 5 extended across Badelon et al. (14) modified the descriprion of stage [ dis-
the physis medially. No fracture appeared to traverse the ossified placemenr ro include fractures with less than 2 mm of displace-
portion of the capitellum (Milch rype 1). menr seen on rhe anreroposrerior or lateral radiograph only or
seen on both views.

Soft Tissue Injuries

The fracture line usually begins in rhe posterolateral metaphysis,
witl1 a soft tissue tear in the area between the origins of the
exrensor carpi radialis longus and the brachioradialis muscle.
The :~r carpi la!ii.i1~gus and brevis muscles l~n
arw.ched rbe..f1:ee...ili.sral..fmg.m· nr alan with [he larcr~collar­
eralligal~th.c..cl!Low.If there is much displacement, both
the anterior and posterior aspects of the elbow capsule usually
are rorn.
A B This sofr tissue injUly, however, is usually localized to the
FIGURE 15-2. Physeal fractures of the latera,l condyle. A: Physeal injury lareral side and may help identify a minimally displaced fracture.
(Milch type II) through the non ossified trochlea. B: Physeal injury (Milch More exrensive soft rissue swelling ar rhe fracture site may indi-
type I) through the ossific nucleus of the lateral condyle. (Redrawn from
Milch HE. Fractures and fracture-dislocations of the humeral condyles. cate more severe sofr rissue injury, which may be an indicarion
J Trauma 1964;4:592-607; with permission.) that the fraCture is prone ro late displacement.
628 Upper Extremity

E F
FIGURE 15-3. Stages of displacement. A and B: Stage I displacement-articular surface intact. C and
D: Stage II displacement-articular surface disrupted. E and F: Stage III displacement-fragment rotated.
(A, C, and E: Reprinted from Jakob R, Fowles N, Rang M, et al. Observations concerning fractures of
the lateral humeral condyle in children. J Bone Joint Surg (Br/1975;57 :430-436; with permission.)
 Chapter 15: The ELbow 629

Displacement of the Fracture and Elbow Joint rarely is the case. The posterolateral instability of the elbow
usually is a result of the injury, not a cause of it (80).
The degree of displacemenc varies according ro the magnitude
of the force applied and whether or not the cartilaginous hinge
Mechanism of Injury
of the articular surface remains intact. If the articular surface is
intact, the resultant displacement of the condylar fragment is As Heyl (49) has stated, the local biomechanics of the distal
simply a lateral tilt hinging on the intact medial articular surface. humerus must be different in children because of the rarity of
If the fracture is complete, the fragmenc can be rotated and this injury in adults. Two mechanisms have been suggested:
displaced varying degrees; in the most severe fractures almost "push off' or "pull off."
0
the full 180 so thar the lateral condylar articular surface opposes The pull off or avulsion theory has more advocates (13,15,
the denuded metaphyseal fracture surface. Wilson (101) showed 55,79,95). In early srudies (13,95) this injury was consistently
that in addition ro this coronal rotation of the distal fragment, produced in young cadavers bya~~the forearm with the
rotation also can occur in the horizontal plane. The lateral mar- elbow extended and the forearm supinated. The results of these
gin is carried posteriorly, and the medial portion of the distal studies were confirmed by the work of Jakob and Fowles (55).
fragmenc rotates anteriorly. Some of Stimson's (95) work Strengthens the push off theory.
In his cadaver studies, he produced the injury by applying a
Pattern Determines Stability sharp blow ro the palm when the elbow was flexed (15,29,34,
42). Others who support the push off theory have speculated
Because the usual fracture line disrupts the lateral crista of the that because the forearm goes into valgus when extended, the
trochlea (Milch type II), the elbowjoint is..J.!~, creating radial head can thus push off rhe lateral condyle. Some research-
the possibility of posterolateral SUbiuxation of the proximal ra- ers have even proposed thar ir can be a resuJr of a direcr blow
dius and ulna. Thus, the forearm rotates along the coronal plane ro rhe olecranon (24,34).
into valgus, and there also may be lateral translocation of the It is likely that bOth mech.anisms can produce rh.is injuty.
lateral condyle with the radius and ulna (Fig. 15-4). This concept The more common type of [racrure, which extends to the apex
of lateral translocation is important in the late reconstruction of the trochlea, is probably a result of avulsion forces on the
of un treated fracrures. condyle, with the sharp articular surface of rhe olecranon serving
In Milch type I physeal fractures, where the fracture line to direct rhe force along the physealline inco the trochlea (Fig.
traverses the lateral condylar epiphysis, the elbow remains rea- 15- 5). When a child falls forward on the paJm with rhe elbow
sonably stable because the trochlea remains intact. Toral coronal flexed, the radial head is forced againsr rhe capitellum and may
totation of the condylar fragment can occur with this injury. cause rhe less common Milch type I physeal fracrure that courses
The axial deformity that results is pure valgus without transloca- rhrough the capitulorrochlear notch.
rion (Fig. 15-4).
This posterolateral elbow instability with the lateral condylar Signs and Symptoms
physeal injury has led to the mistaken concept that this injury
Compared wirh the marked distortion of the elbow that occurs
is associated with a primary dislocation of the elbow (26). Such
with displaced supracondylar fractures, little disrortion of the
elbow, other than that produced by the fracture hematoma, may
be present with lateral condylar fracrures. The key ro the clinical
evaluation of this fracture is rhe locarion of so[r tissue swelling
concentrated over the lateral aspecr of the disral humerus. 5rage
I displacement may produce only local renderness at the condylar
fracture site, which may be increased by forcibly flexing the
wrist (52). Stage II or III displacement may result in some local
crepitus wirh motion of the lateral condylar fragment. The be-
nign appearance of rhe elbow wirh some stage I and II displace-
ments may accoum for rhe delay of parems seeking trearment
for a child with a minimally displaced fracture.

Radiographic Findings
The radiographic appearance varies according to the anaromic
locarion of rhe fracrure line and the stage of displacement. In
the anteroposrerior view, the meraphyseal flake may be small
and seemingly minimally displaced. The degree of displacement
can often be better appreciated on the true lareral view. In deter-
A Angulation B Angulation and
mining whether the articular hinge is intact (i.e., stage I vs. stage
FIGURE 15-4. Angular deformities. A: Milch type I fractures tend only II), the relationship of rhe proximal ulna ro the disral humerus
to angulate. B: Milch type II fractures are unstable with lateral translo- is evaluated for the presence of lareral translocation. Oblique
cation in addition to angulation. (Redrawn from Milch HE. Fractures
and fracture-dislocations of the humeral condyles. J Trauma 1964;4: views are especially helpful in patients in whom a stage I dlSpIace-
592-607; with permission.) ~ is suspecred.
630 Upper Extremity

FIGURE 15-5. The most common mechanism of

injury is believed to occur when the elbow is
forced into varus (bottom left), which, along
with the exteilSOi' muscles and lateral collateral
ligaments, applies an avulsion force to the lateral
condyle. When the fracture line extends to the
trochlear notch (bottom right), the elbow be-
comes unstable.

In a prospective study of 112 childten with nondisplaced and gested that MRI evaluation might prevem lare displacement or
minimally displaced ftactures of the lateral condyle, Finnboga- delayed union by idemifying those minimally displaced fractures
son et al. (36) identified three groups of ftactures: stable frac- that required percutaneous pin fixation tather than cast immobi-
tures, fractures with an undefinable risk, and fractures with a lization.
high risk of larer displacement. Stable fractures had no gap or A major diagnostic difficulty lies in differentiating this frac-
a small gap and did not extend all the way to the epiphyseal ture from a fracture of the entire distal humeral physis. In a
cartilage; most of these 65 fractures were in younger children young child in whom the condyle is unossified, an arthrogram
and none had later displacement. Fractures with undefinable or MRl may be helpful (Figs. 15-6 and 15-7). Potrer (76) recom-
risk of displacement were of the same type as stable fractures mended MRl with thin (1.5-2 mm) sections and appropriate
but the fracture could be clearly ob~l'I'ved extending all the way pulse sequencing ro provide differential contrasr between sub-
to the epiphyseal cartilage; displacement occurred in 6 (17%) chondral bone, cani lage, and joint fluid.
of these 35 fractures. High-risk fractures had a gap that was as In fractures of the entire distal humeral physis, the proximal
wiJe or almost as wide laterally as medially; displacement oc- radius and ulna usually are displaced posteromedially (Fig. 15-
CUlTed in 5 of 12 (42%) of these fractures. SA). The relationship of the lateral condylar ossification center
Kamegaya et al. (59) reported that magnetic resonance imag- to the proximal radius remains intact. In true fractures involving
ing (MRl) evaluation of 12 minimally displaced «2 mm on only the lateral condylar physis, the relationship of the condylar
radiography) lateral condylar fractures identified 5 fractures that ossification center to the proximal radius is lost (Fig. 15-SB).
crossed the physis inro the joint space and were unstable frac- In addition, any displacement of the proximal radius and ulna
tures. One of 5 fractures with 1-mm displacement was unstable, is more likely ro be lateral because of the loss of stability provided
and 4 of 7 with 2-mm displacemem were unstable. They sug- by the lateral crista of the distal humetus.
 Chapter 15: The Elbow 631

A B
FIGURE 15-6. Unossified lateral condyle. A: Anteroposterior view. A small ossific nucleus can barely be
seen (arrow) in the swollen lateral soft tissues. B: An arthrogram shows the defect left by the displaced
lateral condyle (open arrow). The displaced condyle is outlined in the soft tissues (solid arrow).

Methods of Treatment are suff1cienrly undisplaced that rhey can be neated by simple
immobilizarion withoLlt surgical inrervention (55,63,84). If the
Fractures involving the lateraJ condylar physis can be rreated
franure line is barely perceptible on the original radiograph
with simple immobilization alone, closed reduction and percuta-
(stage I displacement), the degree of displacement usually is min-
neous pinning, or open surgical reduction.
imal and the chance for subsequenr displacemenr is Jow (Fig.
Fractures Requiring Immobilization Only 15-9).
MinimaJly displaced fractures are srable and have considerable Badelon er aJ. (14) determined in rheir long-term study of
inrrinsic soft rissue auachments rhar prevent displacemenr of the Fracrures rreared nonoperatively thar only fractures with rype I
distal Fragment. About 40% of lateral condylar physeal Fractures displacement (i.e., the fracture line is seen on only one radio-
graphic view) can be safely treated nonoperatively. In their expe-
rience, any fracture wirh dis lac~enr, even of Jess than 2 mm,
can disp ace arer in the casr or spline Beary and Wood (18),
in a review of 57 fracrures of rJ1eIareral condyle, found rhar 2
of 24 fractures wirh srage I displacement displaced lare. Bast,
Hoffer, and Aval (16) reported a union rate of98% after nonop-
erarive rreatmenr of 95 nondisplaced or minimaJly displaced
fractures of rhe lareral humeral condyle. Their crireria for nonop-
erative rrearmenr were acure fracture (Jess rhan 24 hours at inirial
evaluarion) and displacemenr of less rhan 2 mm in rhree radio-
graphic planes (anreroposrerior, lareral, and internal oblique).
Two franures thar displaced 6 and 9 days after closed reducrion
required open reducrion and inrernal f1xarion before rhey unired
wirhour complicarions.

Late Displacement
Careful clinical examinarion is important in predining which
fracrures will displace later. The otenrial to dis lace ofren de-
pends more on rhe de ree of associared sofr rissue injury and
W'netler ne aniCLI ar carrilage of rhe trochlea is inran, rarher
rhan on rhe amounr of inirial displacemene Considerable sofr
rissue swelling on rhe lateraJ aspen of the disral humerus, which
can be appreciared borh clinically and on radiographs, should
alen rhe physician to rhe facr rhar the fracture may be unstable
FIGURE 15-7. Arthrogram of stage I fracture of the lateral condyle
(large arrows). Articular surface is intact with no displacement (small and has rhe potential to displace. If crepitus berween the frag-
arrows). ments is derecred wirh morion of rhe forearm or elbow, signifl-
632 Upper Extremity

A B
FIGURE 15·8. A: Total distal humeral physeal fracture in a 2-year-old. The lateral condyle (closed arrow)
has remained in line with the proximal radius. The proximal radius, ulna, and lateral condyle have all
shifted medially (open arrow). B: Displaced fracture of the lateral condyle in a 2-year-old. The relation-
ship of the lateral condyle (closed arrow) to the proximal radius is lost. Both the proximal radius and
ulna (open arrow) have shifted slightly laterally.

cant loss of soft tissue attachments and a potentially unstable placing pins across the fracture. In some fractures of the lateral
fracture should be suspected (17). condylar physis, simple immobilization is all that is necessary.
In those with moderate displacement, confirmation of fracture
CriticaJ VaJue stabiliry by stress testing and arthrography may precede percuta-
Undisplaced fractures usually can be treated with simple immo- neous pin fixation. Mintzer et al. (69) reported good results aftn
bilization with good results. Speed and Macey (93) reported percutaneous pin fixation of 12 lateral condylar fractures with
uniformly excellent results both anatomically and functionally displacement of more than 2 mm. They believed this method
in patients with undisplaced fractures, none of whom had any is appropriate for selected fraoures with more than 2 mm of
abnormalities of growth or premature physeaJ fusion. Simple displacement and an arduographically demonstrated congruent
immobilization of nondisplaced or minimally displaced «2 joint surface. If a satisfactory reduction cannot be obtained, then
mm) fractures in a sling, collar and cuff, or posterior splint reduction should be achieved and maintained by open reduction
appears adequate (93,99,103). Close follow-up and repeat radio- and internal fixation.
graphs to detect any late displacement are mandatory if this
method is used.
Fractures Requiring Open Reduction
Because of the high incidence of poor functional and cosmetic
Closed Reduction and Percutaneous Pinning
results with closed reduction methods, open reduction has be-
Several techniques have been described for initial reducrion, with
come the most widely advocated method for unstable fractures
the recommended elbow position ranging from hyperflcxion to
wirh stage II displacement and fractures with stage III displace-
full extension; however, it appears from clinical experience (425)
and experimental studies that reduction is best achieved with ment (15,19-22,25,26,30,33,34,47,53,55,56,63,64,77,79,
the hrearm supinated and the elbow extended. I'lacing a varus 86,87,89,90,96,99,100, I 02, 103). About 60% of all fractures in-
stress on the extended elbow allows further room for manipula- volving the lateral condylar physis require reduction and internal
tion of the fragment. Unfortunately, it is difficult to maintain fixation (55,63,84).
reduction of a displaced lateral condylar fracture with closed There is almost uniform agreement about the need for open
techniques, and closed reduction is not recommended for treat- reduction of displaced fracrures of the lateral condylar physis.
ment of type 1Il displaced lateral condylar fractures. It has be- Most investigators recommend fixation with smooth Kirschner
come popular to reduce minimally displaced fractures initially by wires in children or screws in adolescents nearing skeletal matu-
closed manipulation, and then stabilize them by percutaneously ri ry.
 Chapter J5: The Elbow 633

A B

FIGURE 15-9. Stage I fracture of the lateral condyle. A: An-

teroposterior radiograph shows l-mm fracture line. B: lat-
eral view shows 2 mm of displacement with posterolateral
Thurston-Holland fragment. C and D: Anteroposterior and
lateral radiographs 4 weeks later show healed fracture with
c callus formation.
634 Upper Extremity

Pin and Screw Fixation other 3 to 5 days. If rhe radiographs again show no displacement,
then a long arm cast is applied and is worn for about 3 weeks,
Smoorh pins are rhe mosr frequenrly used merhod of flxarion
or until fraCtUre union is apparent.
of rhe fragmenr (18,23,34,40,42,53,55,63,79,84,90,93:99.102,
In some fraerures wirh more than rhe allowable 2 mm of
103). Blounr er al. (19) believed rhar ar leasr twO pms were
displacement (rype II injury), rhe fraerure pauern is such rhat
necessalY ro prevenr rorarion. The passage of a smoorh wire
rhe articular canilage appears intact. If rhere is any quesrion
rhrough rhe physis does nor resulr in any growrh dlsrurbance
abour rhe srability at rhe rime of rhe fractUre, the exrremity
(84,93). This is of nore because only 20% of rhe growrh of rhe
should be examined with the patient under general anesthesia.
humerus occurs rhrough rhe disral humeral physis. 1r also ap-
Gentle varus stress views with the forearm supinated and rhe
pears rhar rhe wires can be placed eirher parallel or crossed in
elbow exrended should be taken ro determine jf rhe fracture
rhe disral fragmenrs.
displaces significantly. Arthrography may be performed to deter-
The ideal place for rhe pins is in rhe meraphyseal fragment.
mine rhe srability of the nonossified articular cartilage of rhe
Thev should cross ar the lareral aspecr of rhe meraphysis and
trochlea.
dive;'cre as much as possible ro enhance rhe srability of flxarion.
If th;re is only a smaJl meraphyseal fragmenr, rhe pins can be
placed across rhe physis wi thoU[ concern. Percutaneous Pins
When adequare reduction and inrernal flxarion are performed
For fractures with stage II displacemenr (2-4 mm), ~s srress
early (i.e., within rhe flrsr few days of rhe injury), rhe results are
views should be obtained and arrhrography performed wirh rhe
uniformly good. The key, however, is ro be sure rhar rhe reduc-
pariellt under anesthesia. If the fracture is srable, percutaneous
rion is adequare. HardJcre er aJ. (47) found rhat poor results With
pinning is indicated (Fig. 15-LO).
open reduction occurred when rhe reduction was incomplete.
Surgery alone does nor ensure a good resulr unless rhe reduction
is nearly anaromic and rhe fixation is secure. . . Open Reduction
Early surgical inrervenrion is essenrial, because organIzation
If rhe fracrure is grossly unsrable, open reduerion and internal
of the c10r wirh early fibrin developmem makes ir difflculr ro
fixarion should be performed. We prefer open reducrion and
achieve a reducrion withour extensive soft rissue dissection in
inrernal flxarion of all fracrures with srage III displacement. II'
fractures treated lare. The pins can be buried or lefr protruding
is imporrant to perform rhe open reducrion as soon as possible
rhrough rhe skin wirh no increase in rhe incidence of infecrion.
afrer rhe injury. The standard lateral Kocher approach provides
Leavin bcr pins buried requires a second operarive procedure, even
sufficient exposure of rhe fragment. Often a rear inilie aponeu-
rhough it usually can be accomplished wirh a local anesrheric.
rosis of the brachioradialis muscle lateraJly leads directly to rhe
The fracrure is usually sufficiently srable co allow pm removal
fracture sire. Exrreme care musr be taken ro avoid dissecring
by 3 ro 4 weeks and co allow rhe parienr to begin prorecred
~posterior ponion of rhe fragmenr, because this is r e
active range of motion of rhe elbow at 2 ro 3 weeks..
enrrance of the only blood vessel supplying rhe lareral condylar
Screw flxarion has been used less frequently m children, al-
epiphysis.
though it was recommended by Jeffrey in 1958: Connor and
A posrerolateral approach was recommended by Mohan,
Smith (56) used fully rhreaded Glasgow screws 10 35 patients
Hunter, and Colton (71) because of the exceJlenr exposure ir
and found limirations of 5 ro 25 degrees of extension in 9; in
provides with minimal dissection. Anorher suggested advantage
5 parienrs rhe screw backed OU[ and was found loose. Sharma
is rhe improved cosmeric results by more posterior placement
er aJ. (85) reported painless, full range of elbow monon In 36
of the surgical scar. Mohan er al. reported no complicarions in
of 37 children who had displaced (> 2 mm in any direction)
20 patients in whom this approach was used.
lareral condylar fracrures fIxed wirh parrially rhreaded 4-mm AO
The qualiry of the reducrion is determined by evaluating the
cancellous screws. One parienr had delayed union, with loss of
fracture line along rhe anrerior aspect of rhe articular surface.
LO degrees of elbow morion.
This can usually be determined either by direcr vision or by
digiral palpation. We prefer ro use smoorh Kirschner wires rhat
cross just medial to rhe condylar fragment to maintain the reduc-
• AUTHORS' PREFERRED METHOD
rion. The wires penerrate the skin rhrough a separate stab inCI-
\..~ OF TREATMENT
sion posrerior [() the main incision. A long arm cast is applied
wirh rhe elbow flexed 90 degrees and the forearm in neutral or
Immobilization
slight pronation. The casr and pins are removed i.n 3 weeks if
If the fracture is minimally displaced on rhe radiograph (i.e., rhere is adequate healing on radiographs. Early active monon IS
the metaphyseal fragmenr is <2 mm from rhe proximal fragmenr srarted at that time. If necessary, pin removal can be delayed 1
on ameroposrerior and lareral views) and rhe clinical signs also to 2 weeks to aUow further healing in older children.
indicare there is reasonable sofr rissue imegrity, we simply immo-
bilize rhe elbow in a posterior splint with rhe forearm in neurral
Technique of Open Reduction and Internal Fixation
rotation and the elbow flexed 90 degrees (Fig. 15-9). Radio-
of Fractures of the Lateral Humeral Condyle
graphs are taken within rhe first 3 to 5 days after the fracture
with the splinr removed and the elbow comfortably extended. The elbow is exposed through a 5- to 6-cm lareraJ approach,
If there is no displacemellt, the radiographs are repeated in an- placing two rhirds of rhe incision above rhe joint and one third
 Chapter 15: The Elbow 635

A B
FIGURE 15-10. Stage II fracture of the lateral condyle. A: Anteroposterior radiograph shows 4 mm of
displacement of the metaphyseal segment; however, the fracture was stable by stress examination and
arthrography. B: Four weeks after percutaneous pinning, the fracture is healed.

distaJ (Fig. 15-11). In the interval between the braclljoradialis the antecubital structures. The trochlea and the more medial
and the triceps, the dissection is c~ied down to the late~ point of entry of the condylar fracture are inspected. The dis-
humeraJ condYle. The anterior surfaces of the joint are exposed placement and the size of the fragment are always greater than
by separaring the fibers of the common extensor muscle mass. is apparent on the radiographs because much of the fragment
Soft tissue detachment is limited to only that necessary to expose is cartilaginous. The fragment usually is rotated as well as dis-
rhe fragment, the fractute, and the joint; the posterior soft tissues placed. The joint is irrigated to temove blood clots and debris,
are left intact. The anterior joint surface is exposed by rerracting the articular surface and the metaphyseal fragment are reduced
accurately, and the reduction is confirmed by observing the artic-
ular surface, particularly at the trochlear ridge. The posirion is
held with a small tenaculum, bone holder, or (Owe I clip. When
a large metaphyseal fragment is ptesent, twO smooth Kirschner
wires are inserted across it into the medial portion of the metaph-
ysis, When the epiphyseal portion is small, as is more common,
two smooth Kirschner wires are inserted through the condyle,
across the physis, and into the humeral mecaphysis, penerrating
che medial correx of the humerus. The wires are directed 45 to
60 degrees; the reduccion and che posicion of che internal fixacion
are checked by anreroposcerior and laceraJ radiographs before
closing the wound. The ends of the wires are cut off beneath
the skin but are left long enough to allow easy removal. The
arm is placed in a posterior plaster splinr with the elbow Aexed
70 co 90 degrees.
The splint is worn for 2 to 3 weeks after surgery. The pins
can be removed at 3 weeks if union is progressing. Gende active
motion of the elbow is then usually resumed and conrinued
until full range of motion returns.
FIGURE 15-11. Lateral approach for open reduction and internal fixa-
tion of a lateral humeral condylar fracture of the left elbow. The ap- Delayed Union and Nonunion
proach is made through the brachioradialis-triceps interval, an anterior
retractor is used to expose the joint surfaces, and the fracture is reduced If sophisticated surgicaJ treatmenr is unavailable, these fractures
and pinned percutaneously posterior to the incision. may go unrreated or unrecognized for a prolonged period. Even
636 Upper Extremity

in modern medicaJ settings, elbow injuries may be treated as for surgical treatment as a nonunion rather than a simpJe delayed
"sprains," and the diagnosis of a displaced IateraJ condylar Frac- union.
ture is not made. Thus, patients oFten present months or even Flynn (37-39) recommended long-term immobilization For
years later with a nonunited or maJunited fracture fragment. minimally displaced fractures with delayed union. He Found that
70% of minimally displaced fractures had united by 12 weeks.
Delayed Union JefFrey (56) recommended screw fixation with bone grafting.
Delayed union, in contrast to nonunion or malunion, occurs in Hardacre et aJ. (47), however, found that minimally displaced
a fracture in which the Fracture Fragments are in satisfactory fractures with delayed union ultimately united if there was no
position but union of the lateral condylar fragment to the me- significant displacement of the condylar fragment.
taphysis is delayed. Various reasons have been suggested For de- Controversy exists as to whether elbow Funccion can be im-
layed union of lateral condylar Fractures. Flynn and Richards proved by a late open reduction and internal fixation of the
(37) speculated that it was caused by poor circulation to the fracture fragment. Delayed open reduction has been complicated
metaphyseaJ Fragment. Hardacre and colleagues (47) believed by osteonecrosis and further loss of elbow motion. Speed and
that bathing of the fracture site by articular fluid inhibited fibrin Macey (93) were among the flrsr investigators to question
formation and subsequent callus formation. Probably a combi- whether patients treated with late surgery did better than those
nation of these twO factors, in addition to the constan.t ten.sion nor treated. In parients with malunion who were creared late,
forces exerted by the muscle arising From the condylar fragment, they found a high incidence of poor results due to "epiphyseal
is responsible for delayed union. changes" that probably represented osteonecrosis. There have
This complication is most common in patients treated non- been many subsequent reports of osteonecrosis occurring after
operatively. The aggressiveness of treatment is determined by late open reduction. The high incidence of osteonecrosis of the
the symptoms and clinical examination. The fragment usually fragment is believed to be due to the extensive sofr tissue dissec-
is stable during clinical examination, the elbow is nontender, tion necessaty to replace rhe Fragment. Bohler (21), on the other
and the range of elbow motion increases progressively. On ra- hand, had good results in his patients with delayed rreatment.
diography, the position of the fragment remains unchanged. He avoided extensive soft tissue dissection by approaching the
With time, these fractures usually heaJ (Fig. 15-12). Lateral spur fragmenr transarricularly after performing an osteoromy of the
formation or cubitus varus is relatively common with these frac- olecranon.
tures. The need for further treatment depends on the presence The key to preventing osteonecrosis is [Q recognize the course
of significant symptoms or further displacement that may dis- of the blood supply [Q the lateral condyle. Only a smaJl ponion
rupt the join.t surface and cause functionaJ impairment. If neither of the condyle is extraanicular. In his studies, Haraldsson (46)
of these conditions is present, the radiographic persistence of found that the vessels thar supply the lateral condylar epiphysis
the fracture line requires only follow-up observation. If there is penerrate rhe condyle in a smaJl postetior nonarticulat area (Fig.
any question as to the integrity of the joint surface, an arthro- 15-13).
gram may help determine any loss of continuity and the need Jakob and Fowles (55) reponed thar parients treated later

A B
FIGURE 15-12. Delayed union and cubitus varus. A: Stage III lateral condylar fracture in a 7-year-old
boy was treated in a cast. B: Seven months later, delayed union with malunion of the fracture and
cubitus varus deformity were present.
 Chapter /5: The Elbow 637

that there was absolutely no bony continuiry berl'veen the distal

humerus and the condylar fragment. True nonunion with signif-
icant deform ity is rare because it is usually the result of nontreat-
menr of a displaced fracture of the lateral condylar physis 09,
64,84).
True nonunion occurs in patients with progressive displace-
ment of the fragment. The mobile fragment can be palpated,
or the patient has weakness or pain in the elbow. According to
the criteria of Flynn et al. (39), if the fracture has not united
by 12 weeks, it is classified as a nonunion.
Nonunion can occur with or without angular deformiry.
Many patients with nonunions and minimal displacement of
the fragment have no angulation and remain relatively asymp-
tomatic for normal activities (Fig. 15-13). Others have weakness
or symproms when the arm is used for high-performance activi-
ties. Because they are not significantly displaced, these fractures
can often be stabilized with minimal exrraanicular dissection
using a combination of screw fixation and a laterally placed bone
graft.
Nonunion with subsequent displacement of the fragment is
more common arrer unsrable fractures with srage II and III dis-
placement. If the fragmenr becomes free, it tends to migrate
proximally with a subsequenr valgus deformiry of the elbow.
Nonunion can lead to a cubitus valgus deformiry, which in turn
is associated with the developmenr of a tardy ulnar nerve palsy.
Nonunion seems to occur when rhe distal fragmenr is dis-
placed enough to allow rhe cartilaginous articular surface of rhe
condylar fragmenr to oppose the bony surface of the humeral
metaphysis. In such a situation, union is impossible.
FIGURE 15-13. Asymptomatic nonunion of a lateral condyle in a 19- Patients wjth established nonunion lose some range of mo-
year-old military recruit. Because the patient had a completely normal tion bur still function well. Smith (91) reponed an 85-year fol-
and asymptomatic range of motion in his nondominant extremity, op-
erative stabilization was not thought to be necessary.
low-up of a patienr wirh a nonunion, cubirus valgus, and mild
ulnar neuropathy. Despite these complications, rhe patienr was
a musician, playing the French horn for over 35 years. Kalenak
(58) reported a similar 50-year follow-up of nonunion of rhe
lateral condyle in a 74-year-old laborer who had minimal symp-
than 3 weeks after the fracrure did no belTer than those who roms. Orher than rhe secondary effecrs of a rardy ulnar nerve
received no treatment at all. They found that early callus and palsy, rhe functional difficulties caused by an established non-
fibrous tissue made it extremely difficult ro obtain a satisfactory union are not severe (55,72,79). This has led many investigators
open reduction without performing considerable soft tissue dis- ro recommend no rreatmenr at all or no rreatmenr unril rhe
section. AJj their patients treateJ after 3 weeks lost range of patienr has achieved full skeletal growth for an established non-
motion, the average being at least 34 degrees, and osteonecrosis, union elbow deformity (18,20,47,55). Flynn and Richards (37),
premarure physeaJ closure, and valgus deformity were common. however, reported successful treatmenr of nonunion 9 months
In patients who received no treatmellt, valgus deformity due ro ro 3 years afrer fracture and strongly advised early surgery for
nonunion and malunion was frequem, bur no osteonecrosis of established nonunion when rhe condylar fragment is in "good
the lateral condylar epiphysis occurred. They recommended that position" in a child with open physes.
no open reduction be performed for fractures older than 3 weeks, The most common sequela of nonunion with displacement
bue that early ulnar nerve transposition be performed to elimi- is rhe developmenr of a progressive cubitus valgus deformity.
nate the possibility of late ulnar nerve symproms that occur with The fragment migrates both proximally and laterally, giving not
cubitus valgus deformity after nonunion. Dhillon et al. (32) only an angular deformiry but also lateral translocarion of the
and Zionts and Stolz (104) also reported that osteonecrosis was proximal radius and ulna (Fig. 15-14). Milch (67) nored thar
frequent after late open reduction and recommended no treat- lareral translocation is not as likely to develop in rhe more lateral
ment for these fractures. rype of these fractures (Milch type I) because the lateral crisra
of the trochlea is inract (Fig. 15-] 5).
Nonunion Surgical rreatmenr of the nonunion deformiry of the larcral
In 1932, Cooper (28) drew ,memion ro the development of condylar Fragment is difficulr and requires correction of two
nonunion after lateral humeral condylar fractures when he de- problems. First, articular cartilage may be opposing the disral
scribed his findings in two cadaver specimens. He pointed out humeral metaphysis, and union seldom can be obtained withour
638 Upper Extremity

A B
FIGURE 15-14. A: A 10-year-old boy with cubitus valgus resulting from a fracture of the lateral condylar
physis with nonunion. B: Nonunion with cubitus valgus. Radiograph showing both angulation and trans-
location secondary to nonunion of the condylar fragment.

mobiljzarion of rhe fragments and applicarjon of an inrernal

compressive device. The second problem is correction of rhe
angular deformity. In a Milch lype I fracrure panel'll, correcrion
of the angularion may require only a simple closing wedge oste-
oramy (Fig. 15-1 G). Correction of the angular deformiry in a
Milch rype If fracrure partei'll may involve not only correcrion

FIGURE 15-16. In the Milch type I fracture pattern, there is only an

FIGURE 15-15. Nonunion without translocation. Milch type I fracture angular deformity that can be easily corrected with a closing wedge
pattern. Despite nonunion, elbow stability was maintained because the osteotomy. (Redrawn from Milch HE. Fractures and fracture-disloc-
lateral crista of the trochlea had remained intact (arrow). Valgus angu- ations of the humeral condyles. J Trauma 1964;4:592-607; with permis-
lation also developed. sion.)
 Chapter /5: The ELboUJ 639

of the angulation, but also translocHion of the distal fragment 2. Displacement of less than I cm from the joint surface
back ro its original linear alignment. Achieving solid fixation 3. An open, viable lareral condylar physis
with this type of osteoromy is difficult without using appropriate
imernal fixation. Often the deformity is corrected, but because
It also is helpful to distinguish becween three distincr clinical
sicuarions. FirsI', for an esrablished nonunion wirh a large me-
of the extensive soft rissue dissection required, the patient loses
taphyseal fragmenr, minimal migration, and an open lareral con-
range of elbow motion posroperatively. ]al<ob and Fowles (55)
dylar physis, we recommend modified open reduction, screw
poinred out that even with correction of the deformity, tardy
fixarion, and a law'al extraarticular iliac cresr bone grafe This
ulnar nerve paralysis can still develop because it is trapped in
technique is markedly different from rhe surgical trearment of
the cubital tunnel. They recommended simply transposing the
an acure lareral condylar fracrure. The meraphyseal fragment of
ulnar nerve and not treating the deformity.
rhe lareral condyle and rhe disral humeral meraphysis are ex-
Shimada et al. (88) reported excellent or good results in 15
posed, bur no arrempr is made to realign rhe articuJar surface.
of 16 patients at an average follow-up of 11 years after osteo-
Intraarticular dissecrion should be avoided to help prevent any
synrhesis for nonunion of fractures of the lareral humeral con-
further loss of elbow morion. The metaphyseal fragments are
dyle. The one patient with a poor resulr had evidence of os-
debrided by gentle removal of any interposed fibrous tissue. The
teonecrosis of the fragment. The average interval becween injury
lareral condylar fragment usually can be moved distally a small
and osreosynthesis was 5 years (range 5 monrhs to 10 yea.rs).
disrance. The meraphyseal fragments are firmly opposed, and a
Presenting symptOms were elbow pain (n = 7), apprehension
cancellous or conical screw is used to fix rhe fragments wirh
(n = 9), cubitus valgus deformity (n = 6), limitation of morion
inrerfragmentary compression. Iliac cresr bone grafr may be
(n = 3), and dysfuncrion of rhe ulnar nerve (n = 4). Osseous
placed becween the meraphyseal fragments and larerally. The
union was obtained after the inirial operation in 13 of rhe 16
elbow is immobilized in 80 to 90 degrees of flexion for 3 to 4
patients. Of the 3 patients with persistent nonunions, 2 had
weeks (Fig. 15-17).
union afrer a second osreosynrhesis wirh bone-grafring and rhe
Second, in patients with a nonunion who have cosmeric con-
orher, who was asympromaric, refused additional trearment. To
cerns bur no funcrional complaints, trearment is similar to thaI'
prevent progression of cubirus valgus deformity and subsequent
for cubirus varus deformity afrer a supracondylar humeral frac-
ulnar nerve dysfuncrion, Shimada er al. (88) recommended os-
ture. ]f the parient and family desire, a supracondylar osreoromy
reosynthesis for nonunion of lateral humeral condylar fractures
may be performed (62). Rigid internal fixarion should be used
in children because union is easily achieved, rhe range of motion
to allow early motion. Rarely in an adolescent or young adulr
is maintained, rhe funcrion of the ulnar nerve usually rerurns,
wirh high funcrional demands and symptoms of instability, late
and remodeling of rhe articular surfaces can be expected. They
osreosynthesis of rhe lareral condyle may be performed.
nored rhar bone grafting is essential to bridge rhe defecr, to
Third, patients with asymptomaric nonunion, cubitus valgus
obtain congruity of rhe joint, and to promote union; damage
deformity, and symptomaric tardy ulnar nerve palsy should be
to rhe blood supply should be avoided to prevent osteonecrosis.
treared with rransposirion of the ulnar nerve.

• AUTHORS' PREFERRED METHOD

\...~ OF TREATMENT Complications
If an adequare reducrion is obrained promptly and maintained
We disringuish bervveen fracrures seen late (>7-14 days after wirh solid fixarion, results are uniformly good. ]n supracondylar
injury) and established nonunions (usually from 3 months to fracrures, an incomplete reducrion may result in a cosmeric de-
several years after injury). If we believe rhar we can obrain frac- formir;T, bur funcrional resulrs usually are good. ]n displaced
rure union wirhout loss of elbow morion and avoid osteonecrosis fractures of rhe lateral condylar physis, a marginal reducrion
of rhe lareral condyle, then we recommend surgery for selecred can resu!r in borh cosmeric deformities and funcrional loss of
panents. monon.
Trearmenr of an esrablished nonunion of a laretal humeral The complicarions rhat affect the ourcome can be classified
condylar fracture poses a difficulr dilemma. If no treatment is as eirher biologic or rechnical. Biologic problems occur as a resulr
rendered, a progressive cubirus valgus deformity occurs wirh of rhe healing process, even if a perfecr reducrion is obrained.
growrh. Patients usually are asymptOmaric except for rhose wirh These problems include spur formation wirh pseudo-cubirus
high-demand athleric or labor activiries. A mild flexion con- varus or a rrue cubirus varus. The technical problems arise usu-
rracture of rhe elbow is present, bur rhe cubitus valgus deformity ally from errors in management and result in nonunion or mal-
is more cosmetic rhan funcrional. The danger in this approach union wirh or wirhom valgus angularion, and osreonecrosis.
is failure to recognize and rreat early a rardy ulnar nerve palsy. Other technical problems can arise from rhe injury itself, includ-
]fsurgery is performed for an esrablished nonunion, the porential ing neurologic injuries and myosiris ossificans.
risks of osreonecrosis and loss of elbow morion must be carefully
considered.
LateraJ Spur Formation
We believe me crireria outlined by Flynn er al. (37,39) are
Lareral condylar spur formarion is one of rhe mos[ common
helpful in determining jf surgical rreatment is appropriare for
deformiries afrer a fracture involving the lateral condylar physis.
an esrablished nonunion:
Corron (29) believed thar it is caused by coronal rorarion of
1. A large meraphyseal fragment rhe disral fragment, which rends to displace laterally rhe 8ap of
640 Upper Extremity

A B

FIGURE 15-17. A: Established nonunion with a large me-

taphyseal fragment. Band C: After fixation with a cancel-
lous screw and bone grafting of the metaphyseal frag-
C memo

periosreum associated wirh rhe distaJ fragment. Tl1is periosteum ment. After nonoperarive rrearment, it results from the minimaJ
then produces new bone formation in the form of a spur. He displacemenr of the metaphyseal fragment and usually has a
believed that this spur formation produces no functional defor- smooth outline. In patients wirh no real change in canying angle,
mity. MayJahn and Fahey (63) found thar this occurred in at the law-al prominence of the spur may produce an appearance
least 28% of their patienrs. Wadsworth (99) agreed wirh Cotton of mild cubirus varus (pseudovarus). In patients in whom a true
thar it was of no functional importance, and he also believed cubitus varus develops, the presence of the lateral spur accen-
that rhe cosmetic effect is insignificant. tuates the varus alignment (Fig. 15-18A and B). The spur thar
The spur occurs after both Ilolloperative and operative treat- occurs after operative treatmenr has a more irregulat- oudine
 Chapter 15: The Elbow 641

A B

c D
FIGURE 15-18. Spur formation. A: Follow-up radiograph of a boy whose lateral condyle was treated
nonoperatively. The periosteal flap produced a spur on the lateral aspect of the metaphysis (arrow).
This fracture healed with a mild varus angulation as well. B: Clinically, the spur accentuated the lateral
prominence (arrow) of the elbow, which in turn accentuated the mild valgus angulation. (Reprinted
from Wilkins KE. Residuals of elbow fractures. Orthop C1in North Am 1990;21 :289-312; with permission.)
C: Considerable soft tissue dissection was performed in the process of open reduction of this lateral
condylar fracture. D: At 2 months postsurgery, there is a large irregular spur formation secondary to
periosteal new bone formation from the extensive dissection.
642 Upper Extremity

and usually is rhe result of hyperrrophic bone formation from sagjual exrension that makes the cubirus varus that occurs after
extensive dissection ar the time of open reduerion and internal supracondylar fractures such an unacceptable deformity. Some
f1xarion (Fig. 15-18C and D). When performing an open reduc- invesriga[Qrs have nored that children with cubirus varus deform-
tion, care should be taken [Q limir the aggressiveness of rhe ities have pain, decreased range of motion, epicondylitis, and
disseerion and to carefully replace rhe lareral periosreal flap of problems with SPOrtS such as sidearm pirching, swimming, judo,
rhe metaphyseal fragment. and pushups. Davids and colleagues (31) reported lateral condy-
Before rrearmenr, the parenrs should be warned that either lar fractures in six dlildren with preexisting cubirus varus de-
lateral overgrowrh wirh mild cubitus varus or lateral spur may formities from previous elbow fractures, usually supracondylar
develop, regardless of the method of rrearment. They should be humeral fractures. They concluded that posrrraumatic cubitus
raid rhar rhis mild deformity is usually nOt of cosmeric or func- varus deformity may predispose a child [Q subsequenr lateral
tional significance. If rhese problems are explained [Q the parenrs condylar fracture and should be viewed as more than jusr a
beforehand, rhey are less likely [Q be anxious and crirical of rhe cosmeric deformity. They recommended a two-srage correcrion
result should ir be less than perfect. of rhe deformity: ana[Qmic reduction and inrernal fixarion of
rhe lareral condyle, followed by valgus supracondylar osreo[Qmy
Cubitus Varus of rhe disral humerus.
Reviews of lareral condylar fracrures demonsrrare rhar a surpris-
Cubitus VaJgus
ing number heal wirh some residual cubitus varus angulation
Cubirus valgus is much less common after united lareral condylar
(34,41,48,50,60,64,73,81,82,92,97). In some series, rhe inci-
fractures than cubirus varus. It rarely has been reporred ro resulr
dence of cubirus varus is as high as 40% (41,92), and the defor-
from premature epiphysiodesis of the lateral condylar physis (50,
mity seems [Q be as frequenr afrer operarive rreatment as after
98). As wirh cubitus varus, ir is usually minimal and rarely of
nonoperative treannenr (50,81,92). The exaer cause is not com-
clinical or fuoerional significance. The more difficulr type of
plerely unders[Qod. In some insrances, ir is probably a combina-
cubitus valgus associated wirh non unions was discussed in the
rion of borh an inadequare reduerion and srimulation of growrh
preceding section 00 nonuoions.
of the lateral condylar physis from rhe fracture insulr (Fig. 15-
19) (82,92).
Technical Problems
Rarely is the cubirus varus deformity severe enough [Q cause
concern or require further rrearment. This is probably because Nonunion/Delayed Union
ir is a pure coronal varus angularion and does nor have rhe The mosr common rechnical problem is oonunion, usuaJly due
horizonral anterior rotarion of the lateral condyle along wirh rhe ro inadequate treatment. Management of this problem was dis-

A B
FIGURE 15-19. True varus. A: The injury film with a minimally displaced fracture (arrow). This 5-year-
old child was treated with simple immobilization until the fracture was healed. B: Five years later, the
patient had a persistent cubitus varus (arrow) that remains clinically apparent. The carrying angle of
the uninjured right elbow measures 5 degrees of valgus; the injured elbow has 10 degrees of varus.
(Reprinted from Wilkins KE. Residuals of elbow trauma in children. Orthop Clin North Am 1990;
21289-312; with permission.)
 Chapter J5: The ELbo1/) 643

cussed in the previous section dealing with treatmenr of non- Neurologic Complications
unions. Delayed union was also discussed in that section.
The neurologic complications can be divided into t"vo categories:
acute nerve problems at the time of the injury and delayed neu-
Fishtail Deformity ropathy involving the ulnar nerve (the so-called tardy ulnar nerve
Two types of fishtail deformity of the distal humerus may occur. palsy).
The first, a sharp-angled wedge, commonly occurs afrer fractures
of the lateral condyle (Fig. 15-20). This type is believed to be Acute Nerve Injuries
caused by persistence of a gap between the lateral condylar physis ReportS of acme nerve injuries associated with this injuty are
ossification center and the medial ossification of the trochlea rare. Smith and Joyce (89) reponed two patients with posterior
(98,102). Because of this gap, the lateral crista of the trochlea interosseous nerve injury after open reductions of the lateral
condylar fragment, both of whom recovered spontaneously.
may be underdeveloped, and this may represent a small "bony
McDonnell and Wilson (64) reported a transienr radial nerve
bar" in tbe distal humeral physis (48). Rutherford (81) found
paralysis after an aCllle injury.
tbat this type of deformity occurred only in fractures that were
Friedman and Smith (43) reponed a delayed radial nerve
inadequately reduced. Despite some reportS of loss of elbow
laceration from the tip of the screw that was used to stabilize a
motion with this type of fishtail deformity (99), most investiga-
lateral condylar fracture 26 years earlier. This occurred when
tors (14,18,32,41) have not found this type of radiographic de-
the patient sustained a hyperextension injUlY to the elbow.
formity to produce any functional deficiency.
The second type of fisbtail deformity is a gentler smootb Tardy Ulnar Nerve Palsy
curve. It is usually believed to be associated with osteonecrosis Tardy ulnar nerve palsy as a late complication of fractures of
of the lateral pan of tbe medial crista of the trochlea (74). The the lateral condylar physis is well known. One of the earliesr
mechanisms of the development of tbis type of deformity are and most complete studies of this problem in the United States
discussed in the section on osteonecrosis of tbe trochlea. was conducted by Miller (68) in 1924. Forty-seven percenr of
his patients with tardy ulnar nerve palsy had fractures of the
lateral condylar physis as a child. The onset of the symptoms
varied from 30 to 40 years. Subsequently, repons by numerous
other investigators confirmed the frequency of this complication
after the development of cubitus valgus from malunion or non-
union of fractures of the lateral condylar pbysis (27,35,45,57,
(5). The symptoms are usually gradual in onset. Motor loss
occurs first, with sensory changes developing somewhat later
(27,45). [n Gay and Love's series (45) of 100 patients, the aver-
age interval of onser was 22 years.
Various methods of treatment have been advocared, ranging
from anterior transposition of the ulnar nerve (originally tbe
mosr commonly used procedure) to simple relief of the cubital
tunnel. In 1972, Wadsworth (99) lisred nine operative proce-
dures described between 1898 and 1957 for treatment of tardy
ulnar palsy. We prefer simple subcutaneous anrerior transposi-
rion of the nerve.

Physeal Arrest
Physeal arrest may be manifest by no more than premature fu-
sion of the various secondary ossification centers to each other,
with little or no deformity. Such a situation occurs much larer
tban the original fracture. This phenomenon probably occurs
because rhe fracture srimulates rhe ossificarion centers ro grow
more rapidly and rhus they reach maturity sooner, or, rarely, it
is caused by inadvertenr dissection in rhe lateral condylar physis.
Because only 20% of humeral growth occurs in the distal physis,
physeal arrest rarely causes any significant angular or lengrh de-
formities.

Malunion
FIGURE 15-20. An angular fishtail deformity has persisted in this 14-
year-old boy who sustained a lateral condylar fracture that was treated Rarely, the fragment unites in an undesirable posirion. Cubitus
operatively 6 years previously. valgus has been reponed to occur as a result of malunion of the
644 Upper Extremity

A B
FIGURE 15·21. A: Injury film of a 7-year-old who sustained a Milch type I lateral condylar fracture. This
patient was treated with cast immobilization alone. B: Film taken 2 years later showed complete fusion
of the condylar epiphysis to the metaphysis. with the development of a "bifid" condyle.

fracrure fragmenrs (94,99). Malunion of a Milch type 1 Fracrure Myositis Ossificans

parrern can result in the development of a bifid lateral condyle
The only repon of myositis ossiflcans after lareral condylar frac-
(Fig. 15-21). No reliable operative treatment has been described
ture is rhat of Sandegard (84). In his parient, the fracture was
to reestablish rhe congruity of the articular surtaces in conelylar
associated wirh a dislocation. The myositis resolved wirh no
malunions, and they probably are besr left untreared. We have
functional residua. We have seen one patient with myositis ossift-
seen scveral patients wirh mal unions in which the lareral condyle
cans afrer a delayed open reducrion 1 week after injury. This
rotates in the coronal plane, wirh subsequenr cubirus varus defor-
patient had some residual loss of elbow extension.
mity.

Ipsilateral Injuries
Osteonecrosis
Fractures of rhe lareral condyle have been associated wirh elbow
Osteonecrosis of rhe condylar fragmenr may be J,Hrogenlc 111 dislocations (14), fracrure of rhe ulnar shaft (78), and fracrure
origin and is mosr commonly associated with the exrensive dis- of the medial epicondyle (44). Ofren an elbow dislocation is
section necessary to effect a late reduction (H. Brindley, personal misdiagnosed in a parienr wirh a lareral condylar fracture. Loss
communicarion) (47,55,64). Wilson (102), however, described of the lateral crista can make the elbow unstable and allow rhe
partial osrconecrosis in an essenrially nondisplaced fractllre of proximal radius or ulna ro rranslocate laterally. This is a part
rhe lateral condylar physis rhar had a radiographic appearance of a normal pathologic condirion associated with completely
and clinical course similar to those of osteochondritis dissecans. displaced lateral condylar tracrures. In a rrue elbow dislocation,
Osteonecrosis is rare in fracrures of me lafel'al condylar physis the proximal radius and ulna are displaced, nor only medially
that receive little or no initial treatmenr and resulr in nonunion or latel'ally but also proximally (Fig. 15-23).
(55,101).
Overly vigorous dissection of fresh fracrutes can resulr in
osteonecrosis of eirher rhe lareral condylar ossification center
Fractures of the Capitellum
(41,75) or, rarely, the metaphyseal portion of the Fragment, lead- Fractures of the capitellum involve only rhe true articular surface
ing to nonunion (Fig. 15-22). If the fracrure unites, os- of the lateral condyle. This includes, in some instances, the artic-
teonecrosis of the lateraJ condyJe reossifies over many years, ular surface of rhe lateral ni.lra of rhe trochlea. Usually rhis
much like Legg-Calve-Perthes disease in the hip. Any residual fragment comes from the anrerior portion of the distal articular
deFormity usually is relared to loss of motion. surface. There is some variation in rhe rerminology used for rhis
 Gapfe/" '5: The ELbolU 645

A B
FIGURE 15-22. Avascular necrosis developed in this child because of extensive dissection and difficulty
in obtaining a primary open reduction. A: Injury film. B: Two years later, there was extensive loss of
bone in the metaphysis and a nonunion of the condyle.

A B
FIGURE 15-23. Ipsilateral injury. A: Anteroposterior lateral radiographs of an 8-year-old boy with a
true posteromedial elbow dislocation (open arrow) and a Milch type I lateral condylar fracture. B: A
small fracture of the coronoid process of the ulna (closed arrow) confirms the primary nature of the
elbow dislocation.
646 Upper Extremity

A B

c D

FIGURE 15-24. Fracture of the capitellum. A: Osteochondral fracture of the capi-

tellum in an 8-year-old girl. Note small fleck of bone (arrow), which indicates possi-
ble osteochondral fragment. B: Single-spot lateral radiograph after double-contrast
arthrography outlines the large osteoarticular fragment in the anterior recess of
the elbow. C: Intraoperative photograph shows the size of the fracture fragment
and its origin from the lateral humeral epiphysis. D: Intraoperative photograph
after reduction of the fragment into the bed of the capitellum. E: Healed fracture
with articular congruity, restoration of cartilage space, and no avascular necrosis.
(Reprinted from Drvaric OM, Rooks MD. Case report. Anterior sleeve fracture of
E the capitellum. J Orthop Trauma 1990;4:188; with permission.)
 Chapter 15: The Elbow 647

intraarticular fracture. It was originally described as Mouchet's a rather large portion of cancellous bone of the lateral condyle.
fracture (118). Most articles in the English literature prefer the Often the lateral crista of the trochlea is also included (Fig. 15-
tetm capitellum, but occasionally the Latin term capitulum hu- 25). The second, or Kocher-Lorenz, type (114,116) is more
meri is used. In the European literature, these fractures may be of a pure articular fracture with little if any subchondral bone
described as involving the eminentia capitata. attached, and may represent a piece of articular cartilage from
an underlying osteochondritis dissecans. This type of fracwre is
Incidence rare in children (lOS).
In adults these fractures are not uncommon, but they are rare
in children. Marion and Faysse (117), in their review of 2,000
el bow fractures in children, found only one fracture of the capi- Mechanism of Injury
tellum. Since then, this fracture has been frequently reported in The most commonly accepted mechanism is that the anterior
older adolescents (110,113,117,121). Marion and Faysse (117)
articular surface of the lateral condyle is sheared off by the radial
pointed out that verified fractures of the capitellum have not
head (106,110). The presence of cubitus recurvatum or cubitus
been described in children under 12 years of age.
valgus seems to predispose the elbow to this fracture pattern.
However, there have been two reports (105,108) of so-cal led
an terior sleeve ftactures of the lateral condyles, both in 8-year-
aids (Fig. 15-24). These involved a good portion of the anterior
articular surface. However, technically they could not be classi- Diagnosis
fied as pure capitellaI' fractures because they contained nonartic- Often, swelling is minimal. Flexion is restricted by the presence
ular epicondylar and metaphyseal portions in the fragment. This of the fragment. If the fragment is large, it may be readily appar-
fracture often is difficult to diagnose because there is little ossi- ent on the lateral radiographs (Fig. 15-26). On the anteroposter-
fied tissue. It is composed mainly of pure articular surface from ior radiographs, however, the fragment may be obliterated by
the capitellum and essentially nonossified cartilage from the sec- the overlying distal metaphysis (Fig. 15-25). If the fragment is
ondary ossification center of the lateral condyle. small, oblique views may be necessary to show the fragment
(106). In younger children, arthrography or MRl may be neces-
Classification
sary to diagnose this rare Fracture. Letts et aJ. (115) recom-
Two fracture patterns have been described. The first is the more mended computed tomography (CT) to help delineate the frac-
common Hahn-Steinthal type (112,120), which usually contains ture type.

A B
FIGURE 15-25. Fracture of the capitellum in a 13-year-old girl. A: Injury film, lateral view, shows the
large capitellar fragment lying anterior and proximal to the distal humerus. Both the radiocapitellar
(solid arrow) and trochlear grooves (open arrow) are seen in the fragment. B: In the anteroposterior
view, only a faint outline of the fragment is seen (arrows).
648 Upper Extremity

A B

c D

FIGURE 15-26. Fracture of the capitellum. A: Injury film. Lat-

eral view of a 10-year-old with an isolated fracture of the capi-
tellum. The capitellar fragment can be seen lying anteriorly
(arrow). B: On the anteroposterior view, the distal outline of
the lateral condyle appears intact. The capitellar fragment is
seen lying anterior to the trochlea (arrows). C: Fixation of the
fragment was achieved by retrograde placement of pins. D:
Seven months after injury, the fragment has undergone re-
sorption, leaving a defect in the lateral condyle (arrows). E:
Three years after injury, at the end of skeletal growth, the
defect has enlarged. The radial head has migrated proximally
into the defect. Elbow motion is greatly restricted. (Courtesy
E of Jack Earle, M.D.)
 Chapter 15: The Elbow 649

Associated Injuries Reattachment of the Fragment

If the fragments are rea([ached, stability of the fracrure is pro-
Because the mechanism is postulated ro be a pushing off of the
vided by wires or screws inserted through the posterior surface
capitellum by the radial head, it stands ro reason that there may
of the lateral condyle. The investigarors who have advocated this
be an associated radial head or neck fracture (113). In Palmer's
procedure (489,491,494) have almost equally good results with
(119) large series, including both children and adults, 31 % had
reattachment. The major problems with reattachment are associ-
associated injuries of the proximal radius.
ated with osteonecrosis of the reattached fragmenr. Letts et al.
(115) reported satisfactory results wirh fixation of five capitellar
fracrures with Kirschner wires (three fractures), Herbert screws
Treatment (one fracture), and cannulared screw (one fracture). An advan-
Excision of the fragment and open reduction and reattachment tage of screw fixation is that it does not require larer removal.
are the two most common forms of treatment. Closed reduction
is not likely ro be successful.

~ AUTHORS' PREFERRED METHOD

Excision of the Fragment ,~ OF TREATMENT
Through an open arthrotomy, the fragment can be either excised
or reattached. Most investigators (106,110,117) favor excision If the fragment is large, the fracture is acute, and an anatomic
because of its simplicity. In addition, motion and rehabilitation reduction can be achieved wirh a minimum of open manipula-
can be initiated early. [n those series in which excision and re- rion or dissection, rhen we prefer (Q reattach it wirh two small
placement were compared (110,116), excision appeared ro pro- compression or Herbert screws inserted from posrerior ro ante-
vide better results. In addition, the earlier the fragment was rior rhrough a lateral approach. Enough bone must be present
excised, the better were the results. Even when large fragments in rhe capitellaI' fragment ro engage rhe screw threads and if
were excised, joint instability did not appear to be a problem possible countersink the heads of the cancellous or Herbert
(111). In patients in whom treatment is delayed, although the screws (Fig. 15-27). However, if it is an old fracture, if rhere is
results are not as good as when treatment is provided immedi- any comminution of the fragment, or if there is little bone in
ately after injUly, improvement in function can be expected, which (Q engage the screw threads, we believe the appropriate
even with late excision (110). treatment is simply (Q excise the fragment and srart early motion.

A B
FIGURE 15-27. Postoperative anteroposterior (A) and lateral (8) radiographs of the patient seen in Fig.
15-26. There was enough bone in the fragment for it to be secured by the screw threads.
650 Upper Extremity

Complications ro show whether the fracture line courses through the secondary
ossification center of the medial condylar epiphysis or whether
The major complication is osteonecrosis of the fragment (Fig.
it enters the common physealline separating the lateral condylar
15-26). This, of course, occurs only in fractures in which the
ossification center from the medial condylar ossification center.
capitellar fragmem is retained. Posttraumatic degenerative ar-
thritis can occur whether the fragments are excised or retained. This common physealline terminates in the notch of the troch-
Many patients who are treated either operatively or nonopera- lea. The law·al crista of the trochlea is ossified from the lateral
tively can expect to lose some range of motion, but rhis is nor condylar epiphysis. Only the medial crista is ossified by the sec-
always of functional or cosmetic significance. It is important ondary ossification centers of rhe medial condylar epiphysis. We
to emphasize to the parems before rhe onset of treatment that believe that this fracture is a mirror image of the lateral condylar
complications can occur regardless of the method of treatmem. physeal injury and thus has characteristics of Salter-Harris type
IV physeal injuries (Fig. 15-28). The deformiry that develops if
the fracture is untreated is nonunion, similar ro that after lateral
Fractures Involving the Medial Condylar condylar physeal fracture, rather than physeal fusion, as occurs
Physis after a typical Salter-Harris type IV injury. The resultant defor-
Fractures involving the medial condylar physis have twO compo- mity is cubitus varus instead of the cubitus valgus deformity that
nems. The imraarticuJar component involves, in some manner, occurs with nonunion of the lateral condyle.
the trochlear articular surface. The extraarticular portion in- Characteristically, the metaphyseal fragment includes the in-
cludes the medial metaphysis and medial epicondyle. Because tact medial epicondyle along with the common flexor origin of
the fracture line extends imo th.e anicular surface of the trochlea, the muscles of rhe forearm. These flexor muscles cause the loos-
these are often called trochlear fractures. For purposes of descrip- ened fragment to rotate so that the fracture surface is facing
tion in this chapter, fractures of rhe trochlea are those that in- anteriorly and medially and the articular surface is facing poste-
clude only the articular surface.

Incidence
Fracwres involving the medial condylar physis are rare in skele-
tally immature children. In the combined series of 5,226 frac-
wres involving the distal humerus mentioned previously, only
37 fractures involved the medial condylar physis. These were all
grouped into three series (163).
Many of the large series of elbow fracture in the literature
(128,130,133,140,143) and early fracture texts (510,541) do
not mention these fractures as a separate entity. Blount (124)
described only one such fracture in his classic text. In Faysse
and Marion's (135) review of more than 2,000 fractures of the
distal humerus in children, only 10 fractures involved the medial
condylar physis. It can be safely said that the occurrence rate is
less than 1% of all elbow fractures in children.
Although it has been reported in a child as young as 2 years
of age (122), this fracture parrern is generally considered ro occur
during later childhood. A
Most series (135,145) show medial condylar fractures occur-
ring somewhat later than lateral condylar fractures. A review of
38 patients in nine series (122,127,129,132,134-136,147,150)
in which the specific ages were given showed that 37 patients
were in the age range of 8 to 14 years. Thus, this fracture seems
to occur after the ossification centers of the medial condylar
epiphysis begin to appear. However, this fracture can occur as
early as 6 months of age, before any ossification of the distal
humerus has appeared (123,131), making the diagnosis ex-
tremely difficult.
B

Surgical Anatomy and Pathology FIGURE 15·28. A: Anteroposterior radiograph of a 9-year-old boy
demonstrating the location of the ossification centers. A common phy-
Fractures of the medial condylar physis involve both intra- and seal line (arrow) separates the medial and lateral condylar physes. B:
Relationship of the ossification centers to the articular surface. The
extraarticular components. They behave as Salter-Harris type IV common physis terminates in the trochlear notch (arrow). C: Location
physeal injuries, but nor enough fractures have been described of the usual fracture line involving the medial condylar physis (arrows).
 Chapter 15: The ElbolV 651

Once rhe fragment becomes disassociated from rhe distal hu-

merus, the forearm flexor muscles produce a sagi naJ anterior
roration of the fragment.

Classification
Classification, as with fractures of rhe lareral condylar physis, is
based on the location of the fracture line and the degree of
displacement of the fracture.

Location of the Fracture Line

Milch (144) classified fractures of the medial condylar physis in
adults into two types. In type I fractures, the fracture line tra-
verses the apex of the trochlea. In type II fractures, it traverses
the capitulotrochlear groove. He believed that the origin of rhe
FIGURE 15-29. Displacement of the medial condyle. The pull of the fracrure line depended on whether the radial head, as in type
forearm flexor muscles rotates the fragment so that the fracture surface II, or the semilunar norch of the olecranon, as in type I, served
is facing anteromedially and the articular surface is posterolateral. (Re-
drawn from Chacha PB. Fractures of the medial condyle of the humerus as the impinging force for the abduction injury. Both fracture
with rotational displacement. J Bone Joint Surg [Am) 1970;52: patterns occur in children (Fig. 15-31), bur type I fractllres seem
1453-1458; with permission.) to be more common because the common physeal line, which
serves as a point of weakness, ends in (he apex of the trochlea.

Displacement of the Fracture

riorly and larerally (Fig. ] 5-29) (122,127). Rotarion of rhe frag- Kilfoyle (142) described tht-ee fracture displacement patterns
ment is especially accentuated when rhe elbow is exrended. Cha- rhat can be helpful in de(ermining appropriate (reatment (Fig.
cha (127) also nored that often the lareral aspect of rhe common 15-32). In rype I, the fracture line in the medial condylar me-
Aexor origin and the anterior capsule of the joint wete rorn and (aphysis extends down w the physis. He noted (hal' some of
the fracture surface could usually be reached through this ante- these may represent incomplete supracondylar fractures. Unless
rior opening into the joint. there is a greenstick crushing of the medial supracondylar col-
The blood supply to rhe medial epicondyle and medial me- umn, these fractures are usually of no clinical significance. In
raphysis COUl"ses exrraarricularly along with the medial flexor type II, the fracture line ex(ends inw the medial condylar physis.
muscle groups. The blood supply to rhe lareral ossificarion center The intraarricular porrion, as it is in preosseous carrilage, is often
of the medial crista of rhe rrochlea, however, must rraverse the not recogniz.ed. In this second type, the medial condylar frag-
surface of the medial condylar physis. Disruprion of these small ment usually remains undisplaced. In type III, (he condylar frag-
intraarricular vessels by the fracrure line can result in disruprion ment is both rotated and displaced.
and subsequent loss of circulation to the lareral porrion of the Bensahel (123) and Papavasiliou (145) and their co-workers
medial crista, leading to the development of a fishtail deformity. found (hat type III displacemenr fracrures, which accounted for
Because the fracture line eorets the groove of the trochlea, only 25%, were more likely w occur in older adolescenrs, and
rhe elbow joint becomes unsrable, allowing a varus deformity type I fractures were more common in younger children. These
to develop. studies also confirmed the correlation between the eype of dis-
placement and the method of rreatment.
Medial condylar physeal fractures have been reported in asso-
Mechanism of Injury ciation with greenstick fractures of the olecranon (130) and with
Two separare mechanisms can produce physeal fractures of rhe ([ue posrerolateral elbow dislocations (Fig. 15-33) (123,149).
mediaJ condyle. Ashhursr's (122) patients described falling di- Some investigawrs (123,131) found that child abuse was more
recdy on rhe point of the flexed elbow. This mechanism also common in their younger patienrs with these fractures than with
was implicated in other reports (123,127,138,147). [n rhis other elbow fractures.
mechanism, ir is speculated that the sharp edge of rhe semilunar
notch of rhe olecranon splits the rrochlea direcdy (Fig. 15-30A).
Diagnosis
In three more recent series (123,132,136), many patients sus-
rained rhis injury when they fell on their oursuetched arms. The Clinically and on radiographs, a fracture of the medial condylar
theolY is rhat this is an avulsion injury caused by a valgus suain physis is most often confused with a fracture of the medial epi-
at rhe elbow (Fig. 15-30B). Fowles and Kassab (136) reporred condyle. In both types of intra- and extraarricuJar fractures,
a patient with a concomitanr valgus greensrick fracture of rhe swelling is concenrra(ed medially, and there may be valgus insta-
olecranon associated with a fracture of the medial condylar phy- bility of (he elbow joint. [n a ([ue inrraarticular fracture, how-
sis. They believed this provided further evidence rhar rhis was ever, [here is varus instability as well. Such is usually not the case
a valgus avulsion type of injury. with an isolated exrraarricular fracture of the medial epicondyle.
652 Upper Extremity

Olecranon Olecranon

FIGURE 15-30. Medial condyle fracture mechanisms of injury. A: A direct force applied to the posterior
aspect of the elbow causes the sharp articular margin of the olecranon to wedge the medial condyle
from the distal humerus. B: Falling on the outstretched arm with the elbow extended and the wrist
dorsiflexed causes the medial condyle to be avulsed by both ligamentous and muscular forces.
 Chapter" 15: The Elbow 653

Type I

FIGURE 15-31. Medial condyle fracture patterns. Left: In the Milch

type I injury, the fracture line terminates in the trochlear notch (arrow).
Right: In the Milch type II injury, the fracture line terminates more lat-
erally in the capitulotrochlear groove (arrow). (Redrawn from Milch H.
Fractures and fracture-dislocations of the humeral condyles. J Trauma A
1964;4:592-607; with permission.)

Ulnar nerve paresrhesia may be presenr wirh borh rypes of Frac-

cures.
In older children wirh a large meraphyseal Fragmem, involve-
menr of the enrire condyle usually lS obvious on radiographs;
in younger children, in whom only the epicondyle is ossified,
fracture of the medial condylar physis may be erroneously diag-
nosed as an isolated Fracrure of the medial epicondyle (Fig. 15-
34) (129,134,136).
In differentiating these twO Fractures, it is helpFul to remem-
ber rhat medial epicondylar Fractures ofren are associared wirh
elbow dislocarions, usually posterolateral, and that elbow dislo-
carions are rare before ossificarion of the medial condylar epi-
physis begins. Wirh medial condylar physeal Fracrures, rhe elbow
tends to subluxare posreromedially (129) because of rhe loss of
trochlear stability.
Any meraphyseal ossification with the epicondylar Fragment
suggests the presence of an inuaarticular Fracture of rhe medial
B
condyle and is an indicarion for Further evaluarion. Often the
medial condyle and rhe medial epicondyle are markedly dis- FIGURE 15-33. A: Injury film of a 1O-year-old girl who sustained a type
III displaced fracture of the medial condyle associated with a posterolat-
placed as a unir (139). A positive far pad sign indicares that rhe eral elbow dislocation. B: Open reduction and Kirschner wire fixation
injuly has entered rhe elbow joint and a fracrure of rhe medial was performed using an anteromedial approach. (Courtesy of Elizabeth
condyle is likely (138). Isolated Fractures of the medial epicon- A. Szalay, M.D.)

Type I Type II

FIGURE 15-32. Kifoyle classification of displacement patterns. (Redrawn from Kifoyle RM. Fractures of
the medial condyle and epicondyle of the elbow in children. Clin Orthop 1965;41 :43-50; with permis-
sion.)
654 Upper ExtremitJI

A B

FIGURE 15-34. Missed medial condyle fracture. A: Initial

film of a 6-year-old who was originally diagnosed as having
a displaced fracture of the medial epicondyle (arrows). B:
Normal side for comparison. C: Three months later, the pa-
tient continued to have a painful elbow, and there was
ossification of the metaphysis (arrow) adjacent to the epi-
condyle. c

<.lyle are exuaarticular and usually do not have posirive fat pad proached by a posteromedial incision that allows good exposure
signs. of both the fracwre site and the ulnar nerve. Rigid fixation is
If the true location of the fracwre line is questionable in a imperative and is easily achieved with smooth Kirschner wires
younger child, arthrography or MRl of the elbow should be (Fig. 15-33) or with screws in older adolescents. Two wires are
performed. necessary because of the sagi ttal rotation forces exerted on the
fracture fragment by rhe common flexor muscles. EI Ghawabi
(132) reported frequent delayed union and nonunion in frac-
Treatment
tures that were not rigidly stabilized.
For displaced fractures, open reduction with internal fixation In KiJfoyJe's displacement type I and ][ fracture patterns,
seems to be the most popular treatment method (123,126,132, usually enough residual internal stability is preseIlt to allow the
136,141,142,145-148). The fracture fragment can be ap- fracture to be simply immobilized in a cast or posterior splint
 Chapter 15: The ElboUJ 655

(123,132,135,142,145). As with ftactures of the lateral condylar tify the landmarks accurately ror pin placement. Unless these
physis, union may be slow. In fractures treated promptly, results can be defined wjthout question, we usually proceed with an
have been satisfactory (127,134,136). Because rhere is usually open reduction through a medial approach. The posterior sur-
more displacement in older children, the results in this age group face of the condylar rragment and the medial aspect of the medial
are not as satisfactolY as those in younger ones, who tend to crista of the trochlea should be avoided in the dissection because
have [-elatively nondisplaced fractures (123). these are the sources of blood supply to the ossi fic nuclei of
The real problem lies in rractures that are discovered or seen the trochlea. Fixation with twO parallel pins should be in the
many weeks after the original injury. Fowles and Kassab (136) metaphyseal segment ir possible (Fig. 15-35). Cancellous screw
reporred poor results when the fracture was treated surgically 3 fixation can be used in adolescents near skeletal maturity.
to 4 wecks after the original injUIy. As with lateral condylar Osteonecrosis of the trochlea can occur after both operative
fractures, this was believed to be due to the extensive dissection and non operative treatment (see the following section on Com-
necessary to achieve an adequate reduction. For this reason, they plications). Thus, the parents should be warned of this possible
concluded that rractures in which the time span was greater than complication before treatment.
3 weeks after injmy should be left alone.

Complications
~ AUTHORS' PREFERRED METHOD
\..~ OF TREATMENT The major complication is failure to make the proper diagnosis.
This is especially true in younger children, in whom a medial
We usually treat type I nondisplaced fractures with simple obser- condylar rracture can be confused with a displaced fracture of
vation and a posterior splint. Follow-up radiographs at weekly the medial epicondyle (Fig. 15-34). When the diagnosis is ques-
intervals Jre taken to ensure there is no late displacement. When tionable, especially in a child with no ossification of the trochlea,
there is good callus at the metaphyseal portion of the fracture examination with anesthesia, arthrography, or MRl may be
line, the splint is removed and early active motion initiated. We helpful.
continue ro rollow the patient until there is a rull range or motion Untreated displaced fractures usually result in nonunion with
and obliteration or the fracture line. cubitus varus deformity (Fig. 15-36) (136,150). We have seen
Type II and III displaced fractures must be reduced and stabi- one nonunion arter a rracture of the medial condyle. When the
lized. Usually rhis is difficult to do by closed methods because condylar fragmenc finally ossified, the lateral edge of the rrag-
the swelling associated with this injury makes it difficult to iden- menc appeared ro extend to the capitulorrochlear groove.

A B
FIGURE 15-35. Stage II fracture of the medial condyle in a 10-year-old girl. Anteroposterior (A) and
lateral (B) radiographic views. .
656 Upper Extremity

FIGURE 15-36. Nonunion in addition to cubitus

varus deformity. A: Original film of a 5-year-old girl
who sustained an injury 1 year previously. The me-
taphyseal fragment (arrow) is attached to the me-
dial epicondyle. B: Film taken 2 years later. Some
ossification has developed in the medial condylar
A epiphysis (arrow). (Courtesy of Roy N. Davis, M.D.)

Delayed union has been reponed in patients treated with occurring afcer this type of injury. The neuropathy almost com-
insecure fIxation or simply placed in a cast (132,142). pletely recovered after an terior transposition of the ulnar nerve.
Some disturbance of the vascular supply to the medial condy-
lar fragment appea.rs to occur during open reduction and internal
Fractures of the Trochlea
fixation. Several investigators have reponed subsequenr avascular
changes in the medial crista of the trochlea (132,136,142,145). Osteochondral fractures involving only the articular ponion of
Hanspal (137) reviewed Cothay's original patient (129) 18 years the trochlea are extremely rare in skeletally immature children:
after delayed open reduction and found that despite some mini- only one such fractLIre has been reported in the English-language
mal loss of motion, me patienr was asymptomatic. Radiography, literature. Grant and Miller (152) reponed on a 13-year-old boy
however, demonstrated changes compatible with osteonecrosis who had a posterolateral dislocation of the elbow with marked
of the medial condyle. valgus instability and fractures of the medial epicondyle and
Both cubitus varus and valgus deformities have been reponed radial neck. When the elbow was explored to secure the epicon-
in patiems whose fractUres united unevenrfully. The valgus de- dyle, a large osteochondral fragment from the medial crista of
formity appears to be due to secondary stimulation or over- the rrochlea was found lying berween the rwo articular surfaces.
growth of the medial condylar fragment. Some simple stimula- The fragment was replaced and fixed with Smillie nails, and a
tion of the prominence of the medial epicondyk also may satisfactory result was obtained. However, the presence of the
produce the false appearance of a cubitus valgus deformity. Cubi- ftagment was not detected preoperatively.
tus varus appears to result from decreased growth of the trochlea, In an older child who sustains an elbow dislocation and in
possibly caused by a vascular insult. Principles for treating non- whom there is some widening of the joint after reduction, an
union of lateral condylar fractures generally are applicable to intraarticular fracture of the trochlea or capitellum should be
nonunions of the medial condyle. suspected. Arthrography or MRI, or occasionally CT-anhrogra-
EI Ghawabi (132) described one pania! ulnar neuropathy phy, should be used for confirmation.
 Chapter 15: The ELboUJ 657

Fractures Involving the Entire Distal

Humeral Physis
Incidence
After the first period of ineerest in rl1is injury during the early
1900s, there was almost a complete absence of any discussion
of this injury in the English literature unei! the early 1950s. In
fact, twO researchers, Siris (186) and Wilson (193), doubted
whether this existed as a separate fracture type.
Smith's (187) description in his 1954 textbook, Surgery of
the Elbow, sparked a renewed ineerest in this fracture. He focused FIGURE 15·38. The cross-sectional surface of the supracondylar area
attention on the maintenance of the relationship between the (A) is much thinner than the cross-sectional area through the distal
radius and capitellum as a distinguishing feature in this type of physis (B).

ll1Jury.
From 1960 to 1978, many individual patients were reponed
(159,166,172,175,179,184,185,189). Once the presence of this
injury became recognized, larger series appeared. Seven separate Because fractures coursing along the distal humeral physis
series reponed a total of 45 fractures (154,162,163,170,176,177, traverse the anatomic centers of the condyles, they are the pediat-
]82), and Abe et al. (153) reported on a series of21 fractures. ric counrerpart of the adult bicondylar fracture. Because the
Originally thought to be a rare injury, it appears that fractures fracture is distal, the fracture surfaces are broader than those
involving the entire distal humeral physis occur frequently in proximally through the supracondylar fractures (Fig. 15-38).
children. The major problem is the initial recognition of this This broader surface area of the fracture line may help prevent
Injury. tilring of the disral fragment. Because the articular surface is not
involved by the fracture lines, development of joint incongruiry
with resultant Joss of elbow motion is unlikely if malunion oc-
Surgical Anatomy curs.
The distal humeral epiphysis extends across to include (he sec- Finally, part of the blood supply to the medial crista of the
ondary ossification of the medial epicondyle until abour 6 to 7 trochlea courses directly through the physis. The blood supply
to this area is vulnerable to injury, which may cause avascular
years of age in girls and 8 to 9 years in boys. Thus, fractures
invoJving this total physeal line include the medial epicondyle changes in this part of the trochlea.
up to this age. In older children, only the lateral and medial Because the physeal line is more proximal in young infants,
condylat physeal lines are included. it is nearer the center of the olecranon fossa (Fig. 15-37). A
Most fractures involving the total distal humeral physis occur hyperextension injury in this age group is more likely to result
before the age of 6 or 7. The younger the child, (he greater in a physeal separation than a bony supracondylar fracture (160,
16] ).
the volume of (he distal humerus that is occupied by the distal
epiphysis. As the humerus matures, the physeal line progresses
more distally, with a ceneral V forming between the medial and Mechanism of Injury
lateral condylar physes (Fig. 15-37). Ashhurst (155) bel ieved
that this V-shaped configuration of the physeal line helps pro- The exact mechanism of rhis injury is unknown and probably
tect the more mature distal humerus from physeal fractures. varies with the age group involved. A few consistent factors are
evident.
First, many fractures of the entire distal humeral physis have
occurred as birth injuries associated with difficult deliveries (154,
156,]57,165,167,175,185,190). Siffert (185) noted that the
clinical appearance of these injured elbows at the rime of delivery
was nor especially impressive. There was only moderate swelling
and some crepitus.
Second, DeLee et aJ. (163) noted a high incidence of con-
firmed or suspected child abuse in their very young patients.
Orher reports 054,162,178,180,192) have confirmed the fiT-
quency of child abuse in infants and young children with these
fractures.
Bright (158) has shown rhat a physis is more likely to fail
A B
with rotalY shear forces than with pure bending or tension forces.
Young infanrs have some residual flexion coneractures of the
FIGURE 15·37. A: At 5 months of age, the metaphysis has advanced
only to the supracondylar ridges. B: By 4 years of age, the edge of the elbow from intrauterine positioning; this prevents the hyperex-
metaphysis has advanced well into the area of the epicondyles. tension injulY thar results in supracondylar fractures of the elbow
658 Upper Extremity

in older children. Rotary torces on the elbow, which can be C/a 55 ifica tion
caused by child abuse or birrh trauma in young intants, are
probably more responsible tor this injury rhan hyperextension DeLee er al. (163) c1assifled tracrures at the enrirc disral humeral
or varus or valgus torces, which produce other tracture patterns physis into three groups based on the degree at ossiflcarion at
in older children. the larual condylar epiphysis (Fig. 15-39). Group A tractures
Abe et al. (153) reported on 21 children, ranging in age trom occur in intants up to 12 months at age, betore the secondary
I to 11 years (average 5 years), with fracture-separations at ossificarion cenrer at the lateral condylar epiphysis appears (Fig.
rhe distal humeral epiphysis, all at which were sustained in 15-39A and B). They usually are Salter-Harris rype I physeaJ
tails. injuries. This injury otten is not diagnosed because at the lack

AB c

D E
fIGURE 15-39. A: Group A-anteroposterior view of a small infant who had a swollen left elbow after
a difficult delivery. The displacement medially of the proximal radius and ulna (arrow) helps to make
the diagnosis of a displaced total distal humeral physis. B: Normal elbow for comparison. C: Group
B-anteroposterior view showing the posteromedial displacement of the distal fragment (arrows). The
relationship between the ossification center of the lateral condyle and the proximal radius has been
maintained. 0: Group (-anteroposterior view with marked medial displacement of the distal fragment.
E: Group (-lateral view of the same patient showing posterior displacement of the distal fragment.
There is also a large metaphyseal fragment associated with the distal fragment (arrow).
 Chapter 15: Tbe Elbow 659

of an ossification centet in the latetal condylar epiphysis. Group

B fractures occur most often in children 12 months to 3 years of
age in whom there is definite ossification of the lateral condylar
epiphysis (Fig. 15-39C). AJthough there may be a small flake
of metaphyseal bone, this is also essentially a type I Salter-Harris
physeal injury. Group C fractures occur in older children, from
3 to 7 years of age, and result in a large metaphyseal fragment
that IS most commonly lateral but can be medial or posterior
(see Fig. 15-39D and E).
These fractures are almost always extension-type injuries with
rhe distal epiphyseal fragment postel'ior to the metaphysis. A
rare flexion type of injury can occur in which the epiphyseal
fragmell[ is displaced anteriorly (157) . Srricker and colleaoues
0
(188) reporred a coronal plane transcondylar (Salter-Harris type
IV) fracture in a 3-year-old child that was initially misdiagnosed
as a fracrure of the lateral humeral condyle. Three years after FIGURE 15-40. The true nature of this injury as involving the entire
distal humeral phYSIS was not appreciated until periosteal new bone
open reduction and pin fixation, no growth disturbance was became visible 3 weeks after injury.
evident.

Clinical Signs and Symptoms

epiphysis is displaced posteriot and medial in relation to the
In an infant less than 18 months of age, whose elbow is swollen
metaphysis of the humerus (Fig. 15-39C and D).
secondary to trauma or suspected trauma, a fracture involving
Because they have a large metaphyseal ftagment, type C frac-
the entire distal humeral physis should be considered. In a young
tures may be confused wi[h either a low supracondylar fracture
Infant or newborn, swelling may be minimal with litde crepirus.
or a fracture of the lateral condylar physis. The key diagnostic
Poland (183) described the crepitus as "muffled" crepitus be-
point is the smooth outline of [he distal metaphysis in fractures
cause the fracture ends are covered with softer cartilage than
involving the total distal physis. With supracondylar fracrures,
the fltm osseous tissue in other fractures about the elbow. The
the distal portion of the distal ftagment has a more irregular
relationship between the epicondyles and the olecranon is main-
border.
tained. Because of the large, wide fracture surfaces, there is less
Differentiation from a ftactute of the lateral condylar physis
tendency for tilting with rotation of the distal fragment, and the
and the rare elbow dislocation in an infant can be made on
angular deformity is less severe than that with supracondylar
radiography. With a displaced fracture of the lateral condylar
fractutes. Often in older children, the elbow is so swollen that
physis, the relationship between the lateral condylar epiphysis
a clinical assessment of the bony landmarks is impossible, and
and the proximal radius is usually disrupted (Fig. 15-8B). If the
radiographic evaluation must provide confirmation of the diag-
lateral crista of [he trochlea is involved, [he proximal radius and
nosis (Fig. 15-39A and B).
ulna may be displaced posterolaterally.
Elbow dislocations are rare in the peak age group for fractures
Radiographic Findings of [he entire distal humeral physis. With elbow dislocations, [he
displacement of the proximal radius and ulna is almost always
Radiographic diagnosis can be difficult, especially if the ossifica-
posterolateral, and the relationship between the proximal radius
tion center of the lateral condyle is not visible in an infant. The
and lateral condylar epiphysis is disrupted.
only relationship dut can be determined is that of the primary
If differentiation of this injury from an intraarticular fracrure
osslhca[lon centers of the distal humerus to the proximal radius
is uncertain, arthrography or MRl may be helpful (Fig. 15-6C)
and ulna. The proximal radius and ulna maintain an anatomic
(154,156,159,168,171.177).
telationship to each othet but are displaced posteriorly and medi-
In neonates and infants in whom ossification has not begun,
ally in relation to the distal humerus. This posteromedial rela-
ultrasonography can be used to outline the epiphysis of the hu-
tionship is diagnostic. AJthough theoretically the distal fraoment
merus (164,191). Comparison with the opposite uninjured hu-
can be displaced in any direction, with rare exceptions 0 (57 )
meral epiphysis may help determine the presence of a sepatation.
most fra~tLltes reported have been displaced posteromedially.
If the diagnosis is delayed, new periosteal bone forms around
Valdlsertl and Kelescian (190) were [he first to emphasize the
the distal humerus, and the whole epiphysis may remain d is-
c?nsistency of this posteromedial displacement. Comparison
placed posteriorly and medially (Fig. 15-40).
views of the opposite uninjured elbow may be helpful to detet-
mine the presence of posteromedial displacement (Fig. 15-39A
and B).
Treatment
Once the lateral condylar epiphysis becomes ossified, dis-
placement of the entire distal epiphysis is much more obvious. Treatment is first directed tOward prompt tecognltlon of the
The anatomic relationship of the lateral condylar epiphysis with injury. Because this injulY may be associated with child abuse,
the radial head is maintained, even though the distal humeral [he parents may delay seeking rreatment.
660 Upper r~wremj~y

A,S c
FIGURE 15-41. Remodeling of untreated fractures. A: Anteroposterior view of a 2-year-old who had
an unrecognized and untreated fracture of the distal humeral physis. The medial translocation is appar-
ent. There was no varus or valgus tilting. B: Four years later, there had been almost complete remodeling
of the distal humerus. A small supracondylar prominence (arrow) remains as a scar from the original
injury. C: Clinical appearance 4 years after injury shows no difference in the alignment of the elbows.

De Jager and Hoffman (162) reponed 12 fracrure-separ- flexing the elbow and pronaring rhe forearm. The disral epiphysis
arions of [he disraJ humeral epiphysis, rhree of which were ini- is more securely held wirh rhe elbow flexed and rhe forearm
rially misdiagnosed as fracwres of rhe lareral condyle and one pronared (Fig. 15-42). \XJhen rhe forearm is supinated wirh rhe
as an elbow dislocarion. Because of rhe frequency of cubirus elbow flexed, rhe disral fragment tends to displace medially. This
varus afrer rhis injury in young children, rhey recommend closed is usually a pure medial horizonral rranslocarion wirhour medio-
reduction and percuraneous pinning in children under 2 years lareral coronal tilring.
of age so rhar rhe carrying angle can be evaluared immediarely In neonates and very small infanrs in whom general anesthesia
afrcr reducrion and correcred if necessary. or percuraneous pin fixation may be difficulr, we usually simply
Open reducrion has been repolTed by several invesrigarors, immobilize the exrremiry in 110 ro 120 degrees of hyper flexion
usuaJly performed because of misdiagnosis as a displaced fracrure wirh [he forearm pronated. The extremity is rhen externally Sta-
ofrheJarcral humeral condyle (154,170,179,184,192). Mizuno bilized wirh a figure-of-eight splint.
(177), however, recommended primary open reducrion because In mosr older infants and young children, exrernal immobili-
of his poor resulrs wirh closed reduerion. He approached rhe zarion usually is nor dependable in maintaining the reduction.
fracture posreriorly by removing rhe rriceps inserrion from rhe In rhese patients, we usually perform the manipulation wirh the
olecranon wirh a small piece of carrilage. patienr under general anesthesia and secure rhe fragmenr with
If rhe fracrure is old (>5-6 days) and rhe epiphysis is no cwo lareral pins (Fig. 15-43). Because of rhe swelling and imma-
longer mobile, manipularion should nor be arrempred and rhe ruriry of the disral humerus, rhe medial epicondyle is difficulr
elbow should be splinred for comfort. Many essenrially unrreated ro deflne as a disrinct landmark, making it risky to attempr
fracrures n.:model complerely wjrhour any residual deformiry if rhe percutaneous pJacemenr of a medial pin. If a medial pin is
rhe disral fragmenr is only medially rranslocared and nor tilred necessary for srable fracrure flxation, a small medial incision can
(Fig. 15-41). be made ro allow direct observation of rhe medial epicondyle.
[n small infants and young children wirh minimal ossificarion of
rhe epiphyseal fragmenr, an inrraoperarive arthrogram is L1sualJy
~ AUTHORS' PREFERRED METHOD obtained ro help derermine rhe qualiry of the reducrion.
\..~~ OF TREATMENT The cast or splint and pins are removed in 3 weeks ro alJow
resumption of active elbow motion. The pa[ienr is then followed
\Xfe usually firsr anemp[ a manipularive closed reducrion of fresh unri! full motion is regained and rhere is radiographic evidence
fracrures. The elbow is firsr manipulared into extension to cor- of normal physeal and epiphyseal growrh. Usually, 3 weeks of
recr rhe medial displacemenr, rhen rhe fragmenr is srabilized by immobilizarion is sufficient.
 Chapla 15: The Elbow 661

A,S c
FIGURE 15-42. Supination versus pronation. A: In this fracture involving the entire distal humeral physis
in a 9-month-old. the elbow was initially flexed with the forearm in supination. The Jones view shows
that the proximal radius and ulna remain translocated medially in relation to the distal humerus. B:
Comparison Jones view of the uninjured elbow shows the true relationship of the proximal radius and
ulna to the distal humerus. C: When the injured elbow was flexed with the forearm pronated. the
normal relationship was reestablished.

A,S c

FIGURE 15·43. A: Injury film of a 20-month-old showing medial displacement

of the distal fragment. B: The posterior displacement of the condylar fragment
(arrow) is better defined after an arthrogram. C: Manipulation with the forearm
in pronation shows the fragment is anatomically reduced. The arthrogram out-
lines the articular margin of the condyles (arrow). D: Fixation is achieved by two
D lateral pins placed percutaneously.
662 Upper Exrremiry

If treatment is delayed more than 3 to 5 days and the epi- reported neurologic injury in one child who was treated for an
physis is not freely movable, rhe elbow is simply immobilized "elbow dislocation." About 16 hours after teduction and splint-
in a splint or cast. Any resulting deformity is probably better ing with the elbow acutely flexed, the child could not move
created later with a supracondylar osteoromy rather than risk her hand, and no radial, median, or ulnar nerve function was
the complication of physeaJ injury or devascularization of the detectable. At last follow-up after open reduction and internal
epiphysis by performing a delayed open reduction. Only occa- fixation with Kirschnet wires, the neurologic deficit was slowly
sionally does an uncreated patient bave a deformity severe resolving.
enough ro require sutgical correction at a later date. Because
the articular surface is intact, complete functional recovery can
Nonunion
usually be expected.
Only one nonunion aftet this fracture has been reported; it oc-
curred in a patient seen 3 months after the initial injury (77).
Complications Because of the extreme vascularity and propensiry for os-
teogenesis in this area, union is rapid even in patients who receive
Child Abuse
essentially no treatment.
Child abuse should always be considered in children with this
injury, especially a type A fracture pattern, unless it occurs at
birrh. A young infant is unlikely ro incur this type of injury Malunion
spontaneously from the usual falls that occur during the first Significant cubitus varus deformity is not uncommon after this
year of life. Of the 16 fractures reported by DeLee et a1. (63), injury (Fig. 15-45). Marmor and Bechro (74) reponed an es-
6 resulted from documented or highly suspected child abuse, aH sentially untreated fracture that reSLLlted in significant cubitus
in children under 2 years of age (Fig. 15-44). varus. Five of seven fractures in Holda and colleagues' series
(170) resuIred in angles ofcubitus varus of 10 to 15 degrees, even
Neurovascular Injuries when open reduction was performed. Abe et a1. (153) reported
Neurovascular injuries, either transient or permanent, are rare cubitus varus deformities in 15 of 21 children, 7 of whom were
with this fracture, probably because the fracture fragments are treated with closed reduction and casting, 2 with closed reduc-
covered with physeal cartilage and do not have sharp edges as tion and percutaneous pinning, 4 with open reduction and inter-
do other fractures in this area. In addition, the fracture fragments nal fixation, and 2 with skin traction. Review of radiographs after
usually are not markedly displaced. Hersch and Sanders (169) reduction revealed that the deformity was caused by incorrect

FIGURE 15-44. A: A 6-month-old victim of child abuse. The fracture involving the distal
humeral physis was old, as indicated by the proliferative new periosteal bone formation
(open arrow). Acutely there was a separation of the proximal humeral physis (black
arrow). B: Another child, 9 months old, who had an acute fracture through the distal
humeral physis, as manifest by posteromedial displacement of the proximal radius and
ulna (closed arrow). An old healing fracture is also seen in the ipsilateral radius (open
arrow).

A B
 Chapter 15: The Elbow 663

FIGURE 15-45. An anteroposterior view of a residual cubitus varus in

a 2-year-old 6 months after the original injury. This patient was treated
initially with only simple immobilization.

reduction (12 fractures), redisplacement during immobilization

(2 fractures), or physeal damage (1 fraerme). B
Because the fracrure surfaces are wider with rhis injury than
FIGURE 15·46. Avascular necrosis. A: Injury film in a 5-year-old with
with supracondylar fractures, the distal fragment tends ro tilt marked displacement of the distal epiphysis. Closed reduction followed
less, which seems to account for the lower incidence of cubirus by lateral pin fixation was performed. B: Nevertheless, radiographs
varus after this injury than after untreated supracondylar frac- taken 14 months later showed early evidence of avascular necrosis of
the medial condyle. (Courtesy of Salvador J. Mendez, M.D.)
tures (Fig. 15-45).

Osteonecrosis
Osteonecrosis of the epiphysis of the lateral condyle or the uoch- deformity that continued ro progress with growth and a signifi-
lear epiphysis has rarely been reponed after fractures of the entire cant loss of elbow motion. The etiology of this complication
distal humeral physis. Yoo et al. (194) reponed on eight patients was discussed in the section on osteonecrosis of the trochlea.
with osteonecrosis of the trochlea after fracrure-separations of
the disral end of the humerus. Six of the eight fracrures were
misdiagnosed initially as medial condylar fracrures, lateral con-
APOPHYSEAL INJURIES OF THE DISTAL
dylar fracrures, or traumatic elbow dislocation. All eight patients
had rapid dissolution of the rrochlea within 3 ro G weeks after
HUMERUS
injury, followed by the development of a medial or central con- Fractures Involving the Medial Epicondylar
dylar fishtail defect. We have noted osteonecrosis of the trochlea Apophysis
after three fracrures of the entire humeral physis, twO of which
History Review
were inadequately reduced and one of which was anaromically
reduced by closed methods (Fig. 15-46). All three had marked Recognition of Entrapment
displacement of the distal epiphyseal fragment. In one, the os- In the early 1900s, it was recognized that this fracrure was often
reonecrosis of the trochlea produced a secondary cubitus varus associated with dislocation of the elbow, and the apophyseal
664 Upper txtmnity

fragmem could become entrapped within the joint (215,236,

TABLE 15-1. FRACTURES OF THE MEDIAL
247). Much of the discussion of that era centered on the manipu- EPICONDYLAR APOPHYSIS:
lative techniques used to extract the fragment from the joint INCIDENCE
(215,236).
Overall incidence: fractures of the distal humerus, 14.1 %
Overall incidence: fractures of the elbow region, 11.5%
Operative/Nonoperative Controversy Age: peak, 11-12 years
Sex: males. 79% (4:1, male:female)
In 1950, Smith (242) stated that many of the complications
Association with elbow dislocation: approximately 50%
I)reviously aruibuted ro this injury were acrualJy misconceptions. (15%-18% of these involve incarceration of the epicondylar
Since then, the proponems of uniform nonoperative manage- apophysis) -
mem (205,224,233,252) have far outnumbered the proponents
of uniform operative management (222). In the interval since
the third edition of this volume, little has been written about
the treatment of this injury; most of the focus has been on
the increased recognition of this injury occurring during arm
ated with elbow dislocations. In at least 15% to 18%, the frag-
wrestling (227,228,232).
ment is incarcerated in the joint (Table 15-1).

Incidence Surgical Anatomy

In the combined series of 5,226 fractures of the distal humerus Ossification
(see Chapter 13), the percemage oHractures involving the medial Apophysis. The medial epicondyle is a traction apophysis, so
epicondylar apophysis was just behind that of fractures involving the term apophysis rather rhan ph)'sis is used throughour rhe de-
the lateral condylar physis. Fractures involving the medial epi- scription of this injury. The forces across its physeal plare are
condylar apophysis constituted 14.1 % of fractures involving the tension rather than the compressive forces present across the
distal humerus and 11.5% of all fracrures in rhe elbow region. condylar physeal plates of the distal humerus. Because it is an
apophysis, it does not contribute ro the overall lengrh of the
distal humerus.
In the early ossification process, rhe medial epicondylar
Age
apophysis is parr of the total distal humeral epiphysis. With
Fractures involving the epicondylar apophysis have a later peak growrh and maturity, it becomes separated from the rotal distal
age, much like that of fracrures involving the medial condylar humeral epiphysis by intervening metaphyseal bone. In younger
physis. The youngest reponed patient with this injury was 3.9 children, when there is a separation of the roral distal humeral
years (206). In the large series of fractures of the medial epicon- epiphysis, the medial epicondylar apophysis is included as parr
dylar apophysis reported, most occurred between ages 9 and 14, of rhe disral fragment.
wi th the peak age incidence being 11 to 12 years (199,217,221,
222,225,233,242,251,252,279). Posteromedial Location. The medial epicondylar apophysis ac-
tually arises from the posterior surface of the medial distal hu-
meral metaphysis. As was mentioned in Chaprer 14, this poste-
Sex rior location is important when percutaneous pin fixation is
performed. Likewise, this posterior posirion affects the image of
Fractures of the epicondylar apophysis affect boys by a ratio of the apophysis on radiographs (Fig. 15-47).
almost 4 to 1. In the six largest series in the literature on this
injury, boys constiruted 79% of the patients (217,229,234,237, Ossification Sequence. Brodeur and Silbersrein (203,240) have
247,252). described many of the unique aspecrs of the ossification process
of the medial epicondylar apophysis. The foJ lowing discussion
is paraphrased from their work.
Association with Dislocation of the Elbow Ossification begins from 4 to 6 years of age, with fusion
occurring at about 15 years of age. Ir is rhe last secondary ossifica-
The reported incidence of association with dislocation of the tion center to fuse with rhe distal humeral metaphysis. The ossifi-
elbow has varied from as low as 30% to as high as 55% in many carion center starts as a small ecceneric oval nucleus (Fig. 15-
of the reported series (199,208,2l3,231,252). Two bilateral in- 47A). As ir matures, parallel sclerotic margins develop along
juries associated with bilateral elbow dislocations have been re- borh sides of the physis (Fig. 15-47B). There may be some
ported (200,246). Both patients sustained their injuries while irregularity of the ossification process, which gives the ossific
participating in gymnastics. nucleus a fragmented appearance. This fragmentarion may be
In summary, the peak age for fracrures of rhe epicondylar falsely interpreted as a fracture.
apophysis is 9 to 12 years. The injury occurs in boys four times Because the apophysis is posteromedial, the ossification cen-
more often than in girls. About 50% of such injuries are associ- ter may be difficult to visualize on the anteroposrerior radio-
 Chapter 15: The ELbow 665

A B

c D

E
FIGURE 15-47. Ossification of the medial epicondyle. A: The concentric oval nucleus of ossification of
the medial epicondylar apophysis (arrow). B: As ossification progresses, parallel smooth sclerotic margins
develop in each side of the physis. C: Because it is somewhat posterior, on a slightly oblique anteroposter-
ior view the apophysis may be hidden behind the distal metaphysis. D: The posterior location of the
apophysis (arrow) is appreciated on this slightly oblique lateral view. E: On the anteroposterior view,
the line created by the overlapping of the metaphysis (arrow) can be misinterpreted as a fracture line
(pseudofracture).
666 Upper Extremity

graph, espccially if the elbow is slightly oblique (Fig. 15-47C).

The posrerior posirion of rhe apophysis is best appreciared on
the lateral radiograph. If the elbow is slightly oblique, the outline
of the epicondyle may be better appreciated (Fig. 15-470). Be-
cause of this posterior location on rhe anteroposterior radio-
graph, (he distal medial metaphyseaJ border may overlap rhe
ossific nucleus of the apophysis. This overlapping may appear
as;} lucent line rhat can be misinterpreted as a fracture (Fig. 15-
47E). Ulnar Collateral
Anterior band
Soft Tissue Attachments Oblique band
Flexor Mass. The flexor mass, which includes the ol'lgm of A Posterior band B
the Hexor carpi radialis, Hexor carpi ulnaris, flexor digitorum
superficial is, and palmaris longus and part of rhe pronaror reres,
originates from the anterior aspect of the apophysis (Fig. 15-
48) (240,250). Part of the flexor carpi ulnaris also originates all
the posterior aspect of the epicondyle.

Capsule. In rhe younger child, SOme of the origin of the capsule

extends up to rhe physeal line of the epicondyle. In the older
child and adolescent, as the epicondyle migrates more proxi- c D
mally, the capsule is artached only to the medial crisra of rhe
trochlea (198,212). Thus, in the younger child, the fracture line FIGURE 15-49. Ligamentous structures. A: The ulnar collateral liga-
ment is divided into anterior. posterior, and oblique bands. B: On exten-
involving the medial epicondylar apophysis can enter the joint sion. the anterior fibers of the anterior band are taut. The posterior
because part of the capsule is attached to the epicondylar frag- fibers of the anterior band and the entire posterior band are loose in
ment. In rhe older child, however, if rhere is a pure avulsion this position. C: In flexion, the posterior fibers of the anterior bands
and posterior band become taut. The anterior fibers of the anterior
force on the epicondyle, the capsule may remain attached to the band become loose. D: When the epicondyle is rotated anteriorly, the
outer border of the rrochlea. In this age group, rhe fracture may entire anterior band can become loose. (Reprinted from Woods WG,
be totally extraarticular. Tullos HS. Elbow instability and medial epicondyle fractures. Am J
Sports Med 1977;5:23-30; with permission.)

Ligamentous Structures
The rwo major medial collateral ligaments originate from this
apophysis. The ulnar collateral ligament is composed of rhree and are raut in flexion (Fig. 15-49). Thus, this posrerior band
separarc bands (Fig. 15-49) (223,254). Woods and Tullos (254) provides stability only in flexion. Because the radial collateral
poinred our that rhe major stabilizing ligamentous srructlll'e in ligaments do nor artach directly to the ulna or radius, but instead
the elbow is the anterior band of the ulnar collareral ligament. arrach ro rhe orbicular ligamenr (239) they provide only minimal
The anrerior portion of the band is taut in extension, and the srability to the elbow joint.
posterior fibers are taut in flexion. The fibers of the posrerior
band of rhe ulnar collareral ligament are rela.xed in exrension
Mechanism of Injury
Acute Injuries
Injuries to the medial epicondyJar apophysis mosr commonly
occur as acute injuries in which a distincr event produces a partial
or a complete separarion of the apophyseal fragment. Three the-
ories have been proposed abour rhe mechanism of acure medial
epicondylar apophyseal injuries: a direct blow, avulsion mecha-
nisms, and association with elbow dislocation (Table 15-2).
: - - - " ' r - - - - Capsu Ie
Direct Blow
II'...---Pronator leres Srimson (244) speculated thar this type of injury could occur as
,---Common flexor origin a resulr of a direct blow on the posrerior aspeer of rhe epicondyle.
·'----Ulnar collateral ligament However, among more recenr investigators, only Watson-Jones
(248) described this injury as being associared wirh a direcr blow
FIGURE 15-48. Soft tissue attachments. Anteroposterior view of the {Q the posterior medial aspeer of the elbow.
distal humerus demonstrating the relationship of the apophysis to the In those rare patienrs in whom the fragment is produced
origins of the medial forearm muscles. The origin of the ulnar collateral
ligament lies outside the elbow capsule. The margin of the capsule is by a direcr blow ro the medial aspect of rhe jOlnr, rhe medial
outlined by the dotted line. l'picondylar fragment is ofren fragmented (Fig. 15-50). In rhese
 Chapter {5: The Elbow 667

TABLE 15-2. FRACTURES OF MEDIAL

CONDYLAR APOPHYSIS:
MECHANISM OF INJURY

Acute injuries
Direct blow
Avulsion mechanisms
Avulsion in elbow extension (valgus stress)
Avulsion with elbow flexed (pure muscle forces)
Associated with elbow dislocation
Chronic tension stress injuries

InJUrieS, rhere also may be more superficial ecchymosis in the

skin.

Avulsion Mechanisms
Many investigators ascribe to the theory that some of these inju-
ries are due to a pure avulsion of the epicondyle by the flexor
muscles of the forearm (225,235,238,253). This muscle avulsion
force can occur in combination with a valgus stress in which
the elbow is locked in extension, or as a pure musculature COI1-
rraction rhat may occur with the elbow partially flexed.

FIGURE 15-51. Hyperextension forces. When a person falls on the out-

Avulsion and Extension (Valgus Stress) stretched upper extremity, the wrist and fingers are forced into hyper-
Smith (242) believes that when the child falls on the outstretched extension (solid arrow), which places tension on the forearm flexor mus-
upper extremity wirh rhe elbow in exrension, rhe wrist and fin- cles. This sudden tension along with the normal valgus carrying angle
tends to place a strong avulsion force on the medial epicondyle (open
arrow).

gel's are ofren hyperextended as well, placing an added tension

force on the epicondyle by rhe forearm flexor muscles (Fig. 15-
51). The normal valgus carrying angle tends to accentuare these
avulsion forces when the elbow is in extension. Many of the
proponents of this theory point to the other associated elbow
fractures rhat have been seen wi th this inj ury as evidence to
confirm that a valgus force is applied across the elbow at rhe
time of the injury. These associated injuries include fractures of
rl1e radial neck with valgus angulation and greensrick valgus
fractures of the olecranon (225,243,253).

Isolated Muscle Avulsions

Isolated avulsion also can occur in adolescenrs wirh rhe simple
act of rhrowing a baseball. In rhis instance, rhe sudden con-
tracture of the forearm flexor muscles may be sufficient to cause
the epicondyle to fail (Fig. 15-52). The literature has reflected
a high incidence of media! epicondylar apophyse:ll avulsions oc-
curring with arm wrestling in patienrs near skeletal maturiry
(226,228). The largest series, reported by Nyska et al. (232)
from Israel, involved eight boys 13 to 15 years of age, all of
whom were treated conservatively with good results.
FIGURE 15-50. Direct fragmentation. The fragmented appearance of
the medial epicondyle (arrows) in a 13-year-old who sustained a direct Associated with Elbow Dislocations
blow to the medial aspect of the elbow. (Reprinted from Wilkins KE.
Fractures of the medial epicondyle in children. Instr Course Lect 1991; The final mechanism proposed is that this Injury is associated
40: 1-8; with permission.) with a dislocation of rhe elbow in which the ulnar collareral
668 Upper Ex·tremity

FIGURE 15-53. Partial avulsion. The epicondylar fragment was only

partially avulsed. This partial fragment also had an associated portion
of the metaphysis (arrow). both of which were incarcerated into the
FIGURE 15-52. Muscle avulsion. Isolated avulsion of the medial epi- elbow joint. (Courtesy of Randal R. Betz, M.D.)
condyle occurred suddenly in this 14-year-old little league pitcher after
throwing a curve ball. (Reprinted from Wilkins KE. Fracture of the me-
dial epicondyle in children. Instr Course Lect 1991;40: 1-8; with permis-
sion.)

ro the apophyseal fragment. Rarely, rhe fracrure line passes

through the apophysis, with only parr of rhe apophysis being
avulsed (240). These partial avulsions may appear as only minor
ligament provides the avulsion force. If the elbow is dislocated injuries. However, the partial ftagment can be incarcerated
when the patient is initially seen, there is no doubt that this is within the joint just as easily as rhe full apophysis (Fig. 15-53).
a major factor in the producrion of this fracture. However, the
question of this being caused by an occult or partial elbow dislo- Chronic Incarceration
cation that has reduced spontaneously is often raised. Some in- When the fragment becomes incarcerated into the joint, the raw
vestigarors (199,200,217) have noriced the development of calci- bone surface may become adherent ro the coronoid process of
fication in the lateral collateral ligaments and adjacent lateral rhe ulna (237). In lare cases, rhis union of the fragment to rhe
periosteum in elbows postfracrure. They believed this was evi- coronoid process may make extracrion difficult. A universal find-
dence rhat rhis ligament had been stretched during the process ing when the fragment is incarcerated within the joint is a thick
of elbow dislocation. Marion and Faysse (229) found that most fascial band rhar binds the ulnar nerve ro the underlying muscle
elbow dislocations associared with rhis injury were posterolateral, (197,210,235). The constricrion by this band is believed ro be
bur some pure lateral, posrerior, and posteromedial dislocations responsible for eirher the immediare or lare dysfuncrion of rhe
were also observed. ulnar nerve.
The quesrion arises as ro whether incarceration of the epicon-
dylar fragment inro rhe joint can occur wirhour a dislocation. Associated Injuries
Parrick (235) believed rhat when an extreme valgus stress was Other elbow fracrures that can be associated wirh this injury
applied ro the joint, a vacuum was creared within rhe joinr that include fracrure of rhe radial neck, olecranon, or coronoid pro-
"sucked in" the avulsed epicondylar fragmenr. This theory has cess. If rhe epicondyle fragment is only rotated on irs axis, laxiey
nor been universally accepred (238,241). of rhe anterior band of the ulnar collateral ligament can occur.
Acutely, it appears that any of rhese mechanisms can produce This can produce some medial elbow instabiliey during extension
this injury. The direct blow mechanism appears to occur onJy (254).
rarely. Mosr of these injuries probably are associared with an
elbow dislocation thar mayor may nor have reduced sponra-
neous!y. Classification
The various classifications proposed for this injury (199,229,
243,249) are prerey much the same. We have combined them
Pathology
to form a comprehensive classification (Table 15-3) that can be
Acute Fractures useful in derermining the proper method of trearmenr. In rhe
Usually the epicondyle is displaced distally. Corron (210) de- discussion of rhis classification, the clinical and radiographic
scribed two patients in whom rhis fragmenr was displaced proxi- findings are delineared for each eype offracrure parrern. Initially,
mally. Avulsion usually involves only rhe apophysis. However, we have separared rhese injuries into twO primary categories
a small flake of metaphyseal bone is occasionally found arrached based on wherher rhe injuries are acure or chronic.
 Chapter J5' T/;e Elbow 669

TABLE 15·3. FRACTURES OF THE MEDIAL

EPICONDYLE APOPHYSIS:
CLASSIFICATION

Acute injuries
Undisplaced or minimally displaced
Displaced fractures
Incarcerated fractures (without elbow dislocation)
Incarcerated fractures (with elbow dislocation)
Chronic tension (stress) injuries

Acute Injuries
Undisplaced or Minimally Displaced Fractures. In undis-
placed fracrures, the physeal line remains intact. The cJ inical
manifestations usually consist only of swelling and local tender-
ness over the mediaJ epicondyle. Crepitus and motion of the FIGURE 15-55. Significantly displaced. Anteroposterior view of an
elbow in which the epicondyle (arrow) is significantly displaced both
epicondyle usually are nor present. On radiography, the smooth- distally and medially. In addition, the fragment is rotated medially.
ness of the edge of the physeal line remains intact. Although
there may be some Joss of soft tissue planes medially on the
radiograph, displacement of the elbow fat pads may not be pres-
ellt because the pathology is exrraarricular (220). tuS berween the fragments may not be present. There may have
Minimally displaced fractures usually result from a stronger been an elbow dislocation that reduced spontaneously or by
avulsion force, so there is often more soft tissue swelling. Palpa- manipulation. On the other hand, there may have been no docu-
tion of the fragment may elicit crepitus because the increased mentation of the original dislocation. On radiography, the long
displacement allows motion of the fragment. On radiography, axis of the epicondylar epiphysis is rotated medially (Fig. 15-
thete is a loss of parallelism of the smooth sclerotic margins of 55). The displacement usually exceeds 5 mm, but the fragment
the physis (Fig. 15-54) (240). The radiolucency in the area of remains proximal [Q the true joint surface. This fragment may
the apophyseal line is usually increased in width. contain a metaphyseal fragment.

Significantly Displaced Fractures. In significantly displaced Entrapment of the Epicondylar Fragment into the Joint.
fractures, there is no question as [Q whether the fragment is Without Elbow Dislocation. In many instances the elbow appears
displaced: it may be palpable and freely movable. Because it is reduced. The key clinical finding is a block [Q motion, especially
displaced a considerable distance from the distaJ humerus, crepi- extension. The epicondylar fragment is usually berween the joint

A B
FIGURE 15·54. Minimally displaced. A: Anteroposterior view of a minimally displaced fracture. The
smooth sclerotic margins of the physis are disrupted. B: Uninjured elbow for comparison.
670 Upper E>::tremity

A B
FIGURE 15-56. Incarceration within the joint. A: The clues to entrapment are complete absence of the
epicondyle from its usual medial location (open arrow) and its subsequent location at the level of the
joint (closed arrow). B: On the lateral view the outline of the epicondyle is hidden by the overlying
olecranon (closed arrow). The fragment also contains a small portion of the metaphysis (open arrow).

surfaces of the trochlea and the semilunar notch of the olecranon. First before a satisfactolY closed reduction of the elbow joint can
On radiography, any time the fragmeJ1( appears at the level of be obtained (Fig. 15-57).
the joiJ1(, it must be considered to be tOtally or partially within
the elbow joiJ1( until proven otherwise (Fig. 15-56) (235). If the Fractures Through the Epicondylar Apophysis. Fraccures
radiograph is examincd carefully, the elbow is usually still found thl'Ough the body of the epicondyle can result from either a
to be incompletely reduced. Because of an impingemeJ1( of the direct blow or avulsion of only part of the apophysis. In either
fragment within the joiJ1(, a good aJ1(eroposterior view may be case, the fragments mayor may not be displaced. The normal
difficult to obtain due to the inability to extend the elbow fully. lucent line formed by the overlying metaphyseal border should
If the fraccure is old and the fragment is fused to the coronoid not be confused with this injury. Although described by Silb-
process, widening of the medial joint space may be the on Iy clue erstein and colleagues (240), this intrafragmenr fraCture is a rare
that the fragment is lying in the joint (197). The epicondylar presen tanon.
ossification center may become fragmented and mistaken for
the fragmented appearance of the medial crista of the trochlea
Diagnosis
(206,237,241). Absence of the apophyseal center on radiographs
may be further confirmatory evidence that the fragment is within Clinical Findings
the joint. Comparison radiographs of thc opposite elbow may Valgus Stress Test. Because many of the clinical diagnostic
be necessary to delineate the true pathology. points have been discussed in the previous section on the classifi-
cation of this injury, much of the emphasis in this section is
on the determination of elbow insrability. Because the anterior
With Elbow Dislocation. Even if the elbow is dislocated, the oblique band of rhe ulnar coJJateral ligament may be attached
fragmeJ1( can still lie within the joiJ1( and preveJ1( reduction. ro the medial epicondylar apophysis, rhe elbow may exhibit some
Recognition of this fragment as being within the joint before a instability postinjury. To evaluate the medial srability of the
manipulation should alert the physician of the possible need for elbow, a simple valgus stress has been advocated by Woods and
open reduction. There should be adequatc relaxation during Tullos (254) and Schwab er aJ. (239). This test is performed
the manipulative process. An initial manipulation to extract the wirh the patient supine and the arm abducted 90 degrees. The
fragment from the elbow joint may need to be accomplished shoulder and arm are externally rotated 90 degrees. The elbow
 Chaptfr J5: The Elbow 671

A B
a
FIGURE 15-57. Dislocation with incarceration. A: Anteroposterior view showing posterolateral dislo-
cation of the elbow. The presence of the medial epicondyle within the elbow joint (arrow) prevented
a closed reduction. B: Lateral view of the same elbow demonstrating the fragment (arrow) between
the humerus and olecranon.

must be flexed at least ] 5 degrees ro eliminate the stabilizing Fat Pad Signs Unreliable. Fractures of the medial epicondyle,
force of the olecranon. If the elbow is unstable, simple gravicy even if displaced, may not produce positive fat pad signs (220,
fOrces will open the medial side. A small additional weight or 240). If the fracture is only minimally displaced and the result
sedation may be necessary ro ge[ an accurate assessment of the of an avulsion injury, there may be no effusion because all the
medial stabiliry with this [est. The practicality of [his valgus injured tissues remain extraarticular. In those associated with
stress tes[ is discussed in more detail in the fonhcoming section elbow dislocation, there is rupture of the capsule, so its abilicy
on the Authors' Preferred Method of Treatment. ro confine the hemarthrosis is lost. In minimally displaced frac-
tures of the medial epicondyle with significant hemarthrosis, one
mUSl be especially thorough in the evaluation to ensure that an
Evaluate Ulnar Nerve. The function of the ulnar nerve musr
unrecognized fracrure involving the medial condylar physis is
be carefully assessed. h is especially wise to document [he pres-
not present.
ence or absence of an ulnar nerve injury before instituting
therapy.
Differential Diagnosis
The major injLlly ro differentiate is one involving the medial
X-Ray Findings condylar physis. This is especially true if the secondary ossifica-
Bewa/"e Absent Apophysis. Widening or irregularicy of the tion centers are not present (see earlier section on Fractures [n-
apophyseal line may be [he only clue in fractures that are only volving the Medial Condylar Physis). If there is a significant
slightly displaced or nondisplaced. If the fragment is significantly hemarthrosis or a significant piece of metaphyseal bone accom-
displaced, the radiographic diagnosis is usually obvious. How- panying the medial epicondylar fragmenr, then arthrography
ever, if the fragment is rotally incarcerated in the joint, it may may be indicated ro determine if there is an intraarticular compo-
be hidden by the overlying ulnar or distal humerus. The clue nell[ ro the fracture (Fig. ] 5- 58).
here is the total absence of the epicondyle from i[s normal posi-
tion just medial ro the medial metaphysis.
Poner (76) sugges[ed that properly performed MRI may dis-
Treatment
close acute or chronic injury to the medial epicondylar apophy- Areas of General Agreement
sis. Recommended pulse sequences for evaluation of rhe apophy- There seems to be universal agreement as to the proper method
sis include E![-suppressed gradient echo imaging. On MRl, of treating fractures that are undisplaced or only minimally dis-
increased signal intensity and abnormal widening of the medial placed. These first two cypes are easily treated with simple immo-
epicondylar physis are seen, typically wi[h sU[I'oundi ng sof[ [issue bilization for comfort. Many investigators have recommended
edema. initiation of motion early to prevenr stiffness, the most common
672 Upper Extremity

FIGURE 15-58. Intraarticular extension. A: Injury

film in this 7-year-old girl who was initially suspected
of having only a fracture of the medial epicondyle.
In addition to moderate displacement, there was a
significant metaphyseal fragment (arrow). B: An
arthrogram reveals intraarticular components
(arrow), which define this instead as a fracture in-
volving the medial condylar physis. (Courtesy of Carl
A,S McGarey, M.D.)

complication of this injury (200,242). Likewise, if the fragment Results Poorer with Diswcation. The results of fractures asso-
is incarcerated in the joint, the accepted treatment is to extract ciated with a documented elbow dislocation are poorer (199,
the fragment from the joint by manipulation or surgical inter- 217) for patients treated operatively and nonoperatively. Fowles
ventIon. and colleagues (217) wrote that surgical intervention only added
The controversy seems to be in determining the propel' to the original trauma produced by the dislocation, increasing
method of treatment for patients with significant displacement the residual loss of motion.
(the fragment is displaced >5 mm).
Indications for Operative Intervention. The indications for
operative intervention in acute injuries are divided intO twO cate-
Nonoperative Management gories: absolute and relative. The single absolute indication is
incarceration of the epicondylar fragment within the joint. The
Operative Versus Nonoperative Controversy relative indications include ulnar nerve dysfunction and a need
Operative Results No Better. In reportS in which only one for elbow stability.
method (i.e., operative or nonoperative) of treatment of all dis-
placed fractures was used, one can find results to support either
Incarceration in theloint-Absolute. If the fragmenr is found
method. The best argument for smgical management comes
in the joint acutely, it must be removed. However, there are
from Hines et al. (222) in Oklahoma. where rhe practice was
proponenrs of both nonoperative and operative techniques for
to surgically repair all fractures displaced more than 2 mm. They
extracting the fragment.
found thar 96% of their patients had good to excellenr results.
Bad results were attributed mainly to technical errors. Equal
Nonoperative Extraction. Various methods of extracting the
results were obtained by Joseffson and DanieJsson (224) from
fragment by nonoperative methods have been proposed. The
Sweden, where these injuries were all treated nonoperatively.
success rate of extraering the fragment successfully from the joint
AJthough more than 60% of their patients demonstrated radio-
by manipulation alone is only about 40% (235). AJI the nonop-
graphic nonunion, they had an equal number of good resul.ts at
erative methods require either heavy sedation or light general
a mean follow·up of 11 years. Many more reports in the Ijtera-
anesthesia.
turc (211,233,252) also demonstrate the overall good l'Csults
with nonoperative management.
Roberts' Manipulative Technique. The manipulative technique
most commonly used is the one popularized by Roberts (236)
Comparison Studies. The best comparison of the results of which has gained wide acceptance by many other investigarors
operative versus nonoperative treatment comes from reports in (202,214,215,221,236,238,249). It involves placing a valgus
which both methods were practiced in the same institution. Becle stress on the elbow while supinating the forearm and simultane-
et al. (199) had superior results in patients treated nonoperatively ously dorsifJexing the wrist and fingers ro place the forearm
compared with those treated operatively. This same superioriry muscles on s[retch; [heoretically, this should cx[racr [he fragment
of nonoperative management has been found in subsequent re- from the joint. To be effective, this procedure must be performed
portS as well (200,217,252). within the first 24 hours after injury (202,238)
 Chapter} 5: The Elbow 673

Faradic Stimulation. Patrick (235) recommended stimulating explored surgically. One of the original fears was that the raw
the forearm muscles with faradic electric current to supplement surface of the fracture fragment would create scar tissue around
the manual manipulative process. or adjacent ro the nerve and cause continued dysfunction. Thus,
originally it was recommended that the ulnar nerve be uansposed
Joint Distention. Fowles et al. (217) and Masse (230) found that at the time of open reduction (221,243,248). Subsequent repom
if manipulation fails to dislodge the fragment from the joinr, have not found this to be neccssalY (207,246).
distending it with air or Auid might facilitate the extraction
process. Delayed DysftUlction Nonexistent
There is some quesrion as ro whether delayed ulnar nerve symp-
Operative Extraction. Failure to extract the fragment by ma- tOms can even occur after fractures of the epicondyle that are
nipulative techniques is an indication ro proceed with open sur- not associated with dislocation of the elbow. Patrick (235) could
gical extraction. Once open extraction and reduction have been not find any instance in which a delayed ulnar neuritis developed
performed, many methods have been advocated to stabilize the in a review of over 100 patients with uncomplicated fractures
fragment. The simplest appears to be the use of sutures (221). involving the medial epicondylar apophysis. He found some
Excision also has been advocated, especially if rhe fragment is patients with lare ulnar neuritis in fractures that were associated
comminured (197,202,245). with dislocation of the dbow. Bernstein et al. (200,211) found
that their patients with initial ulnar nerve symptOms all did well
Incarceration Discove1"ed Late. when treared nonoperatively. Thus, the original fear of delayed
Original Opinions-No Treamlent. If the fragment has been ulnar nerve dysfunction has been dispelled.
lodged in rhe joinr for more than 4 weeks, the results with late
removal have been poor. Patrick (235) found that by 4 weeks, Joint Stability-Relative
the fragmem had become fused to the articular surface of the Woods and Tullos (254) believe that athletes can exhibit a signif-
coronoid process. Forceful removal of the fragment after this icant disability if they have even minor forms of valgus instability
period of time produced a raw defect in the articular surface after elbow injuries involving the medial epicondylar apophysis.
of the coronoid process. This defect subsequently scarified rhe This is especially true in athletes who must have a stable upper
opposing trochlear articular surface. In addition, the long-term extremity, such as baseball pitchers, gymnasts, or wrestlers. In
presence of rhe fragment in rhe joint sublux:m:s rhe joint and the younger person « 14 years of age), the anterior band of
strerches the capsule and ligamellts. If the fragment is removed the ulnar collateral ligament often displaces with the apophyseal
after these ligaments and capsules have undergone secondary fragment. In older individuals (15 years or older), large frag-
changes, elbow stability may be lost. Blount (201) recommended ments may be avulsed without a ligamentOus injulY. Rather than
thar these fractures wirh rhe fragment incarcerared in rhe joinr depending on arbitrary measurements of fracture displacement,
be lefr untreared if more than 6 weeks has passed since rhe Woods and Tullos (254) recommended the use of the gravity
original injury. valgus stress test to determine the presence or absence of valgus
instabiliry. They believed that demonsttation of a significant
More Recem Views-Removal Recommended. The opinion that valgus instability, using this simple graviry test, was an indication
surgety is detrimental in patients with late incarceration has been for surgical intervention in patients who require a stable elbow
for their athletic activities. Pimpalnerkar et al. (146) also sug-
challenged by the more recem studies of Fowles er al. from
Tunisia (216). In their patients in whom the fragment was surgi- gested rllat clinical evidence of instability, as shown by gravity
cally extracted an average of 14 weeks after injury, 80% more valgus stress testing, is an indication for operative fixation.
dbow motion was regained. In addition, the parients' preopera-
tive pain was relieved and the ulnar dysfuncrion resolved. On a
long-term basis, intraarticular retention of the fragment may not • AUTHORS' PREFERRED METHOD
be all rhat disabling. Rosendahl (237) reported an 8-year follow- ,~ OF TREATMENT
up of a fragment rerained within the joint. The epicondyle had
fused ro the semilunar surface of the ulna, producing a large We use the classification scheme (Table 15-3) as a rough guide
bony prominence clinically. There was only minor loss of elbow regarding our treatment options. We also strongly consider the
motion, wirh little funcrional disability. expected activity of tbe involved exuemity in deciding on non-
operative versus operative treatment (Table 15-4).

Ulnar Nerve Dysfunction-Relative

Basically a Nonoperative Fracture
Acute Management
Ulnar nerve dysfunction is a relative indication for operative For most uncomplicated fractures, regardless of the number of
intervention. If there are mild to moderate ulnar nerve symptoms millimeters of displacemenr, we prefer nonoperative manage-
at the rime of rhe injury, usually there is no need to explore the ment (Fig. 15-59). This includes fractures associated wi th elbow
nerve, because mosr of these mild symptoms resolve sponta- dislocations. The parents are warned that regardless of the type
neously (200,211). If the dysfuncrion is complete, then the ulnar of treatment, some loss of elbow extension may oCCUI". They
nerve is probably wrapped around the fragmenr and must be should be reassured, however, that this loss of motion, if it does
674 Upper Extremity

rissue injuly associared wirh an elbow dislocarion, rhe parienr

TABLE 15-4. AUTHOR'S RECOMMENDED
TREATMENT may nor feel comfortable iniriaring early motion until abour 5
to 7 days posrreducrion.
Nonoperative treatment
Nondisplaced, minimally displaced
Significantly displaced in patients with low-demand upper ex- Avoid Early Aggressive Physical Therapy
tremity function
Operative treatment Physical th.erapy sl10uld be used only if volumary active morion
Abso,lute: irreducible incarcerated fragment in the elbow joint is difficult ro obtain. The therapisr should emphasize modaJlties
Relative: ulnar nerve dysfunction
designed to decrease swelling and pain and reesrablish. strengrh.
Relative: patient with high-demand upper extremity function
Range of morion should be achieved only by acrive means, nor
by passive scretching.

Operative Indications
occur, is usually nor of any funcrional or cosmetic significance. Our indicarions for operative intervention are basically twofold.
The elbow is immobilized inirially wirh a removable posrerior Firsr and foremost are fracrures in which rhe fragments cannor
splinr, used mainly for comfort and some suppOrt. be exrracred by manipularive means from wirhin the elbow joinr.
Secondly, we srabilize rhe epicondyles operarively in parients
whose expected high-level physical activity requires a srable
Early Motion Essential elbow. We realize, however, rhar it is difflculr to predicr rhe
Because stiffness is the mosr common complicarion of rhis in- arhleric or work porential of a young child.
jury, we encourage early acrive motion. The parienr is encour-
aged to remove the splinr and srarr active morion as soon as 3
Acute Incarceration in the Joint
(Q 4 days posrinjury. The splint is exchanged for a sling as soon

as rhe patienr fcds he or she no longer needs it for supporr. The IF rhe elbow is reduced and the ulnar nerve is intacr, we use rhe
same goes for the sling: ir also is discarded when ir is no longer manipulative rechnique advocated by Roberrs (638) ro arcempr
needed. This regimen of early morion also is used in fractures to extracr rhe Fragment before reducrion. IF rhis rechnique fails
associared wirh a documented dislocarion. Redislocarion after ro remove rhe Fragmenr, or if rhere is any ulnar nerve dysFunc-
elbow dislocation is rare, bur elbow sriffness is common, so ir rion, we proceed directly wirh an open procedure. The Fragment
is more imporrant to iniriare morion as soon as possible afrer is rhen extracred undel' direct vision jusr beFore reducing rhe
reducrion of rhe elbow. Because of rhe greater amoun t of soft elbow dislocarion. If rhe elbow is reduced and rhe Fragment

A B
FIGURE 15-59. Nonoperative management. A: Postreduction film of a 13-year-old girl who sustained
a displaced medial epicondyle following an acute elbow dislocation in her nondominant extremity. She
was treated nonoperatively. B: One year later the fragment has remained distally displaced with an
apparent fibrous union. The patient, however. had a full painless range of elbow motion. (Reprinted
from Wilkins KE. Fractures of the medial epicondyle in children. Instr Course Leet 1991;40: 1-8; with
permission.)
 Chapter 15: The Elbow 675

Operative Technique
Our operative rechnigue involves a direcr medial approach to
rhe fracrure sire. We make a longitudinal incision jusr anrerior
to the medial epicondyle. The fragmenr is usually displaced dis-
tally and anteriorly. The periosreum is removed from the fracrure
site and rhe c10r is exrracred by irrigarion. Ir is imporranr ro

FIGURE 15-60. Pin fixation. Stabilization with pins, although ade-

quate for stability, is unsatisfactory because it prevents early motion,
which is essential for full recovery.

is incarcerared, we avoid rhe inirial manipuJarion and proceed

direcdy wirh an open exrracrion. We usually srabilize rhese frac-
rures wirh a single rhreaded screw rarher rhan wires or pins (Fig.
15-60). This alJows almosr immediare morion.
Follow-up is essenrially rhe same as wirh closed rrearmenr.
Acrive morion is iniriared 5 ro 7 days posroperarively.
A

Prevention of Valgus Instability

Primarily for High-Demand Athletes
Probably our mosr common indicarion for operarive inrerven-
tion is to ensure a srable elbow in parients participaring in high-
demand acrjvities wirh rheir upper extremiry (Fig. 15-61). This
usually involves rhe dominanr exrremiry of baseball pirchers,
rennis players, or foorbaJI guarrerbacks. In wresders and gym-
nasrs, rhe srabiliry of rhe nondominant exrremiry also musr be
considered. This is best achieved wirh operarive Jlxarion.

Valgus Stress Test Impractical

We have not found the valgus mess test to be helpful in deciding
on rhe need for operative stabilization of an athlere's medial
epicondyle. Almosr all of rhese patienrs with any signiflcanr ellS-
placement have a positive valgus streSs tesr. Our decision is based
primarily on rhe parient's need to have a very srable elbow for
his or her arhleric or work acriviry.

B
Stabilize for Early Motion FIGURE 15-61. Operative stabilization. A: Injury film in a 12-year-old
gymnast. Even though this was a nondominant extremity, it was
Fixarion musr be stable enough to allow early marion. Pins pto- thought that both elbows needed stability. B: Radiographs taken 4
vide srabiliry bur do nor allow early motion. Forrunarely, mosr weeks postoperatively showing stabilization of the fragment with a
patienrs are marure enough so rhar rhe fragment can be secured single screw. There was also calcification of the lateral ligaments (ar-
rows), confirming that the elbow was probably originally dislocated as
wirh a rhreaded screw. If a fully rhreaded screw is used, ir is well. (Reprinted from Wilkins KE. Fractures of the medial epicondyle in
overdrilled in the epicondylar fragmenr to allow compression. children. Instr Course Leer 1991;40: 1-8; with permission.)
676 Upper Extremity

idenrify and protect rhe ulnar nerve, but a complete dissection ated for any length of time (Fig. 15-62). The managemenr for
of the nerve usually is unnecessary. A small towel clip is used Jate incarceration was detailed in the previous seerion on treat-
to reduce the fi'acture while the elbow is flexed and the forearm ment.
is pronated. Again, rhe medial epicondyle is normally situated
posteriorly. The Fragment is reduced and stabilized temporarily Ulnar Nerve Dysfunction. The orher major complicarion asso-
with one or two small ](jrschner wires. The final fixation is ciated with this injury is rJle development of ulnar nerve dysfunc-
achieved using a screw, either partially threaded and overdrilled tion. The incidence of ulnar nerve dysfunction varies from 10%
in the epicondylar fragment to compress it against the metaphy- to 16% (l99,229). If the fragment is entrapped in rhe joint, the
sis or a cannulated 4.0-mm screw. After removal of the Kirschner incidence of ulnar nerve dysfunction may be as high as 50%
wires, the elbow is checked to ensure vaJgus stability and reesrab- (97).
Jishmenr of a full range of motion. Afrer closure of the surgical Tile incidence of delayed ulnar nerve neuritis is low. More
incision, the extremity is placed in a long arm cast, which IS profound ulnar nerve injury has been reported after manipulative
bivalved at 7 to 10 days, and active motion is initiated. procedures (235). Thus, in patients with incarcerated fragments
in rhe joint, manipulation may not be the procedure of choice
if a primary ulnar nerve dysfunction is present. Patienrs in whom
the fragmenr was left incarcerated in the joint for a signiflcanr
Fragmented Apophysis
time have experienced poor recovery of the primary ulnar nerve
If rhe epicondyle is fragmented and there is a need to achieve injury (229).
elbow stability, an ASIF spike wasller can be used to secure the
mulriple pieces to the metaphysis. This may enrail a second Dysfunction. Although the ulnar nerve is the major nerve in-
procedure to remove the spike washer once the epicondyle is jured, the median nerve may be encased between a bony frag-
securely united to the meraphysis. If rhis is impossible, we simply ment and the distal humerus (181). It is speculated that the
excise rhe fragmenrs and reattach the ligamenr to the bone and nerve can be eurrapped between the apophyseal fragment and
periosteum at the base of the epicondylar defect. rhe distaJ humerus at the time of the original injury. This type
of injury is described in greater detail in the section on complica-
tions of elbow dislocations.
Complications
Minor Complications. Odler complications are minimal in na-
Although much has been written about fractures involving the ture. Nonunion of rhe fragmenr with the disral metaphysis oc-
medial epicondylar apophysis, few complications are attributed curs in up to 50% of fractures with significanr displacement
to the fracture itself. The major complications that result in loss (199). This appears to be more of a radiographic probJem than
of function are failure to recognize incarceration in the joint and a funcrional problem.
ulnar or medial nerve dysfunction. Most of the other complica- Anorher common problem is loss of the final degrees of elbow
tions are minor and result in only minimal functional or cos- extension. A Joss of 5% to 10% can be expected to develop in
metic sequelae (TabJe 15-5). abour 20% of these fractures (243). Little functional deficit is
attribured to this loss of elbow dysfunction. Prolonged immobi-
lization seems to be rhe key factOr in loss of elbow extension.
Major Complications
Again, it is important to emphasize before treatment is begun
Failure to Recognize Incarceration. Failure to recognize incar-
tbat loss of motion is common after this injury, regardless of
ceration of the epicondylar fragment into the joint can result in
the merhod of treatment used.
significant loss of elbow marion, especially ifit remains incarcer-
Myositis ossificans has been described as a rare occurrence
following vigorous and repeared manipulation to extract the
fragment from the joint (212). As with many other elbow inju-
ries, myosi tis may be a result of the treatment rather than rhe
injury itself.
TABLE 15-S. FRACTURES OF THE MEDIAL Myositis ossiflcans must be differentiated from ectopic calcifi-
EPICONDYLAR APOPHYSIS:
COMPLICATIONS
cation of the collateral ligaments, which involves only the liga-
mentous srructures. This may occur afrer repeJted injuries to
Major the epicondyle and ligamentous structures (Fig. 15-63). Ofren
Failure to recognize incarceration in the elbow this calcified ligament is asymptomaric and does not seem to
Ulnar nerve dysfunction
Minor create functional disability.
Loss of elbow extension The cosmetic effects are minimal. In some parienrs, an accen-
Myositis ossificans tuarion of the medial prominence of the epicondyle creates a
Calcification of the collateral ligaments false appearance of an increased carrying angle of the elbow
Loss of motion (251). Smith (242), in his extensive review, recognized only a
Cosmetic effects
Nonunion in the high-performance athlete slight decrease in the carrying angle in two patients.
Nonunion in the high-performance athlete may be difficult
to treat. One of the authors had as a parient a high-performance
 Chapter 15: The Elbow 677

A B
FIGURE 15-62. Late incarceration. A: Anteroposterior radiograph of a 12-year-old who had unrecog-
nized incarceration of the medial epicondyle. There was also some ulnar nerve dysfunction. B: Lateral
view shows only a faint overlay (open arrows) of the epicondylar fragment. The fragment was extracted
late. Normal motion was never regained.

adolescem baseball pitcher who had to stop pitching after non- Fractures Involving the Lateral Epicondylac
operative managemem of a medial epicondyle fracture. The pa- Apophysis
tiem had developed a fibrous nonunion (Fig. 15-64). Auempts
Incidence
to establish union surgically were unsuccessful. The patient con-
tinued playing baseball bur had to change to a position in the Fracture of the lateral epicondylar apophysis is a rare injury. In
outfleld. the review of 14 reportS (see Chapter 13) discussing 5,226 frac-

A B
FIGURE 15-63. Heterotopic calcification. A: Injury to an ll-year-old who had moderate displacement
of the medial epicondyle (arrow). B: One year later she had considerable calcification of the ulnar
collateral ligament (arrows). Other than mild instability with valgus stress, she had full range of motion
and was asymptomatic. (Courtesy of Mark R. Christofersen. M.D.)
678 Upper Extremity

FIGURE 15-64. Nonunion in an athlete. This 15-year-old baseball

pitcher had an untreated medial epicondyle fracture 1 year before this
radiograph. He developed a fibrous union, but the epicondyle was
shifted distally (arrow). His elbow was unstable enough to prevent him
from pitching.

tures of the distal humerus, only fracture of the lateral epicondy-

lar apophysis was mentioned (663). Five other isolated injuries
have been described in textbooks addressing fractures in children
(666,668,669) .

B
Anatomic Considerations
FIGURE 15-65. Lateral epicondylar apophysis. A: The cartilaginous
Because the presence of this apophysis is often misinterpreted apophysis occupies the wedge-shaped defect at the margin of the lat-
eral condyle and metaphysis (arrow). The dotted line shows the margin
as a small chip fracture, a thorough understanding of the anat- of the cartilaginous apophysis. B: Ossification of the apophysis begins
omy and ossification process is essential for evaluating injuries at the central portion of the wedge defect (solid arrow) and progresses
in th is area. both proximally and distally (open arrows) to form a triangular center.

Late Ossification
The lateral epicondybr apophysis is presenr for a considerable
period but does not become ossified until the second decade. Part of Lateral Condyle
The best discussion of the anatomy of the ossiflcation process is Silbersrein et al. (261) nored that the fracture line involving the
in a report by Silberstein et al. (261), and much of the following lateral condylar physis often involves the proximal physeaJ line of
discussion is paraphrased from their work. JUSt before ossi fica- the lateral epicondylar apophysis. Thus, this apophysis is almost
tion of rhe apophysis, rhe ossification margin of the lateral supra- always included with the lateral condylar fragment.
condylat tidge of the disral metaphysis curves abruptly medially
roward the law'al condylar physis (Fig. 15-65). This causes the
Mechanism of Injury
osseous borders on the lateral aspect of the distal humerus to
take rhe shape of the number 3. The central wedge of this In adults, the most common etiology is that of a direct blow to
defect contains the cartilaginous lateral epicondylar apophy- the latetal side of the elbow. In children, because the for(,~\rm
sis, which begins to ossify around 10 to 11 years of age. extensor muscles originate from this area, it is believed that avul-
Ossification begins at the level of the lateral condylar physeal sion forces from these muscles can be responsible for some of
line and proceeds proximally and distally to form a triangle, these injuries (260). Hasner and Husby (256) believe that the
with the apex directed toward the physeal line. The shape of location of the fracture line in relation to the origins of the
the epicondylar apophyseal ossification center also may be in various extensor muscles determines the degree of displacement
the form of a long sliver of bone with an irregular pattern of that can occur (Fig. 15-66). If the proximal part of the fracture
ossi fication. line lies berween the origin of the common extensors and the
 Chapter /5: The Elbow 679

an avulsion fracture. The key to determining true separation is

looking beyond the osseous tissues for the presence of associated
soft tissue swelling (Fig. 15-67). If the ossification center lies
Extensor carpi radialis longus distal to the osteochondral border of the lateral condylar epi-
physis, it should be considered displaced (Fig. 15-68).

C a p s u l e - - - - - - - - - + + -......
Treatment
Common extensor origin Unless the fragment is incarcetated within the joint (257), treat-
ment usually consists of simple immobilization for comfon.
Radial collateral ligament
Nonunion of the fragment has been teported (255,258). Even
with this radiographic finding, the resultant elbow function Ius
FIGURE 15-66. Soft tissue attachments. The origins of the forearm and been described as being quite good.
wrist extensor muscles. radial collateral ligament, and outline of the
capsule are demonstrated in relation to the lateral epicondylar apophy-
sis. (Reprinted from Hasner E, Husby J. Fracture of the epicondyle and
condyle of humerus. Acta Chir Scand 1951;101: 195-202; with permis- Complications
sion.)
Only one ['ate major complication has been described with frac-
tures involving the lateral epicondylar apophysis: entrapment of
the fragment, either within the elbow joint (257) or between
the capitellum and the radial head (264).
extensor carpi radialis longus, usually there is linle displacement.
If the Fracture lines enter the area of origin of the extensor carpi
radialis longus, then considerable displacement can occur. Chronic Tension Stress Injuries (Little
League Elbow)
This chronic injury is related to overuse in skeletally immature
X-Ray Findings
baseball pitchers. The original radiographic findings were de-
Because the ossification process starrs on the external surface of scribed by Brogdon and Crow in 1960 (204). Later, Adams
the apophysis and proceeds centrally, the ossification center (195) demonstrated that the radiographic changes were due to
often appears separated from the lateral metaphysis and lateral excessive throwing and emphasized the need fot pteventive pro-
condylar epiphysis. This natutal separation can be confused with grams. This injury is thought to be due to excessive tension on

A B
FIGURE 15-67. Lateral swelling. A: Soft tissue swelling in the area of the lateral epicondylar apophysis
(arrows) should make one suspect that this is an undisplaced fracture involving the apophysis. The
fragmentation of the apophysis is due to irregular ossification. B: A small avulsion of the lateral epicon-
dyle (open arrow) in an adolescent who is almost skeletally mature. There was considerable soft tissue
swelling in this area (solid arrows).
680 Upper Extremity

A B
FIGURE 15·68. Avulsion injury. A: Avulsion of a portion of the lateral epicondyle in an adolescent
(arrow). The fragment is at the level of the joint. Most of the epicondyle has fused to the condyle. B:
Appearance 9 months later showing fragmentation and partial union of the fragment. (Courtesy of R.
Chandrasekharan, M.D.).

the medial epicondyle with secondary tendinitis. Thete also can niques. The spectrum of these chronic injuries is outlined in
be a repeated compression on the lateral condyle, producing an Table 15-6.
osteochondritis. [n chronic tension stress Injuries (Little League elbow syn-
Studies have shown that as long as the rules outlined by the drome), the hiscoly is usually quite characteristic. It is found in
Little League are followed (i.e., twO innings per game, six innings young baseball pitchers who are throwing an excessive number
per week), the incidence of these chronic tension stress injuries of pitches or who are JUSt starring to throw curve pitches (204,
is fairly low (218,219,226). Mosr of the problems arise when 234). Clinically, this syndrome is manifested by a decrease in
overzeaJous parents and coaches require excessive pitching pre- elbow extension. Medial epicondylar pain is accentuated by a
season and at home between practices. Albright (l%) Found a valgus stress co the elbow in extension. There is usually signifi-
greater incidence in pitchers who had improper pitching tech- callt local tenderness and swelling over the medial epicondyle.

A B
FIGURE 15·69. Acute tension stress. A: Anteroposterior view of the pitching arm of a 10-year-old with
medial epicondylar pain. The apophyseal line is widened and slightly irregular. B: Same view of the
opposite elbow for comparison.
 Chapter /5: The ELboUJ 681

AVASCULAR NECROSIS OF THE

TABLE 15-6. SPECTRUM OF CHRONIC TENSION
STRESS INJURIES OF MEDIAL
TROCHLEA
EPICONDYLAR APOPHYSIS Definition
Stress fracture of the epicondylar physis This term is used to define rhree differenr parhologies characrer-
Calcification of the ulnar collateral ligaments
ized by a disturbance of the growth process of rhe centers of
Hypertrophy of the medial epicondyle
Acceleration of growth maturity with generalized synovitis and ossificarion of the trochlea. These are classified as idiopathic,
stiffness congenital, and posttraumatic.
Osteochondritis of the lateral condyle

Idiopathic
Hagemann's disease (aseptic osteonecrosis of the humeral troch-
lea, or osteochondriris of rhe humeral rrochlea, or osteochondro-
sis of the humeral rrochlea) is avascular necrosis of rhe rrochlea
On radiographs, the density of the bone of the distal humerus that appears with no prior history of trauma (268).
is increased due to rhe chronicity of the stress. The physeal line
is irregular and widened (Fig. 15-69). If the suess has been going
Congenital
on for a prolonged period, there may be hypertrophy of the
distal humerus with acceleration of bone growth. The bone age There are twO reports of seemingly congenital forms of rrochlear
of rhe elbow is grearer rhan rhe parient's chronologic age (Fig. hypoplasia. In a repon ofjapanese parients (279), rhe hypoplasia
15-70). was bilateral, with symproms present since early childhood. An-
We use a multifaceted approach that involves education of orher repon (276) involved an African-American family in which
the parents, coaches, and player. Once symptoms develop, all rhe morher and rhree offspring had severe bilareral forms of
pitching activity must cease until the epicondyle and adjacent aplasia of the trochlea.
flexor muscle origins become nontender. In addition, local and
sysremic measures ro decrease the inflammatory response are
Posttraumatic
used. Once the initial pain and inflammation have decreased, a
program of forearm and arm muscle strengthening is initiated. This most common form follows some rype of elbow rrauma.
The pirching rechnique is also examined ro see if any corrections In some cases, rhe rrauma is occulr or poorly defined. This form
need ro be made. Once strength has been reestablished in the results in a spectrum from simply a small defect of the trochlea
muscles in the upper exrremity and morion has been fully rees- (fishtail deformity) ro complete destruction of the medial aspen
tablished, rhe parient is gradually rerurned ro pitching. This is of the distal humerus with a progressive axial deformi ty, de-
done on a gradual basis, carefully moniroring rhe number of creased range of motion, and associated disabling instability of
innings and pitches within a specified period of time. the elbow.

A B
FIGURE 15·70. Chronic tension stress. A: Anteroposterior view of a 13-year-old pitcher with chronic
pain and significant loss of elbow motion. The bone age is around 15 years. B: Same view of the opposite
elbow with a bone age of 13 years.
682 Uppel' Extremity

Historical Perspective Trauma to Distal Humerus Most Common Cause

Idiopathic Cases (Hagemann's Disease) It has been desnibed as a complication of almost any fracture
type to the disral humerus, except for isolated epicondylar inju-
Osteonecrosis of the trochlea was first described in 1933 by
ries. Avascular necrosis of the trochlea has been reponed as a
Uhrmacher (284) in a 7-year-old patiem. Almost 20 years after
consequence of the following injuries.
this initial description, Hagemann (268) published his classic
article on the idiopathic nature of this type of avascular necrosis.
Thus, the idiopathic form has become known, at least in the Distal Fractures of the Lateral Condylar Physis
European literature, as Hagemann's disease (263). A close inves-
tigation of many of the cases of so-called Hagemann's disease, The term fishtail deformity was coined in the classic arricle on
however, reveals that rhere was usually some amecedent elbow lateral condylar fractures by Wilson published in 1955 (288).
rrauma that mayor may not have comributed to the develop- This term, which usually represents a localized avascular necrosis
ment of the avascular necrosis (263). of the trochlea, has subsequently been used by others in their
reports on fracrures of the lateral condyle (275,278,286,288,
297).
Trauma-Related Cases
The first description of avascular necrosis of the trochlea follow- Fractures of the Medial Condylar Physis
ing elbow trauma was in 1948 by McDonnell and Wilson (274).
This type of fracrure is especially vulnerable to developing avas-
In their scries, the problem occurred as a com plication of both
cular necrosis of the trochlea because of the close proximity of
latcraJ condylar and supracondylar fractures. Seven years later,
the fracture line to the blood supply of the trochlea (264,270,
Wilson (288) described the eypical fishtail deformity occurring
273,280,285). It can occur in cases treated either operatively
after some fractures of the latera] condylar physis. There was little
or nonoperatively. Operarive management of rhis fracrure can
mention as to rhe col'lsequence or etiology of this complication in
increase the incidence or exrent of the avascular necrosis by iatro-
these arricles. Such was also the case in other articles in which
genic injulY ro the most medial blood supply to the rrochlea,
avascular necrosis of the trochlea can be seen in the clinical
which is exrraarricular.
phorographs in many of the cases illustrated (264,265,269,
271-273,285-21\8). Usually there was Iinle or no mention of
the significance of this finding in the captions. Supracondylar Fractures
Avascular necrosis of the rrochlea also has been described follow-
Vascular Etiology ing very distal supracondylar fractures (263,265,274,278). This
can occur in borh displaced and nondisplaced fractures. The
Not until 1984, when Morrissey and Wilkins (278) reported index case for Morrissey and Wilkins' arricle (278) was actually
five cases of avascular necrosis of the trochlea, was its relarionship a very distal nondisplaced supracondylar fracrure thar developed
to the unique blood supply of this area suggested. They poimed a typical fishtail deformity.
out that according to the classic arricles of Haraldsson (266,267)
on the blood supply of the distal humerus, the medial crista of
the trochlea has twO separate blood supplies that can be injured Separation of the Total Distal Humeral Physis
with trauma. This relationship of the unique blood supply to
Again, rhe velY distal location of rhe fracrure line allows it ro
the various patrerns of avascular necrosis is discussed in detail
transect the rransphyseal vessels at the lateraJ ponion of rhe me-
in the following sections relating to etiology and the patterns of
dial crista during the acute fracture (269,278,289,290). Many
necrOSIs.
of rhese recover, and the avascular necrosis is never evident be-
A more recem article by Yoo and co-workers (290) also relates
cause this often occurs in rhe preosseolls stage of the develop-
avascular necrosis to a vascular etiology with their observation
ment of the trochlea.
that it occurred with a higher incidence in their cases of total
distal humeral physeal fraccures.
T-Condylar Fracture

Incidence If comminution occurs, some of the T-condylar fractures can

injure the delicate blood vessels thar supply rhe trochlea. Fortu-
Seldom Reported nately, most of these occur in the older age group, in which
Because it is seldom reponed in the literature, the exact incidence the vulnerability of the distal humerus to avascular necrosis is
is unknown. As mentioned previously, many cases are illustrated lessened.
in various repons with little or no mention of its occurrence or
significance. We reccmly reponed on a series of 30 cases col-
Sprain of the Elbow
lectcd over the past 20 years from various sources (283). Ir is also
our experience that it is probably one of the most unrecognized This entity also has been described as "following a sprain" of
sequela of injuries to the distal humerus. rhe elbow (265). However, this was probably an unrecognized
 Chapter 15: The ELbow 683

and undisplaced very distal supracondylar or distal physeal in- to enter the posterior aspect of the lateral trochlear ossification
Jury. center. Their terminal branches lie JUSt under the articular sur-
face (Fig. 15-710). Thus, they are particularly vulnerable to
injury when the fracture line occurs through this area, as is typi-
Iatrogenic cal in fractures of the medial condylar physis or lateral condyle
Sometimes an extensive surgical approach and dissection of the or aT-condylar fracture. By the same tOken, a fracture in the
soft tissue is necessary to obtain a good open reduction of a supracondylar area in which the fracture line is very distal, or a
fracture about the elbow, especially when seen and treated on a total distal humeral physeal displacement, also can disrupt the
delayed basis. This can injure the vessels that supply the trochlea, lateral trochlear epiphyseal vessels as they course along the sur-
with subsequent avascular necrosis (270). When surgically ap- face of the metaphysis or at their entrance intO the physeal plare.
proaching the medial condylar anicular surface from a medial
approach, the vessels supplying the medial aspect of the medial Medial Vessels
crista are on the extraarticular surface of the crista of the trochlea Another set of vessels enters medially rhrough rhe nonarticulat-
and must be carefully avoided. ing surface of the trochlea (Fig. 15-71B and C). This ser of
vessels supplies rhe most medial aspect of the medial crista or
the medial portion of the trochlear epiphysis. As shown in Har-
Etiology aldsson's (266,267) studies, there appear ro be no anastomoses
between these two sets of vessels supplying the trochlear epi-
Three theories have been proposed to account for the posttrau-
physis.
matic changes that occur in the distal humerus after fractures
in the vicinity of the trochlea: malunion, partial growth arrest,
and vascular injury. Age Factors
Most of the reponed cases of avascular necrosis of the trochlea
occur in children who are at least 6 or 7 years of age. However,
Malunion
it has been recently reponed in younger patients after fract-
Wilson (288) rhoughr this was the result of a malunion of a ure-separation of the entire distal physis of the humerus (290).
lateral condylar fracture with an intervening gap. This type of Ossification centers need blood supply for their appearance
deformity is static, often asymptomacic, and nonprogressive. and development. Before these centers appear, the vessels are
more superficial and less well defined. It is speculated that a
lesion in these immature vessels in children leads only to a delay
Partial Growth Arrest in the appearance of the centers. In older children, where mere
Wadsworth (287) thought this represented a premature fusion is already a well-defined ossification center, disruption produces
of the lateral condylar epiphysis ro che metaphysis. Jakob and a true bony avascular necrosis of one or both of the ossification
co-workers (271) thought this was actually due to a primaty centers of the trochlea. This can result in a partial or total absence
disturbance of the growth cells adjacent to the fracture line of of further epiphyseal ossification, leading to hypoplasia of the
the lateral condyle. These theories can support the development central or whole medial aspect of the trochlea.
of hypoplasia of the central or lateral ponion of the trochlea.
They do not, however, explain the total destruction of the troch- Fracture Location Critical
lea rhat can occur. Growth arrest often takes months or years
The common factor of all these fracture pathologies producing
to produce deforming effecrs, and many of these changes occur
avascular necrosis of the trochlea seems to be the presence of a
rapidly after the initial injury.
fracture line or other injury in proximity to the lateral aspect of
the medial condylar physis or the whole medial crista of the
Vascular Injury trochlea. These fracture lines injure the vessels as they enter their
respective ossification centers of the trochlea.
Two Sepa.rate Sources
The direct relationship between trauma and avascular necro-
In Haraldsson's classic studies (266,267) of the blood supply of
sis of the trochlea also has been suggested by its development
the distal humerus, he demonstrated that the medial crista of
after surgical intervention of the original fracture, especially after
the trochlea had twO separate sources of blood supply. Neither
open reduction from a medial approach.
has anasromoses with each other or with the other metaphyseal
To support the vascular theory, there is also the observation
vessels. In the young infant, the vessels are small and lie on the
that the necrosis of the trochlea follows the trauma rapidly.
surface of the perichondrium (Fig. 15-71A-C). Immediately
When recognized early, the period between the fracture and
before and during the deposition of bony salts in the ossification
the development of changes consistent with avascular necrosis
centers of the trochlea, two distinct lateral and medial nonanas-
is months or weeks (278,290).
romotic sets of nutrient vessels are present.

Patterns of ecwsis
Lateral Vessels
The lateral vessels supply the apex of the trochlea and the lateral Avascular necrosis of the trochlea can appear as either a central
aspect of the medial crista. These vessels cross the growth plate defect (type A) or total hypoplasia manifest by complete absence
684 Upper Extrenzit),

A B

FIGURE 15-71. Blood supply of the trochlea.

A: Intraosseus vasculature in a 3-year-old boy.
Only two small vessels supply the medial
crista of the trochlea (arrows). The central
portion of the crista appears avascular. B: In-
jection studies showing the well-defined me-
dial and lateral vessels (arrows) supplying the
medial crista of the trochlea. C: Close-up view
showing the extent of the vascular supply of
the trochlea. Note that no anastomoses are
seen between these medial and lateral ves-
sels. D: Lateral view through the medial crista
of the trochlea. Note that the vessels pene-
trate the physis posteriorly (arrow) to enter
the epiphyseal cartilage. (A-D: Reprinted
from Haraldsson S. On osteochondritis de-
formans juvenilis capituli humeri. Acta Or-
thop Scand Supp/1959;38: with permission.)
E: Radiograph of a 12-year-old boy. The per-
sistence of the two separate ossification cen-
ters (arrows) of the medial crista is seen. The
area supplied by the lateral vessel is larger
c than that supplied by the medial vessel.

D E
 Chapter /5: The ElbolU 685

A B c
FIGURE 15-72. Fishtail deformity. A and B: Type A deformity. Avascular necrosis only of the lateral
ossification center creates a defect in the apex of the trochlear groove. C: Radiograph of a 14-year-old
boy who sustained an undisplaced distal supracondylar fracture 5 years previously. The typical fishtail
deformity is seen.

of rhe rrochlea (type B), depending on rhe extent of rhe vascular Sequelae
injury.
The clinical signs and symproms differ considerably berween rhe
rwo pauerns of necrosis.
Type A-Fishtail Deformity
ln rhe rype A deformity, only rhe lareral portion of the medial Type A-Arthritic Symptoms
crista or apex of rhe trochlea becomes involved in the necrotic Patients who have type A or fishrail deformiry usually do nor
process. This produces the typical fishrail deformity (Fig. 15- develop any angular deformiries. Early degenerarive joint disease
72). This more common pauem of necrosis seems ro occur wirh with a loss of range of morion is rhe mosr common sequela.
very disral supracondylar fractures or with fractures involving The severiry of rhe fishtail defOl'miry is relared ro rhe degree of
rhe larera] condylar physis. necrosis and seems ro dicrare the severity of the symproms. Wil-
son (288) reporred a 47-year follow-up in a parient whose major
complainrs relared primarily ro arthritis.
Type B-Malignant Varus Deformity
The rype B deformity involves avascular necrosis of rhe entire
rrochlea and somerimes parr of rhe meraphysis (Fig. 15-73). This Type B-Progressive Varus
rype of necrosis has occurred as a sequela of fractures involving In children who have a pattern of wral avascular necrosis of rhe
rhe entire disral humeral physis or fractures of rhe medial condy- rrochlea, including parr of rhe nonarricular surface, usually a
lar physis (285). This can lead to a cubitus varus deformiry in progressive varus deformity develops. Because the rotal medial
which rhe angularion progresses as rhe child marures. rrochlear surface is disrupted, significant loss of range of morion
also develops. These deform iries usually worsen cosmerically and
funcrionaJly as the child marures (Fig. 15-73C and D).
Clinical Signs and Symptoms
There is no parricular clinical sign during rhe evolurion of rhe
Ulnar Neuropathy
necrosis. In mosr cases, rhe symproms develop afrer healing of
rhe fracrure. In facr, in rhe rypical scenario, in which avascular A lare-onser ulnar neuropathy can develop in these parienrs (277,
necrosis of rhe rrochlea occurs after a supracondylar fracture, 282). The hypoplasia of the medial condyle and its associated
rhe parient inirially has full recovery wirh healing of rhe fracture. epicondyle produces a shallow ulnar groove. This allows rhe
However, as rhe necroric process develops, the patient develops ulnar nerve to slip anreriorly. In addirion, the medial head of
rhe lare onser of symproms of degenerative joint disease such as the triceps muscle also slips anteriorly. There is no consensus
sriffness, loss of morion, and pain following physical acrivity. on the <:tiology of the ulnar neuroparhy. It is rhought to be due
686 Upper Ex·tremity

FIGURE 15-73. Avascular necrosis of the entire trochlea.

A: Type B deformity. Loss of blood supply from both the
medial and lateral vessels results in avascular necrosis of
the entire medial crista along with a portion of the meta-
physis. B: Radiograph of a 4-year-old boy who sustained a
type II physeal fracture involving the entire distal humeral
physis. In this injury film there is a large metaphyseal frag-
ment on the medial side (arrow). C: Appearance 5 months
later. A mild varus deformity present is due to an incom-
plete reduction. The ossification in the medial metaphyseal
fragment has disappeared. 0: Radiograph taken 4 years
after injury. The entire medial crista and adjacent medial
metaphysis have remained avascular. The varus deformity
has progressed. E: Correction was achieved by performing
a combination lateral closing wedge and medial transloca-
A tion osteotomy.

B c

D E
 Chapta 15: The Elbow 687

(Q a mulriplicity of fac(Qrs, including malalignmenr of rhe joinr, T -CONDYLAR FRACTURES

abnormal posirion of rhe ulnar nerve and ericeps rendon, loss
of prorecrion by a deep ulnar groove, and rhe acme angle of In T-condylar fractures, the fracture line originates in the central
enrrance of rhe (WO heads of rhe flexor carpi ulnaris. Each of groove of the trochlea and courses proximal co the olecranon
rhese facwrs has a variable bearing 011 rhe eriology of rhe neurop- and rhe coronoid fossae, where it divides and separares the medial
arhy. In some of rhose cases reponed wirh late-ol1set ulnar neu- and lareral bony columns of rhe distal humerus. If rhe proximal
roparhy, there were exrensive bony changes wirh rhe presence fracrure lines are oblique, rhe fracture may be rermed Y-condylar.
of ganglions on rhe medial aspecr of the joinr (282). However, This injUly is rare in the skeJerally immarure child.
late-onser ulnar neuroparhy can occur in children afrer orher
types of injuries wirhour radiographic findings of rrochlear hypo-
plasia (281). Incidence
Primarily in Adolescents
Treatment The early modern lirerarure refleers only reports by Blount (292)
and Zimmerman (319), who each described a case in an 11-
Because rhe avascular necrosis of rhe trochlea is a direer conse-
year-old parient. The average age of parients reponed in rhe
quence of erauma (Q rhe vessels occurring ar rhe rime of injury,
rhree major recem series (302,303,310) was 12.6 years. Our
rhere is no effeerive prevenrion or rrearmenr of rhe primary ne-
clinical experience wirh II cases over a 20-year span has con-
crosis. Trearmenr entails addressing only rhe sequelae of rhe
firmed rhese dara, wirh rhe average age being 11 years. Thus,
avascular necrosis of rhe erochlea.
Maylahn (306), who reporred on six parienrs near skeletal maru-
riC)', was accurare when he said, "rhe fracrures [T-condylar] rake
on rhe characteristics of an adulr frac(LIre and should be rreared
Loss of Range of Motion as such."
[f rhe loss of range of morion is due to a signiflcanr disruption
of the articular surface irselC rhere does nor appear w be any
good operarive or nonoperarive merhod rhar signiflcandy im- Occurrence in Young
proves elbow funcrion. A good program of muscle srrengrhening
In 1902, Conon (296) echoed rhe view of rhe surgical commu-
may lessen rhe sympcoms w some degree.
niry ar rhar rime when he srared, "rhe frac(LIre [T-condylar] is
In rhe one case rreared surgically by Morrissey (278), he no-
nor only very uncommon, bur very rare [in young children]."
riced rhar the olecranon had migrated proximally because of the
The acrual incidence in younger children is cerrainly rare, bur
cenrral necrotic defeer of rhe disral humerus. He felt rhis creared
ir may be underdiagnosed. This is because ir is ofren confused
an impingement be(Ween rhe olecranon and rhe disral humerus
wirh other fracrures, such as rhose involving the lareral condylar
during full exrension. In rhat case, a parcial resection of the
physis or coral disral physis. Special imaging srudies such as
proximal olecranon improved extension of rhe elbow.
arrhrograms were necessary ro demonsrrare rhe inrracondylar
aspen in a recenr repon inyolving (wo parienrs under 3 years
of age (291). The combinarion of an increased awareness of
Varus Deformity rhe possibility of this injury and a more aggressive diagnosric
If rhe avascular necrosis of rhe rrochlea has resulted in a varus approach may resulr in more cases being uncovered in rhis
deformity of rhe elbow, rhis deformity can be correered by a younger age group.
supracondylar osreowmy (Fig. 15-73E). The correction of rhe The rare occurrence of rhe injLllY is reflected in rhe impor-
rance given in recenr rexrbooks on children's fractures. A few
carrying angle is mosdy cosmetic, wirh liule funcrional improve-
menr. Ir does nor seem co improve rhe range of morion. Surgical (298,309,312,319) conrain only a brief discussion of rhis frac-
(LIre partern; orhers (294,295,300,311,317) do nor menrion ir
rrearmenr carries the risk of increased sriffness (Q rhe already
limired elbow. It can be argued thar if rhis osteocomy is per- at all.
formed relarively early co correcr the varus deformity, this could
decrease the incidence oflate-onset ulnar neuroparhy due co rhe
anrerior migrarion of rhe ulnar nerve and medial head of rhe Mechanism of Injury
mceps. Wedge Effect of the Olecranon (Semilunar Notch)
The primary mechanism of rhis injuly is rhe direcr wedge effecr
of rhe arricular surface of rhe olecranon on rhe disral end of the
Ulnar Neuropathy
humerus. The sharp edge of rhe semilunar norch or coronoid
In the cases of ulnar neuropathy occurring afrer hypoplasia of process acts as a wedge co break rhe trochlea and splir rhe con-
rhe rrochlea, relief of ulnar nerve sympcoms was achieved by dyles, which in rurn separares rhe two columns of rhe disral
n-ansposing rhe ulnar nerve anteriorly in addition to releasing it humerus (297). In our review of II skeletally immarure parienrs
from rhe adhesions around rhe hypoplasric medial epicondyle wirh this injury, the venical fraerure line always exrended down
(277,282). co rhe apex of rhe erochlea, rending co confirm rhis mechanism.
688 Upper Extremity

In a biomechanicaI srudy performed on adulr cadaver specimens, The mecnanism of tnese hactures has evolved from borh
Mchne and Marra (307) examined rhe force of rhe olecranon biomechanicaJ and clinical srudies. The biomechanicaJ studies
on rhe rrochlea wirh varying degrees of Aexion of rhe elbow. The involve the wedge mechanism of the olecranon against the distal
situarion rhar most consistenrly produced T -condylar fracrures flLlmerus. The clinical srudies are rhe resulrs of indireer observa-
occurred when trte force was applied direcrJy co rne olecranon rions as co wherher injuring force was applied co the distaJ hume-
with rhe elbow in more than 90 degrees of Aexion. rus in either a flexion or exrension position.

A B

c D
FIGURE 15-74. Mechanism patterns. A and B: The more common flexion pattern in which the condylar
fragments are situated anterior to the distal shaft. C and D: An extensor pattern in which the condylar
fragments are situated posterior to the distal shaft. The muscle origins on the respective condyles cause
them to diverge in the coronal plane (arrows) and flex in the sagittal plane.
 Chapter 15: The Elbow 689

Flexion Injuries
The most common mecnanism producing this fracture pattern
is said to be a direct blow ro the posterior aspect of the elbow
(313), usually when the child falls directly on the flexed elbow.
This flexion mechanism ill young children contributes to its
rarity because mosr upper exrremity injuries in children have a
component of elbow hyperextension. Injuries ro the elbow
caused by a flexion mechanism are rare. In these flexion injuries,
the wedge effect is produced ar rhe apex of the trochlea by the
central portion of the trochlear norch. In these flexion injuries,
rhe condylar fragments usually lie anterior ro the shaft (Fig. 15-
74A and B).

Extension Injuries
In a few cases, rhe T-condylar fracture may be caused by a fall
on the oursrretched arm with the elbow in only slight flexion.
This exrension mechanism has been suggesred by parients in
rheir description of the dynamics of the fall, and indirectly by FIGURE 15-75. Intact articular surface. A T-condylar fracture in a 7-
year-old boy. The thick articular cartilage remains essentially intact,
rhe position of the distal fragments in relation to the diaphyses preventing separation of the condylar fragments. This fracture was se-
of the humerus-in orher words, lying posterior (Fig. 15-74C cured with simple percutaneous pins.
and 0). In the exrension type of injulY, the coronoid portion
of the semilunar notch produces rhe wedge effect.

(Fig. 15-75) (310). Thus, the disruption and displacement are

Role of Muscles primarily in the osseous supracondylar area. The elasticity of the
cartilage of rhe distal end of the humerus often protects the
Ir has been suggesred rhat contraction of the elbow flexor and
articular surface from being completely disrupted.
extensor muscles may playa role in rhe displacement pattern of
rhis fracrure. Because of rheir origins on rhe epicondyles, they Variable Resistance to Failure
aCcentuate borh tne separation in rhe coronal plane and rhe Corron (296) reasoned that in the distal humerus, the condyles
fOlward displacement in the sagittal plane. This displacement present variable resistance ro failure. The external (lateral) con-
pattern ofren is evident on rhe injuty ftlms (Fig. 15-74C and dyle has a weakened resistance. The medial condyle exhibits a
0). srronger resisrance to separation. Ir was his opinion that rhis
variable resisrance explained [he infrequency of both T -condylar
and medial (internal) condyle fractures and the higher incidence
Pathology of lareral condyle fractures.
The More Common Adolescent Pattern
Classification
The fracture patrern in rhe adolescent is similar to thar of tne
adult. The condylar fragments are ofren separated, with rhe artic- Various classiftcations (302,308,314) for adult T-condylar frac-
ular surface being complerely disrupred. In addition to separa- rures have been proposed, but there are problems with applying
rion of rhe condylar fragments by the force of the original injl\lY, these classiftcarions LO children's injuries. For example, the num-
rhe muscles rhat originate on these condylar fragmenrs rorare ber of children with rhis fracture is so small that no clinician
rhem in bmh the coronal and sagirtal planes (Fig. 15-74C and can include all types offracrure patterns in his or her own experi-
0) (297). In the sagittal plane, the position of the condylar ence. In addition, there is no useful classifIcation for rhe younger
ftagments in telarion ro rhe humeral shaft and metaphysis can patient, in whom the unossified intacr articular cartilage is nor
eirher be anterior (flexor mechanism; see Fig. 15-74B) or poste- visible on radiography. For example, the Jarvis type III (302)
rior (exrension mechanism; see Fig. 15-740). fracture-dislocation or Chutro-Posados fracture has never been
observed in our clinical experience, nor has ir been reponed in
orher series. The C-3 fracture in the AO classiftcarion (308,
The Rare Patterns in the Young Child 319), which has articular surface comminution, also has nor
been reporred in the literarure in children.
Articular Surface Remains Intact
In rhe skelerally immarure parient, rhe central portions of the Authors' Suggested Classification
condylar fragments are usually separated, bur rhe articular sur- We have tried LO simplify the classificarion so rhat it will be
face may remain intact because of its large cartilage component useful in determining trearment oprions. We feci rhere are rhree
690 Upper Extremity

major types based on the degree of displacement and comminu- rreatment, the surgeon may need ro obtain ejther varus or valgus
tion of the fracture fragments. Type I fractures are minimally stress films under general anesthesia (291). In many cases, rhe
displaced (Fig. 15-76A and B). Type II fractures are displaced use of contrasr medium in the form of an arthrogram is also
but do not have comminution of the metaphyseal fragments quite helpFul.
(Fig. 15-76C). Type III fractures are displaced fracrures with
comminution of the metaphyseal fragments (Fig. 15-760 and
E). Treatment
In a child, the integrity of rhe articular surFace may be difflculr Basic Principles
to derermine without using arthrography or MRl. Because the
initial integrity of the art,icular surface may not be that important Because of rhe rarity of this injury, no one can recommend a
to the prognosis, we feel that this factor does nor significantly plan of management based on multiple case experience. Mosr
conrribure to a general classification scheme. Adolescent T-con- of rhe experience in the past has been based on isolated cases or
dylar fractures may be classified as in adults. small series (291,302,303,305,310). Regardless of rhe method of
treatmenr, certain basic principles musr be considered in trearing
these Fractures. A treatment plan must be individualized for the
Diagnosis specific fracture and rhe surgeon's level of experrise and experi-
Clinical Signs and Symptoms ence. The Following principles must be considered in planning
a merhod of treatment:
Clinically, these fractures are most often confused with exten-
sion-type supracondylar fractures. The extended position of the I. Elbow articular mobility depends on articular congruity, cor-
elbow, along with the massive swelling, is almost identical co recr alignment of the axis of morion, and debris- and bone-
that of the displaced extension type of supracondylar fracture. free Fossae.
2. The srability depends on the inregrity of the lateral and me-
dial supracondylar columns.
Imaging Studies
3. The T-condylar fracture is an articular fracture, so rhe flrsr
Plain X-Rays goal is to resrore and stabilize the joint surface.
Diagnosis NotAlways Obvious Plain x-ray fil ms are the corner- 4. Closed methods alone usually cannot produce an acceptable
scone ro the diagnosis. In the older child, the diffel'entiation must result because of the muscle forces applied to the Fragment.
be made from thar of a comminured supracondylar fracture. 5. Mosr patienrs are adolescenrs wirh minimal potential For
Sometimes rhe diagnosis is not obvious until the fragments have bone remodeling.
been partially reduced, which allows the vertical fracrure lines 6. AJthough surgical reduction may produce an acceptable ra-
splitting rhe trochlea ro become more evident. [n rhe younger diograph, it may add ro rhe already exrensive damage to soFr
child, rhe diagnosis is much more difflculr because the articular rissues; rhis in turn can contribure ro posroperative sriFFness.
surface is nor visible. In addition, because of its rarity, rhe sur-
geon may not consider the possibility of a T-condylar fracture
in this age group. Current Trends Toward Surgical Stabilization
The currenr literature reflecrs good results with SurgiCll manage-
Differential Diagnosis ment. Zimmerman (319) advocated establishing an anaromic
reducrion with internal fixation so rhat early morion could Facili-
The diagnosis must exclude the more common fracture patterns
rare a more rapid rehabilitarion. In the twO cases in young chil-
of either the jsolatedlateraJ or medial condyles, or the complete
dren described by Beghin and colleagues (291), operarive inter-
separation of the distal humeral physis. In these latter fractures,
venrion was necessary to achieve a satisfacrory reducrion. A
an important sign is the presence of a medial or lateral Thursron-
review of the three most recenr series (302,303,310) indicares
Holland fragment in rhe metaphysis (291). The key differential
thar surgical management has been established as rhe presenr
for the T-condylar fractllre is the presence of a venical fracrure
trend by vinue of the Fact thar 29 of the 31 elbows in these
line extending down ro the apex of the trochlea.
combined series were treated operarively. The invesrigators in
these series maintained that open reduction and inrernal fixation
Computed Tomography and Magnetic Resonance was the best way ro restOre the imegrity of rhe articular surface
Imaging and stabilize rhe Fracture sufficiently to allow early mobilizarion.
All but one of rhe parienrs in rhis combined series who were
In rhe acute injury, rhe use of these imaging modaliries does nor
treated surgically demonstrared good or very good resulrs ar Fol-
appear ro have much practical value. In younger patienrs, this
low-up.
often requires a separate anesthesia or heavy sedation outside
rhe operating room.
Popular Surgical Approaches
Dynamic Studies Under Anesthesia
The surgical approach mosr widely :lccepred is the posrerior
The diagnosis may be suspecred aFrer a careful evaluarion of rhe longitudinal splirring of the triceps wirhom an osteoromy of rhe
staric x-ray films. However, ro serde the issue beFore deflnirive olecranon. This approach gives adequare exposure of rhe Fracrure
 C/Ulpm /5: The Elbow 691

A B

C D

FIGURE 15-76. Types of T-condylar fractures. A: Type I-Lateral view of undisplaced T-

condylar fracture in a 6-year-old. B: The T-condylar fracture line (open arrows) was not
appreciated until it healed. There are both medial and lateral Thurston-Holland fragments
(solid arrows). ((ourtesy of Ruben D. Pechero, M.D.) C: Type II-a displaced T-condylar
fracture with very little metaphyseal comminution. D and E: Type III-two views of a
markedly comminuted T-condylar fracture with multiple displaced fragments (arrows) in
E a 12-year-old.
692 Upper Extremity

and the articular surface and does not seem ro produce any loss a hinged cast brace for an additional 2 to 3 weeks. This allows
of strength from splitting the triceps (303). Although one case the initiation of protected active motion. However, with the
demonstr:Hed radiographic evidence of avascular necrosis of rhe present emphasis on shon hospitalization, we find that skeletal
rrochlea (310), another reported a nonunion (303), and many traction is less acceptable for both social and financial reasons.
had some loss of range of motion, none of these surgically treated Skeletal traction may be the only acceptable method of [[eatment
cases demonstrated any significant loss of elbow funerion or in patients seen on a delayed basis with extensive skin abrasions,
discomfort. severe soft tissue injury, or gross comminution, in which cast
Another surgical approach that has become popular is the application or other operative interventions might carry a high
one advocated by Bryan and Morrey (293). This is a triceps- risk of infection.
sparing approach in which the extensor mechanism is reflected
laterally, exposing the whole distal humerus. Type II (Displaced Without Comminution)
Open Reduction and Internal Fixation. If thete is wide separa-
tion of the condylar fragments with marked disruption of the
~ AUTHORS' PREFERRED METHOD articular surface, stability and articular congruity can be estab-
,~ OF TREATMENT lished only with an open surgical procedure. We prefer the
BIJ'an-Morrey posterior triceps-sparing approach (293). The pa-
Because of the rarity of this fracture in children, rhere is no tient is placed prone on the opetating table with the arm sup-
standard recommended treatment. Therefore, we are outlining ported on a pillow and the forearm hanging down off the edge
our recommendations based on a combination of our clinical of the operating table. This provides the best approach for direer
experience and the experience of others in a few series (302,303, visualization of the posterior surface of the distal humerus. Ole-
310). Our first consideration in these fractures is to reestablish cranon osteotomy is reserved for those fractures in adolescents
the ilHegrity of the articular surface ro maintain the congruity with severe articular comminution.
of the joint. Usually this cannot be achieved adequately by closed
methods, so we proceed with an open surgical technique. We
First, Reconstruct Articular Surftce. Our firsr priority is ro rees-
have found our simple classification to the three types based on
tablish the integrity of the articulat ftagments-in other words,
the degree of displacement or comminution to be heJpful in
to convert jt to a supracondylar fracture (Fig. 15-79A-C). It is
guiding the aggressiveness of our treatment.
also critical that the olecranon and cotonoid fossae be cleared
of bony fragments or debris to eliminate the chance of bony
Type I (Undisplaced or Minimally Displaced)
impingement with their respective processes. The best way to
In type I injuries, there is little displacement of the bony supra-
stabilize the condyles is with a screw passed transversely rhrough
condylar columns. In children, the periosteum is often intact
the center of the axis of rotation in such a manner as to apply
and can provide some imrinsic stability. In addition, the thicker
transverse compression. This may require a small temporary sec-
articular and epiphyseal cartilage in the skeletally immature child
ondary transverse pin proximal to the screw to prevent rotation
may still be intact, even if the bony epiphysis appears severed
of the fragments as the guide hole is drilled or the compression
by a venical fracture line. Because of this, we have found twO
screw is being applied. This pin can be moved after the fragments
methods ro be successful for these types of fractures.
are secured.

Closed Reduction-Percutaneous Pin Fixation. These frac-

tures require minimal manipulation under general anesthesia Secoild0', Stabilize Supracondylar Columns. Once the condylar
and articular integrity has been reestablished, the distal frag-
and radiographic control ro reestablish the supracondylar col-
umns. If there is anterior or posterior wtation in the sagittal ments must be secured to the proximal fragment by stabilizing
[he supracondylar fragment columns. The decision hete is how
plane of the metaphyseal portion of the column, a pin placed
important it is ro initiate early motion. If it is a younger child
into that column can be used as a "joy stick" to manipulate
with rapid bony heaJing, pin fixation is often satisfactory so that
the fragment into a satisfactory position. Once a satisfactOlJ'
reduction is achieved, the pin can then be advanced across the they can be I'e moved in 3 weeks to start protected motion, similar
to treatment of a supracondylar humeral fracture. If it is an older
fraerure site for fixation. These fractures usually require multiple
adolescent nearet to skeletal maturiry, we prefer fixarion-usu-
pins placed percutaneously, such as those used in comminuted
supracondylar fractures (Fig. 15-77). Because of the rapid heal- ally plates or screws-that allows early motion (Figs. 15-79E and
ing, the pins can be removed at 3 weeks to allow early aerive F and J 5-80). Before application of the plates, the supracondylar
motion. columns can be stabilized temporarily with pin fixation (Fig.
15-800).
Traction. If rhe articular cartilage is intact, ir may close as a
hinge with traction (Fig. 15-78). The rotational displacement
Principles of Plate Fixation
of the condyles created by the origins of the forearm muscles
can be neutralized with olectanon traction, in which the elbow The plates must be strong. The thin semitubular platcs are inade-
is suspended at 90 degrees of flexion. There is usually adequate quate and may break (Fig. 15-81) (318). The reinforced mallea-
stability from the callus around the fracture site at 2 to 3 weeks ble reconstructive type of plates used for fixation of pelvic frac-
ro discontinue the traction. The elbow is then immobilized in tures provide very secure fixation. Recently, a J type of plate has
 Chflpter 15: The Elbow 693

A B

C D
FIGURE 15-77_ Closed reduction and pin fixation. A and B: Two views of a type II T-condylar fracture
in a 15-year-old. C and 0: Because an anatomic reduction was achieved by manipulative closed reduction,
it was secured with simple multiple pin fixation placed percutaneously. The articular surface was mini-
mally displaced. The pins were removed at 3 weeks. At this age, healing was rapid enough to pull the
pins at 3 weeks to allow active motion. Ultimately he was deficient only 10 degrees from achieving full
extension.
694 Upper Extremity

A B

c D
FIGURE 15-78. Treatment with traction. Treatment of the 6-year-old child with a T-condylar fracture
shown in Fig. 15-76A and B. A: This patient was treated with traction. Once the fracture was reduced,
the T-condylar nature of the fracture line was fully appreciated. The articular cartilage appeared intact
and served as a hinge to maintain reduction. B: Lateral view in traction. Although the distal fragment
remained extended, it was believed to be in an acceptable position. C and D: Anterior and lateral views
2 months after injury. The architecture of the condylar articular surface has been well maintained.
(Courtesy of Marvin Mumme, M.D.)
 Chapter 15: The Elbow 695

A B
E F

FIGURE 15-79. Sequence of reconstruction of the distal humerus. A-C:

First, the articular portions are reassembled with provisional Kirschner
wire fixation, followed by screw fixation. D: Kirschner wires can then
also be used to provide temporary fixation of the distal humerus. E: A
one-third tubular plate is attached to the medial side. F: A 3.5 pelvic
reconstruction plate was attached to the posterolateral border. (Re-
printed from Heim U, Pfeiffer KM. Internal fixation of small fractures,
c D 3rd ed. Berlin: Springer-Verlag, 1988; with permission.)

A B
FIGURE 15-80. Plate and screw fixation. A and B: Injury films of a type II flexion pattern in a 16-year-
old boy. (Figure continues.)
696 Upper ElCtre1l7ity

C D
FIGURE 15-80. (continued) C and D: Articular integrity was first restored with a transcondylarcompres-
sion screw. The condyles were secured to the metaphysis and distal shaft using pelvic reconstruction
plates placed at 90 degrees to each other.

A B
FIGURE 15-81. Inadequate fixation. A: Immediate postreduction film of a 14-year-old secured with
short semitubular plates and a small transcondylar screw. B: Six weeks later the small compression screw
in the condyle had lost fixation and the lateral plate had fractured. The patient was resecured with
large pelvic reconstruction plates and a large transcondylar compression screw.
 Chapter 15: The Elbow 697

been designed thar also can provide rigid fixarion when used ro providing compression through the axis of rotarion. This can
srabilize the lateral column (316). Ir is besr ro place rhe plares usually be done wirh minimal soft rissue dissection. Once this
at 90 degrees ro each other, which makes for a more stable is srabilized, the supracondylar columns are then reestablished
construct (30 1,304,315). by placing the extremiry in olecranon uaction and allowing rhem
In most cases in the adolescenr, this is essenrially an adult rype ro reconstitute with callus formation. Traction must be main-
of fracture parrern. The reader is therefore referred ro Fractures tained unril there appears co be good osseous tissue formed in
in Adults for a more detailed description of the various other the supracondylar areas (Fig. 15-82). While in tracrion, motion
techniques used in rreating adults wirh rhis rype of fracrure. can be iniriated. This rechnique also can be used in patients seen
late with contaminated soft tissue abrasions or severe soft tissue
problems.
Postoperative Care
If plate flxation is used, we place the extremiry in a supporting
Complications
posterior splinr for 5 ro 7 days ro allow rhe soft tissue swelling
ro decrease and the incisions co heal. At this time, aerive flexion It is importanr ro emphasize ro the parenrs initially that this is
and extension are initiared and rhe arm is protected with a re- a serious fracture. Because of the considerable soft tissue injury
movable casr brace. If there is considerable stiffness after 6 ro 8 and the involvemenr of the articular surface of the distal hume-
weeks, then we use the turnbuckle brace as advocared by Green rus, stiffness and loss of motion of the elbow can be ex peered
and McCoy (299) ro regain extension with increasing active regardless of the mode of treatmenr (292,302,306,310). In the
range of morion. adolescenr patienr, failure co provide solid inrernal fixation that
facilitates early motion (i.e., using only pin fixation) can result
Type III (Displaced with Comminution) in a satisfaccolY radiographic appearance but considerable dys-
Limited Open Reduction Followed by Traction. Sometimes funerion due co residual loss of elbow motion (Fig. 15-83).
rhe supraconJyLIr columns are coo fragmented ro produce ade- AJthough neurovascular complications have not been men-
quate fixation. In such cascs, we have found that in children, tioned in the few cases reported in the literarure, it is expected
rhe best inirial merhod of treatment involves reestablishing the that the incidence is about equal to that of supracondylar frac-
articular surface and joinr congruity with a limited open reduc- tures. Because these fractures occur late in the growth process,
rion. The separared condyles are secured wirh a transverse screw partiaJ or cotal growth arrest due ro inrernal fixation is not

A B
FIGURE 15-82. Transcondylar fixation and traction. The anteroposterior and lateral radiographs of a
12-year-old boy who sustained a markedly comminuted T-condylar fracture are seen in Fig. 15-76D and
E. A major portion of the lateral supracondylar column was a totally avascular free fragment. A: Because
it was totally avascular, it had to be removed, but the periosteum was preserved. The articular surface
was reduced and stabilized with a transcondylar screw. The patient was then placed in overhead olecra-
non traction. B: Radiograph of the elbow 8 months after injury shows that the lateral supracondylar
column is completely reconstituted. Even though the articular surface was maintained, there was about
30 degrees of loss of elbow motion ultimately.
6!}8 Upper EKtremity

A B
FIGURE 15·83. Stiff residua. A: Immediate postoperative film of an ll-year-old boy who sustained a
comminuted T-condylar fracture from a direct blow to the flexed elbow. Fixation was achieved by way
of a posterior approach, using multiple smooth pins. This prevented the initiation of early motion. B:
The elbow 5 months postoperatively. Although the bony architecture had been restored, there was
considerable restriction of motion from the soft tissue scarring. A better functional result may have
resulted had more rigid internal fixation been applied that would not have allowed early motion.

thought to be a major complication. By the same token, because Fractures of the Lateral Condyle
thesc are older children one cannot expect much in the way of
13. Ashhursr APC.l1nllnlltomicalllnd SllIgicalmrdy ofFacture., of£be Imver
remodeling. Nonunion (303), avascular necrosis of the trochlea nul ofthe humerus. Philadelphia: I.ea & Fehiger, 1910.
(3] 0), and failure ofinrernal fixation (Fig. 15-8]) also have been 14. B3Jclon 0, BensaJ1el H. Mazda K. et al. Lateral humeral condylar
reponed as complications. fr~ctures in children: a repon of 47 cases.} Pediatr Orrhop 1988;8:
31-34
15. Badger Fe. Fracwres of the lateral condyle of the humerus.} Bone
Joint Surg 1954;36: 147 -148.
l6. Bast Sc. Hoffer MM, Aval S. Nonoperative treanl1ent for minimally
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700 Upper l:,>memit)'

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 Chapter 15: The ElbolU

265. Graham HA. Supracondylar fracrures of rhe elbow in children (Parr 292. Blaum WP, Fractures in c/iildren. Balrimore: Williams & Wilkins,
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26(,. Haraldsson S. The inrerosseous vascularure of rhe disral end of rhe 293. Blyan RS, Morrey BF. Exrensive posrerior exposure of rhe elbow. A
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268. Heglllalln G. Die "Sponranen," Aseprischen Knochen-nL·krosen des 296. Corron Fl. Elbow Fracrures in children. Ann SUig 1902;35:75-104.
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57:430-"36. 1092-1095.
272. Jakob RP, Fernandez DL Lare complicarions of fracrure of rhe latel'al 300. Green NE, Swiomkowski MF. Skeletal tmuma in children. PhiiJdcl-
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Nillth Internatiollal Symposium on 7apical Problems in Orthopedic Sur-
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273. Kilfuyle R..\1. Fracrure, of rhe medi:ll condyle and epicondyle of rhe
302. Jarvis JC, D'Ascous.JL. The pediarric T -supracondylar fracrure.j Pedi-
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274. McIJonneli DP, \'V'i1son Jc. fracrures of rhe luwer end of rhe humerus
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277. Min:lmi A, Sllgawara J. HLIJl1eral trochlear hypoplasia secondary to 1990;14:674,
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318. Wildburger R, Mahring M, Hofer HP. Suprainrcrcondylar fracrures
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291. Beghin JL, Bucholz RW, Wenger DR. Inrercondylar fracrures of rhe 3) 9. Zimmerman H. Fracrures of rhe elbow. In: Wt,ber BG, Brunner C,
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108.3-l086. York: Springer-Vcrl:lg, I 'JNO.
 DISLOCATIONS OF THE ELBOW
GEORGE H. THOMPSON

CLASSIFICATION PROXIMAL RADIOULNAR TRA SLO ATIO

POSTERIOR ELBOW DI LOCATI N' Treatment Options
Diagnosis
Treatment Options RADIAL rEAD DlSLOCATIO
Complications Unusual Dislocation Parrerns
Recurrenr Posterior Elbow Dislocations Rate Causes
Congenital Elbow Dislocarions Diagnosis
Posteromedial Dislocation Treatment Options
A TERrOR LBOW DISLOCATIO S Complications
Diagnosis
ISOLATED DISLOCATTO S OF THE UL A
Treatment Options
MEDIAL A D lAT·RAL ELBOW D1SLOCATIO S UBL XATION OF THE RADIAL HEAD (Pulled
Diagnosis Elbow yndrome)
Treatment Options Diagnosis
IVERG T ELBOW 01 LOCATIO Treatmenr Options
Trearmenr Options Complications

We thank Kaye Wilkins fot his contribution ro this chapter and Occasionally, the proximal radioulnar joint is disrupted.
ptevious editions. Much of this chapter is his effon. Most commonly, the radius and ulna diverge from each other
Disruptions of the arricular surfaces of the elbow represenr in a mediolateraJ direction. Rarely, the radius and ulna rranslo-
a spectrum of injuries ranging from dislocation w subluxation. cate, with the radius medial and the ulna lateral.
As such, collectively they are common injuries, although the Isolated dislocations of the radial head are uncommon and
incidence of each subrype can vary widely. An importanr ana- must be differenriated from congenital dislocations. Isolated dis-
wmic feature of the elbow is its three separate arriculations: locarions of the proximal ulna are exceedingly rare and have not
radiocapitellar, ulnouochlear, and proximal radioulnar joinrs. been reponed in children.
The larrer articulation usually functions as a unit but can be included in this classificarion is rhe velY common subluxarion
disrupted. of rhe radial head Ot "pulled" elbow. This is not a true subluxa-
rion bur rather a panial entrapment of the annular ligament in
the radiocapitellar joint.
CLASSIFICATION
A modification of the classification of elbow dislocations from
the previous edition (03) is presenred in Table 16-1. POSTERIOR ELBOW DISLOCATIONS
Elbow dislocations are described with respect w the position
of the proximal tadioulnar joinr in relation w the distal humerus: Dislocations of (he elbow joint are uncommon in children. Hen-
posterior, anrerior, medial, or lateral. The common posterior rikson (36) studied 1,579 injuries about the elbow in skelerally
dislocation is subdivided inw posterolateral and posteromedial immature patients in Gothenburg, Sweden, in 1966, and found
dislocations. only 45 dislocations, for an overall incidence of 3%. He found
rhat the peak incidence of supracondylar fractures was in rhe
first decade of life, whereas mat of elbow dislocarion was in rhe
second decade, usually berween 13 and 14 years of age, when
George H. Thompson: Departmenr of Onbopaedic Surgery, Cosc Wesrern
Reserve Universir)', and Deparrmenr ol"l'"diarric Orrhopoedics, Rainbow Babies the physes begin to close. The same second-decade peak inci-
and Children's Hospiral, Cleveland, Ohio. dence was reported by Josefsson and Nilsson (46) in 1986. In
706 Upper Extremity

cheir series, most elbow dislocacions occurred in conjunction

TABLE 16-1. CLASSIFICATION ElBOW
with spores activities.
DISLOCATIONS
Within the pasc four decades, four series (55,71,83,85) have
Proximal radioulnar joint intact reporred elbow dislocations in bach adults and chilJren, buc
Posterior some overall stacistics regarding the incidence in children can
Recurrent posterior be obcained by combining all four series. In the 317 dislocacions
Unreduced posterior
Anterior reponed, including 147 in childl'en, all were posrerior (posterior,
Medial and lateral posrerolateral, or posteromediaJ) excepr for 10 laceral disloca-
Proximal radioulnar joint displaced cions, 5 anrerior dislocarions, and 16 unclassified. Male gender
Divergent ~nd the left elbow were predominantly involved, and there was
Translocation a high incidence of associated elbow fracwrcs.
Radial head dislocation
Carlioz and Abols (11) reporred 58 elbow dislocations in
Subluxation of the radial head
children and adoJescenrs, of which all were poscerior. The mean
rtge ar dislocacion was 12 yertrs, wich a range from 6 (0 15 years.
Adapted from Wilkins KE, Beaty JH, Chambers HG et al. Fractures
and dislocation of the elbow region. In: Rockwood CA, Wilkins KE, There were 41 boys (7] %) and 35 lefr elbows (60%). Associaced
Beaty JH eds. Fractures in Children, 4th ed. Philadelphia: elbow fractures occurred in 37 children (64%).
Lippincott-Raven, 1996.
Diagnosis
Mechanism of Injury
In posterior or posterolateral dislocarions, first the medial or
ulnar collaceralligamenrs are disrupced, allowing valgus insrabil-

FIGURE 16-1. Mechanism of injury. A: Initially the elbow is forced into extension with rupture of the
medial collateral ligaments. The normal cubitus valgus accentuates a valgus force at the elbow. B: The
lateral slope of the medial crista of the trochlea forces the proximal ulna posterolaterally (small arrow).
The biceps tendon serves as a fulcrum for rotation and valgus hinging of the forearm. C: The proximal
ulna and radius are then impacted posteriorly and held against the distal articular surface by the contrac-
tion of the biceps and triceps.
 Chapter /6: Disloctltium of the ElboUJ 707

icy. This can result in an avulsion fracrure of the medial epicon- and amibuted ro this to the ftequenr valgus stability following
dyle and its associated flexor muscle origin. The proximal radius closed reduction.
and ulna become displaced laterally with the inracr biceps tendon With posterior dislocations there is considerable soft tissue
acring as a cenrer of rotation for the displaced forearm. injury: and an associated risk of neurovascular injuries and asso-
The most commonly accepted mechanism of posterior elbow ciated fractures (Fig. 16-2).
dislocation involves the application of both abducrion and exten-
sion forces. However, there is conrroversy as ro whether the Soft Tissue Injury
elbow is initially hyperextended. Osborne and Correrill (74) be- The anterior capsule is ruprured with a tension force thaI' allows
lieved that initially the elbow was in slight flexion and that the the joinr cavicy ro be exposed. Posteriorly, the radial head can
lateral sloping surface of the medial crista of the trochlea served strip the capsule from the posterolateral aspect of the lateral
as a cam mechanism ro convert the vertical thrust on the forearm condyle, along with the adjacenr periosteum. Because of the
inro one of lateral rotation and valgus strain. Other investigators large amount of cartilage on the posterolateral aspect of the lat-
believe that there is first hyperextension of the elbow with rup- eral condyle, the posterior capsule may not rearrach firmly. This
rure of the ulnar collateralligamenrs (44,87). Once this stabiliz- lack of a strong reattachmenr is believed ro be a major facror in
ing force is disrupted, the elbow is forced inro further valgus recurrenr elbow dislocations (74).
(Fig. 16-1). Experimenrally, in cadavers, posterior dislocations Medially, the ulnar collateral ligamenr system is disrupted
have been most commonly produced by initial hyperextension eirher by a direcr tear of the ligamenr or avulsion of the mediaJ
(87,96). However, Sojbjerg et al. (90), in a study of 10 cadaver epicondyle (87,90). Cromack (14) found that with medial epi-
elbows, found mat a posterior dislocation is the result of a valgus condylar fractures, the origins of the ulnar collateral ligamenrs
and external rotation force acting on a semi flexed elbow. Dislo- and medial forearm flexor muscles remain as a unit, along with
cation could not be produced with a varus and inrernal rotation most of the pronacor teres, which is stripped from its humeral
force. O'Driscoli et al. (73) found similar results in their study origin proximal co the epicondyle. These structures are then
on 13 fresh autopsy specimens. They also found that the anrerior displaced posterior co the medial aspecr of the distal humerus.
portion of the medial or ulnar collateral ligament remained intact If the epicondyle remains attached co the humerus, then the

Biceps muscle

~f----:M-~-Brachial artery

A. 4\ti~'----h/ffft--,t--Med ian nerve

rr---tff-- Brachialis muscle
2
'-+411--- Lacertus fibrosus

--'r-'\-fJr.--frI------ Pronator teres

muscle

FIGURE 16-2. Pathology. 1: The radial head and olecranon are dislodged posterolaterally. 2: The brachi-
alis muscle is stretched across the articular surface of the distal humerus. 3:) The origins of the medial
forearm flexion muscles are either torn or avulsed with the medial epicondyle from the medial condyle.
4: The median nerve and brachial artery are stretched across the medial condyle and held firmly by the
lacertus fibrosus. 5:) The medial condyle lies in the subcutaneous tissue between the brachial is anteriorly
and the pronator teres posteriorly. 6:) The lateral (radial) collateral ligaments ohen avulse a piece of
cartilage or bone from the lateral condyle.
708 Upper Exrremity

ulnar collateral ligaments and muscular origins of the common Radiographic and Other Imaging
Hexor muscles must be torn. With posterolateral displacemem
Routine radiographs usually are diagnostic of a posterior elbow
of the forearm, the medial aspect of the distal humerus dissects
dislocation. In the anteroposrerior view, there is a greater super-
the intnmuscular space ber\veen the pronaror teres posteriorly
imposition of the distal humerus on the proximal radius and
and the brachialis anteriorly. The brachialis, because it has little
ulna. The radial head may be proximally and laterally displaced,
distal tendon, is easily ruptured. The tem in the anterior Glpsule
or it may be totally behind the distal humerus, depending on
usually is in this same area.
whether it is posterolareral, posrerior, or posteromedial (Fig. 16-
On the lateral side, the structure most commonly torn is
3). In addirion, the normal valgus angulation berween the fore-
the annular ligament (90). On rare occasions, the entire lateral
arm and the arm usuaJly is increased. On the lateral view, rhe
collatcralligament either avulses a small osteochondral fragmem
coronoid process lies posterior ro the condyles. The radiographs
from the lateral epicondyle or tears completely within its sub-
must be examined closely for associated fractures.
stance.

Neurovascular Injuries Treatment Options

When the elbow is dislocated, the medial aspect of the distal
humerus lies subcutaneously between the pronator teres poste- Nonoperative
riorl)' and the brachialis ameriorly. The median nerve and bra- Closed Reduction
chial artery lie directly over the humerus in the subcutaneous In rhe combined series (55,71 ,83,85) of 317 dislocations, only
tissues. In a cadaver and clinical study by Louis et al. (57), there 2 cases in the series by Linscheid and Wheeler (55) could not
was a consistent pattern of disruption of the collateral arterial be reduced by closed methods. In the Carlioz and Abols series
s),stem about the elbow. In almost a]1 extremities studied, there (11),2 dislocations reduced spontaneously and closed reduction
was a complete disruption of the anastomosis between the infe- was successful in 50 cases, but failed in 6 cases (l 0%). Josefsson
rior ulnar collateral artery and the anterior ulnar recurrent anny. et al. (45) reponed that all 25 dislocations without associated
If the main brachial arterial trunk is injured, rhe loss of rhis fracrures were successfully reduced.
collateral system can resulr in severe compromise of circulation Because of rhe considerable soft tissue injury, ir is essential
to rhe forearm and hand. to reduce rhe elbow promptly. Royle (85) found rh<lt those re-
The ulnar nerve also is at risk because of its anatomic site duced soon after the injury had better outcomes than those in
posterior to the medial epicondyle. which reduction was delayed.
All methods of closed reduction are direcred toward suf£!-
Associated Fractures
ciendy overcoming the muscle forces so rhat the coronoid pro-
Concomjtant fraerures occur in over one half of posterior elbow
cess <lnd radial head can slip past rhe disral end of the humerus.
dislocations (55,71,83,85). Fractures involvll1g the medial epi-
JUSt before the reducing forces are applied, rhe forearm should
condyle, radial head and neck, and cotonoid process are most
be hypersupinated to dislodge the coronoid process and radial
common. hactllres involving the lateral epicondyle, lateral con-
head from their position behind the distal humerus. The reduc-
dyle, olecranon, capitellum, and trochlea occur less frequently.
ing forces must be directed in rwo major direcrions (Fig. 16-4).
In the 58 dislocarions reponed by Carlioz and Abols (l 1), there
The first reducing force musr be along the long axis of the hume-
were 24 fractures involving the medial aspect of the elbow, 6
rus to overcome the comractions of tl1e biceps and brachialis
fractures from the lateral region, 2 wirh fractures from both
anteriorly and the triceps posteriorly. Once these forces are neu-
regions, 2 coronoid process fractures, and 3 radial neck fractures.
tralized, the proximal ulna and radius must be passed from posre-
rior to anterior. This requires a second force along rhe long axis
Signs and Symptoms
of the forearm. This may require that the elbow be extended or
Clinically, the presence of a posterior elbow dislocation usu<llly even hyperextended ro lever rhe coronoid process past rhe dist<ll
is obvious. TJ~e primary differcmial diagnosis is an extension- humerus.
rype supracondylar fracture of the distal humerus. With borh Some investig<ltors (56, 101), however, have strongly advised
injuries, the elbow is held scmiFlexed, and swelling may be con- againsr initial hyperextension. Loomis (56) demonstrated that
siderable. Swelling usually is less wirh a dislocation than wirh a when rhe coronoid process is locked against the posrerior aspecr
supracondylar fracture. However, there is still enough sofr tissue of the humerus and the elbow is extended, the force applied is
disruption, such as rearing; of the brachialis muscle <lnd colhrnal magnified by as much as five times ;\cross the anterior musclcs
vessels, to produce considerable hemorrhage and swelling. Crepi- because of the increased leverage. This places a considerable
rus usually is absent wirh a dislocation. With a postet'ior elbow strain on the already injured anterior c<lpsule and hrachialis mus-
dislocation, the forearm is shortened. The prominence produced cle (Fig. 16-5). On the orher hand, when the disraJ force is
by the disr:d humeral articular surface is more distal and is palpa- applied to rhe proximal forearm with the elbow Flexed, the force
ble as a blunt articular surface. The tip of the olecranon is dis- exerted against the muscles across the elbow is equal to the dis-
placed posteriorly and proximally so rhat irs triangular relation- rracti ng force.
ship with the epicondyles is losf. Overlying the olecranon fossa, Osborne and Conerill (74) suggested that the besr way to
the skin may have a dimpled appearance. If the dislocation is dislodge the coronoid process and radial head from the distal
posrcrolateral, the radial head <l1so may be prominent and easily humerus is inirially to hypersupinate the forearm and then to
palpable in the subcutaneous tissues. apply tranion along the fore<lrm with the elbow Flexed. Others
 Chapter 16: Dislocations of the Elbow 709

A B
FIGURE 16-3. Radiographic Findings. A: Anteroposterior radiograph. The radial head is superimposed
behind the distal humerus. There is increased cubitus valgus. The medial epicondyle has not been avulsed.
B: Lateral radiograph demonstrating that the proximal radius and ulna are both displaced posteriorly
to the distal humerus.

A B c
FIGURE 16-4. Reduction forces of posterior dislocations. A: First the forearm is hypersupinated (arrow)
to unlock the radial head. B: Simultaneous forces must be applied distally along the axis of the humerus
(arrow 2) and distally along the axis of the forearm (arrow 3). C: Once the coronoid is manipulated
distal to the humerus, the elbow is then flexed (arrow 4) to stabilize the reduction.
710 Upper Extremity

A B
FIGURE 16-5. Hyperextension forces. A: Normally, the brachialis is stretched across the distal humerus.
B: Hyperextending the elbow before it is reduced greatly increases the arc of motion and leverage
placed across the brachialis. This can result in rupture of large portions of the muscle. (Reprinted from
Loomis LK. Reduction and after-treatment of posterior dislocation of the elbow. Am J Surg 1944;
63: 56-60; with permission.)

rf
/
~'
l

A B

FIGURE 16~. Reduction by "puller" techniques. A: Supine position. With the elbow flexed to almost
90 degrees, a force is applied to the anterior portion of the forearm with one hand while the other
hand pulls distally along the forearm. Appropriate counterforces must be applied to counteract these
manipulating forces. B: Prone position. The same forces are applied to the proximal portion of the
anterior forearm and distal forearm. In the prone position the table provides a counterforce against
the anterior portion of the distal humerus. (Redrawn from Parvin RW. Closed reduction of common
shoulder and elbow dislocations without anesthesia. Arch Surg 1957;75: 972-975; with permission. Copy-
right 1957, American Medical Association.)
 Chapter /6: DisLocatiolis of tbe ELbow 711

(7,8) have warned that with posterolateral dislocations, rhe lat- forearm pronated that the anrerior portion of the medial collar-
eral displacement of the proximal radius and ulna musr firsr be eralligamenr was intacr and rhe parient could begin early mo-
correcred to prevent rhe median nerve from being entrapped or rion.
injured during reduction. Pronating rhe forearm during reduc-
rion also lTiay be a factor in entrapping rhe median nerve.
Surgical Procedures
AJrhough numerous reducrion techniques have been advo-
cared, they all have rhe common goal of applying rhe [WO major Open Reduction
rraction forces along rhe axes of rhe humerus and forearm. Each Indicarions for primaJY open reducrion are an inabiliry ro obrain
of rhese forces is resisted by its respective counrerforce. There a concentric closed reduction, an open dislocarion, and a dis-
appears to be [WO main groups in the merhod of applying force placed osteochondral fracrure.
ro counteracr rhe muscles of rhe arm: the "pullers" (6,15,75)
(Fig. 16-6) and the "pushers" (54,66,68) (Fig. 16-7). There also Inadequate Closed Reduction. Carlioz and Abols (11) reported
are combined unassisred pusher-puller rechniques (30,53). rhar 19 of 58 posrerior dislocations required open reduction. In
13, rhe reduction was srable and the surgeJY was for rhe rrear-
Postreduction Care menr of displaced fractures. In 6, open reduction of rhe joint
Some type of immobilization, usually a posterior splint, is advo- was necessary: 2 each for an entrapped medial epicondyle, ulnar
cated by mosr invesrigators after successful closed reducrion. The osreochondral fragment, and ligamenrous fragment.
srandard period of immobilizarion recommended is usually 3 In adults with posterior elbow dislocarions without concomi-
weeks (55,56,75,88), alrhough some have advocated early mo- rant fracture, those neared operarively for primaJY repair of liga-
rion (84,85,108). Ninety degrees of elbow flexion appears ro be menrs had no better function or srability rhan rhose treated
rhe standard position of immobilizarion. O'Driscoll er al. (73) nonoperarively (47,48). The mean lack of elbow extension in
believed rhar if rhe elbow was srable ro valgus stress wirh rhe both groups was 10 degrees. Similar results were reponed by

A B

FIGURE 16-7. Reduction by "pusher" techniques. A: Lavine's method. The child is held by the parent
while the elbow is draped over the edge of the chair. The olecranon is pushed distally past the humerus
by the thumb of the physician while the other arm pulls distally along the axis of the forearm. B: Meyn's
technique with patient lying prone on the table. (Reprinted from Meyn MA, Quigley T8. Reduction of
posterior dislocation of the elbow by traction on the dangling arm. Clin Orthop 1974;103: 106- 107; with
permission.)
712 Upper Extremity

Josefsson er al. (45) in 28 children and adolescenrs with simple Before reduction, it is important to emphasize to the parents
posterior dislocations treated nonoperatively. However, Durig that there may be some loss of motion, especiaJly extension,
et al. (18) recommended primary operative treatment of uncom- regardless of the treatment. This is usually not of functional or
plicated dislocations, because early surgery produced satisfact01Y cosmetic significance.
functional resul tS in all 10 of their patients. Cromal< (14) re- A careful neurologic examination must be done before and
poned full function in 14 children and adolescents treated by after the reduction with special attention to the median nerve.
early operative repair. This same careful examination must be made at all follow-up
evaluations.
Open Posterif)r Dislocations. Open dislocations usually have a
higb incidence of arterial injuries (34,50.55,57). For this reason, Complications
operative intervention usually is necessary for debridemenr and
evaluation of tbe brachial anery. Complications of posterior elbow dislocations can be divided
into those occurring early and those occurring later. Early com-
Associated Fractures. The presence ofa displaced fracture, such plications include neurologic and vascular injuries. Late compli-
as the medial epicondyle, is a common indication for surgical cations include loss of motion, myositis ossificans, recurrent dis-
intervention (11.23,102). Surgery for associated fractures pro- locations, tadioulnar synostosis, and cubitus recurvatum. The
duced slightly more excellent results than nonoperarive treat- special problems of chronic, unreduced dislocations are not con-
ment in the series of Carlioz and Abols (1l). Similar results were sidered complications of treatment.
reponed by Wheeler and Linscheid (102). Fowles er al. (23),
however, had poorer results in 9 children in whom the medial Neurologic Injuries
epicondyles were stabilized surgically. They recommended sur-
In the combined series (55,71,83,85) of317 patients, 32 patients
gery only for children in whom the medial epicondyle is en-
(l0%) had nerve symptOms after reduction. There was no break-
uapped or significantly displaced after closed reduction. Repair
down as to the ages of the patients with the nerve injuries.
of an associated medial epicondylar fracture also may improve
Twenry-one injuries involved the ulnar nerve, seven the median
elbow stabiliry in athletes (87, I 08).
nerve; in fout patients, both the median and ulnar nerves were
involved. Most were transient paresthesias with rapid recovery.
Postoperative Care
Only one patient failed to recover fully (55). Carlioz and Abols
Immobilization after surgery depends on the procedure per-
(11) reported no neurologic injuries with 58 dislocations in chil-
formed. After open reducrion, management is similar to that
dren and adolescents, although two children had transient ulnar
after satisfact01Y closed reduction. The length ofimmobilization
nerve symproms.
for fractures usually is 4 to 6 weeks.
Ulnar Nerve Lesions
There is an increased incidence of ulnar nerve injuries associated
~ AUTHOR'S PREFERRED METHOD with elbow dislocations (11,13,24,55, I 0 1). There were 21 ulnar
,~ OF TREATMENT nerve injuries plus 4 combined ulnar and median nerve injuries
in the combined series (55,71,83,85). Watson-Jones (101) de-
The "push-off" technique of reduction of an elbow dislocation scribed 16 nerve lesions in 97 elbow dislocations, 12 of which
is preferred in younger children, usually 9 years of age or less. involved the ulnar nerve; 9 of these there were associated with
In this age group, rhe child often can be seated comfortably in medial epicondylar fracture. Galbraith and McCullough (24)
the parent's lap (Fig. 16-7). Hanging the arm over the back of found 6 ulnar nerve injuries in 187 elbow dislocarions, with or
the chair may provide some stabilization. withom fractures, in their srudy of acute nerve injuries in closed
For the child 9 years ofage or older and the young adolescent, elbow injuries. Four of these patients had medial epicondyle
the puller technique advocated by Parvin (75) is used (Fig. 16- fractures and two had radial head fractures; all had posterior
6). The forearm must remain supinated during the process of elbow dislocations. Linscheid and Wheeler (55) reponed neuro-
reduction. Occasionally, it is necessary to hypersupinate tbe fore- logic complications in 24 of 110 elbow disclocations, including
arm to unlock the coronoid process and radial head before reduc- 16 ulnar nerve injuries alone and 4 injuries to both the ulnar and
tion. Closed reduction is done either with heavy sedation or medial nerves. They recommended ulnar nerve transposition if
general anesthesia. After reduction, radiographs are obtained to ulnar nerve symptoms were present in a patienr undergoing open
assess t11e adequacy of the reduction (Fig. 16-8). The elbow is reduction and internal fixation of a displaced medial epicondylar
immobilized in a posterior splLnt with the elbow flexed 90 de- fracture. CottOn (I3) reported 10 children with posterior dislo-
grees and the forearm in mid-pronation. This forearm position cations associated with medial epicondylar fractures and ulnar
is chosen simply to allow the patient to be more functional in nerve neuropathy. Except for the one patient described by
the splint. Linscheid and Wheeler (55), these reported ulnar nerve injuries
Because the major complication of elbow dislocations is stiff- were transient and resolved completely.
ness, the splinr is removed in about 5 days and the patienr begins
active elbow motion. In 7 to 10 days, the patient can discard RadiaJ Nerve Lesions
the splint and simply use a sling. The emphasis is on early active Watson-Jones (J01) is the only investigator to report a radial
motion to prevenr the stiffness that often occurs after this injury. nerve injUJy associated with an elbow dislocation. He described
 Chapter 16: DisLocatiollS oj the ELbow 713

A B

c D
FIGURE 16-8. Closed reduction. A: Anteroposterior radiograph of a 9-year-old girl with a posterior
dislocation of the right elbow. The proximal radius and ulna are superimposed on the distal humerus,
and there is increased cubitus valgus. B: Lateral radiograph shows the proximal radius and ulna posterior
to the distal humerus. C: Following closed reduction using a puller technique, there has been a concentric
reduction. D: Lateral radiograph.
714 Upper f'y,:trernity

cwo patiems in whom the symptoms rapidly resolved after reduc- duetion. Hallen (29) demonsrrated in cadavers that pronation of
non. the forearm while the elbow is hyperextended, forces the median
nerve posteriorly duting the process of teduction, making ir also
Median Nerve Lesions vulnerable to entrapment. This type of entrapment has been
The mosr serious neurologic injury involves the median nerve, reponed frequently (4,7,8,16,21,27,63,78,80,94). Delay in di-
which can be damaged directly by the dislocation or can be agnosis is common. The medial epicondyle is commonly frac-
entrapped within the joint. Median nerve injuties occur mosr tured. In a few patients, the nerve was so severely damaged after
commonly in children 5 to 12 years of age. There were seven being entrapped that resection of the injured portion with re-
median and four median-ulnar nerve injuries (3%) in the com- anastomosis was necessary (7,27,63). Good recovery of function
bined series (55,71,83,85). was reported.
If the nerve has been entrapped for a considerable period,
Types ofMedian Nerve Entrapment. Fourrier et aL (21) in the Matev sign may be present on the radiographs (63). This
1977 delineated three types of medial nerve entrapment (Fig. represents a depression on the posterior surface of the medial
16-9): epicondylar ridge where the nerve has been pressed against the
Type J. Either avulsion of the medial epicondyle along with bone (Fig. 16-10) (4,16,27,29,78,80,94). This groove is repre-
the superficial head of the pronator teres muscle or simple rup- sented radiographically by two sclerotic lines parallel to the
ture of the muscle origins and ulnar collateral ligaments (Fig. nerve. This sign disappears when the pressure from the nerve
16-9A) allows the median nerve, with or without the brachial has been released.
artery, to become posteriorly displaced. If the lateral displace- Type 2. The nerve is entrapped becween the fracture surfaces
mem of the proximal radius and ulna is not correcred before of the medial epicondyle and the distal humerus (Fig. 16-9B).
reduction, the nerve is especially prone to being entrapped be- The fracture heals and the nerve is surrounded by bone, forming
cween the [[ochlea and the oJecranon during the process of re- a neoforamen (78,82,94). This mayor may nor be visible radio-

c
FIGURE 16-9. Median nerve entrapment. A: Type 1. Entrapment within the elbow joint with the median
nerve coursing posterior to the distal humerus. B: Type 2. Entrapment of the nerve between the fracture
surfaces of the medial epicondyle and the medial condyle. C: Type 3. Simple kinking of the nerve into
the anterior portion of the elbow joint. (Redrawn from Hallett J. Entrapment of the median nerve after
dislocation of the elbow. J Bone Joint Surg [Br] 1981 ;63.408-412; with permission.)
 Chapter 16: DisLocations of the ELbollJ 715

is ruptured (28,34,38.50,57,61), but it also can be thrombosed

(l05) as well as entrapped in the elbow joint (35,76,105). Pearce
(76) reported an entrapped radial artery in which there was a
high bifurcation of the brachial artery.
When there is a complete rupture, there usually is evidence
of severe ischemia distally. Unfortunately, the presence of good
capillary circulation to the hand or a Doppler pulse at the wrist
does not always mean the artery is intact (28,38). Arteriograms
usually are not necessary because the arterial injury is at the site
of the dislocation. A new technique using intravenous digital
angiography has been used to confirm complete obstruction of
the brachial artery if there is clinical evidence of distal ischemia
(38).
'q ~.::-..._--- Treatment usually consists of relocation of displaced brachial
aneries (35, I 05) and operative repair of those that are ruptured
FIGURE 16·10. The Matev sign impingement of the median nerve
against the posterior surface of the medial condyle produces a depres- or severely damaged. Ligation of the ends has been done, espe-
sion with sclerotic margins. {Redrawn from Matev I. A radiographic sign cia.lly if there was good capillary circulation distally (34,50), but
of entrapment of the median nerve in the elbow joint after posterior this may predispose to late ischemic changes such as claudication
dislocation. J Bone Joint Surg fBr} 1976;58: 353-355; with permission.)
and cold sensitivity. Most investigatOrs recommend direct arte-
rial repair or a vein graft (28,38,57,61,86). Louis et al. (57)
recommended arterial repair because their cadaver studies dem-
onstrated that a posterior elbow dislocation usually disrupted
graphically. The medial epicondyle is osteomized to free the the collateral circulation necessary to maintain distal blood flow.
nerve.
Type 3. The nerve is kinked and entrapped between the distal
humerus and the olecranon (Fig. 16-9C). Only three injuries of Loss of Motion
this type have been reported (4,77,79). Resection and reanastO- Almost all patients with elbow dislocations lose some range of
mosis resulted in return of good function over 6 to 24 months. elbow motion (I I ,23,45,47,48). This loss is less in children than
Al Qattan et aJ. (2) described a fourth type of median nerve in adults (45) usually only 5 to 10 degrees of extension, and
entrapment. In a 14-year-old boy the median nerve was trapped rarely is of functional or cosmetic significance. However, this
in a healed medial epicondylar fracture (type 2) in an anterior potential for loss of motion must be explained to the parents
to posterior direction and then passed through the elbow in a
before reduction and may be an indication for a supervised reha-
posterior to anterior direction (type I) 18 months after a poste- bilitation program.
rior dislocation with a medial epicondylar fracture. The nerve
was so severely damaged that it was resected and repaired with
sural nerve grafts. Myositis Ossificans versus Heterotopic Calcification
The combination of an associated fracture of the medial epi- T rue myositis ossificans should be differentiated from hetero-
condyle and significant median nerve dysfunction was cited by topic calcification, which is a dystrophic process. Myositis ossifi-
Rao and Crawford (80) as an absolute indication for surgical cans involves ossification within the muscle sheath that can lead
exploration of the nerve because of the frequency of median to a significant loss of range of motion of the elbow. Disruption
nerve entrapment with fractures of the medial epicondyle (types of the brachialis muscle is believed to be a contribucary faccar
I and 2). Magnetic resonance imaging may be helpful in defining (56). Fortunately, myositis ossificans is rare in children (45,97).
rhe course of the median nerve if entrapment is suspected. Once AJrhough heterotopic calcification in the ligaments and capsule
the entrapped nerve is removed from the joint, neurologic func- of the elbow is common (45,83) it rarely results in loss of elbow
tion typically improves even if the nerve appears seriously dam- function (Fig. 16-11).
aged. Resection and reanastomosis rarely are necessary. Thompson and Garcia (97) found no myositis ossificans in
8 of 10 children 0 to 15 years of age with elbow injuries. The two
children with myositis ossificans had supracondylar fractures. In
Arteria/Injuries
Neviaser and Wickstrom's (71) series of 115 patients, 10 had
AneriaJ injuries are common with posterior elbow dislocations radiographic evidence of myositis ossificans; all, however, were
in children and adolescents (28,34,35,38,50,57,61,76,86,105). asymptomatic. Only Roberrs (83) differentiated true myositis
Only eight vascular injuries (3%) were reported in the combined ossificans from hererotopic calcification. In his series of 60 el bow
series (55,71,83,85). However, Carlioz and Abols (11) reported dislocations, only 3 patients had true myositis ossificans.
four patients with diminished radial pulses that resolved after Linscheid and Wheeler (55) noted that the incidence of some
reduction. Arterial injuries frequently are associated with open type of heterotopic calcification was 28%, which was most com-
dislocations in which collateral circulation is disrupted (34,50, mon around the condyles. Only in 5 patients was it anterior to
57,86), and they also have been reported in association with the capsule (which probably represented true myositis ossificans
closed dislocations (28,35,38,105). Usually the brachial artery in the brachialis muscle). Four of these patients had some de-
716 Upper Extremity

A B
fiGURE 16-11. Heterotopic calcification. A: An elbow that had been dislocated 2 months previously.
There is heterotopic calcification in the ulnar collateral ligaments (arrow). B: Lateral view of the same
elbow. Some true ossification has occurred where the brachial is inserts into the coronoid process (arrow).

crease in elbow funcrion. Josefsson et al. (45) reponed that 61 % only (wo (0.1 %) recurrenr dislocations were reponed (55,71,
of 28 children with posterior dislocations bad periarticular calci- 83,85).
ficarion, bur this did nor appear to be functionally significant.

Radioulnar Synostosis
Recurrent Posterior Dislocations
In dislocations with an associated fractures of rhe radiaJ neck,
Recurrent posterior elbow disloGllion is rare. It is discussed in the incidence of a secondary proximal radiouJnar synostosis is
detail in rhe nexr secrion. Jn the combined series of dislocations, increased (Fig. 16-12). This can occur regardless of whether the

A B
FIGURE 16-12. Radioulnar synostosis. A: Injury radiographs demonstrating a posterolateral dislocation
associated with a type II proximal radius epiphyseal fracture (arrow). Open reduction of the proximal
radial fracture was performed. B: Six months later, the patient developed a proximal radioulnar synosto-
sis (arrow). (Courtesy of Ruben Pachero, M.D.)
 C/lf/pter /6: Di.sloCfltionJ of the Elbow 717

radial neck fracrure is neared operarively or nonoperarively (8, ulnar collateral ligamenrs, and this furrher conrributes co rhe
11,73). Carlioz and Abols (11) repolTed a synosrosis in one of instability. Wirh recurrenr dislocations, rhe radial head impinges
rhree parienrs with a posrerior elbow dislocarion associared with againsr rhe posterolareral margin of rhe capitellum, crearing an
radial neck fracrures. osteochondral defect (Fig. 16-14).
Osborne and Corterill (74) attributed the failure of the cap-
Cubitus Recurvatum sule to reanach co rhe presence of a considerable amount of
articular cartilage, which provides a poor surface for rearrach-
Occasionally, a severe elbow dislocation resuJrs in significanr menr, and synovial fluid, which furrher inhibits healing. With
tearing of rhe anrerior capsule. As a result, afrer reduerion, when recurrenr dislocations, secondary changes tend co develop (Fig.
all the sriffness created by rhe dislocarion has subsided, rhe pa- 16-14). In addition co the defeer in the capitellar aniculaJ sur-
tienr may have some hyperexrension (cubirus recurvarum) of rhe face, a similar defect develops in the anrerior articular margin
elbow. This usually is minimally sympcomatic. of rhe radial head. When these two defects appose each Other,
recurrence of the dislocation is more likely. Subsequenr srudies
Recurrent Posterior Elbow Dislocations have confIrmed these findings in almosr all recurrenr disloca-
tions, especially in children (J 8,32,72,95,98, 107).
Although recurrenr posrerior elbow dislocarions almosr always
O'Driscoll et al. (88) described posterolateral instability in
involve adulr patients (18,26,32,37,43,49,51,60,62,65,67,72,
five patienrs, including two children, in whom laxity of the ulnar
74,95,98,100,107,109) the inirial dislocation has occurred be-
part of the radial collateral Ilgament allowed a transicory rotary
fore skeletal marurity. Approximately 80% of rccurrenr disloca-
subluxation of the ulnoh u meraJ joint and a secondalY dislocation
tions are in males. Three investigarors have reponed bilareral
of the radiohumeral joinr. Patients wirh posrerolateral instabiliry
cases (49,67,81).
often describe a hiscory of recurrenr temporalY dislocation of the
elbow, but when examined exhibit no unusual clinical findings.
Diagnosis The instability is diagnosed with a posterolateral rotalY insta-
Mechanism of Injury bility test. In some patienrs posterolateral rotalY instability can
The parhoJogy of recurrenr dislocation involves rhe collateral be detected only with the patienr complerely relaxed under gen-
ligaments, capsular laxity, and bone defecrs. eral anesrhesia. This tesr is performed by holding the arm over
the head while applying proximal axial compression plus a valgus
Ligamentous and Capsular Laxity. Osborne and Correrill and supination force co the forearm with rhe elbow flexed co
(74) suggesred rhat arricular changes a.re secondary and that rhe only 20 co 30 degrees (Fig. 16-15). O'Driscoli et "I. reponed
primary defect is a failure of the posrerolareral ligamencous and that surgical repair of the lax ulnar portion of the radial collateral
capsular srrucrures co become rearrached after reduerion (Fig. ligament eliminated the posterolateral rotary instability (72).
16-13). Posrerior dislocarions usually cause arrenuation of the Schwab er al. (87) described treatmenr of the laxity of the

~~t!~~~~-Lateral"pocket" '~=::""""~~,.---Defectin
condyle
lateral

'-----'\--iW-f4--+----Lax ulnar collatera I

ligament

FIGURE 16-13. Pathology of recurrent dislocation. The three components that allow the elbow to
dislocate: a lax ul:nar collateral ligament, a pocket in the radial collateral ligament, and a defect in the
lateral condyle. (Reprinted from Osborne G, Cotterill P. Recurrent dislocation of the elbow. J Bone Joint
Surg fBr] 1966;48.340-346; with permission.)
718 Upper Extremity

A B

c o
FIGURE 16-14. Pathologic changes of recurrent dislocation, A: Anteroposterior radiograph of a 13-
year-old who had recurrent dislocations, An osteochondral fragment (arrow) is attached to the lateral
ligament. B: An oblique radiograph shows the defect (arrow) in the posterolateral condylar surface. C:
Radiographs of an 11-year-old after his first dislocation. D: One year later, after recurrent dislocation
and subluxations, blunting of the radial head has developed (arrow). (Courtesy of Marvin E. Mumme,
M.D.)

medial collateral ligament with advancement of the medial epi- an orthosis that blocked the last 15 degrees of extension. After
condyle proximally to tighten the medial coJJateral ligament. his patient wore this orthosis constantly for 2 years and with
vigorous activities for another 6 months, there were no further
Bone Defects. In addition to the previously described osteo- dislocations, but the follow-up petiod was only 1 year. Beaty
chondral defecrs in rhe capirellum and radial head, bone defecrs and Donati (5) emphasized that physical therapy and the use of
include a shallow semilunar notch resulting from a coronoid an orthosis should be tried before surgery is considered.
fossa process fracture or multiple recurrent dislocations. Osteo-
chondral fragments in the elbow joint also can contribure to Surgical Procedures
instability. The treatmenr of tecurrent posterior elbow dislocations is pre-
dominately surgical. Various surgical procedures have been de-
Treatment Options scribed to correct bone and soft tissue abnormalities (Fig. 16-
I G).
NOlloperative
There appears to be only one report of successful nonsurgical Bone Procedures. These are directed more toward correcting
management of recurrent elbow dislocations. Herring (37) used dysplasia of rhe semilunar notch of the olecranon. Milch (67)
 Chapter 16: DisLocatiorzs of tbe ELbow 719

inserted a boomerang-shaped bone block. Others (26,65,100)

Axial compression found that a simple bone block was all that was necessary (Fig.
16-16A). Mantle (62) increased the slope of the semilunar nOtch
in two patients with an opening wedge osteotomy of the coro-
noid process (Fig. 16-16B).
Schwab et al. (87), believing the ulnar collateral ligament to
be the mainstay of elbow stability, advocated tightening the me-
dial side by osteotomizing the medial epicondyle and reattaching
it proximally, but reported no results.
!

~ __ //~Ubluxation
Soft Tissue Procedures. Reichenheim (81) and King (51) trans-
ferred the biceps tendon just distal to the coronoid process to
~- reinforce it (Fig. 16-16C). Kapel (49) developed a cruciate liga-
ment reconstruction in which distalJy based strips of the biceps
and triceps tendon were passed through the distal humerus and
FIGURE 16-15. Posterolateral rotary instability. Posterolateral rota-
sutured to the olecranon and coronoid process respectively (Fig.
tional instability is best demonstrated with the upper extremity over 16-160). Beaty and Donati (5) modified this technique by
the radial head. The radial head can be subluxed or dislocated by apply- transferring a central slip of the triceps through the humerus
ing a valgus and supination force to the forearm at the same time
proximal axial compression is applied along the forearm. (Reprinted posterior to anterior and attaching it to the proximal ulna.
from O'Driscoll SW, Bell DF, Morrey BF. Posterolateral rotary instability The most widely accepted technique is that described by Os-
of the elbow. J Bone Joint Surg [Am] 1991 ;73 441; with permission.) borne and Cotterill (74), in which the lateral capsule is reat-
tached to the posterolateral aspect of the capitellum with sutures
passing through holes drilled in the bone (Fig. 16-16E). The
joint should be inspected at surgelY because osteocarrilagenous

A B c

D E
FIGURE 16-16. Surgical procedures for recurrent dislocation. A: Bone block. B: Coronoid osteotomy. C:
Biceps tendon transfer. D: Cruciate ligament reconstruction. E: Lateral capsular reattachment of Osborne
and Cotterill.
720 UpperExffemi~

loose bodies may be present (32,60,95). Since Osborne and Cot- Unreduced Posterior Elbow Dislocations
terill's (74) initial report of eight patients, successful use of chis
U nrreated or neglected posterior dislocations of the elbow in
technique has been reported in numerous others (18,32,60,72,
children are extremely rare in North America. Most reported
95,98,107). Zeier (109) and O'Driscoli er al. (72) reinforced
series are from other countries (1,22,52,59,69,89). In 1925,
the lateral repair with strips of fascia lata, triceps fascia, or pal-
Speed (93) from the United States reponed six, including four
maris longus tendon. Malkawi (60) transferred the ulnar nerve in children.
and reinforced the medial repair in a patient with ulnar neurop-
athy. Diagnosis
Children with untreated dislocations typically have pain and
Posttreatment Care limited mid-range of motion. Pathologically, there is subperios-
teal new bone formation that produces a radiohumeral horn,
Postoperatively, especially after the repair described by Osborne myositis ossificans of the brachialis muscle, capsular con-
and Cotterill (74), the arm is immobilized in a long arm cast tractures, shortening of the triceps muscle, contractures of the
with the elbow flexed 90 degrees for approximately 4 weeks. medial and latera! collateral ligaments, and tightening of the
Active range of motion exercises are then begun. ulnar nerve (21,22,89). These factors have to be considered when
planning rreatmenr.

Complications Treatment Options

The major complication after correction of recurrent disloca- Nonoperative
tions is loose OSteocartilagenous fragments and destruction of Closed reduction of dislocations recognized within 3 weeks of
the articular surface of the joint (Fig. 16-17). Loose fragments injury may be possible (1,22). If this fails or if the dislocation
musr be removed at initial surgery and later should they occur. is of longer duration, open reduction is necessary.

A,B c

FIGURE 16-17. Effects of recurrent dislocation.

This girl began to have recurrent dislocations of
her elbow at age 9. A: The ease at which the
elbow redislocates is shown in this radiograph.
Band C: Radiographs taken at the beginning of
episodes of dislocation. Her dislocation contin-
ued. D and E: Four years later the elbow demon-
strated marked changes in its architecture. (Cour-
D,E tesy of David J. Mallams, M.D.)
 Chapter 16: Dislocations of the Elbow 721

Surgical Procedures Mahaisavariya et a1. (59) reponed decreased flexion con-

Open reduction through a posterior approach, as described by tracture and better functional results in 34 patients with unre-
Speed (93), involves lengthening of the triceps muscle and release duced elbow dislocations 1 to 3 months after injury in whom
or transposition of the ulnar nerve (22,69,89). Others have advo- the triceps tendon was not lengthened compared with 38 pa-
cated a posterolateral or medial and lateral incisions for better tients who had the triceps lengthened at surgery.
exposure (1,52). Satisfactory results usually cam be obtained if
a stable concentric reduction is achieved within 3 months of the
initial dislocation (1,52). Results decline thereafter but still may
Congenital Elbow Dislocations
produce some improvement in function (22,69) (Fig. 16-18). It must be remembered that a chronic elbow dislocation may
Internal fixation of the elbow to maintain reduction is used for be congenital. Because of the abnormal nature of these elbows,
2 to 4 weeks, followed by vigorous physical therapy (22,69). they are prone to injury. In addition, because of the relatively
Two large Kirschner wires or Steinmann pins may be used to free range of motion of the elbow before injury, the child or
stabilize the elbow and minimize the risk of intraarticular parents may not have recognized that the elbow has been dislo-
breakage. cated since birth.

A B

FIGURE 16-18. Unreduced dislocation. A: Preop-

erative anteroposterior radiograph. The elbow
sustained an injury 3 years before surgery. Elbow
motion was extremely limited and painful. The lat-
eral supracondylar ridge had been eroded by the
radial head (arrow), B: Lateral radiograph, The
posterior position of the olecranon is apparent, C:
Anteroposterior radiograph 3 months postopera-
tively. Total elbow motion was 30 degrees, but
c there was less pain and more stability,
722 Upper Extremity

FIGURE 16-19. Congenital elbow dislocation. Lateral (Al and

anteroposterior (Bl radiographs of an elbow with congenital dis-
location. The patient had sustained a minor injury. The fact that
similar findings were seen in the opposite uninjured elbow con-
A,S firms the congenital origin. (Courtesy of Earl A. Staple, M.D.)

The key to differentiating a congenital from an acute rrau- hyperextension of the elbow also has been implicated (104).
matic elbow dislocation is examination of the radiographic archi- Twisting of the forearm on the elbow commonly occurs.
tecture of the articulating surfaces. In a congenitally dislocated
elbow, there is marked atrophy of the humeral condyles and the
Signs and Symptoms
semilunar notch of the olecranon (Fig. 16-19). However, these
same changes can result from chronic recurrent dislocation after The elbow is in extension with fullness in the antecubital fossa.
trauma, making the differenciation between congenital and trau- Swelling usually is matked because of the soft-tissue disruption
matic difflcult. Certainly, if other congenital anomalies are pres- associated with this type of dislocation. There is severe pain
ent or the child has an underlying syndrome, such as Ehlers- with attempted motion. A careful neurovascular examination is
Danlos Ot Larsen's syndrome, the dislocation is likely to be con- mandatory.
genital.
Radiographic and Other Imaging Studies
Posteromedial Dislocation Routine anteroposterior and lateral radiographs are diagnostic.
Posteromedial elbow dislocations are rare. One patient described In most cases, the proximaJ radius and ulna dislocate anteromed-
by Wilkins et aJ. (103) developed a recurrent dislocation. This ially rather than purely anteriorly (Fig. 16-21). Associated frac-
12-year-old boy had trochlear hypoplasia secondary to a very tures are common. In children, the triceps insertion may be
distal supracondylar fracture (Fig. 16-20). It was believed that avulsed from the olecranon with a small piece of corrical bone
hypoplasia of the trochlea contributed to the instability of the (106). This fracture usually reattaches to the olecranon after
medial aspect of his elbow joint, predisposing him to recurrent reduction. Wilkerson (104) reported an anterior dislocation as-
dislocations. As he grew, his medial ligaments tightened, and sociated with a displaced olecranon fracture in a 7-year-old boy.
subsequently he became asymptomatic. Inoue and Hotii (40) reporred an ] l-year-old girl with an ante-
rior elbow dislocation with displaced fractures of the trochlea,
capitellum, and lateral epicondyle. These were repaired with
ANTERIOR ELBOW DISLOCATIONS open reduction and internal fixation using Herbert bone screws.

Anterior elbow dislocations are also rare. Of the 317 elbows in Treatment Options
the combined series (55,71,83,85), only five were anterior, for
an incidence of slightly over] %. They are associated with an Nonoperative: Closed Reduction
increased incidence of complications, such as brachial artery dis-
Reduction usually is accomplished by flexing the elbow and
ruption and associated fractures, compared with posterior dislo-
pushing the forearm proximally and downward at the same time
cacions (12,40,42,92,104,106).
(l06). As for the posterior dislocations, a Force must first be
applied longitudinally along the axis of the humerus with the
Diagnosis elbow semiflexed to overcome the forces of the biceps and tri-
ceps. The longitudinal force along the axis of the forearm is
Mechanism of Injury
directed toward the elbow (Fig. 16-22). To make reduction eas-
Anterior elbow dislocations usually are caused by a direct blow ier, the distal humerus can be forced in an anterior direction by
to the posterior aspect of the flexed elbow (40,106). However, pushing on the posterior aspect of the distaJ arm.
 Chapter 16: Dislocations of the Elbow 723

A,B c
FIGURE 16-20. Posteromedial dislocation. A: At 6 years of age, this boy sustained what was thought
to be a simple undisplaced but very distal supracondylar fracture. This radiograph taken 4 weeks after
injury shows periosteal new bone formation along both supracondylar columns (arrow). B: Four years
later, he began sustaining recurrent posteromedial dislocations. C: Radiograph after reduction, at that
time, shows delayed development of the medial ossification center of the crista (arrow). It was thought
that this hypoplastic trochlea contributed to his elbow instability. (Courtesy of Stephen A. Cord, M.D.)

A B
FIGURE 16-21. Anterior dislocation of the elbow. A: Initial lateral radiograph. The olecranon lies ante-
rior to the distal humerus. B: Initial anteroposterior radiograph. The proximal ulna and radial head lie
anteromedial, and the elbow carrying angle has drifted into varus. (Courtesy of Hilario Trevino, M.D.)
724 Upper Extremity

A B c
FIGURE 16-22. Reduction of anterior dislocation. A: With the elbow semiflexed, a longitudinal force
is applied along the long axis of the humerus (arrow 7). Pulling distally on the forearm may be necessary
to initially dislodge the olecranon. B: Once the olecranon is distal to the humerus, the distal humerus
is pushed anteriorly (arrow 2) while a proximally directed force is applied along the long axis of the
forearm (arrow 3). C: Finally, the elbow is immobilized in some extension (arrow 4).

Surgical Procedures Complications

Surgery usually is not required unless the dislocation is open, There appears ro be an increased incidence of brachial artery
me brachial arrery injury is present, or there is an associated rupture or thrombosis associated wirh anterior elbow disloca-
fracrure that does not realign satjsfacroriiy after closed reduction. tions (42,92). When present, prompt atTerial repair is necessary.
Open reducrion and internal flxation of the fracrure may then
be necessary (40,104).
MEDIAL AND LATERAL ELBOW
Postreduction Care DISLOCATIONS
Bec::Luse most anterior dislocations occur in flexion, the elbow These are rare dislocations. Lateral dislocations, either incom-
should be immobilized in some extension for 2 to 3 weeks, plete or complete, are more common than medial dislocarions.
followed by active range of motion exercises. Early motion after There are no recent repons of medial dislocations in children.
open reduction and internal fixation of an associated olecranon
fracture usually can be allowed (40,104).
Diagnosis
Signs and Symptoms
~ AUTHOR'S PREFERR D METHOD
,~ OF TREATME T In an incomplete lateral dislocation, the semilunar notch arricu-
lates with rhe captilulorrochlear groove and the radial head ap-
Closed reduction (Fig. 16-22) is the initial procedure of choice. pears more prominent \aterally. There may be reasonably free
A distal force must be applied in line with and parallel ro the extension and flexion, so lateral dislocation may be overlooked.
long axis of the humerus firsr. Once the length has been recst:lh- In a compll'tc lateral dislocation, rhc olecranon is rorally lateraJ
lished, a posteriorly directed force along rhe axis of the forearm ro the capitellum. This gives the elbow a markedly widened
is applied until the elbow is reduced. appearance.
 Chapter 16: DisLocntiollS of the ELbow 725

Radiographic and Other Imaging Studies the elbow, and then direct medial or lareral pressure (opposire
the direcrion of the dislocation) is applied over the proximal
Anteroposterior and lateral radiographs of (he elbow usually are
forearm (Fig. 16-23).
diagnostic. On the lateral view (he elbow may appear reduced.

Treatment Options
DIVERGENT ELBOW DISLOCATION
These rare dislocarions are treated by closed reduerion. A longi- Divergent dislocarion represenrs a posrerior elbow dislocation
tudinal force is applied along (he axis of the humerus to distract with disruprion of rhe interosseous membrane between rhe prox-

A B

c D
FIGURE 16-23. Lateral elbow dislocation. A: Initial anteroposterior radiograph in this 6-year-old with a
lateral dislocation and displaced medial epicondyle fracture. B: Lateral radiograph shows slight posterior
dislocation. C and 0: Postreduction radiographs demonstrate anatomic reduction of the dislocation. The
medial epicondyle is satisfactorily aligned.
726 Upper Extremity

A,S c
FIGURE 16-24. Medial-lateral divergent dislocation. A: Anteroposterior view demonstrating disruption
of the proximal radioulnar joint with the radius lateral and the ulna medial. B: Lateral radiograph
confirms that the radius and ulna are both posterior to the distal humerus. C: A radiograph taken 4
weeks after injury shows periosteal new bone formation (arrows), indicating where the soft tissues were
extensively torn away from the proximal ulna.

imal radius and ulna with rhe radial head displaced laterally and Postreduction Care
rhe proximal ulna medially (Fig. 16-24). These dislocations are
After successful closed reduction, the elbow is immobilized in 90
extremely rare (3,9,] 7,20,33,39,64,70,88,9] ,99).
degrees of flexion and rhe forearm in neutral for approximarely 2
Divergenr dislocarions usually are caused by high-energy
to 3 weeks. Active range of motion exercises are rhen begun.
rrauma. Associated fractures of the radial neck, proximal ulna,
Mosr patients typically regain full elbow morion, including fore-
and coronoid process are common (9,20,99). It has been specu-
arm pronation and supination.
lared that, in addirion to rhe hyperextension of rhe elbow that
produces rhe dislocation, a strong proximally direcred force is
applied parallel to the long axis of the forearm, disrupting the PROXIMAL RADIOULNAR
annular ligament and interosseous membrane and allowing the TRANSLOCATION
divergence of rhe proximal radius and ulna.
Translocation of rhe proximal radius and ulna is another ex-
rremely rare injury (9,10,19,25,31,41,58). It is commonly
Treatment Options missed on rhe anreroposterior radiograph unless rhe proximal
Nonoperative: Closed Reduction radius and ulna are noted to be completely reversed in relarion
to rhe distal humerus.
Divergent dislocations are typically easily reduced via the closed
Translocarions are believed to be caused by a fall OntO rhe
method wirh general anesthesia (Fig. ] 6-24A). Reduction is pronared hand with rhe elbow in full or nearly full exrension,
achieved by applying 10ngiwdinaJ rracrjon wirh the elbow sem-
producing an axial force on rhe proximal radius. The anterior
iextended and ar rhe same rime compressing the proximal radius
radial head dislocarion occurs first, followed by the posrerior
and ulna togerher.
dislocation. The radial head, depending on the degree of prona-
rion, can be lodged in rhe coronoid fossa or dislocared poste-
riorly. More pronarion allows rhe radial head to dislocare posre-
Surgical Procedures: Open Reduction
riorly benearh rhe rrochlea. As a consequence, fractures of the
This is rarely indicared. There have been only twO divergenr radial head, radial neck, or coronoid process may occur (9,10,
dislocarions reported rhar required open reducrion (20,64). 19,58). Isbisrer (41), however, believed rhe eriology may be iar-
Closed reduction failed in one child (64), and the orher had a rogenic: an inappropriare reducrion rechnique of rhe posrerior
displaced fracrure of the proximal ulna (20). dislocation.
 Chapter 16: Dislocations of the Elbow 727

A B
FIGURE 16-25. Proximal radioulnar translocation. A: Position of the proximal radius and ulna with a
proximal radioulnar translocation. B: If the forearm is forced into pronation during reduction, the ulna
may become lodged in the capitulotrochlear groove and the radius forced anterior to the trochlea.
(Redrawn from Harvey 5, Tchelebi H. Proximal radio-ulnar translocation. J Bone Joint Surg 1979;
61 :447-449; with permission.)

Treatment Options of morion is a common sequela of proximal radioulnar transloca-

tion.
Nonoperative: Closed Reduction
Closed reducrion wirh general anesrhesia can be arrempred bur
is usually unsuccessful (Fig. 16-25). MacSween (58) reponed a RADIAL HEAD DISLOCATION
successful closed reducrion wirh rhe elbow flexed 100 degrees
and rhe forearm fully supinared. Isolated traumatic dislocation of rhe radial head is an uncommon
injUlY. Most reportS have single case reportS (113,121,124,136,
140,143,145), but some small series have been reponed (117,
Surgical Procedures: Open Reduction
118,126,127,129,130,135,137,141,144-146,148,149). The
Mosr reponed radioulnar rranslocarions have required open re- diagnosis usually is missed initially.
ducrion (9,10,19,25,31,41). Internal fixation also may be neces- In reports in which ages were given, the mean was 7 years.
salY for an associated displaced fracture. Harvey and T chelebi Vesely (146) combined rhe experience of the members of the
(31) used an osteotomy of the proximal ulna to expose and Association of Bone and Joint Surgeons [Q accumulare 17 dislo-
reduce rhe radius. This was complicated by a poscoperarive ulnar cations; 13 were anterior, 3 were larera], and 1 was posrerior.
nerve paralysis that recovered complereJy over 2 months. Two recurred.

Postreduction Care Unusual Dislocation Patterns

Mer successful closed or open reducrion, a long arm casr with Isolated radial head dislocations are variants of Monteggia lesions
rhe forearm in neutral position is worn approximately 4 weeks, (l18, 123, 126,127,129,133). Often, if rhe parient and the radio-
followed by an active range of marion exercises. The presence graphs are carefully examined, an occult fracrure of rhe olecranon
of a fracrure may prolong the immobilization. Mild residual loss or proximal ulna is discovered (127). The fracrure rna)' not be
728 Upper Extremity

head dislocation. They described four dislocations that were

chronic, recurrent, and precipirared by Further injury. The radial
head dislocated when the forearm was supinated and reduced
when it was pronated. In addition to ligamentous repair, a supra-
condylar osteotomy was performed to correct the distal humerus
deformity.

Osteochondritis Dissecans
K1ekamp et al. (I28) reported seven older children and adoles-
cents wirh osteochondritis dissecans of the capitellum who devel-
oped instability of the radial head: five subluxations and two
posterolateral dislocations. Treatment was based on the presence
of loose bodies and the characteristics of the osteochondral de-
fect.

Birth Trauma
This is an extremely rare mechanism of injury. Danielsson and
Theander (12l) reponed an anterior dislocation, Schubert (140)
an isolated anrerolateral radial head dislocation, and Bayne and
Rang (I 13) an anteromedial dislocation. Interestingly, all three
B infants were breech deliveries.
FIGURE 16-26. Ulnar bow sign. A: The normal posterior border of the
ulna is represented by a straight line. B: In minimal type I Monteggia
lesions. there is loss of this ulnar straight line with anterior bowing of
the posterior border of the ulna and complete dislocation or partial
Diagnosis
subluxation of the radial head anteriorly. (Reprinted from Lincoln TL, Mechanism of Injury
Mubarak SH. "Isolated" traumatic radial-head dislocation. J Pediatr Or-
thop 1944;14:455; with permission.)
The mechanism creating an isolated dislocation of the radial
head appears to be the same as in Monteggia lesions (123,126,
127,129,137). The only difference is thaI' rhe olecranon and
apparent until bowing of the proximal ulna or olecranon devel- proximal ulna are not visibly fractured. The mechanism of injury
ops during the healing phase (I18). of rhe various Momeggia lesions are discussed in Chapter 12.
Lincoln and Mubarale (I29) reviewed isolated anterior radial In the 12-year-old reported by Sranley (143), be Found an
head dislocations in which there was no overt evidence of a exrreme degree of hyperextension of the elbow due to ligamen-
fracture of the ulna. In each, there was subtle anterior bowing touS laxity. He believed this laxiry conrribured significandy ro
of the shaft of the ulna. They described this as the ulnar bow the eriology. This finding has not been menrioned by orher
sign. Normally the dorsal margin of the ulna is a straight line invesrigators, but most of rhese disJoca[ions occur ar around 7
(Fig. 16-26). Based on their findings, they suggested that the years of age, when ligamentous laxity is at irs peale (Fig. 16-23).
term isolated radial head dislocation was a misnomer and that Wiley er al. (148) found in cadaver srudies [hat anrerior disJo-
these were actually variants of type I Monteggia injuries. Others carions of the radial bead could be produced only with grear
have reported radial head dislocation in association with nondis- force. Dislocation required complere division of the anterior
placed (greenstick or plastic deformation) fracture of the olecra- capsule and annular ligamenr, prona[ion, and application of an
non (122,127,130). anterior force to [he pos[erior aspect of [he radial head. Tearing
Because most of these injuries are occult Momeggia lesions, of the interosseous membrane sometimes occurred before [be
there is often subtle bowing of the ulna. In type I Monteggia dislocation could be acbieved.
lesions, the ulna demonstrates the typical ulnar bow sign in
which the shaft of the ulna is bowed anteriorly and the radial Relationship to Congenital Dislocation of the Radial
head is dislocated anteriorly (Fig. 16-26). In type 1II Monteggia Head
lesions, the proximal ulnar metaphysis or olecranon is bowed
radially (laterally) and the radial head is dislocated anterolat- Iris imporranr ro be able [Q differentiare a congenital disloc2[ion
erally. Late repair produces better results in anterior dislocations of rhe radial bead that requires no (I'earment from an acure or
than in anterolateral dislocations (137). chronic traumatically disloca[ed radial head rbat may require
treatmenL Congenital dislocarions are commonly bilateral, pos-
Rare Causes terior, and associared with orber anomalies such as Eblers-Danlos
syndrome, but some are idioparhic (112,131,132,134,139). Be-
Cubitus Varus Deformity
cause of the lack of significant disability, rbe parenrs ofren are
Cubitus varus aFter a supracondylar fracture of the distal hume- unaware that [heir cbild has a congeni[al radial head dislocarion.
rus has been shown by Abe er al. (110) to predispose to radial If the child susrains an injury to rhe elbow wirh subsequenr
 CbfljJtt'l" /6: Dis/ou" ;om of the ELbow 729

pain and swelJing, :1ccurate radiographic interpretation may be full flexion and extension. Pronation usually is full while supina-
difflculr. tion is limited. In chronic dislocations thete is typically some
Isolated traumatic dislocations of the radial head in newborns loss of pronation and flexion. The carrying angle may be in-
have been documented (113,121,140). This gives credence w creased and there may be valgus instability.
the theory that many congenital dislocations may actually have
a traumatic etiology that was unrecognized.
Radiographic and Other Imaging Studies
Because most congenital dislocations are bilateral, it was ini-
tially thought that unilateral dislocations were probably trau- Routine radiographs demonstrate an isolated radial head disloca-
matic in origin. However, Agnew and Davis (111) reported six tion, but distinguishing a traumatic from a congenital disloca-
patients with isolated unilateral dislocations in whom there had tion can be difficult. In a review of 50 patients with congenital
been no hiswly of rrauma and the presence of the dislocation dislocations of the radial head, Mardam-Bey and Ger (131)
had been recognized since early childhood. Thus, there is doubt found the following radiographic characteristics in all their pa-
whether all unilateral radial head dislocations are traumatic. tients: relatively shorr ulna or long tadius, hypoplastic or absent
Southmayd and Ehrlich (142) reported three children with capitellum, partially defective trochlea, prominent ulnar epicon-
symptomatic subluxations of the radial head, twO of whom had dyle, dome-shaped radial head with long neck, and grooving
unilateral involvement. ! t was uncertain whether there was a of the distal humerus. Similar findings have been reported by
relationship with congenital dislocation of the radial head. Simi- McFarland (132) and Miura (134). Unfortunately, these same
larly, Bell et al. (114) reported congenital subluxations and dislo- changes can be found in children with long-sranding traumatic
cations of 34 elbows in 27 patients without other musculoskele- dislocations (112,118,120) (Fig. 16-27). When the radiographic
tal anomalies; only 7 were bilateral. findings described by Mardam-Bey and Ger (131) are seen, all
Mardam-Bey and Gel' (131) atgued that if there were other that can be said with certainty is that the dislocation is long-
congenital musculoskeletal abnormalities, if there was a positive standing. The congenital nature is determined by the presence
family history of dislocated radial heads, or if the patient had of other factors.
bilateral dislocations, these were probably congenital in origin.
The absence of early trauma alone is not a reliable criterion, Arthrography
because trauma may occur as an occulr incident at an early age. Arthrograms were advocated by MiZllno et al. (135) in the differ-
entiation of congenital and traumatic dislocations. Their differ-
entiation was based on whether the radial head was intraarticular
Signs and Symptoms
or extraarticular. If the radial head remained within the intact
In an acute injury the elbow is swollen, motion is limited, and but distended capsule, the dislocation was considered congenital.
the radial head mayor may not be palpable. In a chronic disloca- In 15 traumatic dislocations, the capsule was torn and the radial
tion, the radial head usually is palpable and there is a lack of head was extraarricular.

A B
FIGURE 16-27. Progression of changes. A: Initial injury radiograph in a 5-year-old who sustained an
acute minimally displaced anterior dislocation of the radial head. This dislocation was not appreciated
initially. 8: Three years later, the displacement had progressed and the radius had grown proximally.
The radial neck also has become narrowed and elongated (arrows). These findings are similar to those
described for a congenital dislocation of the radial head. (Courtesy of Charles T. Price, M.D.)
730 Upper Extremity

Treatment Options stability with a rotation osteoromy of the radius at mid-shaft.

With the radial head reduced in maximum supination, the distal
Nonoperative: Closed Reduction
shaft segmenr was then rotated and fixed in pronarion. This was
Most acute radial head dislocations can be sacisfacwrily created thought to decrease the tension on the biceps, theorized to be
by closed teduction and immobilization (126,144-146,148, one of the major deforming forces.
149), but nonoperative treatmenr is not appropriate for chronic
radial head dislocations. Previously it was believed that disloca- Radial Head Excision
tions older than 1 momh should be left alone and possibly Excision of the radial head in long-standing dislocations relieves
rreated by radial head excision if the elbow became sympromatic discomfort but usually produces minimal improvement in mo-
(144). More recenrly, it has been recognized that chronic disloca- tion (149). However, Hresko et aI. (l25) demonstrared signifi-
tions can be significanrly improved by surgical reconsrruction. cant improvement in motion in 27 elbows in 25 patients under
18 years of age who had radial head excision for a variety of
conditions that caused stiff, painful radiocapitellar joints.
Surgical Procedures
Open Reduction Postreduction Care
Neviaser and LeFevre (136) described an acute dislocation thac
required open reduction because the radial head was bu[[onholed After successful closed reduction, the atm is immobilized in a
through the capsule. Danielsson and Theander (l2l) reponed long arm cast wi th the elbow flexed 90 degrees and the forearm
an infam with an irreducible anrerior dislocation of the radial in full supination for 3 ro 6 weeks (126,144-146). Supination
head in which complete displacemenr of the annular ligamenr decreases the pull of the biceps muscle and tenses the interos-
required division and then repair. If creatmenr is delayed for seous membrane. Weisman et al. (147) reported two children
more than a week, open reduction may be necessary if a closed with late dislocations in whom there appeared ro have been
reduction is unsuccessful. Open reduction is universally neces- an elbow dislocations with spontaneous resolution. Dislocation
sary 3 weeks following injury. As long as 3 years after injury, occurred with the arm immobilized in 90 degrees of elbow flex-
open reduction with annular ligamenr reconsrruction can pro- ion but without supination.
duce good results (118,130,141). Techniques used for recon- A similar immobilization position is used after open reduc-
struction are modifications of the procedure described by Bell tion, with or without an osteoromy. This is conrinued for ap-
Tawse (115). A more anaromic and physiologic reconsrruction proximately 6 weeks or unril the osteoromy is healed.
technique of the annular ligamenr using two holes drilled in the
proximal ulna has been described by See I and Peterson (141).
~ AUTHOR'S PREFERRED METHOD
,~ OF TREATMENT
Ulnar Osteotomy
In addition w open reduction and reconstruction of the annular
Most acute radial head dislocations can be treated bv closed
ligamenr, osteoromy of the proximal ulna sometimes is necessary
manipulation. The key ro maintaining the reduction is t~ immo-
ro achieve reduction of the radial head (117,118,133,137), Bou'-
bilize the elbow in hyperflexion (2:120 degrees) (Fig. 16-28).
yala et a1. (117) reponed the use of this technique in 15 parienrs,
The forearm is usually held in neutral rotation. The radius
including 9 with isolated dislocations of the radial head. There
should always point toward the capitellum. Forearm supination
were no redislocations, and all had improved elbow motion.
can be increased ro decrease the deforming force of the biceps
Their technique is essencially the same as that used for chronic
brachii. To support the hyperextended elbow, a figure-of-eight
Monreggia lesions (115,116,119,137,138) McGuire and Myers
cast, similar ro the one used for supracondylar fractures, is used.
(133) reported seven patienrs treated with open reduction and
For long-standing POSt traumatic dislocations, I prefer open
ulnar osteowmy withouc annular ligamenr reconsrrucrion. The
reduction and reconstruction of the annular ligament using a
ulnar plate was conroured unri! the radial head rotated against
lateral strip of triceps tendon as a modification of [he BeU Tawse
the capitellum during a full range of pronation and supination.
All patiems regained full elbow motion. McGuire and Myers
(115) procedure popularized by LJoyd-Robens and Bucknill
(130) and others (Fig. 16-29) (116,118,119,137,141). I have
believed that redirecting the radial head ro the capitellum re-
no experience with the technique described by See! and Peterson
sulred in stabiliry. This is essentially what occurs when a
Monteggia fracture is reduced closed. The annular ligament is
(141), although it appears ro be an excellent alternative. The
radiocapiteJlar joint can be stabilized with a small Steinmann
rorn, but does not require reconstruction for stability.
pin rather than a Kirschner wire to decrease the risk of pin
Complications can occur with the reconstruction technique
of open reduction, annular ligament reconstruction, and ulnar breakage.
osteowmy. Rodgers et aJ. (138) reporred 14 complications in 7
patients undergoing these procedures. Ultimately, there wete 3 Complications
good, 2 fair, and 2 poor results.
Annular Ligament Calcification
Radial Osteotomy Dystrophic calcification of the capsule and annular l\igamenr
If the radial head was anterior and could be reduced closed by after reduction of radial head dislocations is common (122,130,
manually supinating the forearm, Futami et al. (124) achieved 136,144). It appears as a semilunar calcification surrounding the
 Chapt.er 16: DisLocations of the ELbow 731

A B
FIGURE 16-28. Closed reduction. A: Acute injury radiograph shows that the long axis of the radius
(dotted line) passes proximal to the center of the capitellum, indicating a dislocation. B: After reduction,
this relation has been reestablished and is maintained with the elbow immobilized in hyperflexion.

A B

FIGURE 16-29. Open reduction. A: Radiograph of a S-year-old

who had sustained an acute elbow injury 6 months previously. The
radial head dislocation was not appreciated on the initial radio-
graphs. B: After a Bell Tawse procedure, a Steinmann pin is used
for fixation. The strap from the triceps fascia is passed through
the olecranon (arrow). C: Six months after surgery, the reduction
c has been maintained.
732 Upper Extremity

radial head and may become evident as early as 2 weeks after nation the lateral edge of the radial heal is wider and more
injury. In most patients, this calcification spontaneously resolves. square at its margin, thereby restricting slippage. McRae (164)
This localized, well-defined calcification is not to be confused demonstrated that forearm pronation maintains the displace-
with the diffuse pattern of myositis ossiflcans after elbow injuries. ment of the annular ligament.
Although the annular ligament slips proximally, it only par-
tially covers the radial head. This anatomic finding has been
Loss of Motion confirmed in numerous cadaver experiments (163,164,171). Sal-
lloyd-RobertS and Bucknill suggested that untreated traumatic ter and Zaitz (171) found that if the annular ligament slipped
lesions result in a significant loss of elbow motion that can con- over the equator of the radial head, the maximum anteroposter-
siderably decrease the power and dexterity of the extremity ior diameter, the ligament could not be reduced to its origjnal
(130). Their patient had no distal radial ulnar subluxation and position. The two reportS of surgical exploration of this injury
could do heavy labor without difficulty. He was also essentially in the acute stage confirmed this observation (171,176). After
pain free. Most patients with untreated radial head dislocations 5 years of age, the distal attachment of the annular ligament to
develop secondary cubitus valgus deformity and valgus instabil- the neck of the radius has strengthened sufficiently to prevent
ity when performing upper exrremity weight-bearing activities its tearing and subsequent displacement (171).
(i.e., as in gymnastics). It was initially believed that the radial head diameter was less
in children than jn adults and this contributed to subluxation
of the annular ligament. However, cadaver studies of infants,
ISOLATED DISLOCATIONS OF THE children, and adults have shown that the ratio of the head and
ULNA neck diameters is essentially the same (169,171). Griffin (156)
suggested that the lack of ossification of the proxjmal radial
Isolated dislocations of the ulna have been described in adults epiphysis in children less than 5 years of age made it more pliable,
(see Chapter 22 in Fractures in AduLts). However, there have thereby facilitating slippage of the annular ligament.
been no known reports of this injury occurring in children. Amire et aJ. (150) performed a controlled study compa6ng
30 normal children with 100 who had sustained subluxation of
the radial head. They found an increased incidence of hypermo-
SUBLUXATION OF THE RADIAL HEAD bility or ligamentous laxity among children with pulled elbows.
(PULLED ELBOW SYNDROME) Also, there was increased incidence of hypermobiljry in one or
both parents of the involved children compared with normals.
Subluxation of the head of the radius or pulled elbow is a com- It was these investigators' contention that hypermobiliry could
mon elbow injury in young children (150,152-154,156-158, be a factor predisposing children to this condition.
162,167,168,172,173). The term nursemaid's eLbow and other Thus, the most widely accepted mechanism today is that the
eponyms and synonyms have been used to describe this condi- injury occurs when the forearm is pronated, the elbow extended,
tion (161,171). The demographics associated with the subluxa- and longitudinal traction is applied to the patient's wrist or hand
tion of the radial head have been well described (150,152-154, (Fig. 16-30) (163,164,172). Such an injury rypically occurs
156-158,162,167,168,172,173). The mean age at injury is usu- when a young child is lifted or swung by the forearm or when
aUy 2 to 3 years, with the youngest reported patient 2 months the child suddenly steps down from a step or off a curb while
of age. It rarely occurs after 7 years of age. Sixty percent to 65% one of the parents is holding the hand or wrist. The investigator
of the children affected are girls, and the left elbow is involved also has seen a number of children who, while falling backward,
in approximately 70%. It is difficult to determine the actual grab an object for support, thereby applying longitudinal trac-
incidence because many subluxations are treated in primary care tion across an extended, pronated elbow.
physician's offices or resolve spontaneously before being seen by
a physician. Unusual Mechanisms
Newman (166) reported that five of six infants under 6 months
of age with a pulled elbow sustained the injury when rolling
Diagnosis over in bed with the extended elbow trapped under the body.
It was believed that this maneuver, especially if the infant was
Mechanism of Injury
given a quick push to turn over by an older sibling or a parent,
Longitudinal traction on the extended elbow is the usual mecha- provided enough longitudinal traction to displace the annular
nism of injury. Cadaver studies have shown that longitudinal ligament proximally.
traction on the extended elbow can produce a partial slippage
of the annular ligament over the head of the radius and into the
Signs and Symptoms
radiocapitellar joint, sometimes tearing the subannular mem-
brane. Displacement of the annular ligament occurs most easily The hiscory is critical in malung the diagnosis. There usually is
with the forearm in pronarion. In this posirion the lateral edge an episode of a sudden longirudinal pull on the elbow of the
of rhe radial head, which opposes rhe main porrion of the annular young child. The initial pain usually subsides rapidly and the
ligament, is narrow and round at its margin (162,163). In supi- child does not appear co be in distress except that he or she is
 Chilpter 16: Dislocations of the Elbow 733

FIGURE 16-30. The injury most commonly occurs when a longitudinal pull is applied to the upper
extremity. Usually the forearm is pronated. There is a partial tear in the orbicular ligament, allowing it
to subiuxate into the radiocapitellar joint.

reluctant to use the involved extremity. The upper exrremity is in 3 infanrs with subluxation of the radial head. Careful review
typically held at the side with the forearm pronated. A limited of the radiographs of children with true subluxation found that
painless arc of flexion and extension may be present. However, the line was more than 3 mm lateral to the center of the capi-
any attempt to supinate rhe forearm produces pain. Although tellum in almost 25% (174). To determine this subtle change
there is no evidence of an elbow effusion, local tenderness may requires a direct measurement on the radiograph. One problem
be present over the raclial head and annular ligament. ]n some is that these views often are taken with the forearm supinated
patienrs the pain may be referred proximally to the shoulder or and the subluxation is reduced when the technician forces the
distally to the wrist (l50, 157). forearm into supination to position it for the radiograph. Bret-
Unfortunately, the classic history is not always present (153, land (151) found that if the best radiograph that can be obtained
167,168,170,172). In some studies 33% t049% of patients had is an oblique with the forearm in pronation, radial head subluxa-
no history of a sudden longirudinal pull (170,172). There are tion is the likely diagnosis.
several reasons why the history may nOt be characteristic: the Mehara and Bhan (165) reported a new radiologic sign of
parenrs are reluctant to give rhe true mechanism for fear they distal shift of the radius compared with the ulna. They found
may be accused of child abuse, the injLlly can be sustained in a that the proximal radial length was altered in 21 of 25 patienrs
fall (153,170), or the injury was not observed by a reliable adult (84%) with radial head subluxations. The normal relationships
witness. Often, the child is crying and thus impossible to exam- were restored after reduction.
ine adequately until he or she has calmed down. ]n these nonclas- Should radiographs be raken of every child before manipula-
sic patients, other causes, such as occult fractures or early septic tion is attempted? ]f there is a classic history, the child is 5 years
arthritis, must be carefully ruled out. of age or younger, and the clinical findings strongly support the
diagnosis, radiographs probably are not necessary (150,153,168,
17 J, J76). If, however, rhere is an atypical history or clinical
Radiographic and Other Imaging Studies examination, radiographs should be obtained before manipula-
tion is attempred.
Results of anteroposterior and lateral radiograph usually are nor-
mal (152,153,156,158,163,168,171,172,174), but subtle ab- Arthrography
normalities may be present. Normally, the line down the center Matles and Eliopoulos (163) reported the use of anhrograms in
of the proximal radial shaft should pass through the center of some parients. Interposirion of the annular ligament produces
the ossification center of the capitellum (radiocapitellar line) a defect between rhe radial head and the capitellum that is visible
(155,174). Frumkin (155) demonstrated rhat this did not occur on arthrography (Fig. 16-31).
734 Upper Extremity

A B

c D
FIGURE 16·31. Irreducible annular ligament. A: Arthrogram of the normal uninjured left side shows a
well-defined margin to the capsule and annular ligament at the radial neck (arrows). 8: On the affected
side, this margin has lost its sharp definition and the lateral aspect has migrated somewhat proximally.
C: On the lateral radiograph of the normal elbow the radial head articulates directly with the capitellum
(arrows) when the elbow is fully flexed. D: On the injured side there is some limitation to full flexion.
At surgery, the gap between the two articular surfaces (arrows) was filled with the interposed annular
ligament. (Courtesy of Robert M. Campbell, Jr., M.D.)

Ultrasonography palpated when rhe annular ligament reduces. Macias et al. (161)
When rhe diagnosis is nor eviden r, ulrrasonography may be hel p- reponed rhar hyperpronarion was more successful rhan supina-
ful (160,162). The diagnosis is made by demonsrraring an in- rion in a randomized srudy. Reduction was successful in 40 of
crease in rhe echonegarive area between rhe arricular surfaces 41 patients (98%) in the hyperpronarion group, compared wirh
of the capitellum and the radial head (radiocapitellar distance). 38 of 44 parients (86%) in rhe supinarion group. They con-
Kosuwon et aJ. (160) found that this distance is normally about cluded thar rhe hyperpronation technique was more successful,
3.8 mm with forearm pronated. With a subluxated radial head, required fewer arremprs, and was often successful when supina-
this measured 7.2 mm. A diffetence of3 mm between the normal rion failed.
and affecred sides, therefore, suggests radial head subluxation.
Surgical Procedures: Open Reduction

Treatment Options This is rarely indicated. Even if untreated, most radial head
subluxations reduce spontaneously. The only indication for sur-
Nonoperative: Closed Reduction gery is a chronic symptomaric irreducible subluxarion (Ill ,176).
Almost all sublLDcations are correerable by closed reduction. This In rhese, rhe annular ligament must be partially rransected to
is usually besr done by forearm supination (153,156,157,161, achieve reduerion (Fig. 16-31).
162,167,168,172,173). Some have recommended that supina-
Postreduction Care
tion be performed wirh the elbow flexed, and others have found
thar supination alone with the elbow exrended can effecr a reduc- After a successful closed reduction of a first rime radial head
tion. In all parients, a snapping sensarion can be both heard and subluxation, immobilizarion of the extremity is not necessary if
 Chapt£'}' J 6: Di,·locations of the Elbow 735

rhe child is comfonable and using rhe arm normally. Salrer and plained co rhe parenrs rhere will be a brief episode of pain fol-
ZaJrz (171) recommended rhe use of a sling, mainly co prevenr lowed by compbe or signiftcanr relief of the sympcoms. The
rhe elbow from being pulled a second rime. Kohlhaas and Roeder patienr usually is seared on rhe parenr's lap. The parienr's fore-
(159) recommended aT-shirr rechnique for flexed elbow stabili- arm is grasped wirh rhe elbow semiflexed while rhe thumb of
zarion in very young children. This provided adequate immobili- rhe surgeon's opposite hand is placed over the lareral aspecr of
zation without rhe use of a sling by pinning rhe sleeve of the rhe elbow. The forearm is Elrsr supinared. If rhis fails co produce
long sleeve T-shin co the opposire chesr. the cbaracreristic snap of reducrion, rhen the elbow is flexed
maximally unril the snap occurs (Fig. 16-32). Jusr before reach-
Parent Education ing maximal flexion, there ofren is an increase in the resisrance
After rhe reducrion, ir is imporranr co explain co the parenrs ro flexion. AI' rhis point, a linle extra pressure coward flexion
rhe mechanism of injury and ro emphasize rhe need co prevenr must be applied, which usually produces rhe characreristic snap
longitudinal pulling on the upper exrremiries. as rhe annular ligamenr suddenly returns ro its normal posirion.
If rhis fails, rhe hyperpronarion technique of Macias et aI. (l61)
~ AU I-iOR'S PREFERRED METHOD is used.
,~ OF TREATMENT Whar should be done if a definire snap or pop is nor fell' or
if rhe patient fails ro use the exrremiry afrer manipularion? If
FirsI', ir is imporranr CO tty ro elicir the classic hiscoly of rhe rhe sublux.ation has occurred more than 12 to 24 hours before
child having had a longitudinal force applied across rhe extended rhe child is seen, rhere ofren is a mild secondary synovi tis, and
el bow. The enrire exrremiry is rhen carefully examined. The recovelY may nor be as dramatic. There also may be a small
characreristic focal tenderness should be pinpoinred directly over amount of blood in rhe elbow joinr. The imponant facr ro derer-
the radial head. If rhere is clinical evidence of an elbow effusion, mine is wherher rhe initial diagnosis was correcr. This requires
then radiographs of the upper exrremiry are obrained 1'0 assess radiographs, if they were nor tal<en before the manipularion, and
for other injuries before manipularing the elbow. a careful reexamination of rhe entire exrremiry. If the radiograph
Once rhe diagnosis of subluxarion of the radial head is clearly results are normal and rhe elbow can be fully flexed with free
established clinically, manipulation is performed. It is ftrsr ex- supinarion and pronarion, rhe physician can be assured rhat the

FIGURE 16-32. Reduction technique, "nurse maid's" elbow. Left: The forearm is first supinated. Right:
The elbow is then hyperflexed. The surgeon's thumb is placed laterally over the radial head to feel the
characteristic snapping as the ligament is reduced.
736 Upper t.'.x:tremity

suhluxared annular ligamenr has been reduced. In rhis circum- elbow. Rcvicw of recorded cases and the lirerature wilh report of J
case. SlIIg G)'Jlfrol Obstet 1922;35:776-788.
srance, rhe patienr's arm is placed in a spline or sling for a few
) 3. l.otron FJ. Elbow dislocation and ulnar nerve injury. j Roul' joint
days co one week and reexamined clinically fust and radiographi- SUit 1929;11:34H-352.
cally if needed. 14. Cromack PI. The mechanism and nature of the injury in dislocations
of che elbow and a mechod of treatment. Aust NZ j Surg 1960;30:
212-216.
Complications 15. Crosby EH. Dislocation of the elbow reduced by me.lns of traction
in four directions . .! Bone joint Surg 1936;18: 1077.
Unreduced Subluxations 16. Danielsson LG. Median nerve entrapment and elbow disloca[ion. A
case report. Acta Orthop ScamI1986;57:450-452.
There are no repom of long-term sequelae from unrecognized 17. Delee Jc. Transverse divergent dislocation of the elbow in a child.
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sponraneously. The only problem seems to be the discomfort" 18. Durig M, Gauer EF, Muller W. Die Operative Behandlungder Rezid-
ivicrcnden und Traumatischen Luxation des Ellenbogengelenkcs nach
CO rhe parienr unril the annular ligament reduces.
Osborne une Cotterill. Arch Orthop Unfitll Chir 1976;86: 141-156.
19. EldofO, Nybonde T, Karlsson G. Luxation of the elbow compiicated
hy proximal radio-ulnar translocation. Acta RadioI1990;31: 145-146.
Recurrent Subluxations 20. EI l3ardouni A, Mahfoud M, Ouadghiri M, et al. Divergent disloca-
cion of [he elbow. A case report. Rev Chir Orthop 1994;80: 150-152.
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5% co 39% (153,156,157,167,168,172,173,175). Children 2 coms d'une luxation du coude. Rev Chir Orthop 1977;63: 13-16.
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Recurrenr subluxarions are relarively common. After 2 or 3 of closed fractures or dislocations of che elbow. Injury 1979; II:
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2 weeks. This trearmenr seems co be effecrive because it allows 25. Gillingham Bl, Wright ]G. Convergent dislocation of the clbow.
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joint Slt~lJ 1943;25:448-449.
27. Green NE. Case report. Entrapment of the median nervc following
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69. Naidoo KS. Unreduced posterior dislocations of the elbow. j Bone Clin Orthop 1974;100:74-77.
joint Surg [Br] 1982;64:603-606. 99. Vicente P, Orduna M. Transverse divergent dislocation of rhe elbow
70. Nakano A, Tanaka S, Hirofuji E, et al. Transverse divergel1l disloca- ill a child. A case report. Clin Orthop 1993;294:312-313.
738 Upper Extremity

100. ~Iainwright D. Recurrenr disJocation of rbe elbow joinr. Proc R Soc cause of developmenral dislocation of the radial head. CLin Orthop
Med 1947;40:R85-886. 1997;338:36-41.
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wri.~t. } Bone }oinr Surg 1930; 12: 121-140. rion.} Pet/iat;· Orthop ]994;14:454-457.
102. Wheeler DK, Linscheid RL. Fracrure-dislocations of the elbow. Gin 130. L1oyd-Robcrts GC, llucknill TM. Anterior dislocation of the radial
Orrhop 1967;50:95-106. head in children. Aetiology, natural hisrory and management.} Bone
103. Wilkins KE, Beary ]H, Chambers HG, et aJ. Fraclures and disloca- joint Stllg {Br} 1977;59:402-407.
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13:223-225. rures.} Bone joint Slag {Br} 1986;68:336.
105. Wilmshursr AD, Millner PA, Batchelor AG. Brachial anery enrrap-
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15:477-481.
106. Winslow R. A casc of complete antnior dislocatioll of borh bones of
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107. Wirvoct], Tayon B. La luxation rccidivante du coude. A propos de
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{AmI 1991;73:1086-1089.
108. Woods GW, Tullos HS. Elbow instability and medial epicondyle
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138. Rodgers WB, Waters PM, Hall JE. Chronic IVlomeggia lesions in
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110. Abe M, Ishizu T, Nagaoka T, et al. Recurrenr posterior dislocation
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t12. Almquist EE, Gordon LH, Blue AI. Congenital dislocation of the 47:1019-1023
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[13. Bayne 0, Rang M. Case repon. Medial dislocation of the radial head head dislocation in children.} Pedi.l/tr Orthop 1999; 19:306-312.
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392-.'396- a Il1cch'lnism of injury in childrcn. litjltry 1986;17:182-183.
115. Bell TawseA]S. The trcarll1enrofmalunited anlerior Montcggi~ frac- 144. Srclling 1'H, Cote RH. Traumaric dislocation of head of radius in
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523-526.
119. Cappellino A, Wolfe SW, Marsh ]S. Use of a modified Bell Tawse
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dius ar the elbow.} Bone Joint 511rg {Br} 1974;56:501-507.
Orthop 1998;18:410-414.
149. Wiley .1.1, Loeher J, :vIclnryrc W. Isolated dislocation of rhe radial
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121. Daniclsson I.e, The;1I1der G. Traumatic dislocation of the radiaillcad
at birth. Acta Radial Diilgll {Stuc!,b} 1981 ;22:279-382.
122. Ealwaker J. Posttraumatic calcification of the annular ligament of the
radius. SI~eL RadioL 1992;21: 149-154. Subluxation of the Radial Head (Pulled
123. Evans E.M. Pronarion injuries of rhe I'()rc'arm wirh 'pecial rcK:rl'llce Elbow Syndrome)
ro rhc ;llHcrior Monreggia franure.} BOl/ejoint SltIg [Br} 31 :'578-588.
150. AmiI'D, Frankl U, Pogrund H. PuJled elbow and hypcrmohiliry of
124. Furami T, TSllkamoro Y, Fujita T. Rotation osteotomy for dislocation
of rhe cldial head. 6 Cases followed for 7 (3-10) years. Acta Orlbop joinrs. Gin Orthop 1990;257:94-99.
SCrlild 1992;63:455-456. 151. Bretland PM. Pulled elbow in childhood. Br } Radial 1994;67:
125. Hresko MT, Rosenburg BN, Pappas AM. Excision of the radial head 1176-1185.
in patients younger than 18 years.} Pa/ian' Orthop 1999; 19: I06-1 13. ] 52. Broadhlll'st BW, Buhr AJ. The pulled elbow. BM} 1959; I:
126. Hudson DA, De Beer ]DV. Isnlared traumatic dislocation of the radi:Ji 10IS-1019.
hcad in children.} Bone Joint SUig fBI) 1986;68:378-381. J 53. Choung W, Heinrich SD. Acute annular ligamcnt interposition into
127. Hlnne AC. Antcrior dislocation of the head of rhe radius associated the radiocapirellar joinr in children (nursemaid's elbow). J Pediarr
with undisplaced fracture of the olecranon in children.} Bone Joim Orthop 1995; 15:454-456.
Surg (Hi) 1957;39:508-512. 154. Costigan PG. Subluxation of the annular ligameIH ar the proximal
128. Klebnlp], Creen NE, Meneio GA. Ostt'Ochondriris dissecans as a radio-ulnar join!. ALberta Med BulL 1952;17:7-9.
 Chapter 16: DisLocations of the ELbow 739

155. Frumkin K. Nursemaid's elbow. A radiographic demonsrrarion. Ann 166. Newman J. "Nursemaid's elbow" in infants 6 months and under.]
Emerg Med 1985;14:690-693. Emerg Med 1985;2:403-404.
156. Griffin ME. Review arricle. Subluxarion of the head of the radius in 167. Piroth P, Gharib M. Die Traumatische Subluxation des Radius-
children. Pediatrics 1955;15:103-106. kopfchens (Chassaignacl. Deutsch Med Wochenschr 1976; 101:
157. llIingsworrh CM. Pulled elbow: a study of 100 patients. EM] 1975; 1520-1523.
2:672-674. 168. Quan L, Marcuse EK. The epidemiology and treatment of radial head
158. Jongschaap HCN, Youngson GG, Beattie TF. The epidemiology of subluxation. Am] Dis Child 1985;139: 1194-1197.
radial head subluxation ("pulled elbow") in the Aberdeen Ciry area. 169. Ryan JR. The relationship of the radial head ro radial neck diameters
Health Bull [Edinb] 1990;48:58-61. in fetuses and adults with reference ro radial-head subluxation in chil-
159. Kohlhaas AR, Roeder]. Tee shirr management of nursemaid's elbow. dren. ] Bone Joint Surg [Am] 1969;51 :781-783.
170. Sacchetti A, Ramoska EE, Glascow C. Nonclassic hisrory in children
Am] Orthop 1995;24:74.
with radial head subluxations. ] Emerg Med 1990;8: 151-153.
160. Kosuwon W, Mahaisavariya B, Saengnipanthkul S, et al. Ultrasonog-
171. Salter RB, Zaitz C. Anatomic investigations of the mechanism of
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injury and pathologic anatomy of pulled elbow in young children.
161. Macias CG, Bothner J, Wiebe R. A comparison ofsupinationlf1exion
Clin Orthop 1971;77:134-143.
to hyperpronation in the reduction of radial head subluxations. Pedi- 172. Schunk JE. Radial head subluxation: epidemiology and treatment of
atris 1998; 102: 10. 87 episodes. Ann Emerg Med 1990;19: 1019-1023.
162. Magill HK, Airken AP. Pulled elbow. Surg Gynecol Obstet 1954;98: 173. Snellman O. Subluxation of rhe head of the radius in children. Acta
753-756. Orthop Scand 1959;28:311-315.
163. Mades A, Eliopoulos K. Internal derangement of the elbow in chil- 174. Snyder HS. Radiographic changes with radial head subluxation in
dren. 1m Surg 1967;48:259-263. children. ] Emerg Med 1990;8:265-269.
164. McRae R, Freeman PA. The lesion of pulled elbow.] Bone Joint Surg 175. Teach SJ, Schutzman SA. Prospective study of recurrent radial head
[Br] 1965;47:808. subluxation. Arch Pediatr Adolesc Med 1996; 150: 164-166.
165. Mehara AK, Bhan S. A radiological sign in pulled elbows. 1m Orthop 176. Triantafyllou SJ, Wilson SC, Rychak]. Irreducible pulled elbow in
1995;19: 174-175. a child. A case report. Clin Orthop 1992;284:153-155.
 PROXIMAL HUMERUS, SCAPULA,
AND CLAVICLE
YOUNG KWON
JOHN F. SARWARK

FRACTURES OF THE PROXIMAL HUMERUS Incidence

Diagnosis Signs and Symproms
Classificarion Radiographic Findings
Surgical Anaromy Treatmenr
Treatmem Options Rehabilitation
Complications Prognosis
Complications
tRACT RES OF T IE SCAPULA
Diagnosis DISTAL HUMERAL DIAPHYSEAL FRACTURES
Classification Etiology
Surgical Anaromy Cbssification
Biomechanics Trearment
Treatmem Options SUPRACO IDYLAR PROCESS FRA T RES
Complications Anaromy
Etiology
FRACTURES F THE CLAVICLE Classification
Diagnosis Treatment
Classificarion
Surgical Anaromy GLEN HUMERAL SUBLUXATIO A 0
Biomechanics DISLOCATION
T reatmenr Options Anaromy
Complications Mechanism of Injury
Classi fication
FRACTURES OF THE HUMERA HAFT Signs and Symptoms
Embryology and Developmenr Radiographic Findings
Applied Anaromy Trearment
Mechanisms of Injury Rehabilitation
C1assificarion Complications

FRACTURES OF THE PROXIMAL boch direcc and indirect, is the predominant cause of fractures
HUMERUS in che proximal humerus. In this age group, these fraccures can
involve either the meraphysis, the physis, or both.
Fractures of the proximal humerus are relatively uncommon Because of the thick periosteum in this area and the proximiry
injuries of childhood, with an incidence of 1.2-4.4 per 1,000 [Q the physis, fractures in this region have enormous potential

per year (7,57,125), fewer than 5% of all pediatric fractures (40, [Q heal and remodel, perhaps more so than anywhere else in the

43,56,57,88). body. Thus, proximal humeral fraceures in children, in gener;J,

Fractures of the proximal humerus can be a common birrh- can be expected to heal without significant residual funccional
related injuly (61,101). As an infant is passing through the birth or cosmecic deficits.
canal, the arm may be placed in a variery of awkward positions
that will result in a separation through the physis of the proximal Diagnosis
humerus (22,34,36,37,61,72,101). In older children, trauma,
Mechanism of Injury
Birth Fractures
Young Kwou and John F. Sarwark: Division of Pediatric Orthopaedic Fraerures in the proximal humerus frequently occur during de-
Surgery, Children's Memorial Hospital, Chicago, Illinois. livery (61,101). These fractures are generally believed [Q resulr
742 Upper Extremity

FIGURE 17-1. Hyperextension or rotation of the ipsilateral arm may

result in a proximal humeral or physeal injury during birth.

from hyperextension or rotation of the arm during the passage

FIGURE 17-2. Motor vehicle crashes may result in proximal humeral
through the birrh canal (Fig. 17-1) (22,34,36,37,61,72,101). As fracture due to blunt trauma to the shoulder region.
might be expected, obstetric proximal humeral fractures occur
most frequently during vaginal deliveries of infants with larger
size or breech presentation (14,29.47,101). Prenatal size and part of rhe injuries associated with child abuse (Fig. 17-4) (28).
presentation, however, have not been accurate predictive factors Because no clear fracture pattern in rhe proximal humerus is
for these fractures, because proximal humeral fractures can and suggestive of abuse, an index of suspicion musr remain high
do occur during vaginal deliveries of infants of all sizes and when evaluating infants or young children with humeral frac-
weights (14,29,47). tures (99).
Childhood/Adolescent Fractures
For older children, the mechanism of injury in most proximal Signs and Symptoms
humeral fractures is trauma. The trauma can be a direct blow Clinical features of proximal humeral fractures in newborns may
to rhe shoulder area, especially to the posterior aspect (22,77, be subtle and not readily identified. For example, the infant may
103) or indirecr as in a fall onto an outstretched hand that
transmits the force through the arm to the proximal humerus
(2,9.47). Indirect trauma can result in forced or nonphysiologic
positioning of the upper extremity, which in rum may cause
a fracrure of the proximal humerus. Specifically, six potentia!
mechanisms of upper extremity positioning have been proposed
to explain the resulting proximal humeral fractures: forced exten-
sion, forceJ flexion, forced extension with lateral or medial rota-
tion, and forced flexion with lateral or medial rotation (123).
Although trauma has been acknowledged as the most common
mechanism of pediauic proximal humeral fractures, it is still
controversial whether a fall or a direct blow is the more common
etiology of rhe fracrure.
PeJiatric proximal humeral fractures often occur in children
involved in moror vehicle accidents and spons (Figs. 17-2 and
3) (51). It has been estimated that approximately 50% of shoul-
der girdle fracrures in children are related to sports and play
activities (78). Athletic activities associated with proximal hu-
meral fractures include conract sports, horseback riding (fall
from horses), gymnastics (upper extremity impact and weight
bearing), and baseball (repetitive throwing) (20,56,66,114, lIS).
Less often, pediatric proximal humeral fractures result from
other illnesses such as malignant or benign tumors and pituitary
gigantism (1,54,87,94). They also can be a complication of ra-
diation therapy to the shoulder region (24). In addition, shoul-
der joint neuropathy secondary to Arnold-Chiari malformarion,
myelomeningocele, or syringomyelia has been implicated as an
etiologic factOr in proximal humeral fractures (5,67). An un- FIGURE 17-3. Blunt trauma from contact sports may result in fracture
known percentage of pediatric proximal humeral fractures are of the proximal humerus in children.
 Chapter 17: Proximal Humerus, Scapula, and Clavicle 743

FIGURE 17-4. Although the exact mechanism of injury may vary in

child abuse, fracture of the proximal humerus may result from twisting
at the elbow or forearm.

be irritable when lifted by the arms or when the involved upper

extremiry is moved. The infant may refuse to move the arm,
giving the appearance of paralysis (i.e., pseudoparalysis). In addi-
tion to proximal humeral fractures, the differential diagnosis for
such paralysis includes brachial plexus injury, septic shoulder,
and clavicular fractures. Infants exhibiting upper extremiry paral-
ysis also may be suffering from posterior humeral head disloca-
tion (111).
Older children rypically report a history consistent with a
FIGURE 17-5. Vanishing epiphysis sign.
proximal humeral fracture. They often present with an obvious
deformiry in the anterior shoulder region and refuse to use the
involved arm. Pain, swelling, and ecchymosis, to some degree,
are invariably present, and the overall COntour of the shoulder is
altered in comparison with the contralateral uninjured shoulder. reveal this alteration more clearly. A vanishing epiphysis sign also
Most children with displaced proximal humeral fracture hold has been reported to describe posteriorly displaced transphyseal
the involved upper extremiry in internal rotation ro reduce the fractures ohhe proximal humerus (Fig. 17-5) (50,95). In com-
pull of the pecroralis major muscle on the distal fragment. With parison with the unaffected contralateral side, the epiphysis ap-
posterior fracture dislocations, children demonstrate limited and pears ro vanish on an AP radiograph when it is displaced poste-
extremely painful external rotation. Some children with fractures riorly. For complete evaluation of proximal humeral fracrures
of the greater tuberosiry have an unusual presentation of luxatio in newborns and infants, ultrasonographic studies often are diag-
erecta where the involved shoulder is positioned in extreme ab- nosric and informative (Il,41, 116). Computed romography
duction (27). This position reduces the displacement across the (CT) also may be useful, especially for complex fractures with
fracture as the grearer tuberosiry is pulled superiorly by the supra- posterior dislocations (112).
spinatus muscle. The elbow is rypically flexed in luxatio erecra, For evaluation of proximal humeral fractures in older chil-
allowing the hand to be near or above the head (27,52). Because dren, two radiographs in perpendicular views can be diagnostic
fractures of the lesser tuberosiry will affect the function of the (108). Ideally, a true AP view of the shoulder and an axillary
inserting subscapularis muscle, internal rotarion with the shoul- lateral view provide the most information about the fracture.
der in adduction and abduction with the shoulder in external Because some lesser tuberosiry fractures may only be visible on
rotation will be limited and painful (49,89,119). an axillary lateral view, this radiograph should be included when-
ever possible (42). Often, however, an axillary lateral view is
difficult to obtain in a child with an acutely fracwred proximal
Radiographic Studies
humel'us. In these instances, transthoracic axillary view or Y
The proximal humeral epiphysis is not visible on plain radio- view radiographs can be obtained. An apical oblique view, an
graphs until about 6 months of age (53,81), and plain radio- AP l'adiograph with the x-ray beam at 45 degrees of caudal tilt,
graphs are of limired value in evaluation of proximal humeral also can provide significant information about the proximal hu-
fractures in infants. On an anteroposterior (AP) radiograph, a merus (102). In fact, some authors report that most shoulder
change in the positional relationship between the proximal hu- rrauma can be evaluated with AP and apical oblique radiographs
meral metaphysis and the scapula and acromion often is visible. and that a lateral view (axillary lateral or Y view) can be obtained
A comparison with the uninjured contralateral shoulder may if a humeral fracture is suspected (l0).
744 Upper Extremit)'

When adequate radiographs cannot be obtained, CT is useful

in evaluating proximal humeral fractures. CT may be especially
useful in characterizing posterior fracrure dislocations (33,119).
If rhe child conrinues ro complain of shoulder pain despite nega-
tive radiographic and CT results, an occult fracture must be
ruled our. For rhis purpose, magnetic resonance imaging (MRl)
is diagnostic (7,90,110). A bone scan also may be useful in such
situations. However, due ro the normally increased radionuclide
uptake in the physis of the proximal humerus, a bone scan in
this region may be difficult ra inrerpreL

Classification
Fractures of rhe proximal humerus in the pediatric population
are broadly categorized by their anatomic location. They may
involve the physis, the metaphysis, the lesser tuberosity, or the
greater ruberosity. In addition, the degree of fracrure dispJace-
menr plays an importanr role in the overall treatment option.
Other fracture characteristics that must be evaluated include the
presence or absence of open fractures, concomitant glenohu-
meral dislocations, and fracrure stability.
FIGURE 17-7. Healing undisplaced fracture of the proximal humerus
Fractures involving the physis are classified according ra the
in a 5-year-old child. Note the absence of a physeal injury.
Salter-Harris classification (92) (Fig. 17-6). Salter-Harris type I
injuries wirh fracrures through rhe physis occur mostly in pa-
rienrs under 5 years of age (22,83). After 11 years of age, most
fractures of the proximal humerus are Salter-Harris type 1I inju- ipsilateral upper exrremiry also must be documented, because
ries, with rhe fracrure line exiting through the meraphysis (12, segmental fractures may require alternative treatmenrs (46,71,
22,83). Some Salter-Harris type II injuries are associated with 82). Other isolated fractures of the proximal humerus may in-
an additional anterolateral bony fragment (12). Salrer-Harris clude the greater and the lesser tuberosities (27,49,52,89,121).
type III injuries with the fracture line exiting through the epi- The degree offracture displacemenr in the proximal humerus
physis rarely occur in the proximal humerus of children (22, is classified with respect to the shaft diameter of the humerus
83). The few reported such injuries occurred with and without (77). In grade [ injuries, there is up ro 5 mm of displacement.
concomitant glenohumeral dislocation (16,33,109,120,124). In grade II and III injuries, fractures are displaced by up to one
Salter-Harris type IV injuries involving both the metaphysis and third and two [hirds of rhe humeral shaft diamerer, respectively.
the epiphysis of the proximal humerus have not been reported Displacement of greater than twO thirds of the shaft diameter,
in children. including rotal displacement, is classified as a grade IV injury.
Fractures of the mecaphysis occur mostly in children 5 to 12 In addition to degree of displacemem, fractures in [his region
years of age (Fig. 17-7) and are categorized by their anaromic may demonstrate angulation deformities. Although varus angu-
locarion and degree of displacement (22). The anatomic location lation is most common, fractures can be angulated in any direc-
is described in relation ro the major deforming forces in rhe tion.
region, namely rhe insertions of the pecroralis major and the In high-energy trauma, fractures of the proximal humerus
del raid muscles. Presence or absence of other fracrures in the may be associa[ed with concomi[ant dislocations of the glenohu-

~
~
/;
I
I

FIGURE 17-6. Physeal fractures of the proximal

humerus. A: Salter-Harris I. B: Salter-Harris II. C:
A B c D Salter-Harris III. D: Salter-Harris IV.
 Chapter /7: Proximfll Humerm, Scapula, and Clavicle 745

meral joinr. The direcrion of rne dislocarion may be amerior,

posrerior, or inferior (16,27,28,33,52,80,117). A mess fracrure
of tne metaphysis or a slipped epiphysis can be produced by
• I I
chronic or repetirive rrauma, such as repetitive throwing, gym- ,If,
nasrics witn humeral weighr bearing, and localized radiarion I
rnerapy (20,24,66,114,115). Because of rhe rremendous healing
and remodeling porenriaJ in rhe pediatric proximal numerus,
tnese injuries can be successfully ueared wirh conservative non-
surgical rherapy.

Surgical Anatomy
The proximal humeral ossification cemer cannot be seen on
plain radiographs umil abour 6 monrhs of age (53,81). In addi-
rion [Q rhe proximal humerus, both the greater and lesser ruber-
osiries conrain their own separate ossification cemers. Tne ossifi-
cation cenrel' for the grearer ruberosiry appears ar around 1 w
3 years of age, while rhe ossificarion cenrer for the lesser tuberos-
ity rakes form at 4 w 5 years of age (81,93). The two tuberosities
coalesce ar around 5 w 7 years of age and subsequently fuse
wirh rhe humeral head at 7 w 13 years of age (81,93).
Tne proximal physis of rhe humerus cominues w proliferare
well imo the teenage years and is ultimately responsible for ap-
proximately 80% of rhe overall humeral growrh (8,85,86,105). FIGURE 17-8. The articular surface of the proximal humerus.
Imerestingly, longirudinal growrn ar rhe proximal humeral phy-
sis changes during developmem such tnat it is responsible for
only 75% of humeral growth before age 2, but up w 90% of
growrh after age 11 (8,85,86). For girls, this growth cominues
The vascular supply w rhe proximal humerus arises from
umil around 14 years of age, wirh subsequem fusion of rne
the axillary artery. Disral w rhe pecwralis minor muscle, three
epiphysis w the shafr at 14 w 17 years of age (8,19,105). For
boys, growrh conrinues until about age 16, when closure of the differeD[ arterial branches arise from rhe axjJ1ary arrery before ir
physis begins (8,85,86). For most boys, the proximal humeral becomes rhe brachial arrery to supply rhe upper extremir),. One
physis is closed by about 18 years of age (19). of rhese branches is the subscapular arrelY, which runs wirh
The arricular surface of rhe proximal humerus covers mosr rhe subscapular nerve w supply rhe rorawr cuff muscles. The
of the medial aspen of the epiphysis as well as rhe proximal remaining two branches, the amerior and the posrerior humeral
medial corner of rhe metaphysis (Fig. 17-8). The glenohumeral circumflex arteries, supply rne proximal humerus. Mosr of the
joinr capsule surrounds the articular surface such that most of humeral head vascularity is from rhe arcuare artery, which, in
rhe medial epiphysis as well as the proximal medial corner of turn, is from the ascending branch of rhe amerior humeral cir-
the metaphysis are inrraarticular (Fig. 17-9). Conversely, a pre- cumflex artery (30,55). The posterior humeral circumflex arrelY
dominant proportion of the physis is exuacapsular and remains is a less dominam vascular supplier of the proximal humerus,
susceprib1e [Q injuly. The periosteum is quite strong in the pos-
reromedial aspect of rhe proximal humerus, bur rhe periosreum
in the anterolareral aspen is relarively weak, occasionally allow-
ing rhe fractured fragmem ro penetrate and prevenr reduction
(22).
The proximal humerus is the site of insertion for a number
of different muscles that can influence the pattern of fracrure
displacemenr. These muscles and their attachmems form early
during developmem and are grossly similar w those of an adult
shoulder by rhe rime of birth. The four muscles of rhe roraror
cuff insert omo the epiphysis. The subscapularis muscle inserrs
on rhe anrerior aspen of [he epiphysis on [he lesser ruberosity,
whereas the reres minor, rhe infraspinarus, and rhe supraspinarus
muscles insert omo rhe superior and posrerior aspecr of the epi-
physis near rhe grearer ruberosiry (Fig. 17-10). In addirion [Q
the rorawr cuff muscles, orher muscular arrachmenrs rhar can
cause fracrure displacemem are the deltoid and pecwralis major
muscles. The del wid muscle attaches in the lateral aspect of the
humeral shafr, whereas rhe pecroralis major muscle attaches to
rhe ameromedial aspen of the meraphysis. FIGURE 17-9. Glenohumeral joint capsule.
746 Upper Extremity

FIGURE 17·10. Origins and insertions of the cuff muscles in a child:

subscapularis, teres minor, infraspinatus, and supraspinatus. FIGURE 17-12. Relationship of the brachial plexus and artery to the
proximal humerus and the scapula.

because it supplies a small portion of the greater tuberosiry and

a small portion in the posteroinferior portion of the humeral subscapularis muscle before passing inferior to the glenohumeral
head (30) (Fig. 17-11). joint to the posterior aspect of the proximal humerus (Fig. 17-
The close proximiry of the axillary nerve to the proximal 12). The axillalY nerve provides innervation to the deltoid mus-
humerus makes this neural structure susceptible to injUly during cle as well as a cutaneous sensory function over the lateral aspect
fracrure and fracrure dislocations of the proximal humerus (4, of the deltoid cuff. Documentation of the normal funcrion of
27,117). The axillary nerve is a branch of the posterior cord this nerve before the initiation of treatment is essential.
of th~ brachial plexus. It traverses the anterior aspecr of the Most fractures of the pediatric proximal humerus involve the

Transverse cervical a.
Inferior thyroid a.
Thyrocervical trunk
Suprascapular a.

Anterior --f-~'"
Highest thoracic a.
circumflex
Thoracoacromial a.
flUmeral a.
lateral thoracic a.
Posterior
circumflex
humeral a. ----jf---l'

Profunda
brachii a.

FIGURE 17·11. The arterial anatomy of the shoulder region.

 ChIT/lei' /7: Proximal Humerus, SCIf/It/fl, tlnd Clavicle 747

physis (12,22,83). The exrracapsular locarjon of rhe proximal

humeral physis makes rhis srrucrure susceptible to injury. Physeal
fracrures are thought to occur through the zone of hypertrophy
and spare the reserve as well as the proliferarive cells in the physis
(92). Therefore, children with Salter-Harris rype I or II fractures
still maimain excellent potential for longitudinal growth and
remodeling in rhe proximal humerus (6,22).
In children 5 to 12 years of age, a significant proporrion of
proximal humeral fractures involve rhe meraphysis rarher rhan
rhe physis (22). This rather unexpecred finding has been amib-
ured w rhe rapid meraphyseal growrh thar occurs during rhis
age, which, in rum, results in a relarive suucrural weakness of
rhe meraphysis (22).
Various muscular arrachments ro rhe proximal humerus con-
uibure w rhe degree and rhe overall pattern of fracrure displace-
mene. Wirh fracrures of the physis (Salter-Harris rypes I, II,
and III), the rOtawr cuff muscles displace the epiphysis inw
abducrion, flexion, and slight enemal rotation, whereas rhe me-
raphysis is displaced ameriorly and medially by rhe pecroralis
major muscle. Wirh meraphyseal fracrures proximal ro rhe pec-
roralis major muscle, rhe proximal fragmem is abducred, flexed,
and exrernally ro[ared by the roraror cuff muscles. The delroid
muscle displaces [he disral fragmem proximally, whereas rhe pec-
roralis major muscle displaces the same fragment ameriorly and
medially. If rhe fracrure occurs berween the inserrions of the
delroid and the pectOralis major muscles, the proximal fragment
is adducred by the pull of the pectOralis major muscle, and the FIGURE 17-13. Sling and swathe for immobilization of proximal hu-
distal fragment will be pulled proximally by the delroid muscle. meral fracture.
If rhe fracture occurs distal ro the delroid muscle insertion, rhe
proximal fragmenr is abducted by the delwid muscle and dis-
placed anteriorly by rhe pecroralis major muscle. The disraJ frag-
mem is pulled proximally and medially by rhe biceps and the be evaluated via ultrasonography. With or without anaromic
triceps muscles (21). reduction, the affected upper extremiry shouJd then be immobi-
lized to the body by using a safery pin to atrach the shirt sleeve
ro the shirt (94). Proximal humeral fracrures in rhis age group
Treatment Options
heal quite rapidly, rypically within 2 ro 3 weeks, and resulr in
Because of their tremendous porenrial for healing and remodel- no residual functional or cosmetic defIcits (22,36,47,62,101,
ing, fracrures of rhe proximal humerus in children rarely require 122). Nondisplaced or minimally displaced proximal humeral
operative reduction and fixation (Table 17-1). This is especially fracrures in older children also should be ueated nonoperarively.
uue for obstetric proximal humeral fracrures in infanrs. These lnirial managemem of these fractures wirh sling-and-swarhe im-
fracrures are quite amenable ro gentle reducrion wirh minimal mobilization (Fig. 17-13) followed by protected motion provides
or no anesrhesia. If desired, the adequacy of the reduction can excellent long-rerm results (13,22,77).

TABLE 17-1. INTERVENTIONS FOR PROXIMAL HUMERUS FRACTURES

.Operative
Operative Reduction!
Reductionl Internal
ImmobilizCltion Immobilization Fixation

Birth fractures x
Chronic slipped proximal X
humeral epiphysis
Metaphyseal fractures x
SH·I before age 11 yr X
SHI after age 11 yr x
748 Upper Extre111itJI

Initial management of displaced proximal humeral fracrures types of shoulder immobilization include sling-and-swathe,
may requite reduction of the fracture before immobilization. thoracobrachial bandage, hanging arm cast, shoulder spica cast,
Because the remodeling potential of the fracture decreases with salute position shoulder spica cast, and "statue of liberty" cast
the increasing age of the child, the degree of acceptable displace- (13,22,36,59,77).
ment and angulation also changes with the age of the child. Some investigators recommend reducing aJl grade III and
Generally, relatively greater displacement and angulation can be grade IV fractures and immobilizing grade IV fractures in salute-
accepted in younger children. For fractures in children under position shoulder spica casts (77). Other investigators suggest
the age of II, good to excellent long-term outcomes can be gende reduction of Salter-Harris type I and II fractures in chil-
expected regardless of the fracture displacement (22,59,77 ,103). dren over 1] years of age, followed by immobilization with thor-
Grossly displaced or angulated proximal humeral fractures in acobrachial bandage or shoulder spica casts or more likely percu-
children over 11 are managed with fracture reduction and some- taneous pinning (Fig. 17-14) (22). If a Salter-Harris type II
times with specialized immobilization (22,59,77,100). Various fracture cannot be adequately reduced, Dameron and Reibel

A B

c D
FIGURE 17-14. A: Salter-Harris I fracture of proximal humerus. B: Intraoperative pinning through the
metaphysis. c: Postoperative view. D: Healed physeal fracture.
 Chapin /7: Proximal Hllmems, Scapula, and Clavicle 749

recommend creatment with a saJute-position shoulder spica cast ment, indications for operarive treatment of pediatric proximal
with the arm posirioned in external rorarion, abduction, and humeral fractures are limited (18). Reported indications for op-
flexion (22). An acceptable reduction of proximal humeral frac- erarive inrervenrions include open fractures, fractures associated
rures in children over 11 years of age has been proposed by some wirh neurovascular injury, fractures associated wirh mulriple
to be less than 50% displacement and 20 degrees of angularion rrauma, displaced inrraarricular fractures such as Salrer-Harris
(100). Regardless of rhe specific rrearment options, nonoperative type III fracru res, irreducible fracrures, and signi fican tly cLs-
rreatment of pediarric proximal humeral fractures has produced placed fracrures in older adolescents (12,40,60,68,73,76,98,106,
good to excellent results in all age groups (22,59,77,100). 120).
Multiple maneuvers exist for the reduction of pediacric proxi-
mal humeral fractures. Most fracrures can be reduced by apply-
ing longitudinal tracrion to rhe arm while positioning ir in ab- , . AUTHOR'S PREFERRED METHOD
ducrion and flexion. If rhis maneuver does not sufficiently reduce ,~ OF TREATMENT
rhe fracrure, berrer reduction can be obrained by moderare ab-
duction, flexion to 90 degrees, and external rotarion (77). Alrer- I manage mosr fracrures of rhe proximal humeraJ physis nonop-
natively, the fracture can be reduced by direcr manual manipula- erarively. This includes undisplaced and mosr displaced physeal
tion of the fragments while rhe arm is placed in marked injuries of rhe proximal humerus. J prefer to percuraneously pin
abduction (~135 degrees), slight flexion (-30 degrees), and markedly displaced fractures involving rhe proximaJ humeraJ
longirudinal tracrion (9,47,122). Despite significant efforts, physis and meraphysis, particularly rhose in children over 12
however, some fractures cannot be adequately reduced because years of age and rhen apply a shoulder immobilizer or Velpeau
of a barrier in the fracrure sire. Anatomic structures thar can bandage (Fig. 17-15). Almosr all meraphyseaJ fractures are
prevenc reduction of proximal humeral fractures include rhe created nonoperarively wirh only a few requiring closed reduc-
periosreum, the periosreal cuff, rhe shoulder joint capsule, and rion. Because of rhe rremendous remodeling porenrial of me-
rhe biceps rendon (26,44,60,62,118). raphyseal fracrures in children, displacements in bayoner apposi-
Because of rhe consisrendy good resulrs of nonoperarive rrear- rion of up to 1 cm are acceprable. The rarionale behind closed

A,S c
FIGURE 17-15. A: Anteroposterior radiograph of displaced fracture of the proximal humerus metaphy-
sis with shortening with apparent inferior subluxation of the humeral head with respect to the glenoid.
B: Attempted axillary view. C: Intraoperative film status after percutaneous pinning. Note the apparent
inferior subluxation while under general anesthesia.
750 Upper Extremity

A,S C,D
FIGURE 17-16. A: Anteroposterior radiograph of displaced, shortened fracture of the proximal hume-
rus. B: Axillary image of same. C: Intramedullary fixation using retrograde technique. Note the satisfac-
tory restoration of alignment. D: Postoperative lateral view.

reducrion and percuraneous pinning of proximal humeral phy- with appropriate anesthesia. If this is associated with a physeal
seal fracrures is a more rapid remrn ro normal acrive and passive injUly, the physeal injury generally does not require furrher
range of motion. There is a minimally increased but acceptable closed reduction or open reduction techniques. If the dislocation
risk of infection. In my opinion, this approach is more acceptable or fracmre cannot be placed in an acceptable position, open
than leaving the fracture unreduced. My preference is to place reduction is generally done through an anrerior or axillary ap-
the pin percutaneously through the metaphyseal fragment up proach to the proximal humerus.
inro the physis as in pinning ofa slipped capital femoral epiphysis
in the hip (Fig. 17-14). After percutaneous pinning, the arm
can be brought alongside the patient's body for more acceptable Complications
and more comfortable immobilization with a shoulder immobi-
Early Complications
lizer. Alternatively, intramedullary fixarjon with flexible nails is
an effective method (Fig. 17-16). Diagnosis of a proximal humeral fracrure can be delayed in a
Displaced fracrures of the lesser tuberosity generally are child wh.o is asymptomatic or minimally symptomaric. In chil-
treated wirh open reduction to resrore the subscapularis tendon dren suffering from mulriple traumas, the diagnosis can be de-
and anterior capsule. Lag screws or suture anchors are very useful layed because of a low level of clinical suspicion. Even after the
in rhis region, particularly for smaller injuries. diagnosis of proximal humeral fracmre is made, full evaluarion
Fracrures of the grearer tuberosity generally are associated and characrerizarion of rhe fracture parrern can remain incom-
wirh acure dislocarions of the shoulder and are treated nonopera- plere because of adequate radiographic smdies. A high index of
tively after following the closed reduction of the shoulder disloca- suspicion, thorough physical examinarion, and insisrence on
tion. Rarely, after closed reduction of the shoulder dislocation, high-qualiry radiographs musr all be presenr ro ensure prompt
the greater tuberosiry fracture reduction is unacceptable, and an diagnosis and treatmenr of proximal humeral fractures.
open approach to repair rhe ruberosity fracrure along with rhe Neurologic injury to rhe brachial plexus can resulr from frac-
rotator cuff is required. tures and fracrure-dislocarions of rhe proximal humerus (4,23,
Fracture dislocations of the shoulder require closed reduction 27,117). Mosr nerve deficits can be diagnosed immediarely bc-
 Chapter 17: Proximal Humerus, Scapula, and Clavicle 751

cause the clinical signs are readily apparent. Rarely, however, cularization may occur in children and lead to excellent clinical
nerve deficits from proximal humeral fractures can evolve slowly results (120). Similarly, glenohumeral subluxation after proximal
and delay the diagnosis (23). Typically, these nerve deficits are humeral fracrures is a rare complication in the pediatric popula-
rransienr, and full funcrion can be expected to return in .less tion that typically results in good clinical outcomes (J 26). These
than 6 monrhs (45). If the neurologic deEcit persists longer than children are best treated with a shorr period of immobilization
3 months, furrher evaluation with electromyography is war- followed by early physical therapy and rehabilitation (94).
ranted. If no evidence of nerve recovery or regeneration is pres-
ent, nerve explotation, repair, and grafting can be considered
(4,15). Salvage operations for permanenr nerve deficits include FRACTURES OF THE SCAPULA
proximal humeral osteotomy and muscle or tendon transfers (3,
17,39,48,84). The unique anaromy of the scapula protects this bony structure
Fracrures of the proximal humerus in children also can be from severe injulY. The scapula has 17 different muscle attach-
associated with other injuries, including rib fracrures and pneu- ments and is encased in multiple layers of muscle and other soft
mothorax (94). In adults, these fracrures l1ave been associated tissue strucrures. Due to this inherent protection, fractures and
with disruptions and thrombosis of the axillary vessels as well dislocations of the scapula are rare. In fact, it has been estimated
(65,97,107,127). Operative fixation of proximal humeral frac- that only 1% of all fractures involve the scapula (133,135). The
tures with pins and wires have been associated with hardware significance of a scapular injuty, however, is its disproportion-
migrations that can be fatal (64,70). Therefore, seriaJ radio- ately high association with major trauma. The high-energy trau-
gl'aphic monitoring of the hardware after shoulder operations is mas that cause scapular injuries also can result in significant
essen tial. injuries to other major organ systems (150,160,161). Therefore,
all children with scapular fractures must be systematically evalu-
ated to exclude other life-threatening injuries that require imme-
Late Complications diate medical attention and intervention.
Humerus varus after trauma is a rare complication that typically
affects neonates and children under 5 years of age (25,58,69, 104, Diagoos~s
113). Children with humerus varus have a signiflcanr decrease
in the humeral neck-shaft angle and shortening of the upper Mechanism of Injury
extremity. Although shoulder abducrion may be moderately lim- Glenoid
ited, most children with humerus varus have only mild func- Fractures of the glenoid typically occur in a fall OntO an upper
tionaJ deficits and do not require surgical correction of the defor- extremity. This is believed to drive the humeral head onro the
mity (25,58,69,113). If, however, active abduction and ~exion glenoid fossa, which, in turn, results in the fracture. Depending
are severely limited, correcrive osteotomy of the proximal hume- on the di rection of the force, the fracrure may only injure the
rus can produce good results (32,104). rim of the glenoid or the entire glenoid fossa.
Hypertrophic scarring can occur after surgical reduction of
proximal humeral fracrures. When the scarring is present in the
anterior shoulder region after an anterior deltopecroral incision,
Scapula
the cosmetic deformity may be significant and psychologically Many fractures at other sites of the scapula are avulsion-type
damaging, especially for girls (26,31). Therefore, many investi- injuries from the various muscle attachments. Scapular fractures
garors have argued for the more cosmetically appealing axillary also can occur after a direct traumatic insult ro the bone itself.
or anterior axillary incision (35,63). These insults may be associated with other life-threatening inju-
Limb length inequality after proximal humeral fractures oc- ries, such as hemothorax, pneumothorax, and cardiac contusions
curs more frequently in children treated with surgical inrerven- that require immediate medical attention (J 50, 160). As with all
tion than in those [['eated nonoperatively (6,22,91). The inequal- other high-energy injuries, child abuse must be excluded as a
ity is not signiflcandy affected by the quality of initial fracrure cause for the scapular injury when no clear traumatic cause is
reduction (6). The discrepancy may be more pronounced in evident (142).
older children 0-3 cm) (77). Despite this inequaliry, however,
these children rarely develop any functional deficits to warrant
Signs and Symptoms
surgical intervention. Full arrest of physeal growth after trau-
matic proximal humeral fractures is extremely uncommon (22). Scapular fractures or dislocations, by themselves, do not pose
Although still quite rare, it does occur more frequently in chil- an immediate danger to the patient. However, over 75% of all
dren with pathologic fracrures through unicameral bone cysts patients with scapular fractures have other injuries (128,139,
(38,75,79). If the functional or cosmetic deficit is significant, a 157,160). In one reported series, the rate of mortality among
limb-lengthening procedure may be of benefit for these children patients wi th scapular fractures was over 14% (I 60). Therefore,
(96). before the scapular fracture is investigated, the child must be
Osteonecrosis of the humeral head after proximal humeral systematically examined for other, possibly life-threatening, inju-
fracrures occurs frequently in adults, but is rare in children (74, ries. A full trauma evaluation should be undertaken for head,
126). Even after acute disruption of the vascular supply to the chest, abdominal, and renal injuries. If available, a consultation
proximal humer"l epiphysis, subsequent remodeling "nd revas- with rhe trauma service would also be prudent. Conversely, frac-
752 Upper Extremity

tures of the scapula should be sought in children with life-dueat- Classification

enlng trauma.
Multiple classification systems for scapular fractLlres have been
Orthopaedic evaluation for scapular fracture should include
reported. Many are descriptive and based primarily on the ana-
an examination for other bony deformities and extremity tender-
tomic location. Ada and Miller, for example, classified scapular
ness. Children with scapular fractW"es complain of significant
injuries into those of acromion, spine, coracoid, neck, glenoid,
pain and tenderness around the shoulder girdle and decline to
and body (128). In rheir series, fracrures occurred most ofren
move the affected arm. Localized edema may obscure the overall
in rhe body (35%), followed by the neck (27%). Fractures of
shoulder contour. A comparison with the contralareral shoulder
the coracoid were least common (7%). Similarly, Thompson er
ofren is helpful in determining this loss of comour. Because of
al. (160) classified scapular fracrures into the three broad ana-
the close proximity of the scapula to the axillary artery and the
ramic locations: fractures of the glenoid and the glenoid neck,
brachial plexus, fractures of the scapula often are associated with
fracrures of the acromion and rhe coracoid, and fractures of
neurovascular injury (160) (Fig. 17-12). The ipsilateral arm
rhe body (Fig. 17-17). Other anaromic locarion-based scapular
must be carefully examined to document any arterial or neuro-
fracrure classifications have been reponed by Imatani (J 39) and
logic deficits before the initiation of treatment. \Xfhen injUlY to
Wilbur and Evans (61).
axillary or distaJ vasculature is suspected, an angiogram should
be performed to examine the integrity of the vessels. The classification described below is also based on the ana-
ramic location of the fracrure, with addirional subclassifications
based on mulriple reported studies (Fig. 17-17 and Table 17-
Radiographic Studies 2). It musr be emphasized, however. that most of these studies
Many scapular injuries are initially identified on the AP chest are nor specific for pediatric scapular fractures. Therefore. appli-
radiograph of a trauma series. An AP chest radiograph also may carion of this classification system and irs supporrive studies to
reveal scapulothoracic dissociation. This devastating injury pediarric scapular fractures should be individualized to each
should be suspected if the medial border of the scapula is dis- child. The fracture should be adequately evaluated for its ana-
placed laterally, if there is a clavicular fracture with a large ramic location. displacemenr, comminurion, and articular in-
displacement, or if there is a complete acromioclavicular joint volvement. In addition. ipsiJareral neurovascular status, the over-
separation with large displacement (155). Scapulothoracic all sratus of the patienr. and other concomiranr injuries should
dissociation typically occurs in patients with massive, direct be fully characrerized.
trauma to the chest or proximal upper extremity and is highly Fractures of the body and rhe spine of the scapula, which
associated with ipsilateral neurovascular injury (131,]55). make up nearly 50% of all scapular fracrures, are broadly ca1tego-
When a scapular injury is suspecred. AP and lateral view rized into those with and wirhout displacement. Alrhough iso-
radiographs of the scapula should be immecliarely obtained be- lared fracture of the scapular neck is believed to be a stable bony
cause they are essenrial in characterizing the fracrure. In addirion consrrucr, ipsilateral fractures to both rhe scapular neck and the
to rhese, other views should be obrained to assess various fracture clavicle may lead to disruprion of rhe suspensory mechanism of
patrerns. The Stryker notch view, for example. berter reveals rhe shoulder (133.144). Therefore, fractures of the scapular neck
coracoid fractures. whereas the axillary lateral view is berter are categorized intO those wirh and withour concomirant injuJY
suited to identify glenoid fractures. The axillary lateral view also to rhe clavicle. For similar considerarions, fracrures of the cora-
is helpful in confirming rile location of the humeral head on the coid process are categorized into rhose wirh and without con-
glenoid. Because the three-dimensional structure of the scapula is comitant injury to the acromioclavicular joint.
complex. even high-quality radiographs may not provide all the Fractures of the acromion are categorized into those with and
details necessary to characterize the fracture. In such instances. wirhout displacement. Displaced fractures are furrher subclassi-
CT with three-dimensional reconstructions may be required. fied based on the presence or absence of subacromial narrowing.
CT also is essenrial in characterizing intraarticular injuries of Subacromial space narrowing may occur after inferior displace-
the glenoid. ment of rhe acromion or after superior displacemenr of an ipsi-
Accurate interpretation and assessment of scapular radio- lareral glenoid fracture. When treated conservatively, these frac-
graphs requires recognition and identification of developmemal ture patterns ofren lead to subacromial impingement in adults
variations. Reponed developmental variations of the scapula in- and result in decreased range of shouldet motion and increased
clude Sprengel's anomaly, absent acromion. bipartite or tripar- shoulder pain (143). Although its applicabiliry to acromial frac-
tite acromion, bipartite coracoid, and coracoid duplication (129, tures in younger children is still debared. this finding signifi-
140,148.156,158). Os acromiale. for example. is often mistak- canrly affects the treatmem oprions for acromial fractures in
enly identified as a fraCture. This variation occurs when the older children.
centers of ossification in the acromion fail to unite (129). Os Fractures of the glenoid typically occur when the humeral
acromiale is present in 2.7% of the general population and is head is driven omo the glenoid fossa. Depending on the direc-
bilateral in 60% (145). Typically, os acromiale is located in the rion of rhe force applied to the humeral head, the fracture may
anterior and inferior aspect of the distal acromion and has a involve the entire fossa or just rhe rim. If rhe entire fossa is
smooth and uniform appearance on radiographs. If. however, involved, the fracture line may then exit in multiple locations
radiographic studies and clinical examination cannot distinguish about the scapula. Hence, fractures of the glenoid are classified
between a fracture and a developmental variation, further evalua- imo five distinct groups based on their anatomic location and
tion wirh a bone scan may be indicared (J 41). course of the fracture. This system was initially proposed by
 Chapter 17: ProximaL Humerus, ScapuLa, and Clavicle 753

\
\, \,

\
la Ib

\
\
\
,

\
II III IV

, \ \
\ \ \

\
\ ~
Va Vb Vc VI
FIGURE 17·17. General classification of scapular/glenoid fractures.

TABLE 17-2. TREATMENT OF SCAPULAR FRACTURES

Scapular Scapular
Scapular Neck Neck Displaced
Body Fracture- Fracture- Coracoid Acromial Glenoid
Fracture Undisplaced Displaced Fracture Fracture Fracture

Observation x X X X
Open reduction X X
Open reduction/posterior approach X
754 Upper Extremity

Type I fracture Scapulothotacic dissociation occurs when all attachments or

articulaEions berween the thorax and the scapula are completely
severed. When there is an ipsilaterJI neurovascular injury, ir is
sometimes referred to as a forequarter ampmation. This is in
conrrast to scapulothoracic dislocarion, where only the inferior
scapulothoracic articulation is displaced (J 31). Although intra-
thoracic dissociations have been reponed 05.3), scapulothoracic
dissoci;l(ions are typically lateraJly displaced. These injuries are
cJtegorized as open or closed with intacr or compromised neuro-
vascular status.

Surgical Anatomy
AP view During development, the scapula forms in the first rrimester of
g sration. Jt first appears near the level of lower cervical spine,
Type II fracture
C4-C7, and rhen descends to its final position on me lateral
(translational displacement) aspect of the upper thorax during development. Mosr of the
scapula is formed by intramembranous ossification. Numerous
centers of ossification exist for the scapula: rhree for the body,
two for the coracoid process, two to five for the acromion (129),
and one for the glenoid. These ossification centers during child-
hood are ofren mistakenly identified as fracrures. In some devel-
opmental anomalies, distinct ossification centers fail to fuse and
persist into adulthood (148). These conditions are also fre-
quently characterized as fractures. With few exceptions, how-
ever, a developmental variation and a fracture can be distin-
guished by clinical history, physical examination, and
radiographic appearance.
in its final form, the scapula is roughly triangular and has a
complex three-dimensional srrucrure. It is responsible for linking
AP view Axillary view
rhe upper extremity to rhe axial skeleron (hg. 17- [9) and con-
tains atrachments to 17 distinct muscles. The anterior aspect of
Type II fracture the scapular body is a relatively flat surface, most of which is
(angulatory displacement) covered by rhe subscapularis muscle. The posterior aspect of the
scapula is divided into tvvO fossae by the scapular spine. These
superior and inferior scapula fossae arc mostly covered by the
supraspinarus and the infraspinatus muscles, respectively. The
anteromediaJ border of the scapular body provides arrachment
to the serratus anterior muscle. The posteromedial bordet con-
tains the attachmenr sires of the Icv;HOI' scapulae, rhomboideus
Axillary view

FIGURE 17-18. Classification of fractures of the glenoid neck.

ldcberg and later expanded by Goss (Fig. 17-18) (132,137,138). 1

·rn)C [fracrures are isolared glenoid rim Fractures, wirh la involv- )
ing rhe anteriot rim and wb involving the posterior rim. Type
ll, III, and IV fractures are glenoid fractures with fracrure lines
exiting through lateral, superior, and medial aspens of the sca-
pula, respectively. Type V fractures are various combinations of
type II, III and IV fractures. Type Va, for example, is a combina- \
\
tion of rypes II and IV. Type Vb is a combination of rypes III
and IV, whereas type V c is a combination of type II, III, and
IV. Type VJ fracrures are comminuted fractures of the glenoid
\
fossa. These vatious types of glenoid franures are associated with FIGURE 17-19. Relationship between the scapula, clavicle, and
distinct panerns of morbidity and treatment options. sternum.
 Chapter 17: PI'oximaL Humerus, ScapuLa, and CLavicLe 755

major and minor, and latissimus dorsi muscles. The omohyoid ing abduction, flexion, and extension. In addition, with the clavi-
muscle anaches ro the superior aspect of the scapular body, cle, the scapula acts ro link the axial skeleton ro the upper extrem-
whereas the teres minor and major muscles and the rriceps mus- iry. It provides a scaffold from which the upper extremiry
cle arrach ro the lateral border. The scapular spine provides at- suspends and articulates in order to funceion. Therefore, its
tachments ro the rrapezius and delroid muscles, and the long srructural integriry is essential ro the proper funCtioning of the
head of the biceps muscle originates from the superior rim of upper exrremiry.
the glenoid. Finally, the pecroralis minor muscle, as well as the A traumatic insult may cause fracrures in multiple locations
conjoined tendon of the coracobrachialis and short head of [he about the scapula, with one fracrure influencing the stabiliry of
biceps muscles, anach ro the coracoid process. anOther. Goss solidified this idea and subsequently proposed the
In addition ro [hese muscle anachments, the scapula parrici- concept of a superior shoulder suspensory complex (SSSC)
pates in the formation of both glenohumeral and acromioclavi- (133). The SSSC is a set of bony struts attached to a circular
cular joints. The glenohumeral joinr is stabilized by multiple complex of structures at the lateral end of the scapula (Fig. 17-
dynamic and static forces abou[ the joint, which are discussed 20). The superior and inferiot bony strutS are the middle clavicle
separately. The acromioclavicular joint is stabilized in parr by and the lateral scapula body/spine, respectively. The circular
[he presence of twO coracoclavicular ligaments that position the complex is composed of acromioclavicular ligament, acromion,
distal clavicle immediately medial to the acromion. The twO glenoid process, coracoid process, coracoclavicular ligament, and
ligamenrs are the conoid and the trapezoid ligaments, with the distal clavicle. As a whole, the SSSC is responsible for linking
conoid being the more medial of the two. the upper exrremiry ro the axial skeleton. Traumatic injury to
In close proximiry ro [he scapula are a number of neurovascu- any single component of the SSSC will likely result in a mini-
lar structures that can be injured during a scapular fracture. Mos[ mally displaced fracture, because the inherent stabiliry of the
notable are the brachial plexus and the axillary artery, which circular complex is still intact. However, when multiple struc-
course across the anterosuperior aspece of the scapula. They are
tures of the circular complex are injured, a double disruption
immediately posrerior and inferior to the tip of the coracoid
to the circle occurs. This, in turn, results in signiflcant instabiliry
process. Medial ro the base of the coracoid process is the scapular
and displacement at one or all of the fracture sites. Similarly,
notch wirh the overlying transverse scapular ligament. The su-
injury to one of the strucrures of the ring complex with a con-
prascapular nerve and artery pass under and over the ligamenr,
comitant injury to a bony Strut also may create an unsrable
respectively, in the scapular notch and are susceptible to injury
consrruct. Goss therefore proposed rhat the rreatmenr decisions
with nearby fractures. The axillary nerve navels within an inter-
for scapular injuries should be based on the maintenance of
muscular interval immediately inferior ro the glenoid and is also
SSSC integriry (133).
susceptible to injury with displaced fracrures of the glenoid neck
(149).
Treatment Options
Biomechanics
Isolated fractures of the scapular body do not affect the integrity
The scapula can prorracr, retrace, abduct, and elevate. Irs motion of the SSSC (Table 17-2). In addition, because of the numerous
augments the movements about the glenohumeral joint, includ- muscle attachments, fracrures of the scapular body are quite

Acromioclavicular
ligaments Acromioclavicular
Clavicle Clavicle
ligaments
Acromial
process

Coracoid Acromion
process
I Coracoid
\ process
\
,~ ,-
+--\-\--- Glenoid
,,
'-,*\
\
process --+-f--- Glenoid
" \
fossa

A B
FIGURE 17-20. Superior shoulder suspensory complex. A: Anteroposterior view of the bone-soft tissue
ring and superior and inferior bone struts. B: Lateral view of the bone-soft tissue ring.
756 Upper Extremity

stable and can be rreated conservatively. Conservative rreatmenr term morbidity (163). For glenoid rim fractures with resulting
of nondisplaced or minimally displaced scapular body fracrures shoulder subluxation or instability, however, operative reduction
in adults is generally associated with excellent results; therefore, and fixation are recommended to prevent permanent or recur-
similar treatment is recommended for equivalent fractures in rent dislocations. (130,134,135). In adults, snoulder instability
the pediarricpopulation 039,154,157,162). In adults, scapular occurred wnen the fracture was displaced more than 10 mm or
body fractures with significant displacement of more than 10 when the fracture involved more than either 25% of the anterior
mm, however, resulted in unfavorable outcomes when treated or 33% of tne posterior aspects of the glenoid (130). Anterior
conservativdy (154). Unfortunately, a comparable srudy of pedi- and posterior approaches to the glenoid generally are recom-
arric scapular body fliactures has not yet been reported, and ideal mended for open reduction and internal fixation of anterior and
treatmel1t can only be inferred. posterior rim Fractures, respectively (133).
Nondisplaced or mildly displaced scapular neck fractures NondispJaced glenoid fossa fractures (types TIl-VI) aJso can
be successfully [I'eared nonsurgically (133). Displaced fractures,
without concomitant injury to the clavicle can be treated conser-
on the other hand, are associated with significant morbidity
vatively (146). In the presence of ipsilateraJ clavicular injury,
(pain, stiffness, and limited range of motion) when treated with-
however, surgical intervention generally is recommended to rees-
out surgical reduction. For glenoid fossa fractures, maximal ac-
tablish tne SSSC (128,136,144,151). Recommendations val)' as
ceptable inrraarricular displacement is believed to be 5 mm (130,
to whether open reduction and fixation of the clavicle is suffi-
159). Again, lack of definitive studies prevent the formation of
ciel1t to stabilize the fracture (136) or whether the neck fracture
absolute indications for surgery in the pediatric population. In
also must be reduced in addition to tne clavicle (144). For pa-
type IV glenoid fractures, where significant comminution is pres-
rients in whom surgical intervention is not possible, skeletal
ent, acceptable operative reduction and fixation may be difficult
tracrion may be an acceptable option (130). to acnieve (133,138), and these fractures may be better treated
Fracrures of the coracoid process typically occur at the base. with nonsurgicaJ options (133,138). For open reduction and
Isolated fractures of the coracoid process usually are nondis- internal fixation of these fractures, a posterior approach generally
placed and can be treated conservatively with a sling and mobili- provides the most acceptable exposure (133).
zation as tolerated. Displaced coracoid fractures occur with ipsi- Initial treatment of scapular dissociations generally focuses
lateral injmy to the distal clavicle or the acromioclavicular joint. on stabilization and repair of the neurovascular injulY. If the
Most investigators favor open reduction and internal fixation of axillary artelY and the brachial plexus are completely destroyed,
these Fractures to restore the integrity of the SSSC (147,157, an early amputation should be consideted (155). For most pa-
1G1). Displaced coracoid fractures near the suprascapular notch tients including cnildren, nowever, tne limb is salvaged whenever
with injulY to the suprascapular nerve also have been described, possible. Immediate exploration of the brachial plexus is war-
with some investigators arguing for early exploration (152). ranted when a concomitant vascular injUlY requires an operative
Isolated fractures of the acromion in children are typically repair. In the absence of a vascular injury, however, the brachial
nondisplaced. In adults, acromial fractures wirh subacromial nar- plexus need not be acutely explored. After a period of 4 to G
rowing are associated with subsequent development of subacro- weeks, rl1e extent of the brachial plexus injUlY should be docu-
mial impingement when treated nonsurgically (143). Therefore, mented before any surgical reconstruction, including nerve re-
most investigators tecommend open reduction and internal fixa- pair or musculotendinous transfer (133,155). Immediate opera-
tion for displaced acromial fractures where the subacromial space rive stabilization of an ipsilateral clavicular ftacture generally is
has been compromised (143). In addition, as described above, not neceSS<lry, unless the bony instability further compromIses
when fracrures of tne acromion occur with anodler disruption the integrity of the neurovascular structures.
in the SSSC, the resulting deformity and instability may warrant
operative fixation (133).
Fractures of the glenoid neck typically are nondisplaced un-
, . AUTHOR'S PREFERRED
less otner elements of the SSSC are disrupted. These fracrures
\...~ TR ATMENT
generally have excellent outcomes with nonsurgical treatment.
Significant displacement or angulation, however, may limit gle-
Most problems related to injuries of the scapula are not necessar-
nohumeral motion 030,154). In adults, glenoid neck fractures ily related to treatment but are more often related to failure to
with more than 10 mm of displacement or 40 degrees of angula- accurately evaluate associated major systems injuries (68). There-
tion result in poor outcomes when treated without surgical re- fure, once the patient is stabilized, the approach to the scapula
duction (128). Therefore, it is reasonable to infer that pediatric or glenoid fractures can be more thoroughly undertaken. frac-
glenoid neck fractures witll significant displacement or angula- tures of the glenoid generally are treated witn observation and
tion also requite surgical intervention. The indications for sur- Follow-up, including a program of physical therapy and rehabilj-
gery, unfottunately, remain poorly defined and must be individ- tation. For the rare displaced glenoid fracture, open reduction
ualized to each child. with internal fixation is recommended. This is generally per-
Treatment of glenoid rim fractures (types I and H) is based formed via a deltupectoral approach, but posterior approacnes
on the prescnce or absence of shoulder instability. Closcd treat- to rhe scapula and glenoid may be useFul in this particular injury.
ment of asymptomatic glenoid rim fractures rarely result in long- Intrathoracic dislocation is rare. Most can be reduced by
 Chapter /7: ProximaL Humerus, ScapuLa, and CLavicle 757

closed manipulative methods. In those associated with residual whose medial end is connected to the axial skeleton through the
scapular deformity, an open approach may be required. sternoclavicular joint. The medial twO thirds of the bone is in
With scapulothoracic disassociation it is important to attend the shape of a tube, whereas the lateral end is Ratter and is
to the priorities of trauma care, including an appropriate and stabilized in its position by the two coracoclavicular ligaments
detailed neurovascular examination. Vascular consultation or (trapezoid and conoid). The lateral aspect of the clavicle ral<es
evaluation may be required given the potential for massive injury part in rhe formation of the acromioclavicular joint, which, in
to the brachial artery or plexus. In these instances, early or late effect, is connected ro the upper extremity through the glenohu-
amputation should be considered. meral joint.
Through its joints, the sremoclavicular and the acromioclavi-
Complications cular, the clavicle contributes ro the overall motion of the upper
extremity. The clavicle can protract and retract (228). It also
Lare complicarions associated with scapular franures generally rotates and elevates to contribute to shoulder abduction (164,
involve improper functioning of the upper extremity. Displaced 203,228). In addition, the clavicle provides the attachment site
fractures of the scapular body and spine, for example, infre- for the two predominant mobilizers of the upper extremity: the
quently result in upper extremity weakness and pain with move- pectoralis major and the deltoid muscles. The integrity of the
ment (128). Similarly, fractures of the acromion can result in
clavicle, therefore, is crucial to the optimal functioning of the
pain and decreased range of upper extremity motion secondary
entire upper extremity.
to subacromial impingement (143). Displaced intraarticular
The clavicle is mostly subcutaneous throughom its span,
fractures of the glenoid are associated with glenohumeral sublux-
being situated on the anterosuperior aspect of the thorax. Its
ation or dislocation, as well as early progression of degenerative
structure is palpable and, in some cases, prominent in the upper
arthritis (130,133-135).
thorax. Because of its subcutaneous location, it is one of the
Of special consideration are the concomitant injuries fre-
quently associated with scapular fractures (128,139,157,160). most frequently fracwred bony strucwres in the body. In fact,
Due to their proximity, the axillary and the suprascapular nerves it is the bone most commonly injured during labor and delivery,
may be injured in association with glenoid and cotacoid frac- accounting for nearly 90% of all obstetrical fractures (179,189,
tures, respectively (149,152). In addition, the energy required 250). In older children, clavicular fractures occur frequently,
to create scapular fractures likely results in other injuries, such with the reported rates ranging between 8% and 15% of all
as rib fractures, pneumothorax, and vascular avulsions. Allor pediatric fractures (216,219,232). Because of differences in the
portions of the lower brachial plexus are susceptible to injury mechanism and rate of injury, prognosis, and treatment options,
with scapulothoracic dissociations (131,155,158). This devastat- clavicular fractures are broadly categorized by their anatomic
ing injury also has been associated with tbe development of location: medial third, middle third, and distal third (Fig. 17-
compartment syndrome in the upper arm (162). 21). Most clavicular fractures occur at the middle third, with
the reponed rates ranging from 76% to 85% (226,232). The
second most common site of clavicular injury is the distal third,
FRACTURES OF THE CLAVICLE with the reported rates between 10% and 21 % (226,232,243,
249). Fractures in the medial third of the clavicle are relatively
The clavicle has the important function oflinking the axial skele- uncommon and represent only 3% to 5% of all clavicular frac-
ron to the upper extremity (Fig. 17-19). It is an S-shaped bone tures (232,249).

)
)

\ \
\ \

\ \
A B c
FIGURE 11-21. A: Fracture of the medial third of the clavicle. B: Fracture of the middle one third of
the clavicle. C: Fracture of the lateral third of the clavicle.
758 Upper EwremilY

Diagnosis ecchymosis, and edema, to some degree, are invariabJy present,

and in fractures with large displacement, a bony prominence or
Mechanism of injury
deformity may be noted. Most children with clavicular fractures
The clavicle is the most common site of all obstetrical fractures, keep their heads turned to the side of the fracture in order to
and clavicular fractures occur in 1% to 13% of all births (177, relax the sternocleidomastoid muscle (198). It must be camioned
179,189,195,196,206,237,250,251,264). The incidence of ob- rhat, on rare occasions, atlanroaxial subluxarion and clavicular
stetric clavicular fractures increases with larger feruses and with fracture may occur together. Attributing acute torticollis entirely
decreasing experience of the obstetricians (179,206,218). In ad- to the clavicular fracrure may delay the diagnosis of atlantoaxial
dition, deliveries involving the use of insrruments or specialized subluxation, which can lead to the development of permanent
obstetric maneuvers are more likely w result in a clavicular frac- atlantoaxial rotatory fixation (165).
rure (179,196,206,218). Therefore, it has been postulated that Examination of children with either acromioclavicular or
the fracrure occurs as a result of excessive lateral to medial pres- sternoclavicular joint injuries may produce crepitus and instabil-
sure on the shoulders during passage through the narrow birrh ity over the affected joint. Of special note are children with acute
canal. Accepting that this mechanism appears likely, it also must posterior dislocations of the sternoclavicular joint. Because of
be noted, however, that the most clavicular fracrures occur dur- their proximity, srrucrures of the mediastinum are susceptible
ing deliveries of normal-sized [Q small fetuses with excellent ob- to botll compression and injury. Compressions of the great ves-
stetric care. Thus, it appears that obstetrical clavicle fractures are sels, the esophagus, or the trachea can lead to serious and even
unavoidable consequences of some vaginal deliveries. life-threatening emergencies (193,267). Children with these in-
The most common mechanism of clavicular fracrures in older juries may complain of inability to speak, respire, or swallow.
children is a fall onw the shoulder (215,232,260). Other mecha- In addition, pulses in the ipsilateral upper extremity may be
nisms include accidents where the traumatic insult is applied diminished or absent, and the neck veins may be distended.
directly w the clavicle (260). Indirect applications of force, like Because of the potentially life-threarening nature of rhis specific
falling OntO an outstretched hand, are much less likely w result injury, every child with a suspected clavicular injury should be
in clavicular fractures (260). carefully evaluated for these signs and symptoms before the initi-
A significant amount of energy can be directly applied to tbe ation of treatment.
clavicle dming spons-related activities such as footbalJ or la-
crosse. As expected, children parricipating in spons frequently
Radiographic Studies
sustain clavicular fracrures as well as sternoclavicular and acromi-
oclavicular joint dislocations (216,232). A large proporrion of In all age groups, an AP radiograph is the standard srudy with
these injuries may be preventable with the use of protective which a clavicular fracture is initially evaluated. For neonates,
equipmem and adequate padding (258). Many children victim- however, ultrasonography has been a valuable supplement in
ized by child abuse also present with clavicular fracrures. Despite establishing the diagnosis of clavicular fracrures (199,212). Ul-
clinical suspicions, however, no clear pattern for isolated clavicu- trasonography is particularly useful in detecting occult clavicular
lar fractures has been associated wi th child abuse (201,214). fractures as well as sternoclavicular joint dislocations in this early
age group (199,241).
For older children, other radiographic studies may be neces-
Signs and Symptoms
sary to supplement the AP radiograph in evaluating the clavicular
Clavicular fractures in newborn infants may be difficult to iden- fracture. For fractures in the middle third of the clavicle, several
tifY. [n the acute stage, before stabilization of the fracture, infants views may be beneficial: the cephalad-direcred views, the apical
wirh clavicular fractures may voluntarily splint or not move the oblique view, and the apical lordotic view. The cephalad-directed
affected arm to minimize discomfort (180,224). Frequently, this views are helpful in illustrating the degree of fracture displace-
pseudoparalysis is mistaken for a brachial plexus injury, delaying ment (Fig. 17-22). These views are taken with the x-ray beam
rhe correct diagnosis. In order w reduce the pull of the sterno- 20 to 40 degrees cephalad to the clavicle (Fig. 17-23A). The
cleidomastoid muscle across the fracture sire, these infants will apical oblique view is taken with the x-ray beam 45 degrees
also turn their heads toward the side of the fracture. In addition, lateral to the axial axis of the body and 20 degrees cephalad to
infants with acute clavicular fractures typically exhibit an asym- the clavicle. This view is better suited w identify fracrures in
metric Moro reflex (242,254). Generalized edema is present, the middle third of the clavicle, where significant curvature is
which prevents rhe palparion of normal clavicular margins (198). present in the bone (265). The apical lordotic view is a perpen-
Often, rhe diagnosis may be suspected and later confirmed only dicular view of the anteroposterior radiograph. It is tal<en lat-
afrer a mass is noriced over the affected clavicle. This mass repre- erally with the shoulder abducted more than 130 degrees (Fig.
sents a healing fracture callus that forms 7 to 10 days after the 17-23B). This degree of shoulder abduction, however, can cause
initial trauma. Therefore, by the time of such delay in diagnosis, significant discomforr in children with acute clavicular fractures.
the ll'acture has already stabilized to rhe extent that it causes Therefore, this radiographic view may be better suited for evalu-
little discomfort to the infant. ating the healing of the clavicular fracture rather than for the
Clavicular fractures in older children typically are readily ap- initial assessment of the fracture (245).
parelH and less difficult to diagnose. Children complain of mod- Fr:lcwres in the lateral aspen of rhe clavicle may require addi-
erate [0 severe pain around the area of the fracture and voluntar- tional radiographic views for full assessment. In addition ro the
ily immobilize and stop using the affecred arm. Tenderness, views mentioned above, an axillary lateral view is helpful in
 Chapter 17: Proximal Hllmerw, Scapula, and Clavicle 759

FIGURE 17-22. A: Computed tomography image of the

clavicle showing posterior retrosternal dislocation of the
medial end of the clavicle. B: Three-dimensional recon-
B struction of image shown in A.

~-- --------------
( , '->
I

I" \

J
A B
FIGURE 17-23. A: Cephalad-directed views. B: Apical lordotic view.
760 Upper Extremity

Classification
The mosr widely used c1assiflcarion for clavicular fracrures, pro-
posed by Allman, is based on the ana(Omic locarion of rhe frac-
rure. (166) (Fig. 17-21). Type I fracrures occur in rhe middle
rhird of rhe clavicle and generaJly include all fracrures lareral ro
rhe srernocleidomasroid muscle and medial (0 rhe coracoclavicu-
lar ligament. Type II fracrures are in rhe disral clavicle, including
and lareral ro the coracoclavicular Jigamenr. Type III fractures,
which are relarively uncommon, are medial to the srernocleido-
masroid muscle. Within this general framework, h.mher classifJ-
cations exist for injuries to the distal and medial ends of rhe
clavicle.

Distal Clavicular Injuries

Disral clavicular injuries lareral ro the coracoclavicular ligamenr
and injuries to the acromioclavicular joint are categorized by a
system proposed by Dameron and Rockwood (Fig. 17-25)
(180). Although similar to rhe sysrem for adult distal clavicular
injuries, rhis c1assifJcarion sysrem incorporares the observation
rhat the distal clavicle displaces through a disruption in irs perios-
real sleeve rarher rhan by rrue disruprion of the coracoclavicular
ligaments. It should be also noted rhat rrue acromioclavicular
dislocarions rarely occur in children. Mosr fracrures in rhis region
FIGURE 17-24. Serendipity view of the medial clavicle. are eirher meraphyseal or physeal fracrures (188,234). However,

II
evaluaring rhe fracrure and irs displacement. If rhe injury in
rhis ponion of rhe clavicle or rhe acromioclavicular joinr is nor
obvious on rhe obrained radiographs, a radiographic srress view
may provide more useful informarion. A radiographic srress view
is an AP radiograph of rhe lareral clavicle wirh disrracrion on
the ipsilarcraJ upper exrremiry. Disuacrion can be achieved by
asking rhe child (0 hold 5 (0 10 pounds of wcighr wirh his or
her hand or by simply having an assisranr genrly pull rhe arm
downward. The srress view may demonsrrare subrle injuries ro III IV
rhe disral clavicle or rhe acromioclavicular joint. If rhere are
concerns abour rhe inregriry of rhe acromioclavicular joinr, com-
pured romography (CT scan) may be essenrial for fuJi evaluarion
of rhe injury.
Fracrures in rhe media! rhird of rhe clavicle. including srerno-
clavicular dislocarion, are sometimes diffJculr ro characrerize
even with the radiographic views menrioned above. The "seren-
dipiry" view, where a broad x-ray beam with 40 degrees of ce-
phalic tilt projects both clavicles on rhe same fJlm, is heJpful for v VI
evaluating fracrurcs in rhis portion of rhe clavicle (Fig. \7-24)
(246). By comparing wirh rhe uninjured conrralateraJ side, the
locarion of injury and rhe degree of displacemenr ofren can be
derermined. The mosr rapid and effecrive srudy for evaluaring
injuries in rhe medial third of rhe clavicle, however, is CT. CT
provides detailed information about the morphology of the me-
dial clavicle, rhe medial physis, rhe degree of dispJacemenr, and
possible injury ro rhe underlying inuarhoracic srrucrures. There-
fore, CT is an essenrial parr of rhe evaluarion of injury ro rhe
medial end of rhe clavicle and is recommended for borh acure FIGURE 17-25. Dameron and Rockwood classification of distal/lateral
and chronic injuries. fractures.
 Chapter /7: Proximal Humems, Scapula, find Clavicle 761

because distal clavicular epiphyseal ossification does not occur Jar growth and lengthening occur a[ the mediaJ physis (223,236).
until age 18 or 19, rhese injuries may have the radiographic Despire rhis early ossification and growth, complete growth of
appearance of an acromioclavicular dislocation rather than a frac- the clavicle does not occur until early adulthood. The lareral
[ll rc (pseudodislocation) (188,234,261). physis continues co proliferate until 18 to 19 years of age, and
Type T disraJ clavicular injuries are caused by low-energy the medial physis does not close until 23 to 25 years of age (208,
trauma and are characterized by mild strains of the acromioclavi- 239,261).
cular ligaments. There are no other soft tissue or bony abnormal- The distal clavicle articulates with the scapula through rhe
ities, and no gross changes are seen on radiographs. Type II acromioclavicular joinr, a joint that lacks inherent scrucrural sta-
injuries include complete disruptions of the acromioclavicular bility. It is held cogether in part by the acromioclavicular liga-
ligaments with mild damage to the superolateraJ aspect of the ments, which are relatively weak secondary stabilizers. The pri-
periosteal sleeve. Mild instability of the distal clavicle results, mary stabilizers of the joint are the twO coracoclavicular
and minimal widening of the acromioclavicular joint may be ligaments, the conoid and the trapezoid, which place the lareral
seen on a radiograph. In type III injuries, complete disruptions end of the clavicle immediarely next co the acromion. AJthough
of the acromioclavicular ligaments occur in addition to a large the distal clavicle and the coracoid process usually do not arricu-
disruption in the periosteal sleeve. Noticeable superior displace- lare, a coracoclavicula.r joint has been reported in adults (213).
ment of the distaJ clavicle, with the coracoid-clavicle interval In children, rhe disral clavicle and rhe acromion are surrounded
being 25% to ] 00% greater than the contralateral uninjured by rhick periosreum thar forms a protective tube around the
side, is seen on an AP radiograph (175,18]). Similar soft tissue bony structures. The coracoclavicular ligaments are attached to
disruptions are seen in type IV injuries. The distaJ clavicle, how- the periosteum on the inferior surface of the distal clavicle. Be-
ever, is displaced posteriorly and is often imbedded in the trape- cause these ligament attachments are scronger rhan the perios-
zius muscle (169). Minimal changes may be noted on an AP teum, displacement of the distal clavicle occurs through a disrup-
radiograph, so an axillary lateral view is required to identify the tion in the periosteum rather rhan by detachment of the
posterior clavicular displacement. Type V injuries are similar to ligamenrs. In facr, displacement of the distal clavicle through
type III injuries. The difference lies in the fact that the superior this periosteum in children has been likened co having "a banana
aspect of the periosteal sleeve is completely disrupted in type V being peeled out of its skin." As mentioned above, the distal
injuries. This a.llows subcutaneous displacement of the distal clavicular physis does not ossify until early adulrhood (261).
clavicle, occasionally splitting the deltoid and the trapezius mus- Therefore, fractures through the distal clavicular physis or me-
cles. On an AP radiograph, the coracoid-clavicle interval is more taphysis may be mistakenly identified as acromioclavicular joint
than 100% greater than the contralateral uninjured side. In type dislocations.
VI injuries, the distal clavicle is displaced inferiorly with its distal Medially, the clavicle articulates with the sternum and the
end located inferim to the coracoid process (194). first rib through the sternoclavicular joint. Similar to rhe acromi-
oclavicular joinr, this joint also lacks inherenr strucrural stability.
Medial Clavicular Injuries Ir is held together by a series of Strong ligaments, including the
intraarticular disc ligament, the anrerior and posterior capsular
The medial physis of the clavicle is the last physis in the body
ligaments, the interclavicular ligament, and the costoclavicular
to close, and the fusion of this epiphysis to the shaft occurs as
ligament (172). In children, the medial physis of the clavicle is
late as 23 to 25 years of age (208,239). The sternoclavicular
still open, and the capsular ligaments attach primarily to the
ligaments attach primarily to the epiphysis, leaving the physis
epiphysis (172,208,239). Therefore, injuries to the medial clavi-
unprotected outside the capsule (214). Because of its unique
cle typically result in physeaJ fractures with the epiphysis ar-
anatomy, traumatic insults to the medial end of the clavicle in
tached to the sternum.
children typically result in fractures thtough the physis rather
AJong its course, the clavicle also serves as attachment sires
than dislocations through the sternoclavicular joinr. Therefore,
for a number of different muscles. On its superior surface, rhe
these injuries are categorized most appropriately in the SaJter-
clavicular head of the sternocleidomastoid muscle is attached.
Harris classification system (252). Most fractures at the medial
On rhe posterior surface, the trapezius muscle is attached,
end of the clavicle are Salrer-Harris type I or II fractures. These
whereas the pectoralis major and the deltoid muscles are attached
fractures are further subdivided by the direction of the clavicular
on the anterior surface. Inferiorly, the clavicle provides attach-
displacement, either anterior or posterior. Although anteriot dis-
ment sites for rhe subclavius muscle as well as the c1avipectoral
placement of the clavicle occurs more frequently, more attention
fascia.
is given to fractures with posterior dispJacemenr due to the possi-
In addition co rhese muscle attachments, the clavicle provides
bility of concomitant mediastinal injuries and potential emer-
protection to the subclavian vessels and rhe brachia.! plexus.
gent nature of the injury.
These vital structures are locared posrerior to rhe clavicle, cross-
ing rhe clavicle at the junction between the medial twO rhirds
Surgical Anatomy
and lareral one third of the bone (Fig. 17-12). Due co this close
The clavicle appears early during embryonic development. By proximity, the neurovascular sratus of the ipsilareraJ upper ex-
the 5th or 6th week of gestation, it begins ossificarion at twO tremity may be jeopardized in children with displaced clavicular
separare centers, medial and lateral (192,228,233). By the 7th shaft fractures. In addirion, as discussed above, posterior disloca-
or 8th week of gesrarion, its overall contour and shape are already tion of the sternoclavicular joint can lead to compression or
formed (192). During childhood, approximarely 80% ofc1aviCLI- injuries of the great vessels within the mediastinum. Therefore,
762 Upper Er:tremity

neurovascular starus of the ipsilateral upper extremity muSt be splint, on rare occasions, can lead to a number of complications,
documented before the initiation of treatment fot any claviculat including edema, compression of the axillary vessels, and bra-
Injury. cl1ial plexopathy (Fig. 17-26) 091,217,230). Use of a sling, on
the other hand, is rypically well tolerated by children and is not
associated with any of rhese complications. Treatment of borh
Biomechanics nondisplaced and displaced clavicular fractures with a sling has
The clavicle conrribures significantly ro the overall motion and shown remarkably good results. In fact, in comparison with a
optimal h.Inction of the upper extremity. In the anterior ro poste- figure-of-eight splinr, treatment of clavicular fractures with a
rior direction, the clavicle can protract and retract abour 35 sling resulted in similar final onrcomes (167,207,259). There-
degrees (228). Laterally, it can rotate and elevate ro contribute fore, it appears that nonoperative treatmenr of middle rhird cla-
approximately 30 degrees to full shoulder abduction (164,203, vicular fracrures with a simple sling can result in excellent out-
228). The clavicle also provides the attachment sites for the comes without compromising the child's comfort.
major mobilizers of the upper arm in the pecroralis major and Reported indications for operative rreatment of clavicular
the delroid muscles. Finally, rogether with the scapula, the distal fractures include severely displaced and irreducible fracrures that
clavicle forms the SSSc. As proposed by Goss, the SSSC ptO- threaten skin integriry, concomitant vascular injury requiring
vides a scaffold from which the upper extremity suspends and repair, irreducible compression of the subclavian vessels, com-
arricu lates in order ro function (197). promise of rhe brachiaJ plexus, and open fracrures (202,204,229,
240,26i3). In addition, as discussed separately in this chapter,
concomi tant displaced fractures in various regions of the scapula,
Treatment Options including the acromion, the coracoid, and the scapular neck,
General Comments may compromise the SSSC and require operative repair (I 97).

Numerous methods of treating clavicular fractures have been

described. In fact, it has been stated that over 200 methods Distal Third Fractures
of treatment exist (215). For most of these pediatric fractures,
nonoperative treatment should be the prevailing rule rather than Injuries to the distal clavicle in the pediatric population rypically
rhe exception. In addition, the importance of prevention can nor are pseudodislocations of the acromioclavicular joinr, with frac-
be overemphasized, because it is certainly the best of all the tures through the metaphysis or the physis (186,234). The
treatment options. Improved obstetrical care, use of adequate acromioclavicular joint and the coracoclavicular ligaments usu-
equi pment and padding in contact sports, and updated safety ally are undamaged, and most of the periosteal sleeve is intact.
equipment and conditions at child recreational facilities should Therefore, exceptional potential for growth and remodeling ex-
lead ro significant reductions in the incidence and complications ists for these fractures, allowing sLlccessful nonoperative treat-
of clavicle fractures. ment for most injuries to rhe disral clavicle.
Most investig:nors agree that undisplaced or minimally dis-
placed injuries of the disral clavicle (rypes T, II, and III), should
Middle Third Fractures be treated without surgery 071,180,200,234,247). These inju-
Treatment of obstetrical clavicular fractures is always nonopera- ries are managed wirh a sling or a figure-of-eight splint immobili-
tive. For mosr birrh-related c1aviculat fracrures, minimal or no zation followed by early rehabilitation with range of morion
rreatmenr is recommended. If rhe infant appears to be in signifi- exercises. Most children treared with nonoperative management
cant discomforr, the affected arm can be immobilized to the demonstrate no significant long-term funcrional or cosmetic def-
body for a short period of time, typically less than 2 weeks. iCItS.

Immobilization of the affecred arm can be easily and effectively The rreatment of displaced rypes IV, V, and VI distal clavicle
accomplished by using a sz.fety pin to atrach rhe long shirt sleeve fractures remains conrroversial. Some investigarors repon that
to rhe shirt (211,221,253). The parents should be warned to most cnildren experience no functional deficits regardless of the
nor disturb rhe upper extremity by unnecessary excessive move- method of treatment (171,200). Others report that distal clavic-
menrs in rhe acure period. In addirion, rhey should be informed ular injuries with either fixed or gross displacement should be
that the infant will develop a noriceable mass over the fracture [L'eated with open reduction and internal fixation to prevent
sire which will rypically resolve wirhin 6 months (242). permanent deformity 068,175,180,182,188,200,234,248).
Good to excellent resulrs also can be expected from nonopera- One reporr suggested tnat although displaced distal clavicular
Dve trearment ,of most clavicle fractures in older children. A injuries in children under 13 may be amenable ro nonoperative
figure-of-eighr splinr is an acceprable method of nonoperarive treatment, those in children over 13 years of age should be
rrearment and has been widely used wirh successful outcomes treated with open reduction and internal fixarion (I86).
(207,230,242,255). Ir can be applied directly or after an arrempr Although no clear consensus exists for the trearment of grossly
ar closed reducrion wirh retraction of the shoulders (235). In displaced distal clavicular fracrures in children, as long as the
general, younger children do not require reduction of rhe frac- integrity of the SSSC is maintained, it appeats that neither non-
ture because rheir porential for remodeling is greater (23'5). operative or operative management results in Jong-rerm deficit
The figure-of-eighr splinr, unforrunateJy, can be uncomforta- in the normal function of the shoulder. Treatment options,
ble for some children. In addirion, inappropriare use of the thnefore, snould be individualized for each child and his or het
 Chapter /7: Proximal Humerus, Scapula, find Clavicle 763

FIGURE 17-26. A: Anteroposterior radiograph of comminuted clavicu-

lar fracture. B: Skin erosion over fracture fragment due to figure-of-
B eight splint.

family based on their compliance as well as their acceptance of treated withom surgery. Open reduction and inrernal fixation
the possible cosmetic deformity. of these injuries may lead to signiftcant, and sometimes life-
threatening, complications (178,190,223,224). Attempts at
closed reduction, especially in younger children, are not required
Medial Third Clavicular Injuries because these fractures will remodel and result in minimal or
Most pediatric injuries in the medial clavicle are fractures no residual deformiry. The maneuver for the closed reduction
through the physis. Similar ro distal clavicular injuries, these requires applying longitudinal traction ro the ipsilateral upper
fractures have vast potential for healing in an acceptable position, extremiry while the shoulder is abducted to 90 degrees (253).
and subsequem remodeling and nonoperative managemenr is Gende posterior pressure also should be applied over the fracture
appropriate. ro encourage reduction. Mer the reduction is accomplished, the
NondispJaced fractures of the medial physis do not require clavicle should be immobilized wirh a figure-of-eighr splinr or
active intervention. Sympromatic rreatmenr is all (hat is required cast (253).
for these stable fractures. In fact, nondisplaced fractures often Treatment of medial clavicular fractures with posrerior dislo-
are missed during initial examination and are only discovered cation requires immediare evaluation for the presence or absence
after a mass is nOted over the medial clavicle. The parems should of concomitant mediastinal injuries. If physical examination and
be warned (hat the mass is a healing callus surrounding the radiographic evaluations do not reveal mediastinal injuries, these
fracture and (hat it should remodel and disappear in 4 ro 8 fractures are treated wjth a controlled closed reduction. The
months. fractures can be expected to heal and remodel without any signif-
MOSt fractures with anterior displacement also should be icant residual deformiry or pain. If mediastinal Structures are
764 Upper .Extremity

compromised or injured, immediare a[[emprs ar closed reduc- remodeling in this area. Mrer 2 ro 4 weeks of immobilizarion,
rion are required. Under adequare anesrhesia, rhe displaced me- a program of progressive rehabiliration can begin.
dial clavicle is held manually or wirh a rowel clip and manipu- Posrerior dislocarions of rhe medial end at the clavicle of the
lared anteriorly ro reduce the fracture. This reduction maneuver sternoclavicular joint may be eirher pure dislocations or associ-
should be performed while longitudinal rracrion is applied [0 ared with a physeal disruption and may be acure life-threatening
rhe ipsilarcral upper extremiry (253). If closed reducrion is un- injuries. Mosr of rhese injuries can be rreared successfully wirh
successful, open reducrion, wirh rhe assisrance of a rhoracic sur- closed reducrion wirh general anesrhesia and srand-by supporr
geon, may be required. Once reduced, these fractures rypically of the cardiovascular service. The technique for rhe closed reduc-
are srable and require no internal fixarion. Infrequently, how- rion is quire specific and involves rhe placement of a bolsrer in
ever, some fractures may involve a physeal disruption of rhe rhe midline along rhe level of rhe spine and spinous processes.
medial border and require a surure repair. Immobilizarion wirh Both humeri are adducred to rhe level of rhe chest, and anrerior
a f1gure-of-eighr splint or casr for a shorr period of rime should pressure is placed over the deltoid and humeral head toward the
provide adequarc environment for fracrure healing. rable wirh a downward pressure over borh proximal humeri.
This is generally sufficient to provide adequate rerracrion of rhe
shoulder and restore rhe lengrh of rhe clavicle ar the level of the
srernoclavicular joint. Funher downward pressure ro the level
M A THOR'S PREFERRED METHOD of rhe table provides a fulcrum force to reduce the medial end
,~~ OF TREATMENT of the clavicle anteriorly inro the srernoclavicular joint. Rarely
a rowe! clip may be required. It is placed subcuraneously rhrough
The approach [0 neonaral or birrh injuries is one of diagnosis rhe medial rhird of the clavicle ro aid in the reducrion process.
and reassurance and educarion of rhe parents. The family is rold Open reducrion of rhe medial end of the srernoclavicular joint
rhar a bump will develop over rhe fracture sire and rhar rhe is indicared when closed reduction fails or results in an unsrable
fracture will heal uneventfully. If rhe infanr initially demon- rerrosrernal displacement. If the dislocation is unstable, generally
strares discomforr wirh rhe fracture, rhe long arm sleeve of the repair of rhe capsule with a nonabsorbable suture rhrough the
infanr's shin can be pinned ro rhe shirr for 7 ro 10 days [0 capsule of the joinr ar the level of rhe sternum rhrougb holes
provide adequare immobilizarion. drilled inro rhe medial end of rhe clavicle is sufflciem ro provide
Older children who present ro rhe emergency room generally anterior srability of the disJocarion. Imerna! fixarion is not rec-
have a significanr level of pain and discomforr. I prefer eo use ommended in rhis locarion.
a f1gure-of-eighr harness ro provide rerracrion of rhe shoulder, Mosr injuries ro rhe disra! end of rhe clavicle in children
eo gain lengrh ar rhe level of rhe fracture, and ro reduce pain. and adolescenrs are treared nonoperatively. These fracrures heal
Wirh rhe use of rhe f1gure-of-eighr harness, ir is imporranr [0 rapidly because of the early deposirion of periosteal new bone
inspecr rhe skin on weekly follow-ups tor 3 weeI<s ro assure rhar and remodeJing. Generally, patienrs can be rreated wirh a sling
no unusual sharp bone fragmenrs creare any skin problems ar and pain managemenr with appropriare oral analgesics and ice
rhe sire of passage of rhe figure-of-eighr harness over the fracrure ro comrol swelling. Early range-of-morion rherapy is recom-
(Fig. 17-26). The parenrs are once again informed rhar rhe bone mended at approximarely 10 days eo 2 weeks. Clinical union is
will take a couple of months to remodel and rhat rhere may be generally seen by 4 ro 6 weeks.
a bump for up ro a year after rhe fracrure. For the rare type IV, V, or VI displaced distal clavicular
The indications for operative managemenr for clavicular frac- injury, an open approach can be useful in replacing rhe disral
tures in children are rare and include fractures with the potential clavicle in irs periosteal sleeve, and repair of the periosteal sleeve
eo develop both thickness loss over the apex of a fracture or a may be sufflcienr to provide adequate f1xarion.
direcr impingement of the clavicle on either the brachial plexus
or subclavian vessel. Even with these fractures, gentle manipula-
tion and closed reducrion should be attempred. If open repair Complications
is done, the fractured clavicle generally can be placed ineo the Implanrs and inrernal fixarion devices for clavicular fractures
periosreal sleeve and rhe periosreal sleeve can be repaired over have been associared with numerous complicarions, including
rhe fracrured clavicle wirhour the need for addirional inrernal hardware migrarion, infecrion, and nonunion (I 78,190,223,
f1xarion. 224,231,256,257). AJrhough mosr of rhese complicarions can be
Mosr fracrures of the medial end of the clavicle, wirh or adequately n'eated, some can have hlfal results (178). Therefore,
without anrerior displacemenr or posrerior rerrosrernal disloca- whenever possible, fixation of pediatric clavicular fractures
rions, can be treated nonoperatively. Generally 3 eo 6 wceks in a should use minimal or no hardware.
f1gure-of-eight harness or sling is adequare afrer stable reduction. Serious vascular injuries also have been described in associa-
Anrerior displacemenrs of the medial end of rhe clavicle gen- tion with clavicular fractures, including subclavian and axillalY
erally are associated wirh a physeal disruprion and usually can arrelY disruption, subclavian vessel compression, and arreriove-
be [['eared with closed reduction. Longitudinal rraction is applied nous fistula (170,202,209,227,262). In addition, displaced frac-
[0 rhe upper extremiry with moderate abduction of rhe humerus rures of the medial clavicle may resulr in compression or injUlY
and general pressure is applied over the scapuloclavicular joinr. of the great vessels wirhin rhe mediasrinum (193,267). Occa-
Persisrenr insrabiliry of rhe scapuloclavicular joinr is acceprable sionally, rhese compressions can be relieved nonoperarively by
in anrerior displacemenrs because of rhe signiflcanr porenrial for reducing the fracrure and eliminating rhe excessive pressure on
 Chapter J 7: Proxim1/ Humems, Scapula, rind Clavicle 765

the vessels (202,227). However, if nonoperative treatment does berosity. Distal to the tuberosity, the muscular spinal groove
not alleviate the compression, operative reduction of the fracture wraps posteriorly around the humerus. The groove gives origin
and possible vascular repair may be required. Cerrainly, if the ro the uppermost fibers of the brachialis. The periosteum of
srructural integrity of the vessels is compromised, operative re- the humera.l diaphysis is rhick and provides good remodeling
pair by an experienced vascular or thoracic surgeon is necessary. potential (327,331). The main vascular foramen is at mid-shaft,
[n addition to the compression of the great vessels, displaced bur accessory foramina are common-most enter the anrerior
medial clavicular fractures can result in compression of the tra- surface usually below the main foramen, but many are posterior
chea and esophagus, causing difficulty with respiration or swal- (308,364).
lowing (193,267). Clavicular fractures resulting from severe
trauma can be associated with pneumothorax (185,225). Rarely,
a pneumothorax results from obstretrical clavicular fractures
Nerves
(220). The radial nerve ordinarily lies close to the infetior lip of the
Neurologic deficits of the brachial plexus have been reported spiral groove but not directly in it (515). The profunda artery
in association with clavicular fractures. Brachia.! plexus paJsy may either accompanies the radial nerve or passes in a second nar-
present early or late after the traumaric insult, and occasionally rower grove. The nerve is protected from the humerus by a layer
requires operative reduccion of the fracture (170,183,184, of either the triceps or the brachialis until the lower margin of
202,205). Rarely, such nerve deficits can result from inappro- the spiral groove near the lateral intermuscular septum (515).
priate use of the figure-of-eight splints (217,230). AJthough per- The ulnar nerve passes from anrerior to posterior juSt distal to the
manent nerve deficits have been reported, most brachial plexus humeral mid-shaft. A well-formed arcade and internal brachial
injuries resolve spontaneously (205,210). ligament may hold (he ulnar nerve (395). This ligamenr is a.lways
AJthough maJunions are frequent soon after fracture healing, posterior to the medial intermuscular septum and subsequenrly
mosr children experience no long-term deformities because of joins the medial intermuscular septLIm proxima.! ro the media.!
their tremendous potential for remodeling. Occasionally, how- epicondyle. A few patients with a modified arcade have only
ever, significant deformities such as clavicular reduplication and superficial fibers of the triceps medial head passing superficial
c1eidoscapular synostosis may require funher intervention (234, to the ulnar nerve and none deep to (he nerve, ma.!<ing the nerve
244). very close to the bone and vulnerable during a fracrure (395).
Clavicular pseudarthrosis may be congenital, traumatic, or
pathologic 074,176,231,238,243,263,266), but most often it
results from previous injuries. Clavicular pseudarthroses, espe- Muscles
cially congenital or embryonic types, often are completely Several major muscle attachments occur throughout the metaph-
asymptomatic and require no treatment. Operative indications yseal and diaphyseal regions of the humerus. The pectoralis
for pseudarthrosis include unacceptable cosmetic deformity and major muscle inserrs latera.lly and distal to the bicipita.l grove
pain (173,176,222,266). It must be noted, however, thar opera- along the anterior aspect of the humerus. The latissimus dorsi
tive repair with grafting and internal fixation of the pseud- and teres major insert on the upper medial aspect of the humerus
arthroses can result in other complications, such as pneumotho- medial to the bicipital groove. The deltoid courses from the
rax, subclavian vessel damage, air embolism, and brachial plexus clavicle, acromion, and scapular spine to insert over a broad area
deficit (187). of the deltoid tuberosity. The coracobrachia.lis arises from the
coracoid process and inserts on (he anterior media.! aspecr of the
humerus at (he junction of the middle and lower thirds. The
FRACTURES OF THE HUMERAL SHAFT brachialis originates from the anterior humerus about midway
down the shaFt. Knowledge of these muscles and their direcrions
Embryology and Development is essential to understand fracture displacement and treatment
The end of the emblyonic period is marked by vascular invasion (327,383).
of the humerus at age 8 weeks. During the subsequent fetal
period, the humerus resembles the adult bone in both form and
muscular relationships (357,364). A bony collar is present velY
Mechanisms of Injury
early with subsequent enchondral bone formation. The second- Birth Injuries
ary ossification centerS at the ends are not generally ossified
Humeral fractures are more common in breech ptesentations
radiographically until after birth (364).
and with macrosomic infanrs. The mosr diFFIculr posicion is
when the child's arms have gone above the head with maneuvers
Applied Anatomy to bring the arm down after version and exuacrion (423),

Osseous
Child Abuse
The proximal metaphysis of the humerus is wider than the thin-
ner, triangular shaft. Distally, this fla((ens and widens to form Humeral fractures in child abuse represent 61 % of all new frac-
rhe condylar region of the elbow. The deltoid insertS into a cures and 12% of all fractures (417,441). Shaw et al. (482), in
protuberance midway down the shaft known as the deltoid tu- a rerrospective review of 34 humeral shaft fracrures in children
766 Upper Extremity

under 3 years of age, found rhar mosr occurred accidenrally: Signs and Symptoms
only 6 were classified as caused by probable abuse. Child abuse
Evaluation of the Neonatal Shoulder
musr be pan of rhe diflerenrial diagnosis in children wirh hu-
meral diaphyseal fracrures (441). The fracrures may be spiral History
from a twisring injury or rransverse from a direcr blow. The infant who does not move the shouldet poses a diagnostic
challenge. Esrablishing and evaluating a differential diagnosis is
the first concern. By hisrory, was the delivery normal' When
Older Children
was the problem noticed? Does the child move any parr of the
Older children susrain primarily uansverse fracrures from direct extremity? Was rhere a hisrory of marernal gestational diabetes
blows to the arm, frequenrly from falls, pedesrrian/vehicle acci- or of feral macrosomia? Does the child nurse from each breast?
denrs, gunshor wounds, and machinery. Spons injuries are direcr A broad, useful differential diagnosis consists of clavicle fracture,
from conract spons or indirecr from rhrowing. Throwing inju- proximal humeral physeal fracrure, humeral shafr fracrure,
ries occur as a suess injury from overuse or acurdy during rhe shoulder dislocation, brachial plexus palsy, septic shoulder, os-
throwing cycle from poor mechanics (269,303,359,363,366, teomyelitis, hemiplegia, and child abuse.
381,415,490,493,502,514). A stress fracture also has been re-
poned in an adolescenr rennis player (458). Acure rhrowing Examination
fracrures result from a sudden external rotation torque developed Initially, the child should be observed for spontaneous mOtion
on the distal humerus with concomitanr proximal inrernal rora- of the upper extremity. Is rhere any hand or elbow motion? Are
rion from the pecroraJis major between the cocking and accelera- rhere any areas of swelJing, ecchymosis, or incrcaseJ warmrh?
rion phases (339) as the shoulder external rotation and elbow Does rhe child move the ipsilateral lower extremity' The clini-
flexion suddenly change to shoulder inrernal rotation and elbow cial1 should carefully palpare each area of rhe upper extremity,
extension. Humeral fractures may occur from arm wrestling in starring with the clavicle and comparing ir carefully with the
older adolescenrs (284,418,433). Many humeral fracrures are opposire side for any change in soft tissue conrour or renderness.
parhologic rhrough simple bone cysrs or rhrough dysplasric The upper arms and shoulders should rhen be examined, looking
bones from osreogenesis imperfecrl or fibrous dysplasia. Occa- for any tenderness in the supraclavicular fossa. Lastly, the spine
sionally, parhologic fractures occur from benign or maJignanr should be examined for tenderness or swelling.
rumors.
Imaging Studies
Radiographs may be needed of the shoulder, clavicle, humerus,
Classification
and cervical spine. Often rhe shoulder, clavicle and humerus can
The simplesr c1assificarion for humeral diaphyseal fracrures de- be seen on a single ameroposterior view ofborh upper extremiries
scribes rhe locarion (proximal third, middle rhird, or disral third, and rhe chesr. Uluasonography can be used to identify a fracrure
or rhe diaphyseal-meraphyseal juncrion), rhe patrern (spiral, of the clavicle or the proximal humeral epiphysis, a shoulder
shon oblique, or transverse), the direcrion of displacemenr, and dislocation, or a shoulder effusion. A computed romography
any tissue damage. Anaromically, rhe location is noted as proxi- (CT) scan or arthrogram may be necessary. The radiographic
ma;1 to the pecroralis major inserrion, between the pecroralis findings for each fracture are discussed in the parricular anaromic
major and delroid inserrions, below rhe delroid insertion, or at sections.
the distal metaphysea~-diaphyseal juncrion (332). Humeral
sharr fracrures may be segmental, wirh fractures of rhe shaft and Birth Fractures of the Humerus
neck (492), or associated with shoulder dislocarion (283). If they Jn the newborn, a humeral fracture can simulare a brachial plexus
are associated with fractures of the ipsilareral forearm, they result palsy with pseudoparalysis and an asymmetric Moro reflex. The
in the so-caJJed "floaring elbow" (491). fracrure site is render and may have swelling or ecchymosis. The
The Association for the Study of Inrernal Fixation (AO- diagnosis is confirmed by plain radiography (387,423).
ASlr) has a c1assiflcarion for humeral shafr fractures (435), bur
it is not very applicable to most children's fracrures, and like
Older Children
most classifications, it is subject to inrerobserver variability
(393). In older children, the diagnosis is usually evidenr wi th pain,
swelling, and unwillingness to move rhe arm. The arm is ofren
supporred by rhe opposire hand and is held tightly to the body
Incidence
(Fig. 17-27). It is essenrial to perform a complete neurologic
Fractures of rhe humeral shaft represent 10% or less of humerus and vascular examination of the extremity before any trearment
fractures in children (316,392,412) and 2% to 5.4% of all chil- except emergency splinring.
tli'en's fractures (316,513). They are most common in children Children with torus or greenstick fractures may have localized
under 3 and over 12 years of age (285). The incidence is greater renderness but no deformiry. In multiple-uauma victims, careful
in children with more severe trauma (470). The incidence is 12 evaluarion should be made of the arm because the diagnosis can
to 30 per 100,000 per year (404,5l3,518). Birrh injuries ro the be missed, especially if the parienr is medically ul1Srable (406).
humerus have a reported incidence rangll1g from 0.035% ro Humeral fracrures should be soughr in patients with massive
0.34% (306,423). upper extremity rrauma.
 Chapter 17: Pm,\'ilnal Humerus, Scapula, and CialJic!r 767

Holstein and Lewis described a shorr oblique fracture of the

distal third of the humerus with potential radial nerve palsy after
closed reduction (385). This has been called the Holstein-Lewis
fracture,

Treatment
Birth Injuries
Neonatal humeral shaft fractLIres heal and remodel quite well,
with 40% to 50% remodeling within 2 years (Fig, 17-28) (289).
Reported treatments include a sling and swathe (384) or a trac-
tion device using the von Rosen splint (277), The primary po-
tel1tial complication ofbirrh injuries is an internal rotation defor-
miry. Therefore, the fraerure is best stabilized by splinting the
arm in extension. If the parents will be movlng the chiid, the
splinted arm can be bound ro the chest wirh a soft wrap, Chil-
dren with anhrogryposis and brachial plexus palsies are prone
to internal rotation contracrures of the shoulder; these can be
exacerbated if the birth fracture's rotation is not controlled.

Stress Fractures
Virtually all nondisplaced stress injuries heal well with temporary
rest and immobilization (269,337,359,363,415,458,493,503,
514), They can displace if not treated (269). Displaced stress
FIGURE 17-27. A young patient with a humeral shaft fracture, holding
the arm tightly to his side, fractures should be [I'eated like other humerus fracwres,

Acceptable Alignment
Radiographic Findings Because the humerus is not a weight-bearing bone, it does not
Birth fractures of the humerus are usually quite apparent on require the precise mechanical alignment of the lower extremiry.
anteroposterior and lateral radiographs of the humerus, In older The marked mobiliry of the shoulder also allows some axial
children, radiographs should be taken in both the anteroposter- and rotational deviation without Hlnctional problems, Severe
ior and lateral planes to obtain (WO films perpendicular to each internal rotation comracwres can cause difficulties in some over-
other. Most fractures are easily visualized on these radiographs, head activities such as ball throwing and facial hygiene, Varus
A true lateral view of the distal humerus is noted by superimposi- of20 to 30 degrees is necessary before becoming clinically appar-
tion of the posterior supracondylar ridges of the medial and ent (Fig. 17-29) (332,397,457). Anterior bowing may be appar-
lateral epicondyles (488). A supracondylar process of the hume- ent with 20 degrees angulation (397). Functional impairment
HIS, when present, is best seen on an oblique radiograph showing does not occur with 15 degrees or less of imernal rotation defor-
the anterior medial aspect of the distal humerus. miry (332). Even adolescents can correct up to 30 degrees spon-
Displaced fractures above the pecroralis major have marked taneously (332). Beaty (285) gives guidelines based on the pa-
abduction of the proximal fragment with external rotation by tient's age: children under 5 yeats of age tOlerate 70 degrees
the rotator cuff arrachment (327,332), The distal fragmenr is angulation and tOtal displacement, children 5 to 12 tOlerate 40
pulled proximally by the delroid and medially by the pecroralis to 70 degrees angulation, and children over 12 tOlerate 40 de-
major. Displaced fractures between the pecroralis major and del- grees and 50% apposition, However, bayonet apposition is ac-
roid insertions show adduction of the proximal fragment from ceptable (292-294), with I to 2 cm of shortening well tOlerated
the pecrol':llis major and shortening by pull of the delroid on (Fig. 17-30). Clinical appearance is more important than tadio-
the distal ftagment. Ftactures below the delroid insertion have graphic alignment.
abduction of the long proximal fragmenr by tne delroid, but
with shortening and medial displacement of the distal fragment
Nonoperative Treatment
by the pull of the biceps and triceps (332).
Pathologic bone may be evident (500), Simple bone cySts are Nonoperative treatment often increases internal rotation by 3
a common cause of fracrures, Periostitis or periosteal reaction of to 12 degrees at the expense of external rotation (332). This
the humerus necessitates differentiating osteomyelitis or Ewing's rately is a functional problem, Nonoperative methods include
sarcoma from a stress fracture; every effort must be made to a sling and swathe, the U plaster, a hanging arm cast, a thoraco-
idenrify a conical fissure using other imaging techniques (275, brachial cast or dressing, a coaptation splint or functional brac-
299), ing, and [raerion,
 768 Upper Extremity

A,B c

FIGURE 17-28. A: Fracture of the left humerus in

a neonate that occurred during a difficult delivery.
B: After 2 weeks of immobilization, clinical and ra-
diographic union is evident, but with anterolateral
angulation. C: At 2 months after injury, there is con-
siderable remodeling. D and E: At 20 months, there
D,E is essentially complete remodeling of the fracture.
 Chapter J7: Proximal Humerlt', ScapuLfI, find Clavicle 769

FIGURE 17-29. A and B: Radiographic appearance of a malunited humerus fracture

showing 20 degrees of varus. C and D: The same patient with no deformity or disabil-
A,B ity, despite her thin extremities.

c D
770 Upper Extremity

A,B c
FIGURE 17-30. A: Humerus fracture allowed to heal in slight varus and bayonet apposition. Band C:
The ultimate result, with essentially normal alignment.

Sling and Swathe sarisfacrorily in more displaced fracrures, which may require a
The simplesr form of rrearmenr for fracrures is a sling and rhoracobrachial casr (293,384,457) or imernal fixarion. Bohler
swarhe. Ir is sufficienr for parienrs wirh minimally displaced acrually abandoned rhe immediare use of rhe U plaster for a
greensrick and rorus fracrures (375,457). AJrhough rhis rrear- rhoracobrachial casr because of problems with early swelling
mem may yield good resub in displaced fracrures (489), ir can (293,294)
be quire diHiculr ro cannol anrerior angularion (386) and may
Hanging Arm Cast
be uncamforrable.
The hanging arm casr, described by Caldwell as a rechnique
already in use (305), consists of a long arm casr with a sling
U Plaster-Sugartong around rhe neck ried ro the casr along the forearm. The weighr
Bohler (292) described a U plasrer similar ro rhe sugarrong splinr of rhe casr and arm provides longirudinal rraerion. The posirion
used on forearms. Plasrcr of appropriare widrh for rhe upper of the sling is modified to correct anrerior or posterior angularion
arm is formed from over the shoulder along rhe lareral aspeer and varus or valgus. Rorarion is difficulr to comro!. 5rewarr and
of rhe arm, undernearh rhe olecranon, and along rhe medial Hundley suggesred nor using ir in children under age 12 because
aspecr of rhe arm ro rhe axilla. Corron webbing is pbccJ berween children cannot keep rheir arms in a dependenr position during
rhe plasrer and rhe skin, and rhe plasrer is secured using a wrap sleep and ofren keep the arm supponed rarher rhan hanging
(Fig. 17-31). Rcsulrs have been quire good (332), parricularly while awal<e (495). However, excellenr resuIrs are reponed in
in children (398). Holm (384) suggesred applying benzoin be- parienrs under age 10 (516). This is probably due ro rhe marked
fore rhe carron webbing and using a collar-and-cuIT sling abour remodeling and potenrial for good resulrs regardless of rrearmenr
rhe wrisr. To prevenr slippage, Shanrharam (477) suggesred ap- in children. Possible complicarions of rhe hanging cast include
plying rhe splinr from rhe base of rhe neck, over rhe shoulder, inferior shoulder subluxation (516), decreased exrernal rorarion
and around ro rhe a.,xillalY fold, wirh a srrap securing rhe proxi- (320), and shoulder sriffness (279), bur rhese are rarely signifi-
mal end ro rhe chesr. The U plasrer may nor canrrol alignmell[ canr in children.
 Chaptrr /7: Proximal Humerw, Scrlpula, and Clavicle 771

A B

c D
FIGURE 17-31. Coaptation splints with collar and cuff. A: The material used for a sugartong arm splint
is two pieces of cast padding rolled out to the length of the plaster-of-paris splint and applied to each
side of the splint after it is wet. The splint is then brought into the tubular stockinette of the same
width but 4 inches longer than the splint. B: The plaster splint is applied to the arm from the axilla up
to the tip ofthe acromion. C: As the plaster is setting, the splint is molded to the arm. An elastic bandage
holds the splint in place. D: Stockinette is applied and attached to the wrist to form a collar-and-cuff
sling.
772 Upper Extremity

Thoracobrachial Immobilization Traction

Severely unsrable fracrures unconrrollabJe in a hanging casr or Side-arm and overhead sk.in and skeleral forms of rracrion have
U plasrer may necessirare exrending rhe casr ro rhe chesr as a been described (276,384,457,509). If olecranon skeleral rracrion
thoracobrachial cast or splim (293,294,384.386,457). Various is used, rhe AO method of an eye screw in the olecranon is less
rypes of rhoracobrach tal dressings are ofren described as a VeI- likely ro produce ulnar nerve irrirarion than is a rransolecranon
peau, bur rechnically rhis is incorrecr: Velpeau described a rhora- pin (435,457). Excessive tracrion can lead ro nonunion in adults
cobrachial bandage wirh acme elbow flexion. Ifa rhoracobrachial (382) and elbow dislocation in children (376).
casr or splim is used for a grossly unsrable fracrure, usually only
a few degrees of abducrion is necessalY (384). Disral diaphyseal
Operative Treatment
fracrures rarely require exrension ro rhe chesL
There are several surgical alternatives for humeral diaphyseal
Functional Bracing fractures: pinning, exrernal fixation, inrramcJullary rodding,
Funcrional bracing, as described by Sarmienro (473), has been screw fixation, and compression plating. Biomechanically, inter-
quite effecrive in adulrs (280.340,354,371,408,432,437,445). lr locking rods are rhe sriffest in bending, and dynamic compres-
Illay be difficulr ro use in children because size differences require sion plating is stiffesr in corsion. Flexible intramedullary rods
a cusromized brace for each parienr or a large supply of braces; are nor as sriff as imact bone (379).
however', modern rhermoplasrics can keep rhis economical (Fig.
17-32) (286). A prefabricated brace is placed on rhe initial visit Open Reduction and Internal Reduction
if possible or on subsequenr visirs afrer placemem of a U plaster Open reduction and inrernaJ reduction can be performed
or sling and swarhe at the inirial evaluation (520). The patiem through eirher a posterior triceps-splitting approach [as advo-
musr be followed closely and rhe splint tightened as needed. It cared by rhe AO group (435,468)] or through an anterior lateral
should not be used in bedridden patienrs because of loss of approach between the brachialis and brachioradialis wirh exren-
gravity support (280). Sarmienro (270,473) nored difflculry in sion proximally between rhe deltOid and pectoralis (287,348).
conrrolling anterior angulation and indicated rhat patients The normal 4.5-mm dynamic compression plate does nor pro-
should nor lean on rhe elbow. The results in adults may be vide adequare srabiliry for the adult humerus shaft. The broad
funcrionally superior ro rhose of the U plasrer (481). 4.5-mm dynamic compression plate is designed ro allow com-
pact screw placement wirhout causing excessive srress on rhe
humerus (435). Ar least six cortices of SCrew fixarion proximal
and disral co rhe fracrure site are needed. Wirh eirher rhe antero-
lateral or posrerior approach, rhe lareral inrermuscular septum
should be splir in the distal third co release rhe radial nerve's
terher. InrerfragmentalY lag screws should be used when possi-
ble. The plare sl10Ldd be slipped underneath the radial nerve
and vessels and some muscle placed between the plare and (he
nerve. Multiple screws in oblique fracrures without a compres-
sion plare are unsatisfactOry in adulrs (468) bur may be sufficient
in children. Extensively comminuted fracrures should be grafted
wirh autOlogous cancellous bone.
Generally, rhe results are good (287,377,378,436,517,523),
and plating is parricularly advocared in multiple-rrauma patients
co facilitate nursing care and managemenr of other injuries (287).
Potential complicarions include radial nerve palsy, infection, de-
layed union, nonunion, and failure of fixation (523).

Intramedullary Rodding
Several rypes of inrramedullary rods are available. Currently,
there are no indications for reamed inrramedulialY nailing in
children because of potenrial proximal physeal damage and rhe
small diaphyseal diameter. However, they may be used in older
adolescents if the risk of physeal arresr is minimal and rhe canaJ
has sufflcienr diamerer (461). Reamed nailing has been reporred
in parienrs as young as 16 (326,328). The results are generally
good (326,338,372,391,399,426,456,466,505,507,521), wirh a
low risk of nonunion and infection (278).
Unreamed nails, such as Ender nails, Rush rods, or flexible
titanium rods have been used primarily in adulrs. Nails or rods
FIGURE 17-32. Light plastic functional braces are useful to maintain
alignment and allow early restoration of motion, particularly in older can be inserred via a posrerior triceps-splirring approach through
children and adolescents. a hole jusr above rhe olecranon fossa. This can be useful for
 Chapter 17: Proximal Humerus, Srapula, and Clavicle 773

rapid management of fractures, including open fracrures in pa-

rients with mulriple rrauma (303,315,323,335,373). Rods
should not be inserred rhrough rhe greater ruberosity in children
(excepr under extenuating circumstances) because of the proxi-
mal humeral physis and the potential for shoulder impingement
(421,467,494). Inserring these relatively large rods through the
epicondyles results in a high incidence of nail back-out (373).
There are two techniques of using small, flexible, smooth
wires. In the Hackethal technique (370), fluoroscopy is used
with a tourniquer placed on the upper arm. A hole is made jusr
proximal to the olecranon fossa using a criceps-splirring ap-
proach. Smoorh, blunt-ripped Steinmann pins are placed up the
canal of the humerus, progressively filling the canal with smaller
and smaller pins as needed (Fig. 17-33). Results are generally
good (313,336,341,380,430,446,522), alrhough pin back-our
can be a problem and care must be raleen not [0 distract the
fracture sire. The rods should be bent 90 degrees at the cortical
window (446). This technique may be useful for segmental and
pathologic fractures (414).
The other technique consists of using smaJi smooth rods or
Steinmann pins placed rhrough the epicondyles (413,431). The
tips of the rods should be blunt and slightly bent. These are
placed through the lateral epicondyle or through both the medial
and lateral epicondyles. A hole is made in the epicondyle, and
a blunt-tipped Steinmann pin is tapped up the diaphysis using
a mallet or passed by hand, with a drill chuck holding rhe pin.
The bend on the tip of the rods facilitates crossing the fracture

A B
FIGURE 17·34. A: A segmental fracture difficult to align by nonopera-
tive methods treated with two intramedullary smooth pins. B: Align-
ment need be only within the same tolerances as closed reduction.

sire and manipularing the fracrure reducrion. A spline is necessary

postoperarively. Alignment need be only wirhin rhe tolerances
for a closed reducrion (Fig. 17-34).

External Fixation
Borh unilateral and multi planar external fixarion are occasionally
useful for humeral shaft fractures (276,333,394,396). Exrernal
fixators are primarily useful for severe open fracrures or as an
alternative to imernal fixation. In parienrs with open fractures,
immediate external fixation with subsequent bone grafringyields
good results (455,486). Exrernal fixation can be combined wirh
internal fixarion for immediare stability (325) for early rehahili-
tation. Severe open fracrures with bone Joss can be treared wirh
primary shortening followed by callus disrracrion (469) to pro-
vide early soft rissue coverage and subsequent restoration of hu-
meral lengrh. Care musr be ra1cen during pin placement to avoid
radial nerve injulY. If screws are used, limired open screw place-
ment can prevene this injuty (455). Ring fixarors may be useful
FIGURE 17-33. The Hackethal technique involves multiple smooth pins
placed up the humeral shaft through a cortical window just above the for reconstructing the injured humerus (304,310,311,321,389,
olecranon fossa. The pins are placed until the canal is filled. 390,484,485).
774 Upper Extremity

Operative Versus Conservative Treatment fracture provides optimal results (303,405,464). This is also true
for supracondylar humeral fractures in children but is not docu-
Because most humeral fractures are controllable nonoperatively,
mented in diaphyseal fractures (491). The floating elbow is often
there are few surgical indications (288). Potential opetative indi-
associated with other organ system injuries; nerve injury occurs
cations include open fractures, multiple trauma, bilateral inju-
in up to 50% of these patienrs (448).
ries, arterial injuries, compartment syndromes, pathologic frac-
Humeral shaft fractures with ipsilateral brachial plexus palsies
tures, significant nerve injuries, inadequate closed reduction, and
in adults heal best with open reduction and inrernal fixation
ipsilateral upper extremity injuries or paralysis.
(300). The same is true with spinal cord injuries (358). Func-
Preadolescents can almost always be managed nonoperatively,
tional bracing is precluded in these patienrs because the muscles
except with severe soft tissu<: injury. If fracture reduction cannot
do not function. Because of the excellent healing potential in
obtain less than 30 degrees varus and 20 degrees antenor angula-
children, they may be treated nonoperatively if satisfactory align-
tion in older children and adolescents-or more importantly,
ment can be maintained. Older adolescents should be treated
if the arm appears deformed-alternatives such as internal fixa-
like adults.
rion, inrtamedullary rodding, external fixation, a thoracobrachial
cast, or traction should be considered. Inadequate closed reduc-
tion is most common in obese patients and in thin women with Radial Nerve Palsies
!arae breasts (468). However, obesity tends to hide the deformity
of ~he fracture, and large breasts are seldom encountered in chil-
Radial nerve palsies with humeral shaft fractures have been re-
poned in children (Fig. 17-35) (314,420). Primary radial nerve
dren.
palsies occur at the rime of the fracture; secondary radial nerve
Open fractures may require fixation. Small, stable grade 1
palsies OCCUt after manipulation of the fracture. Many clinicians
wounds can still be managed using coaptation splints or other
recommend exploration of primary (270,329,356,385,401,403,
closed methods. Unstable open fractures should be stabilized
435,443,450,465,501) and secondary radial nerve palsies (285,
with internal or external fixation to protect soft tissues (318,
332,356,443,450,483,506,513). The incidence of concomitant
335,409,420,468,510).
radial nerve palsy with a humeral shaft fracture ranges from 2.4%
Multiple-trauma victims are often best treated with internal
to 20.6% (291,336,403,420,427,449,465,479,511) and has
or external fixation for more rapid mobilization (285,287,303,
been reported in 4.4% of children's humeral shaft fractures
348,416,425). This is particularly true in patients with chest
(420). Most occur with middle and distal humeral shaft Frac-
injuries, where thoracobrachial immobilization would compro-
tures, but they may occur with more proximal fractures as well
mise pulmonary cate (335,416,420). Excellenr results have been
(427). In explored primary radial nerve palsies, the incidence
reported with external fixation (318,394,455,486), retrograde
of complete nerve laceration is small (420,443,479,488,511).
rodding using Ender nails or Rush rods (303), and internal fixa-
Commonly, the nerve is tented over the bone, trapped in the
tion (287). In older adolescents, more rigid locked or unlocked
fracture site, or contused. The natural history is excellent, with
intramedullary rodding can be used for patients requiring rheir
recovery rano-ing from 78% to 100% (271,291,296,297,338,
upper extremities for mobiliry (348). However, this luxury does
356,361,443~449,450,470,479,511). Therefore, many clini-
not exist for younger children.
cians recommend observation rather than early exploration (291,
Arterial injury and compartment syndromes requiring fascio-
romy are potential indications for internal fixation (353,451,
460,487). Continued fracture mobiliry can damage a vascular
anastomosis (355,428,460,487), and fasciotomy can make the
fracture less stable. Temporary vascular shunting before internal
fixation allows the orthopaedist and the vascular surgeon to work
under optimal conditions (317).
Most pathologic fractures in children, including those.fr.om
malignancy (463), fibrous dysplasia (360,492), osteogenesJs tm-
perfecta, and simple bone cysts, can be treated nonoperatl:ely.
Simple bone cYStS are discussed larer in the section on pro.xlJ.nal
humerus fractures. Occasionally, patients with osteogeneSlS Im-
perFecta require intramedullary rodding using Bailey-Dubow
rods. A report of a 6-year-old with progressive ossifying fibrodys-
plasia suggests that inrernal fixation may prevent stiffness after
fractures in this condition (438). In Fractures secondary to malig-
nancy, intramedullaty rodding is necessary if exrensive cortical
loss causes instabiliry (322,326,411,421,504). Spontaneous frac-
ture in a severely brain-injured or unresponsive cerebral palsy
patienr is best treated nonoperatively (508).
Ipsilateral injuries, particularly fractures of the proximal or
distal humerus and of the forearm, can be difficult to control. FIGURE 17·35. Radial nerve palsy secondary to a humeral shaft frac-
In adults with a floating elbow, internal fixation of the humeral ture from a low-velocity gunshot wound.
 Chapter 17: Proximal Humerus, Scapula, and Clavicle 775

338,356,361,443,449,450,470,479,511). Open fracrures result- and-cuff sling for forearm support. If alignment is unsatisfactory,
ing in severe soft tissue injury requiring debridement should a new splint is reapplied and molded.
have the radial nerve explored and tagged (499) or preferably In those rare fractures uncontrollable by closed means, I pre-
repaired (349). More severe open fractures should be stabilized fer smooth intramedullary rodding using tvvo 2-mm rods placed
using either intramedullary rodding or internal or external fixa- retrograde through the epicondyles. For unstable fractures with
tion to provide good soft tissue for radial nerve recovery. Early extensive comminution, I prefet to use a unilateral external fixa-
repair of the nerve provides the best anaromic results (290). tor, with small incisions made during screw placement to avoid
Bostman et al. (297) recommended exploration and internal the radial nerve. Open fractures are treared in a similar manner.
fixation in patients with bayonet apposition because the abun- Significant bone loss can be treared using bone transport tech-
dant callus may endanger nerve recovery (297). The recom- niques. I avoid plate fixation because it creares a stress riser,
mended waiting time beFore radial nerve exploration ranges from particularly in growing children. If a fracture occurs distal or
8 weeks ro 6 months (270,271 ,332,338,386,427,449,450,4 57, proximal to the plate, it musr be reexplored for plate removal,
483,513). Nerve grafting up to 18 months after the injuq can necessitating reexploration of the radial nerve and potential nerve
provide good function (290,347). Seddon suggested a physio- damage. I obselve both primaq and early secondaq radial nerve
logic time of allowing I mm per day aftet the I to 2 months of palsies, exploring them only after 1 to 2 monrhs and growth of
Wallerian degeneration and nerve growth through the neuroma 1 mm per day if electromyography shows no return.
(475). Nerves grow I to 3 mm per day (475,476,498), and this
rate has been used clinically with good success (362,499).
In secondaq radial nerve palsies, the surgeon may feel com- Rehabilitation
pelled to explore the nelve because he or she "caused" the radial Patients treated with closed manipulation should be followed
nerve injury. However, natural histoq studies of observed sec- weekly for the first few weeks to ensure rhat alignment is main-
onclaq radial nerve palsies show recovery of 80% to 100% with tained. The coaptation splint or long arm cast should be replaced
nonoperative treatment (297,356). Secondary palsies occurring as needed. Patients with radial nerve palsies must be instrucred
after manipulation may be obselved (291,338,402,445,479). If in finger morion to keep the fingers supple and prevent con-
the palsy occui·s after a considerable time, the nelve is probably tractures. Noncompliance requires formal hand therapy or a ra-
encased in callus and further investigation, including explora- dial nelve ourrigger. Stiffness of [he shoulder and elbow is un-
tion, is warranted (342,496). Late presentation may result in an common in children, but pendulum exercises are srarted ar 3
osseous foramen containing the nelve and requiring decompres- to 4 weeks in older children and adolescents. Some form of
sion (342). immobilization is generally continued for 6 weeks. Patients
should not rerurn to contact sportS until there is adequate heal-
ing, and the family should be cautioned that refracture may
occur during the firsr 6 months after injuq.
Iff AUTHORS' PREFERRED METHOD
,~ OF TREATMENT
Prognosis
Birth fractures have a veq good prognosis for full recovely. To
The prognosis for healing and remodeling of humeral shafr frac-
prevent an internal rotation contracture, I place the arm in either
rures in children is exceJlenr. Internal rotation deformity is usu-
a U plaster or a plaster coaptation splint with the palm facing
ally minimal, and the outlook for radial nerve palsies is good.
anteriorly. A soft wrap holds the arm to the body so the child
Loss of shoulder motion may occur but is more common in
can be carried. The splint can be removed in 2 weeks. On heal-
older patients (386).
ing, the radiographic angulation can be quite worrisome ro the
parents. I like ro show them tadiographs of other infants with
marked remodeling, and keep photographs handy for this pur- Complications
pose.
Malunion
Most humeral diaphyseal fracrures in children are treated
nonoperatively. Torus fractures are n·eated with a commercial Malunion is uncommon in children's humeral diaphyseal frac-
shoulder immobilizer or a sling. Greenstick fractures and dis- tures. Varus of 20 to 30 degrees can be accepted (Fig. 17-29)
placed fractures in younger children are treated with a U plaster (299,332,343,457), but anterior bowing of 20 degrees may be
or a plaster coaptation splint; these are usually applied in the apparent (397). An inrernal rotation deformity of 15 degrees
emergency department with mild sedation. I prefer general anes- causes no funcrional impairment (332). Most patients under 6
thesia if more manipulation is needed. A careful neurologic and years of age grow out of angular deformities (386). Children 6
vascular evaluation is performed before and after manipulation. to 13 years of age may not, although some remodeling is possible
I place a U plaster with Webril padding extending from over even in adolescents (386,440). Obese patienrs are more prone
the delroid, around the olecranon, and up to the axillaq fold, to malunion, but rhey also hide their deformity better (468).
and secure it with a gauze wrap followed by an elastic bandage. Green and Gibbs (365) noted that the deformity visible on the
I have had similar results applying plaster coaptation splines on anteroposterior and lateral radiographs is generally not the maxi-
the medial and lateral aspects of the arm and rewrapping fre- mum deformity, which is the vector sum of the two deformities.
quently with an elastic wrap. The patient is placed in a colJar- This can be appreciated by obtaining a radiograph perpendicular
776 Upper Extremity

to the plane of the deformity, similar to the Stagnara view for Vascular Injuries
scoliosis.
VascuJar injuries require a high index of suspicion and rapid
treatment (301,334,424,429). The fracture should be stabilized
Nonunion sufficiently to prevent disruption of the vascular repair.
Primarily a problem in adults and occasionally in older adoles-
cems, ~here are few reports of humeral nonunion in chil- Infection
dren-one in a child with progeria at age 4 (351), four in chil-
Infections have been reponed in patients undergoing surgeIY.
dten with osteogenesis imperfecta (355), and three from severe
They have not been reponed in closed fractures of the humerus
trauma (410). In adults, numerous treatments have been used
in children, but have been reponed in closed fractures elsewhere
successfully. These include reamed nails (319) and modified
(307,512).
flexible nails (368,452). However, the best results appear to be
from ASIF techniques with the broad dynamic compression
plate and autogenous bone grafting (282,312.346,374,435, Loss of Motion
519). Currently, treatmem in children and adolescents must be
extrapolated from adult treatment. In general, the atrophic ends Loss of shoulder and elbow motion is more common in older
of the nonunion are taken back to bleeding surfaces and apposed, patients (272,386). The joint affected is usually the one closest
to the fracture si teo
a compression plate is applied with fixation of at least six corrical
screws proximally and distally, and bone grafting is performed
(374). The Ilizarov technique also reporredly produces good re- Limb-Length Discrepancy
sults (275,304,310,389,390,484). Electrical stimulation also has
been used with success (324,344,345,477,478,497). Children Overgrowth after humeral fracture occurs in about 81 % of pa-
with dysplastic bone, SUer) as those with osteogenesis imperfecta, tients but is generally minimal « 1 cm) (375). Some generalized
are best treated with intramedullary rodding and bone grafting stimulus to the extremity is evident, with overgrowth of the
(355). carpals as well (474). In patients with limb-length discrepancy
of 3 cm or more at maturity, lengthening may be indicated (330,
447). Unilateral or ring flxators may be used with I1izarov's
Nerve Palsies principles (310,311).
Radial nerve palsies were discllssed previously. They also may
occur immediately after operative treatment (334), or may be Other Complications
delayed <lnd occur many years after imernal fixation (352). Ulnar
nerve paralysis has been reponed from entrapment of the nerve Uncommon complications include reflex sympathetic dystrophy
in the fracture site (395). A small percentage of people have an (350) and fat embolism (400). Late refracture may occur from
abnormal arcade of Struthers in which only super6cial fibers of retained internal fixation (298).
the uiceps medial head pass superficial to the ulnar nerve and
none pass deep to the netve, making the nerve extremely close
ro the bone and vulnerable to an abduction exrension mecha- DISTAL HUMERAL DIAPHYSEAL
nism of fracture, which opens the anterior medial aspeCt of the FRACTURES
humerus (395). In about 10% of the population, the median
nerve crosses posterior to the brachial artelY rather than anterior, Little has been written about dis(al humeral diaphyseal or meta-
placing it closer to tbe humerus. Median nerve palsy has been physeal-diaphyseal junction fractures, which are much less com-
reporred from an apex anterior mid-diaphyseal fracture (422). mon than supracondylar humeral fracrures. Fracrures in this re-
After an easy fracture reduction, tl1e median nerve was caught in gion should not be confused with supracondylar humeral
the fracture between the coracobrachialis and brachialis muscles, fractures. The distal diaphysis is more triangular and the perios-
where the nerve crossed anteriorly. Anterior interosseous nerve teum is thinner than in the supracondylar region (327,331),
palsies have not been reported in fractures above the supracondy- making these fractures generally less stable than supracondylar
lar region. fractures. The conical bone also heals more slowly than meraph-
yseal bone, requiring longer immobilization. The mobile wad,
anconeus, and flexor pronator mass originate off the epicondyles;
Compartment Syndrome
the biceps, brachialis, and triceps all insert distally. Therefore.
The fascia of the upper arm is not as strong as it is in the lower forearm position greatly affects the fracture position. Because
arm, making compartment syndrome less common. Mubaral< the brachial anery is tethered by the lacerrus fibrosus, injUlY to
and Carroll (434) reponed a dorsal forearm compartment syn- the anery is more likely (han with more proximal fractures.
drome in a 9-year-oJd boy with a humerus shaft fracture. Cupra
and Sharma (367) reported on an adult with a triceps compart-
ment syndrome from a middle third minimally displaced frac-
Etiology
rure; this fracture did not disrupt the intercompanmenral Distal humeral diaphyseal-metaphyseal junction fractures may
boundaries. be caused by transverse or longiwdinal loading, torsion. or mo-
 Chapter f 7: Proximal Humerus, Scapula. and Claviclr 777

ments generated by the forearm about the elbow. They are more
often caused by direct blows and twisting rather than ulnar lever-
age in the olecranon fossa. The diagnosis, made on plain radio-
graphs, must be differentiated from a supracondylar humerus
fracture.

Classification
Most distal humeral diaphyseal fractures are transverse, spiral, or
shorr oblique. Occasionally, an oblique or spiral fracture extends
distally toward or beyond the epicondyles (Fig. 17-36). The
description must include the direction of displacement, the neu-
rologic and vascular status, and the degree of comminution.
Medial column comminution predisposes to varus malunion.

Treatment
Nonoperative
Closed treatment usually is possible because acute flexion of the
elbow, with potential vascular compromise, is not required to
maintain reduction. These fractures tend tOward varus malunion
(Fig. ] 7-37) (302), which may be cosmetically unacceptable,

A,B B
FIGURE 17-36. A and B: Distal humeral diaphyseal fracture extending FIGURE 17-37. A and B: Radiographs showing the tendency of distal
to the epicondyles. This fracture was treated by casting with the fore- humeral diaphyseal fractures toward varus malunion This fracture re-
arm in pronation. quired remanipuiation.
778 Uppl'1" Extrel1lit}

A B

c o
FIGURE 17·38. Influence of forearm rotation. Pronation (A and B) of the forearm produces a valgus
angulation at the fracture site (arrows). Supination (e and D) creates a varus angulation (arrows).
 Chapter /1: Proximal HltlllerllS, SCI/pula, find Clavicle 779

A B

C,D E
FIGURE 17-39. The same patient shown in Fig. 17-38. A: The humeral coaptation splint is molded
(arrows) with the forearm in neutral. B: A second forearm coaptation splint is added, and the extremity
is suspended with a loop. C: Radiographs show satisfactory linear alignment. 0 and E: The fracture
healed in bayonet apposition but with satisfactory alignment.

particularly in more distal fractures. With 20% Ot less of humeral should be performed in a similar fashion ro supracondylar hume-
growth occurring distally (295,453,454), significant remodeling rus fractures. However, because the fracture is more proximal,
may not occur. Because of the proximity to the epicondyles with it is difficult ro get the pins into the diaphysis without crossing
rheir muscular origins, supination and pronation affect fracture them at the fracture site (Fig. 17-40). Arrempts should be made
reduction. If one cortex is open, then the muscles originating to pass the wires in intramedu'llalY fashion up the lateral or
on that side should be tightened to reduce the fracture (274). medial and lateral columns separately ro provide stability (Fig.
Because of the varus tendency, this is usually by pronation (292, 17-41) (457). This can be done by drilling the wires, but it is
294,487). However, this is best checked radiographically (Figs. easier to create a starting site at the epicondyles and pass blunt-
17-38 and 17-39). tipped wires up the columns. Holding the wires with a drill
chuck helps, roo. Because of the bony anatomy and the ulnar
Operative nerve, lateral wires are easier to place, particularly in younger
Unstable fractures may require fixation (302,457) and possibly children (Fig. 17-42). AJternatively, the fracture can be managed
open reduction. Closed reduction al1d percutaneous pinning with skeletal traction until callus forms; then either a U plaster
780 Upper Extremity

A B

C,D E
FIGURE 17-40. A and B: Distal humeral diaphyseal fracture in an 18-month-old child treated with closed
reduction and percutaneous pinning (el. The pins cross at the fracture site with decreased stability and
some loss of position D and E: The ultimate outcome was good.
 Chapler /7: Proximal Humerus, Scapula, and Clavicle 781

FIGURE 17-41. Ideally, pin fixation for distal humeral diaphyseal-metaphyseal

junction fractures involves pins placed in intramedullary fashion up the medial
and lateral columns.

A B
FIGURE 17-42. Segmental distal humeral diaphyseal and supracondylar fracture in a 4-year-old boy. A
and B: Both fractures could not be controlled by closed means. (Figure continues.)
782 Upper Extremiry

c D
FIGURE 17-42. (continued) C and D: A lateral column pin acting as an internal splint is technically easier
than medial column pins.

A,S c
FIGURE 17-43. A comminuted distal humeral metaphyseal-diaphyseal fracture in a 14-year-old boy.
Injury films (A) show multiple fragments in the metaphyseal-diaphyseal area. (B) The patient was placed
in traction for 2 weeks until callus appeared and then was transferred to a long arm cast (C).
 Chapter 17: Proxima! Huments, Scapula, and Clavicle 783

splint or a long-arm casr can be applied (Fig. 17-43). Brug and

colleagues repon rhe besr resulrs wirh flexible intramedullary
rodding (302) .

• AUTHORS' PREFERRED METHOD

,~ OF TREATMENT

For disral humeral diaphyseal-meraphyseal juncrion fracrures,

I prefer closed trearmenr. Nondisplaced fracrures are [[-eared wirh
a long arm casr splir [Q allow for swelling. A double suganong
splint is used if sweJling is severe. I reduce displaced fracrures
under general anesrhesia. Because supinarjon and pronarion of
rhe forearm can affecr rhe posirion, I use rhe image intensifier
ro derermine rhe position best for mainraining rhe reducrion;
rhis is usually pronarion. If rhe reducrion obrained is unstable
and cannot be held with a casr, I do not hesitate to rrear it by
percutaneous pinning, with small Steinmann pins placed
through the medial and lateral epicondyles and up their respec-
rive columns, keeping the pins as divergenr as possible at the
fracture site or with lateral column pins. It is helpful [Q inrroduce
them through the epicondyle and then tap rather than drill them
up the column [Q prevent convergence at the fracture site. The
pins are removed once good callus forms.

SUPRACONDYLAR PROCESS
FRACTURES .
Anatomy FIGURE 17-44. Radiographic appearance of a supracondylar process
(arrow).
Occasionally, a proboscis-like supracondylar process extends
from a few cenrimeters above rhe medial epicondyle. The inci-
dence of this process ranges from 0.1 % [Q 2.7%, with the lower
percenrages in blacks and [he higher percenrages in whites (281,
419,439). The process extends obliquely downward and may be area. They may be quire painful and resu!r in compression of
connecred with the medial epicondyle by a cough fibrous band the brachial artery or median nerve (281 ,309,369,399,419). The
(281,309,394,419,439). Frequently, the foramen formed be- process is best seen on oblique views (439). If there are no symp-
[Ween the fibrous band and the humerus is rraversed by the corns of median nerve or brachial arrery compression, they are
median nerve and the brachial artery. They may be entrapped rreared by elevation, ice, and temporaly immobilization for com-
by a fracrure. Anomalous attachments of the coracobrachialis forr. However, if a painful nonunion or neurovascular symptoms
and the pronacor teres may occur on the process (Fig. 17-44) develop, rhe fragment should be excised (439). Fractures with
(369,399). neurologic signs or sympcoms are treated by fragmenr excision
and nerve and arrelY decompression.
Etiology
Supracondylar process fractures are the result of direct blows.
There are no repons of avulsion from rhe anomalous muscle GLENOHUMERAL SUBLUXATION AND
atrachmenrs. DISLOCATIO
Dislocation of the glenohumeral joinr in children is rare. None
Classification of the ancient writings of Hippocrares (460-375 B.C.), G~llen
Supracondylar process fractures are classified as displaced or non- (A.D. 131-201), and Paul of Aegena (A.D. 625-690) made spe-
displaced, wirh notation of median nerve or brachial artery com- cific menrion of this injury in children (601). Mosr texrbooks
promise. thar address children's shoulder problems do nor even discuss
dislocarions of the glenohumeral joint, and orhers barely [Ouch
on rhe subject (533,599,600,607,6\ 0,615). A review of rhe li[er-
Treatment
ature would suggest rhar glenohumeral disJocarjons in children
Supracondylar process fractures have been reponed in children less than 12 are rare. AJ rho ugh severa! case reports have been
(399) and usually are caused by direcr blows to the disral humeral presented, no large series of this entity are available (564,566,
784 Upper Exrremiry

579,614). Rowe, in his 1956 review of 500 dislocated shoulders and externally rotated, much like the effect of wringing out a
(604), found that only 8 patients were under 10 years of age. washcloth. This Structure becomes the primalY site of pathology
In this same series, 99 patients were 10 to 20 years of age, bue in ancerior shoulder instability, either when the anteroinferior
no details on skeletal maturity were given (603,604). Rockwood glenohumeral ligament attachmenr to the glenoid and labrum
reponed a series of 44 patienrs with shoulder dislocarions, pre- is stripped from the anterior neck of the glenoid or as chese
dominantly adolescents (601). Many artic!es have been pub- ligaments are disrupted in subsrance (Fig. 17-45). Disruption of
lished on adolescent patients without discussing their skeletal the capsular labral attachment is known as a Perthes' or Bankarr's
maturity (548,557,586,591). As the child reaches adolescence, lesion.
the incidence of shoulder instability increases, but in the skele- The humeral accachmenc of the capsule of the glenohumeral
tally immature patient, this injuty can still be considered rare. joint is along the anacomic neck of the humerus except medially,
tvtarans et al. (585) in 1992 presented a series of 21 paneors where the attachment is more disral along the shaft. The physis,
with open physes from cwo major trauma ceorers. therefore, lies in an extracapsular position except on rhe medial
side. As in most pediatric joinr injuries, the strong capsular at-
tachment to the epiphysis makes failure through the physis a
Anatomy much more common injury than true capsular/ligamentous in-
jUlY (542,574,611). Therefore, fraceure through the physis is
Developmental anacomy was discussed in the section on frac- more common than a dislocation in the skeleraJly immature
tures of the proximal humerus. The glenohumeral joior consists patient.
of the articulation between the large convex humeral head and The rotator cuff tendons consist of the subscapularis, supra-
the relatively flat glenoid fossa. This joinc is anacomically suited spinatus, infraspinatus, and teres minor muscles. These mus-
co accommodate the wide range of motion necessaty to perform cle-tendon units surround the joint anteriorly, superiorly, and
upper extremity function. To accomplish this range of motion, posteriorly. Tney serve an important function as dynamic sec-
very little bony conscrainris inherent in this joint. The arciculat' ondalY stabilizers of the joint by forming a force-couple with the
surface area and radius of curvature of the humeral head are large shoulder muscles (deltOid, pectOralis major, and latissimus
about three rimes the size of the relatively flat glenoid surface. dorsi). As the glenohumeral joior moves through its range of
Although the glenoid fossa is deepened by the labrum, the mis- motion, the cuff provides a dynamic stabilizing effect, preventing
match in the surface area and the radius of curvature explains excessive translation of tne humeral head on the glenoid. This
the lack of joint stability. is imporcanc when addressing rehabilitation for the prevention
The primary constraint for the joint is the capsularlligamen- of recurrent glenohumeral dislocation.
cous complex. The capsule on its inner surface is reinforced by
thickened areas known as the anterior glenohumeral ljgaments. Mechanism of Injury
This complex capsularlligamentous structure must pl'Ovide sta-
Traumatic Dislocations
bility against abnormal translation while allowing a wide range
of motion. With the arm abducted, the inferior capsule is highly Anrerior dislocations of the shoulder are most common in this
redundant. The most imponanc ligament is the anteroinferior category. Significant evidenc of trauma should be present to
glenohumeral ligament, located within the inferior redundanr assign parients to this grouping, as compared with the relatively
area. It is mechanically designed to tighten as the atm is abducted minor trauma in the atraumatic group. The mechanism of injury

P Hill Sachs
Lesion

Perthe's/Bankart
Lesion A
A B
FIGURE 17-45. A: The tight anteroinferior glenohumeral ligament complex with the arm abducted
and externally rotated. This ligament sling is the primary restraint against anterior instability of the
shoulder. B: A cross-section in the transverse plane through the glenohumeral joint demonstrates the
common lesions associated with anterior instability of the shoulder: Hill-Sachs lesion, Perthes-Bankart
lesion, and redundant anteroinferior glenohumeral ligaments. A,anterior; P,posterior; HH, humeral
head.
 Chapter J 7: Proximal Humerus, Scapula. and Clavicle 785

is similar to that observed in the adult. A force applied to the end of the humerus, and emotional and psychiatric instabiliry.
outstretched hand that forces the arm and shoulder into an ab- True congenital dislocations of the shoulder are most commonly
ducted, externally rotated position is the primary mechanism. associated with developmental defects and multiple congenital
The humeral head is levered out of the glenoid process anteriorly, abnormalities (537,540,555.559598). Arrhrogryposis, ne-
with the head lodging against the anterior neck of the glenoid. glected septic arthritis, and neurologic defects also have been
This occurs commonly in contact SpOtts, falls, fights, and motor implicated in atraumatic dislocations in the young child (527,
vehicle accidents (531,567,592). 557,558,565,609,617).
Traumatic posterior dislocations are much less common. In
most series of posterior dislocations in all age groups, they repre- Classification
sent only 2% to 4% of all dislocations. The history is one of
Etiology of Instability
violent trauma with the arm in a position of flexion, internal
rotation, and adduction. This can occur in falls and in motor 1. Traumatic dislocations
vehicle accidents as the arm braces the body against impact. The a. Primaly trauma to the shoulder itself
other common mechanisms that produce posterior dislocations b. Secondary to birth trauma of the brachial plexus or central
include convulsions and electroshock. In these cases, the shoul- nervous system
der is dislocated posteriorly by the violent contraction of the 2. Atraumatic dislocations-voluntary or involuntary
shoulder internal rotators, which in most cases are stronger than a. Congenital abnormalities or deficiencies of bone or soft
the shoulder external rotators. The history of the injUly and a tissue
high index of suspicion are necessary to avoid missing a posterior b. Hereditary joint laxiry problems, such as Ehlers-Dan los
dislocation (546,547563,596,612). syndrome
In neonates, pseudodislocarion of the shoulder can occur c. Developmental joint laxity problems
(561). This problem reptesents traumatic epiphyseaj separation d. Emotional and psychiattic distutbances
of the proximal humerus, which is certainly much more com- Because of the rarity of this injury, no consensus exists as to
mon than a true traumatic dislocation of the shoulder in this a classification scheme in children and adolescents. In adults,
age group. Most true ttaumatic dislocations of the shouldet in shoulder instabiliry can be classified as to direction, degree, and
the neonatal period occur in babies with underlying birth trauma chroniciry. Two basic schemes have been used to classify other
to the brachial plexus Ot central nervous system. dislocations in children and adolescents; the more common is
Laskin and Sedlin (577) reported on a 3-month-oJd infant based on the direction or location of the dislocation. This scheme
with Erb-Duchenne palsy who sustained a ttaumatic luxatio is useful in describing the clinical and radiographic features of
erecra of the shoulder during a planned shoulder manipulation. the injury, but it does not address the underlying pathology in
Posterior dislocation of the shoulder also can occur as a second- children (601).
alY traumatic phenomenon in unrecognized brachial plexus in-
jury of the upper trunk at delivery (527,580,617,618). Green Direction of Instability
and Wheelhouse (558) reponed a dislocation in a 7.5-momh-
Therefore, a second classification scheme describing the etiology
old infant that was secondary to a septic brain injury.
of the dislocation is also useful when considering treatment op-
tions fot this injury in children. This second system is similar
Atraumatic Dislocations to that used for adults but takes into account congenital and
developmental problems unique to children. As discussed later in
Atraumatic shoulder instabiliry is more common in children and
the section on treatment of this problem, accurate classification is
adolescents than is readily recognized. The child who presents
important in selecting the appropriate conservative versus surgi-
with shoulder dislocation withom a clear-cut significant history
cal options (526,542,597).
of trauma should arouse suspicion that atraumatic instability
There are four directions of dislocation: anterior, posterior,
may be present. These patients have inherent joint laxiry that
multidirectional, and inferior (Iuxatio erecra). As with shoulder
allows the shoulder to be dislocated either voluncatily or involun-
dislocations in adults, anterior dislocation in children is the most
tarilyas the result of a minimally traumatic event (Fig. 17-46)
common, constituting at least 90% of glenohumeral dislocations
(536). Throwing, hitting an overhead tennis shot, or pushing
(Fig. 17-47). Several isolated reports of posterior dislocation in
the body up when in bed does not constitute significant trauma.
children and adolescents have been documented, but posterior
A high index of suspicion should be maintained with this kind
dislocation is rare in children, as in adults (534,553,566,587).
of history. In the voluntary dislocator, conscious selective firing
MUltidirecrionalluxatio of the shoulder has been well described
of muscles while anragonists are inhihited, combined wirh arm
as a distinct clinical enriry by Burkhead and Rockwood (535),
positioning, allows the shoulder to dislocate. A key to the diag-
O'DriscolJ and Evans (548), and Rockwood (601,602). Luxatio
nosis is that arraumaric instabiliry, whether volunrary or involun-
ereera or inferior locked dislocations are uncommon but have
tary, is not associated with much pain. Even if reduction is neces-
been reporred in children (554,577,589).
S;lIY, the pain usually disappears rapidly. ]n most instances,
spontaneous reduction occurs without manipulation (601).
Degree of Instability
Other causes of atraumatic shoulder instabiliry, in addition to
multidirectional joinr laxity, include Ehlers-Danlos syndrome, The degree of instabiliry can be classified as a subluxation or a
congenital absence of the glenoid, deformities of the proximal dislocation. A subluxation is an incomplete dislocation charac-
786 Upper Extremity

A B

FIGURE 17-46. Congenital laxity of the left shoulder

in a 4-year-old boy who is totally asymptomatic and has
a full range of motion of the left shoulder. A: With ab-
duction and extension, the head subluxates anteriorly
and inferiorly. B: An anteroposterior radiograph shows
some lateral displacement of the humeral head. C: With
overhead elevation, the humeral head is noted to dis-
place anteriorly, laterally, and inferiorly. (Courtesy of
C Don Jones, M.D.)

terized by pain, a feeling of slipping, or a dead feeling in the age to the ligament and bony restraints of the joint. A chronic
arm. A complete dislocation of the humeral head Out of the instability exists when an acute dislocation is not reduced, and
glenoid fossa is characterized by a displacement and locking of is usually associated with congenital dislocations.
the head on the rim of the glenoid.
Signs and Symptoms
Chronicity of Instability Traumatic Dislocations
The chronicity of instability can be classified as acute, recurrent, The patient with a traumatic anterior dislocation presents with
or chronic. A single episode of instability can be described as a painful, swollen shoulder. Obvious deformity is present, with
an acute injury. As in the skeletally mature patient, an acute a prominent acromion and the lateral upper arm flattened. The
injury can lead to a recurrent instability, depending on the dam- arm is often supported by the opposite hand and held in an
 Chapter 17: Proximal Humerus, Scapula, and Clavicle 787

A B

c D
FIGURE 17-47. Anterior dislocation of the right shoulder in a 15-year-old girl. A: Note the typical
subcoracoid position on the anteroposterior film. B: On a true scapular lateral film, note the anterior
displacement of the humeral head. C: Postreduction film demonstrates a Hill-Sachs compression fracture
in the posterolateral aspect of the humeral head. D: On the postreduction axillary film, note the postero-
lateral compression fracture of the humeral head.

abducted and exrernally rowed position. Despite swelling, the for about 1 inch so that deltOid firing is initiated. This examina-
humeral head can usually be palpated in a position anterior to tion confirms the status of the axilla.ty nerve (Fig. 17-48).
rhe glenoid. In recurrent anterior dislocation or subluxation, rhe arm is
Careful examination of the neurologic and vascular status is well located with an overall normal appearance of the shoulder.
necessary. The axilla.ty nerve is the most commonly injured wirh The shoulder demonstrares a full range of motion, alrhough the
anterior dislocation, and special attention to its function is neces- cocking posirion is avoided. The apprehension rest wirh the arm
sary on examination (532). The sensory distribution of rhe axil- abducted above 90 degrees is positive. This is a key finding in
laly nerve is along the upper lateral arm; the mOtOr innervarion the diagnosis of recurrent anterior instability.
is to the deltoid and teres minor muscles. Light tOuch is adequate Traumatic posterior dislocation is, again, much less common
for sensory testing in the upper arm region. An easy way to test than anterior dislocation. The patient presents with flattening
deltoid function is to suppOrt the involved elbow in one hand of the anterior aspect of the shoulder and posrerior fullness. The
while using rhe opposire hand to grab the muscle belly of the arm is held at the side, with the forearm internally rotated across
deltoid. The patient is asked to abduct rhe arm againsr resistance the chest. The patient resists any attempt at motion. A hallmark
788 Upper EX"tremi~)1

~j

''''"', \"'''
,\ '.
".-r' 1
dJ )

----/ f-

,,
I
f
~ ,\.\ '~.;; ,~. 0(
1---/ ,
/
/ 1(/',- ~.' I ' •.:. ':.:;" I \ I
-
/

l -<[
A B
FIGURE 17-48. A: Sensory distribution for the axillary nerve important in anterior dislocation. B: Deltoid
muscle can be tested in acute anterior dislocation by grabbing the muscle belly with the right hand
while supporting the elbow with the left. The patient then can actively contract the deltoid by pushing
the elbow against the examiner's hand while the examiner feels the muscle contraction.

of posterior dislocation is the Jack of shoulder external rotation sign and significant translation on an antenor and posterior
and inabiliry [Q supinate the forearm. These findings are difficult drawer tesr.
[Q elicit in the acute siruation. It is advantageous [Q examine the The sulcus sign is a dimpling of the skin below the acromion
shoulder with the patient scated so that the examiner can visual- when manual longitudinal traction is applied to the arm (Fig.
ize the shoulders from above. This view accentuates the posterior 17-49). This produces an inferior subluxation of the humeraJ
fullness and anterior fhmening oftcn present. The neurovascular head away from the acromion that enlarges the subacromial
status should be closely checked. A history of convulsion or space and causes dimpling of the skin. The drawer or shift and
electrical shock should raise a high index of suspicion for poste-
rior dislocation.
In neonates, uaumatic separation of the upper humeral phy-
sis, the so-called pseudodislocation of the shoulder, can exacdy
mllnic an anterior dislocation. The chiJd is irritable and often
holds the arm abducted and externally rotated. There is resis-
tance [Q any type of motion. Deformity in dislocation or pseudo-
dislocation in the neonate is usually abseIl[ or subtle.

Atraumatic Dislocations
The most notable finding in patienrs with atraumatic shoulder
instability is the relative lack of pain associated with the subluxa-
tion or dislocation. Evcn in cases of involuntary auaumatic dislo-
cation, the minor pain associated with the dislocation itself sub-
sides rapidly aftcr reduction. Episodes of arraumatic subluxation
and dislocarion occur much more Frequently than rraumarjc dis-
locations, and in aJmost all cases spontaneous reduction is the
rule.
On clinical cxamination, therc is evidence of multiple joint
laxity (594). Also, multidirectional laxity or instability of the
opposi te shoulder is usually present (548,549,601,602). Charac-
terisrics of multiple joint laxity include hyperextension at the
elbows, knecs, and metacarpophalangeal joints. Not uncom-
monly, striae of the skin are present, and skin hyperelasticity is
FIGURE 17-49. Dramatic demonstration of inferior subluxation of the
a noted characteristic of Ehlers-Danlos syndrome. Multidirec- glenohumeral joint in a patient with multidirectional instability. The
tionallaxiry of the shoulder is characterized by a positive sulcus clinical correlate is the sulcus sign.
 Chapter 17: Proxima! H unurllS, Scapula, and Clavicle 789

FIGURE 17-50. Drawer test. This technique is used to subluxate the shoulder manually both anteriorly
and posteriorly to demonstrate multidirectional laxity.

load test is performed with the examiner seated behind the pa- Point lateral views. The West Point lateral view projects the
tient. The scapula is stabilized with one hand and forearm while anteroinferior glenoid rim ::lnd most clearly shows this lesion
the humeral head is manually translated anteriorly and poste- when it is present. In traumatic posterior dislocation, the reverse
riorly by the examiner's opposite hand (Fig. 17-50). Although Hill-Sachs lesion can be seen on the anterior parr of the humeral
some translation within the glenohumeral joint is expected in head in conjunction with a possible fracture of the posterior rim
all patients, those with multidirectional laxity demonstrate trans- of the glenoid.
brion of greater than 5 mm anteriorly and posteriorly from a In cases of traumatic subluxation of the shoulder in which.
neutral position.
In atraumatic dislocation, the shoulder often dislocates ante-
riorly, posteriorly, Ot inferiorly. The most common direction of
dislocation in voluntaJy instability is posterior Ot inferior. The
patient who can voluntarily dislocate the shoulder can force the
humeral head posteriorly by contracting the anterior deltoid and
internal rotators while inhibiting the antagonistic muscles (Fig.
17-51). The elbow is positioned in horizontal adduction, and
the head is dislocated. The arm can then be abducted and, often
with an audible clunk, the shoulder reduces. Once again, the
hallmark is lack of pain with the dislocation (543,550,573,578,
584,605,608).

Radiographic Findings
Children and adolescents with open growth plates have a low
incidence of true traumatic dislocation of the shoulder. Trau-
matic lesions on plain radiographs are similar to those found in
adults (Fig. 17-52). On the anteroposterior or internally rotated
views of the proximal humerus, the Hill-Sachs compression le-
sion on the posterolateral aspect of the humeral head is com-
monly found. This injury to the proximal humerus occurs as
the humeral head is impacted against the anterior rim of the
glenoid during a dislocation (Fig. 17-53). Bony injuJY to the
anterior glenoid rim can occur with dislocation as well. A variable A B
degn;c of injury from small avulsion-type fragments to substan- FIGURE 17-51. Voluntary anterior dislocation of the right shoulder in
tial bony fractures C::ln occur. These anterior glenoid rim injuries an 8-year-old boy. A: The patient voluntarily has dislocated the right
shoulder anteriorly. B: The shoulder voluntarily reduced. The patient
are best seen as a double density on the anteroposterior view of explained that he was taught to do this by an older brother who also
the shoulder or as a separate fragment on the axillary and West had voluntary dislocation of the shoulders.
790 Upper Extremity

FIGURE 17-52. Traumatic anterior dislocation of

the right shoulder in a 15-year-old boy. A: On the
anteroposterior view, note the Hill-Sachs lesion as
well as the anteroinferior bony fragment off the
glenoid rim. B: Axillary radiograph made with the
arm in 90 degrees of abduction demonstrates the
anterior subluxation as well as the deficiency of
B the anterior glenoid rim.

the diagnosis may be uncleat clinically, an arthrogram with cr matic dislocations are congenital aplasia or absence of the gle-
scan or romograms can sometimes better delineate the extent of noid. In patients with multidirectional laxity and atraumatic
capsular stripping From the anterior glenoid rim. More recently, dislocation, stress radiographs can usually demonstrate instabil-
saline alThrograms and magnetic resonance imaging have en- ity in anrerior, pOSterior, and inferior directions. The inFerior
hanced our ability to define the degree of injury to rhe labrum, component of multidirectional instability can be demonstrated
capsule, and articular surFaces (560,602). CT scanning and mag- by applying weights to the arm in an anteroposterior film. This
netic resonance imaging have been useful for analyzing the sig- shows the humeral head subluxating in its relation to rhe glenoid
nificance of fractures of the glenoid rim (Figs. 17-54 and 17- (571).
55). In addition, the size of the reverse Hill-Sachs lesion of the
humeral head in posterior dislocations is best analyzed with a Treatment
CT scan (576,616).
Traumatic Instability
With atraumatic dislocations in patients who do not have
congenital or developmental defects, radiographs are usually nor- The literature on the specific treatment of shoulder instabiliry
mal. The most common defecrs seen on radiographs with atrau- in children is limited (526,538,600,610). Most clinicians make
 Chapler 17: Proximal Humerus, Scapula, and Clap/ele 791

A B
FIGURE 17·53. Anterior shoulder dislocation in a skeletally immature adolescent patient. A: Anteropos-
terior radiograph demonstrates the common appearance of an anterior dislocation of the shoulder. B:
Postreduction anteroposterior radiograph of the shoulder shows a large posterolateral compression
fracture of the humeral head or Hill-Sachs lesion.

A B
FIGURE 17-54. A: Anteroposterior radiograph of a 14-year-old boy with recurrent anterior subluxation.
Notice the presence of a Hill-Sachs compression fracture on the humeral head and a subtle double
density at the anteroinferior glenoid rim. B: Computed tomography scan shows this to be an avulsion-
type bony injury of the anterior glenoid.
792 Upper Extremiry

and inrernal rotation across the chest. Often, reduction is not

even felt by the patiem or physician. Caution is always used
with any eype of manipulative reduction, and the procedure is
certainly not as safe as gentle traction!coumerrraction or the
Stimson maneuver. Prereduction and posrreduction radiographs
are required to documenr fractures and to demonstrate the direc-
tion of dislocation. Preoperative and postoperative detailed neu-
rologic examinations are indicated as well.
Postreduction immobilization is another highly debated
poine. The adult literature suggests that the period of immobili-
zation may not be truly importam in predicting recurrene dislo-
cations. A sling or sling and swathe with the arm inrernally
rotated is the most common method of immobilization (525,
544).
Closed reduction for acute posterior dislocations is somewhat
similar to that for aneerior dislocations. Traction/countertraction
is the most effective. Traction is applied in line with the defor-
miey, and the humeral head is genrly lifted back into its normal
FIGURE 17-55. Magnetic resonance imaging scan in a patient with relationship with the glenoid. Most clinicians agree that immobi-
recurrent anterior instability of the shoulder. The arrows demonstrate
a calcified bony Bankart's lesion.
lization should be with the arm in neutral rotation or slight
external rotation at the shoulder. This may require the use of a
spica caSt or modified shoulder spica cast, as described by Dam-
eron and Rockwood (542).

treatmem recommendations for patients of all age groups (524,

525,530,531,545,572). Therefore, most of the data presemed Recurrent Dislocation
in this seerion are extrapolated from the adult and adolescent
The true incidence of recurrent dislocation after traumatic shoul-
literature, as well as from the experience of Dameron and Rock-
der dislocation in children is difficult to assess because of the
wood (542).
rarity of the injulY and the varieey of repons in the literawre
(556,569) In 1963, Rowe (603) reporred a 100% incidence of
recurrence in children 1 to 10 years of age with anterior disloca-
Acute Dislocation
tjon. He also reponed a 94% incidence of recurrence in auoles-
Patients with an acute dislocation of the shoulder should cents and young adults (ages 11-20) (603). Elbaum et al. (551)
undergo closed reduction by one of the standard, accepted tech- reporred a recurrence rate of 71 % in 9 pediatric patients with
niques. For amerior dislocation, many reduction techniques have rraumatic anterior dislocations. The average age was 9 years.
been described. Most clinicians prefer light sedation with inrra- After reduction, they were immobilized for 3 weeks and then
venous or imramuscular injeerion. The rraction!counrenraction were n'eated with rehabilitation. However, Rockwood (601) re-
method appears to be the most gemle. A sheet placed in the porred a recurrence rate of only 50% in a series of adolescents
axi Iia of the affected shoulder passes above and below the patiene and young adults 13.8 to 15.8 years of age. Hovelius et aI. (569)
so that couneernaction can be applied to the body while longitu- reponed a 47% recurrence rate in patients less than 20 years of
dinal tranion in line with the deformiey is applied to the arm. age. In a 10-year follow-up srudy, Hovelius et al. (568) found
SteaJy, continuous naction fatigues the muscles that lock the that recurrent dislocation necessitating operative treatment had
dislocation, and evemually reduction is accomplished by disim- developed in 34% of shoulders in patients who were 12 to 22
pacting the humerus from the glenoid. The Stimson maneuver years of age at the time of initial dislocation, compared with
is equally effective. The patiene is placed prone on the examining 28% in patients who were 23 to 29 and 9% in patients who
table, with a weight applied to the affected arm. Both methods were 30 to 40 years old. The eype and duration of the initia.l
are gentle and effective (591). Success with gentle scapular ma- treatment had no effect on the rate of recurrence. Vermeiren et
nipulation has been reponed by Kothari and Dronen (575) and al. (613) reponed a recurrence rate of 68% in patients under
McNamara (588) as a safe, effective way to reduce the disloca- 20 years of age. They reponed a berter prognosis if the disloca-
tion. tion was associated with a fracrure of the joint. Heck (564)
The Steel maneuver in most cases requires no anesthesia (per- reponed a case of traumatic anterior dislocation in a 7 -year-old
sonal communication, J. Steel, 1975). With the patiem supine boy who remained stable at a 5-year follow-up (Fig. 11-56).
on the examining table, the examiner suPPOrtS the elbow in one Endo et al. (552) reporred no recurrence in 2 patients, ages 3
hand while supporting the forearm and wrist in the other. The and 9, with traumatic anterior dislocation. However, the follow-
arm is gently abducted above 90 degrees and slowly externally up was only 2 years in the 3-year-old and 1 year in the 9-year-
rotated. With the arm held above 90 degrees of abduction, it is old. Wagner and Lyne (614) reponed an 80% recurrence rate
then gently adducted while further external rotation is applied. in 10 patients with clearly open proximal humeral epiphyses.
As reduerion occurs, the arm can be taken down into adduction Marans et al. (585) reponed the fate of traumatic anrerior dislo-
 Chapin J 7: Proximal HUn1rl"lI5, Scap II Ifl, arid Clflvicle 793

A c

B
FIGURE 17-56. Traumatic anterior subluxation of the left shoulder in a 7-year-old boy. A: Anteroposter-
ior film of the left shoulder does not reveal any striking abnormality. B: An axillary film shows that the
humeral head is subluxated away from the glenoid fossa. C: Anteroposterior film of the left shoulder
after manual reduction. (Courtesy of Charles C. Heck.)
794 Upper EY:tremity

carions of rhe shoulder in 21 children (15 boys, 6 girls) in whar a favorable resulr and rhar there is no indicarion for surgery wirh
may be rhe largesr documenred series ro dare. AJI rhe children this problem in children.
had one or more documenred anrerior dislocarions after rhe ini·
rial injury. Some of rhe children had been immobilized in a sling
and swarhe for 6 weeks. The lirerarure refleers thar the narural • AUTHORS' PREFERRED METHOD
history of shoulder dislocarions in adolescenrs and young adulrs ,~ OF TREATMENT
demonsrrares recurrence rares for dislocarion of 50% to 90%
despire rhe rreatmenr program used after the initial dislocation. The most important problem in dealing with shoulder disloca-
Multiple surgical procedutes have been described for the tions in children is ro establish whether the dislocation is truly
treatmenr of anterior shoulder instability. Once again, specific traumatic or arraumatic in nature. This is accomplished byob-
results for procedures such as the Purti-Plart, Bankart, and Mag- taining a careful hisrory of the mechanism of injury and perform-
nuson-Stack have not been documenred for children. Barty and ing a physical examination designed ro elicit evidence of multidi-
associates (530) described the effective use of the coracoid trans- rectional instability of the opposite shoulder, generalized joint
fer for recurrent anterior instability in adolescenrs. Capsular pro- laxity, or a congenital or developmental problem. Care should
cedures that specifically address the capsular pathology have been be taken to identify the volunrary dislocaror, who should be
described by Neer and Fosrer (595), Jobe (581), and Rockwood rreated nonoperativeJy in essentially all cases.
and associares (602), bur results in children's dislocarions were In rhe acure traumaric dislocation, wherher anrerior or poste-
nor documenred. Goldberg and colleagues (557) have reported rior, genrle closed reducrion should be performed. Prereduction
on the use of arthroscopic techniques for capsular repair in ado- and posrreducrion radiographs are raken, and a rhorough neuro-
lescems. logic and vascular examinarion is performed. The rracrion/coun-
remaction method under light sedation or a gentle manipulative
reduction should be used. For an anterior traumatic dislocation,
Atraumatic Instability
we immobilize the shoulder in inrernal roration for 4 weeks. For
Treatment of patients with atraumaric dislocations of rhe shoul- a posterior dislocation, the shoulder is immobilized for 4 weeks
der appears more difficulr than trearmenr for uue rraumaric in a commercial splint or modified spica cast with the shoulder
dislocarions. Emphasis should be placed on careful diagnosis in in neutral rotation. After this period of immobilization, a reha-
these cases. Specific congenital bony or neurologic deficirs bilirarion program stressing rotator cuff strengthening is insti-
should be recognized. The sequelae of Ehlers-Danlos syndrome tuted.
or other collagen deficiency syndromes should be noted. As discussed, the recurrence rate afrer a traumatic anrerior
In parienrs with mulridirecrional laxity and volunt;uy or in- dislocation is 50% or higher. Although we hesitate to inrervene
volunralY dislocarions, a signiflcanr histOry of uauma is usually surgically after the initial dislocation, the patienr and parenrs
lacking. These parienrs have minimal pain associated with rhe should be counseled that the recurrence rate is high and that
dislocarion and on clinical examination usually have other signs the rehabilitation program may fail. Wirh a second dislocation,
of mulridirecrionallaxity of the opposire shoulder. Most of these rhe diagnosis of recurrenr dislocation is esrablished and surgical
dislocarions reduce sponraneously and are associared wirh lirrle imervenrion is indicated. We use rhe capsular shift procedure
pain. Rowe er al. (605), Neer (594), and Burkhead and Rock- as described by Rockwood and associates (602). (This technique
wood (535,601,602) have described the use of a vigorous reha- is described in derail in Vol. I of Fractures in AduLts.) If presenr,
bilirarion program involving srrengthening of rhe roraror cuff as the Bankan's or Perthes' lesion is repaired anaromically ro the
rhe treatment of choice for rhese patienrs. Most patients who anterior glenoid rim. Capsular shih is rhen performed to righten
do not h:lI'e significant emotional and psychiarric problems are rhe anreroinferior capsule.
successful in improving rheir shoulder srabiliry wirh such a pro- A 6-monrh course of rehabilirarion follows surgical inrerven-
gram. rion. For the first month, pendulums and gentle elevation exer-
Mosr clinicians would agree rhar surgical inrervenrion is con- cises are performed. The shoulder is prorecred in a sling, espe-
sidered only if a srrict 6- to 12-monrh rehabilirarion program cially at night. The second and third months are used to regain
fails. Romine shoulder reconsrruerions involving subscapularis range of motion, including protecred external rotation. This pro-
shorrening, including the Magnuson-Srack and Purri-Plarr pro- cedure is designed to address the pathology without limiting
cedul'es, or "bone blocks" such as the BristOw are nor suFflcienr motion. The fourth rhrough sixth months are used for a progres-
for prevenring furure instabiliry. Neer and Fosrer (595) described sive strengrhening program, which includes strengthening of the
the inferior capsular shift reconsrruction specifically for parienrs rotator cuFf and deltoid. AI' 6 months, the reconstrucrion is
with multidirectional laxity of the shoulder wirh atraum;uic in- marure enough to release the child to a full activity level.
stability. This procedure arremprs [Q e[iminare rhe overall capsu- For atraumaric dislocarion, reduction can be accomplished
lar laxity and is used only after rehabilitation has failed. Huber iF necessary after an acute dislocation in a fashion similar to that
and Gerber (570) reponed on 25 consecurive children with 36 described for traumatic dislocations. Again, arrention should be
involved shoulders wirh voluntaty subluxarion of rhe shoulder. focused on confirming the diagnosis of atraumatic dislocation.
The children managed by "skillFul neglect" had a sarisfacroty Parienrs with volunralY dislocarion and their families should be
outcome, bur only 50% of those rreated wirh an operarive proce- counseled rhat the dislocarions can be harmful 1'0 the joint and
dure ro prevenr larer degenerarive anhriris had good resulrs. should be discouraged.
They concluded rhar voIunralY subluxarion of the shoulder has Patients wirh arraumaric instability should be treared with a
 Chflpter /7: Proximal Humerus, Senpula, find ClavicLe 795

vigorous rehabilitation program. Only in the face of recurrence problems can lead to pain and evemual arthritic change (528,
after 6 to 12 months of supervised rehabilitation should surgical 533,549,619).
intervention be considered. Great care should be taken to ex- The axillary nerve is the one most commonly injured with
clude the voluntary dislocator as a surgical candidate. Psychiatric shoulder dislocation. Fortunarely, mosr axillary nerve injuries
evaluation is instituted if necessary. A capsular procedure as de- associated with dislocations are neurapraxic, and function re-
scribed by Neer or the capsular shift technique described by turns with time and observation. In the event of complete axil-
Rockwood can be used to eliminate laxity of the joint capsule lary nerve palsy, significant disability can exist due w the lack
in a circumferential manner (594,601,602). Surgical manage- of deltOid funcrion (529,532,539,541,551,582).
ment of the atraumatic dislocaror is difficult and requires metic- Morrison and Egan (593) reported an axillary artelY and a
ulous anention to detail during both the surgical procedure and brachial plexus injUlY in a luxatio erecra dislocation in an 11-
the postoperative rehabilitation program. year-oJd child. The anery was rejoined with a vein graft and the
brachial plexus injury fully recovered.
Rehabilitation
The importance of an extensive rehabilitation program for insta- REFERENCES
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Procedure in recurrent dislocation of the shoulder. Surg Clin North 553-554.
574. Kleinman PK, Goss TP, Kanzaria PK, et al. Injuries of the glenoid
Am 1963:43:1651-1653.
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575. Kothari RU, Dronen Se. Prospective evaluation of the scapular ma-
12:183-192.
nipulation technique in reducing anterior shoulder dislocations. Ann
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Emerg Med 1992;21:1349-1352.
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576. Kummel BM. Arthrography in anterior capsular derangements of the
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577. Laskin RS, Sedlin ED. Luxatio erecta in infancy. Clin Orthop 1971;
[Br} 1991;73:941-946. 80:126-129.
549. O'Driscoll SW, Evans De. Long-term results ofstaple capsulorrhaphy 578. Lawhon SM, Peoples AB, MacEwen GO. Voluntary dislocation of
for anterior instability of the shoulder. ] Bone Joint Surg [Am] 1993; the shoulder. ] Pediatr Orthop 1982;2:590.
75:249-58. 579. Lichtblau PO. Shoulder dislocation in the infant. Case report and
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551. Elbaum R, Parent H, Zeller R, et al. Traumatic scapulohumeral dislo- 580. Liebolt FL, Furey JG. Obstetrical paralysis with dislocation of the
cation in children and adolescents. Apropos of 9 patients. Acta Orthop shoulder: a case report.] Bone Joint Surg [Am} 1953:35A:227-230.
Belg 1994:60:204-209. 581. Lombardo SJ, Kerlan RK, Jobe FW, et al. The modified Brisrow
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553. Foster WS, Ford TB, Drez D. Isolated posterior shoulder dislocation 582. Lucas GL, Peterson MD. Open anterior dislocation of the shoulder:
in a child. Am] Sports Med 1985:13:198-200. case report.] Trauma 1977: 17:883-884.
554. Freundlich BD. Luxatio erecta.] Trauma 1983;23:434-436. 583. Lusard DA, Wirth MA, Wurtz 0, et al. Loss of external rotation
555. Frosch L. Congenital subluxation of the shoulder. Klin Wochenschr following anterior capsulorrhaphy of the shoulder.] Bone Joint Surg
1925:4:701-702. [Am} 1993;75:1185-1192.
556. Gartland JJ, Dowling JJ. Recurrent anterior dislocation of the shoul- 584. Magnuson PB, StackJK. Bilateral habitual dislocation of the shoulders
der joint. Clin Orthop 1954;3:86-91. in twins: a familial tendency. ]AMA 1940;114:2103.
557. Goldberg BJ, Nitschl RP, McConnellJP, et al. Arthroscopic transgle- 585. Marans HJ, Angel KR, Schemitsch EH, et al. The fate of traumatic
noid suture capsulolabral repairs: preliminaty results. Am J Sports Med anterior dislocation of the shoulder in children. ] Bone Joint Surg
1993;21 :656-665. 1992;74: 1242-1244.
558. Green NE, Wheelhouse WW. Anterior subglenoid dislocation of the 586. Matton 0, Van Looy F, Geens S. Recurrent anterior dislocations of
shoulder in an infant following pneumococcal meningitis. Clin Orthop the shoulder joint treated by the Bristow-Latarjet procedure. Acta
1978; 135: 125-127. Orthop Belg 1992;58: 16-22.
559. Grieg OM. On true congenital dislocation of the shoulder. Edinburgh 587. May VR Jr. Posterior dislocation of the shoulder: habitual, traumatic
Med] 1923:30:157-175. and obstetrical. Orthop Clin North Am 1980;11 :271-285.
560. Gudinchet F, Naggar L, GinalskiJM, et al. Magnetic resonance imag- 588. McNamara RM. Reduction of anterior shoulder dislocations by scap-
ing of nonttaumatic shoulder instability in children. Skel RadioI1992; ular manipulation. Ann Emerg Med 1993;22:1140-1144.
21:19-21. 589. McNeil EI.. Luxatio erecta [Letter]. Ann Emerg Med 1984; 13:
561. Haliburton RA, Barber JR, Fraser RL. Pseudodislocation: an unusual 490-491.
birth injuty. Can] Surg 1967: 10:455-462. 590. Mirick MJ, Clinton JE, Ruiz E. External rotation method of shoulder
562. Hawkins RJ, Angelo RL. Glenohumeral osteoarthritis: acute compli- dislocation reduction.] Am Col! Emerg Phys 1979;9:528-531.
806 Upper Extremity

591. Montgomery WH 3rd, Jobe FW. Functional outcomes in arhletes 606. Samilson RL, Miller E. Posterior dislocation of the shoulder. Clin
after modified anterior capsulolabral reconstruction. Am] Sports Med Orthop 1964;32:69-86.
1994;22:352-358. 607. Sharrard WJW. Paediatric orthopaedics and fractures. Oxford: Black-
592. Morrey BF, Janes JM. Recurrent anterior dislocation of the shoulder. well, 1971.
] Bone Joint Surg [Am} 1976;58:252-256. 608. Shvarczman P, Guy N. Voluntary dislocation of shoulder. Postgrad
593. Morrison PO, Egan TJ. Axillary artery injury in erect dislocation of Med 1988;84:265-271.
the shoulder (luxatio erecca): a case repon.] Ir Orthop 1983;260-261. 609. Stern WA. Archrogryposis multiplex congenity. ]AMA 1923;81:
594. Neer CS II. Involuntary inferior and multidirectional instabiliry of 1507-1510.
the shoulder: etiology, recognition, and treatment. Instr Course Lect
610. Tachdjian MO. Paediatric orthopaedics. Philadelphia: WB Saunders,
1985;34:232-238.
1990.
595. Neer CS II, Foster DR. Inferior capsular shift for involuntary inferior
and multidirectional instability of the shoulder.] Bone]oint Surg [Am} 611. Uhthoff HK, Piscopo M. Anterior capsular redundancy of the shoul-
1980;62:897-908. der: congenital or traumatic? An embryological study. ] Bone Joint
596. Norwood L, Terry Gc. Shoulder posterior subluxation. Am] Sports Surg [Br} 1985;67:363-366.
Med 1984;12:25-30. 612. Vastamaki M, Solonen KA. Posterior dislocation and fracture disloca-
597. Ogden JA. Skeletal injury in the child. Philadelphia: Lea & Febiger, tion of the shoulder. Acta Orthop Scand 1980;51 :479-484.
1982:227-228. 613. Vermeiren J, Handelberg F, Casteleyn PP, et al. The rate of recurrence
598. Perrersson H. Bilateral dysplasia of the neck of the scapula and associ- of traumatic anterior dislocation of the shoulder. Int Orthop 1993;
ated anomalies. Acta Radial Diagn (Stockhj 1981 ;22:81-84. 17:337-341.
599. Pollen AG. Fractures and dislocations in children. Baltimore: Wil- 614. Wagner KT, Lyne ED. Adolescent traumatic dislocations of the shoul-
liams & Wilkins, 1973. der with open epiphysis. ] Pediatr Orthop 1983;3:61-62.
600. Rang M. Children's fractures, 2nd ed. Philadelphia: JB Lippincott, 615. Weber BG, Brunner C, Freuler F. Treatment offractures in children
1983. and adolescents. Berlin: Springer-Verlag, 1980:94-95.
601. Rockwood CA Jr. The shoulder: facts, confusions and myths. Int 616. White SS, Blane CE, DiPietro MA, et al. Arthrography in evaluation
Orthop 1991; 15:40 1-405.
of birch injuries of the shoulder.] CanAssoc Radial 1987;38:1 13-1 15.
602. Rockwood CA, Matsen FA, Thomas Sc. Anterior glenohumeral in-
617. Wickstrom J. Birch injuries of the brachial plexus treatment defects
stability. In: Rockwood CA, Matsen FA, eds. The shoulder. Philadel-
in the shoulder. Clin Orthop 1962;23: 187-196.
phia: WB Saunders, 1990:592-598.
603. Rowe CR. Anterior dislocation of the shoulder: prognosis and treat- 618. WickstromJ, Haslam ET, Hutchinson RH. The surgical management
ment. Surg Clin North Am 1963;43: 1609-1614. of residual deformities of the shoulder following birch injuries of the
604. Rowe CR. Prognosis in dislocation of the shoulder. ] Bone Joint Surg brachial plexus.] Bone Joint Surg [Am} 1955;37:27-36.
[Am) 1956;38:957-977. 619. Zuckerman JD, Matsen FA. Complications about the glenohumeral
605. Rowe CR, Pierce OS, ClarkJG. Voluntary dislocation of the shoulder. joint related to the use of screws and staples. ] Bone Joint Surg [Am}
] Bone Joint Surg [Am} 1973;55:445-459. 1984;66: 175-180.
' .. -~~.

SPINE
 CERVICAL SPINE INJURIES IN
CHILDREN
W. C. WARNER, JR.

A ATOMY NEONATAL I JURY

Upper Cervical Spine
OCCIPITAL C I DYLAR FRACTURE
Lower Cervical Spine
ATLANTOOCCIPITAL I STABILITY
HiSTORY
Occiput to C2 Arthrodesis
SYMPTOMS FRACTURES F THE ATLAS
EVALUATION ATLA TOAXIAL INjURI ,5
Odontoid Fractures
RADIO RAPHIC EVALUATION
Os Odontoideum
Plain Radiographs
Traumatic Ligamentous Disruption
Radiographic Evaluation of Specific Areas of the Spine
Atlantoaxial Instability Associated with Congenital Anomalies
Special Imaging Studies
and Syndromes
Dynamic Studies
Atlantoaxial Rotatory Subluxation
I ITIAL MA AGEMENT OF C RVI ,AL Sf'1. E Hangman's Fracture
I JURIES SUBAXIAL INJURIES
Technique of Halo Application Posterior Ligamentous Disruption
srI A CORD r JURY WI HOUT Compression Fractures
RADIOGRAPHIC ABNORMALITIES Unilateral and Bilateral Facet Dislocations
Burst Fractures
SPINAL CORD I JURY IN CHILDREN Spondylolysis and Spondylolisthesis

Injuries to the cervical spine in children are uncommon, ac- Pediatric cervical spine fractures differ from those in adults
counting for only 1% of pediatric fractures and 2% of all spinal not only in pattern but in cause, incidence, and treatment (113).
injuries (4,69,70,89,107,122,139,159,173). McGrory et aJ. Most cervical spine injuries in children undet 11 years of age
(107) estimated that the incidence of pediatric cervical spine occur in the upper cervical spine, unlike in older children, adoles-
injuries was 7.41 in 100,000 per year. However, this low inci- cents, and adults, in whom fracrures occur more commonly in
dence of cervical spine injuries in children may be misleading the lower cervical spine (55,69,89,139). Upper cervical spine
because some injuries are not detected or detected only ar au- injuries are more predominant in young children because of rhe
topsy. Aufdermaur (8) examined the autopsied spines of 12 juve- unique anatomic and biomechanical properries of the immature
niles who had spinal injuries. Clinically and radiologically, a cervical spine. The immatLJre spine is hypermobile because of
fracture was suggested in only 1, but all 12 had cartilage end
ligamentous laxity, and the facet joints are more horizontally
plates that were separated from the vertebral bodies in the zone
oriented. These horizontally oriented facets give less resistance
of columnar and calcified cartilage similar to a Salter I fracture.
[Q forward translarion than the more vertically oriented facets
Only radiographs at autopsy showed the disruption, represented
in adults. This, combined with a young child's relatively large
by a small gap or apparent widening of the intervertebral space
head, changes the fulcrum of neck motion [Q the upper cervical
(8).
spine. Because a child's musculature is not as developed as an
adult's, the cervical spine has less suppOrt during injury. As the
anatomic and biomechanical aspects of the spine change wirh
W. C. Warner, Jr.: Department of Orrhopoeclic Surge!)·, Universiry of maturity, so do the level and type of injuries seen.
Tennessce. Campbell Clinic, Mcmphis, Tennessee. In younger children, most of the injuries are fractures through
 CERVICAL SPINE INJURIES IN
CHILDREN
W. C. WARNER, JR.

A ATOMY NEONATAL I JURY

Upper Cervical Spine
OCCIPITAL C I DYLAR FRACTURE
Lower Cervical Spine
ATLANTOOCCIPITAL I STABILITY
HiSTORY
Occiput to C2 Arthrodesis
SYMPTOMS FRACTURES F THE ATLAS
EVALUATION ATLA TOAXIAL INjURI ,5
Odontoid Fractures
RADIO RAPHIC EVALUATION
Os Odontoideum
Plain Radiographs
Traumatic Ligamentous Disruption
Radiographic Evaluation of Specific Areas of the Spine
Atlantoaxial Instability Associated with Congenital Anomalies
Special Imaging Studies
and Syndromes
Dynamic Studies
Atlantoaxial Rotatory Subluxation
I ITIAL MA AGEMENT OF C RVI ,AL Sf'1. E Hangman's Fracture
I JURIES SUBAXIAL INJURIES
Technique of Halo Application Posterior Ligamentous Disruption
srI A CORD r JURY WI HOUT Compression Fractures
RADIOGRAPHIC ABNORMALITIES Unilateral and Bilateral Facet Dislocations
Burst Fractures
SPINAL CORD I JURY IN CHILDREN Spondylolysis and Spondylolisthesis

Injuries to the cervical spine in children are uncommon, ac- Pediatric cervical spine fractures differ from those in adults
counting for only 1% of pediatric fractures and 2% of all spinal not only in pattern but in cause, incidence, and treatment (113).
injuries (4,69,70,89,107,122,139,159,173). McGrory et aJ. Most cervical spine injuries in children undet 11 years of age
(107) estimated that the incidence of pediatric cervical spine occur in the upper cervical spine, unlike in older children, adoles-
injuries was 7.41 in 100,000 per year. However, this low inci- cents, and adults, in whom fracrures occur more commonly in
dence of cervical spine injuries in children may be misleading the lower cervical spine (55,69,89,139). Upper cervical spine
because some injuries are not detected or detected only ar au- injuries are more predominant in young children because of rhe
topsy. Aufdermaur (8) examined the autopsied spines of 12 juve- unique anatomic and biomechanical properries of the immature
niles who had spinal injuries. Clinically and radiologically, a cervical spine. The immatLJre spine is hypermobile because of
fracture was suggested in only 1, but all 12 had cartilage end
ligamentous laxity, and the facet joints are more horizontally
plates that were separated from the vertebral bodies in the zone
oriented. These horizontally oriented facets give less resistance
of columnar and calcified cartilage similar to a Salter I fracture.
[Q forward translarion than the more vertically oriented facets
Only radiographs at autopsy showed the disruption, represented
in adults. This, combined with a young child's relatively large
by a small gap or apparent widening of the intervertebral space
head, changes the fulcrum of neck motion [Q the upper cervical
(8).
spine. Because a child's musculature is not as developed as an
adult's, the cervical spine has less suppOrt during injury. As the
anatomic and biomechanical aspects of the spine change wirh
W. C. Warner, Jr.: Department of Orrhopoeclic Surge!)·, Universiry of maturity, so do the level and type of injuries seen.
Tennessce. Campbell Clinic, Mcmphis, Tennessee. In younger children, most of the injuries are fractures through
810 Spine

TABLE 18-1. LOCATION OF INJURIES BY AGE

Age <8 yr
Upper cervical spine injuries
AOD
Odontoid fractures
Jefferson fracture
(2 spondylolisthesis
Age >8 yr
Lower cervical spine injuries
Facet fracture-dislocation
Burst fracture

the venebral end plates or synchondroses or ligamenrous inju-

ries. In adolescents, vertebral body fracrures or fracrure-disloc-
ations involving the lower cervical spine are more common and
have the characteristics of adult cervical spine injuries (Table
18-1).
Neurologic deficits occur infrequenrly with pediatric cervical
fraCtures, and when a partial deficit is present, the prognosis is
berter in children than in adults (13,47). Complete neurologic K----,.'
deficits, however, tend co ['emain complete regardless of whether .)------A
they occur in children or adults. This may reflect tne magnirude
of injury that caused the complete neurologic lesion. Orenstein
et al. (119,120) found that deaths from cervical spine injuries
or associated injuries occur most commonly in children 8 years FIGURE 18-1. Diagram of (1 (atlas). The body (A) is not ossified at
birth, and its ossification center appears during the 1st year of life. The
of age or younger. Nitecki and Moir (J 15) found that the body may fail to develop, and forward extension of neural arches (C)
younger the age and the higher the level of injury, the more may take its place. Neural arches appear bilaterally about the 7th week
likely the injury was co be fatal, again reflecting the severity of (D), and the most imterior portion of the superior articulating surface
is usually formed by the body. Synchondrosis of spinous processes unite
the initial injulY and explaining the increased incidence of death by the 3rd year. Union may rarely be preceded by the appearance of
(72,115,119). the secondary center within the synchondrosis. Neurocentral syn-
chondrosis (F) fuses about the 7th year. The ligament surrounding the
Spinal cord injury without radiographic abnormalities
superior vertebral notch (K) may ossify, especially in later life. (Re-
(SCIWORA) has been found with increased frequency in chil- printed from Bailey DK. Normal cervical spine in infants and children.
dren and may be related co rhe relarive hypermobiliry of a child's Radiology 1952;59: 71:3-714; with permission.)
spine (see larer section on SCIWORA). Depending on rhe age
at the time of injury and the level of spinal cord injury, other
problems thar may occur in children are rhe development of
spinal deformiries and lower exrremiry problems, such as con-
1). The ossification center for the anterior arch is presem in
tracrures and progressive subluxation or dislocation of th,e hip
approximately 20% of individuals at birth, appearing in the
JOint.
remainder during the first year of life. Occasionally, the anterior
arch is bifid, aoe! tne body may be formed from rwo cenrers or
ANATOMY may fail to completely appear. The posterior arches usually close
by 3 years of age. Occasionally, rhe posterior synchondrosis be-
Undersr:ll1ding the normal growth and developmenr of the cervi- rween the rwo halves of the neural arch fail to fuse and result
cal spine is essential when treating a child with, a suspecred cervi- in a bifid arch. This common variation must be considered dur-
cal spine injury (130). This will allow the physician to differen- ing any surgical dissection in this tegion. The neurocentral syn-
tiate normal physes or synchondroses from pathologic fractures chondroses that link the neural arches to the body are best seen
or ligamentous disruptions and will alert the physician to any on an open-mourh odontoid view. These synchondroses close
possible congenital anomalies that may be mistalcen for a frac- by 7 years of age and should nor be mistaken for fractures (30).
wre. The canal of the arias is large to allow for the amount of rotation
that occurs ar this joint as well as some fOlwatd translation (31).
The vertebral arteries are abour 2 cm from the midline and run
Upper Cervical Spine
in a groove on the superior surface of rhe arias. This must be
At birth the arias is composed of three ossification centers, one remembered during lateral dissection at rhe occipital cervical
for the body and one for each of the neural arches (Fig. 18- junCtion. The ring of Cl reaches about normal adult size by
 Chapler 18: Cervical Spine Injuries in Children 811

four years of age. Therefore arrhrodesis after 4 years of age should

not cause spinal canal stenosis (Fig. 18-2).
Occipitalization Ot assimilation of the atlas occurs when the
first cetvical vertebra fails to segment from the skull. This may
lead to basilar impression and narrowing of the foramen mag-
num. This anomaly can increase a child's susceptibility to spinal
cord injuty or verrebral artery compromise caused by trauma.
Verrebral artery compromise also can occur in patients wi th
occipitalization from skull traction, resulting in brainstem is-
chemia (14).
The axis develops from at least four separate ossification cen-
ters: one for the dens, one for the body, and two for the neural
arches (Fig. 18-3). Between the odontoid and the body of the
FIGURE 18-2. The epiphysis at the base of the odontoid process is
shown by the small arrow. This is well below the level of the superior axis is a synchondrosis or vestigial disk space that often is mis-
articular facet of the axis. The synchondroses between the body of the taken for a fracture line. This synchondrosis runs well below the
axis and the neural arches are shown by the large arrows. Just above
this are the synchondroses between the odontoid process and the neu-
level of the articular processes of the axis and usually fuses at
ral arches. The odontoid process, therefore, surmounts the body of the about 6 to 7 years of age, although it may persist as a scleroric
axis and is sandwiched between the neural arches. The physis and syn- line until 11 years of age (31). The most common odontoid
chondroses combine to form the letter arches. (Reprinted from Fielding
JW. Selective observations on the cervical spine in child. In: Ahstrom JP fracture pattern in adults and adolescents is transverse and at
Jr, ed. Current practice in orthopaedic surgery. Vol. S. St. louis: CV the level of the articular processes. This fracture should not be
Mosby, 1973; with permission.) confused with the normal synchondrosis, which is more cup
shaped, with the transverse portion below the level of the anicu-
Jar processes in the body of the axis. After 6 to 7 years of age,
the synchondrosis should not be present on an open-mouth
odontOid view. A fracture should be considered if a lucent line
is present after 7 years of age. The neural arches of C2 fuse at
3 to 6 years of age. These are seen as vertical lucent lines on
the open-mouth odontOid view. Occasionally, the tip of the
odontoid is V shaped (dens bicornum) or a small separate sum-
mit ossification center may be present at the tip of the odontoid
(ossiculum terminale) (Fig. 18-4).
The arterial blood supply to the odontoid is derived from
the vertebral and carotid arteries. The anterior and posterior

""""""'--H

G
E -~'--'

FIGURE 18-3. Diagram of C2 (axis). The body (A) in which one center
(occasionally two) appears by the 5th fetal month. Neural arches (C)
appear bilaterally by the 7th fetal month. Neural arches fuse (D) poste-
riorly by the 2nd or 3rd year. Bifid tip (E) of spinous process (occasionally
a secondary center is present in each tip). Neurocentral synchondrosis
(F) fuses at 3 to 6 years. The inferior epiphyseal ring (G) appears at
puberty and fuses at about 25 years of age. The summit ossification
center (H) for the odontoid appears at 3 to 6 years and fuses with the
odontoid by 12 years. Odontoid (dens) (I). Two separate centers appear
by the 5th fetal month and fuse with each other by the 7th fetal month.
Synchondrosis between the odontoid and neural arch (I) fuses at 3 to FIGURE 18-4. Anteroposterior open-mouth odontoid view demon-
6 years. Synchondrosis between the odontoid and body (l) fuses at 3 strating V-shaped dens bicornis and ossiculum terminale. (Reprinted
to 6 years. Posterior surface of the body and odontoid (M). (Reprinted from WarnerWC. Cervical spine anomalies. In: Canale ST, Beaty JH, eds.
from Bailey DK. Normal cervical spine in infants and children. Radiology Operative pediatric orthopedics. 2nd ed. St. louis: CV Mosby, 1995; with
1952;59713-714; with permission.) permission.)
812 Spine

Apical arcade are normally wedge shaped until 7 to 8 years of age (31,96,
133). The vertebral bodies, neural arches, and pedicles enlarge
by periosteal appositional growth, similar to rhar secn in long
bones. By 8 to 10 years of age, a child's spine usually reaches near
Cleft adulr size and characteristics. There are 5 secondalY ossificarion
perforator '" cenrers that can remain open unril 25 years of age (96). These
include one each for rhe spinous processes, transverse processes,
and the ring apophyses about the vertebral end plates. These
Anterior should not be confused wirh fractures.
ascending artery The superior and inferior end plares are firmly bound to the
adjacenr disk. The junction berween the vertebral body and rhe
Posterior end plare is similar to a physis of a long bone. The vertebral
ascending artery body is analogous to the metaphysis, and the end plate to the
physis, where longitudinal growth occurs. The juncrion berween
the venebral body and rhe end plate has been demonstrated to
__ Apical arcade
1"'''---''"- Posterior
____ ascending artery
___ Cleft perforator

B-----/
,.....----'""'1 8'------: A

c
Anterior
ascending artery
Left vertebral /
artery

FIGURE 18·5. Blood supply to odontoid: posterior and anterior as-

cending arteries and apical arcade. (Reprinted from Schiff DC, Parke f-------E
WW. The arterial supply of the odontoid process. J Bone Joint Surg
(Am] 1973;55: 1450-1464; with permission.)
D-------------'=----
------F

ascending arteries arise from rhe venebral arrelY at the level of C3 B

and ascend anteriorly and posteriorly to rhe odontoid, meeting
superiorly to form an apical arcade. These arteries supply small
penetrating branches to rhe body of rhe axis and rhe odontoid
process. The internal carotid arrelY gives off c1efr perforarors
rhar supply rhe superior ponion of rhe odontoid. This peculiar ,------G
arrangement of arteries and vessels is necessary for embryologic
dcvelopment and anatomic function of rhe odontoid. The syn-
chondrosis prevents direcr vascularization of rhe odontoid from
C2, and vascularization from rhe blood supply of C1 is nor
possible because rhe synovial joint caviry surrounds the odon-
L-------G
toid. The formarion of an os odonroideum afrcr cervical tl"auma
may be relared to rhis peculiar blood supply (Fig. 18-5). FIGURE 18-6. Diagram oftypical cervical vertebrae, C3 to C7. The body
(A) appears by the 5th fetal month. The anterior (costal) portion of the
transverse process (B) may develop from a separate center that appears
Lower Cervical Spine by the 6th fetal month and joins the arch by the 6th year. Neural arches
(C) appear by the 7th to 9th fetal week. Synchondrosis between spinous
The rhird and sevenrh cervical venebrae share a similar ossifica- processes (D) usually unites by the 2nd or 3rd year. Secondary centers
for bifid spine (E) appear at puberty and unite with spinous process at
tion pattern: a single ossification center for rhe verrebral body 25 years. Neurocentral synchondrosis (F) fuses at 3 to 6 years. Superior
and an ossification cenrer for each neural arch (Fig. 18-6). The and inferior epiphyseal rings (G) appear at puberty and unite with the
neural arch fuses posteriorly berween the second and thi rd years, body at about 25 years. The seventh cervical vertebra differs slightly
because of a long, powerful, non bifid spinous process. (Reprinted from
and the neurocentra I synchondroses berween the neural arches Bailey DK. Normal cervical spine in infants and children. Radiology 1952;
and rhe verrebral body fuse by 3 to 6 years of age. These vertebrae 59'713-714; with permission.)
 Chapter 18: Cervical !::Jpine Injl/ries in Chiidrell 813

be weaker than the adjacenr verrebral body or disk, which can injury from lack of h.ead control. Other causes of cervical spine
result in a fracture at the end plate in the area of columnar and injulY in infants are child abuse and obstetric trauma (Table 18-
caJcified caniJage of the growth zone, similar ro a Salter I fracrure I) (30,153,162). In teenagers injuries from spons and moror
of a long bone (8). The inferior end plate may be more suscepti- vehicle accidents are more common 007,166). At Children's
ble ro this injury than the superior end plate because of the Hospital in BostOn, cervical spine injuries from unsupervised
mechanical protection afforded by the developing uncinate pro- diving exceeded those occurring in organized athletics over the
cesses 07,87). past 20 years. Haffner et al. (70) have reported an increased
The facet joinrs of the cervical spine change in orientation frequency of spinal injuries from gunshot wounds in teenagers.
with age. The angle of the CI-C2 facet is 55 degrees in the Obtaining an adequate histOlY and physical examination
newborn and increases ro 70 degrees at maturity. In the lower from an injured child may require more time, patience, and
cervical spine, the angle of the facet joints is 30 degrees at birth effort by the treating physician. An adequate histOlY and physical
and 60 to 70 degtees at manll·ity. This may explain why the examination may nor be obtained on the initial examination,
pediatric cervical spine may be more susceptible to injuIY from and repeated examination may be necessary.
the increased motion or translation allowed by the facet joint
01'1enrarlOl1.
Increased ligamentous laxity in young children allows a SYMP OMS
greater degree of spinal mobility. Flexion and extension of the
spine at C2-3 is 50% greater in children between the ages of Children with cervical spine injuries have various signs and
3 and 8 years than in adults. The level of the greatest mobility symptOms. Neck pain or localized tenderness of the cervical
in the cervical spine descends with increasing age. Between 3 spine is the most common presenting symptOm and should alert
and 8 years of age the most mobile segment is C3-C4; from tile physician to proceed with fu[th.er diagnostic workup. The
ages 9 ro 11 years, C4-C5 is the most mobile segment, and patient also may have more subtle complaints, such as headaches,
from ages 12 to 15 yeats C5-C6 is the most mobile segment occipiral pain radiating to the shoulders, limited range of mo-
(34,125). This explains the tendency for craniocervical injuries tion, tOrticollis, bowel or bladder symptoms, seizures, or a snap-
in the young children. ping sensation in rhe neck. In newborns, any unexplained respi-
Several anomalies of the cervical spine may influence treat- ratory distress, delayed motOr response, hypotOnia, or hypertonia
ment recommendations. The arias can fail ro segment from the should be evaluated. Occasionally, a patient may be unrespon-
skull, a condition called occipitalization of the arias, and can sive, so rhe spine must be protected until appropriate spine clear-
lead to narrowing of the foramen magnum, neurologic symp- ance has been obtained. Head or facial rrauma, loss of conscious-
roms, and increased stresses ro the atlanroaxial articulation, ness, or high-speed motOr veh.icle accident are indications for
which often causes instability. The association of occipitalization evaluation of the cervical spine. Sometimes after multiple
of the arias and congenital fusion of C2 and C3 is likely ro lead trauma, the only sign of a cervical spine injury is difficulty wean-
to atlanroaxial instability. Failure of fusion of the posterior arc ing from assisted ventilation. Often this is associated with a
of Cl is not uncommon and should be sought before performing closed head injulY. This can mislead the treating physician intO
any surgical procedure that involves Cl. Wedge-shaped verte- believing that the difficulty in weaning from the ventilator is
brae, bifid verrebrae, or a combination of these also can occur. due to the head injury, and an associated cervical spine injUlY
Klippel-Feil syndrome consists of the classic triad of a short neck, may be overlooked. Positive neurologic findings may be present
low posterior hairline, and severe restriction of motion of the despite a normal-appearing radiograph, a condirion called
neck from fusion of the cervical vertebrae (77,91). Congenital SCrWORA, and should alert the treating physician to a possible
fusion of the cervical spine may predispose a child to injury occulr cervical spine injury (83,122,164,169).
from trauma by concentrating stresses in the rell1aining mobile
segments.
Hensinger et al. (76) reported congenital anomalies of the VALUATION
odontOid process, including aplasia (complete absence), hypo-
plasia (pattial absence in which there is a stubby piece at the Examination of an injured child should begin with inspection
base of th.e odontoid located above the Cl arriculation), and os for associated head or facial trauma. Abrasions and bruising
odonroideum. Os odontOideum consists of a separate ossicle of about the neck that can be caused by direct trauma or from the
the odontoid with no connection ro th.e body of C2. The cause shoulder harness of a seat belt may be dues to an underlying
may be traumatic in nature (76). These anomalies of the odon- cervical spine injulY (Fig. 18-7) (58,66,82,99). An unconscious
roid also may predispose a child ro injury or insrabitiry. patient should be treated as if a cervical spine injulY is present
until proved otheJwise (Fig. 18-8). The spine shoul.d be palpated
for tenderness, muscle spasm, and alignment of the vertebrae.
HISTORY The spinous processes of C2 and C3 should be prominent and
easily palpable. Anterior examination of the cervical spine may
Most cervical spine injuries in young children occur from falls, be difficult in a child. The cricoid canilage is ar the C5-C6
motOr vehicle accidents, or pedestrian-vehicle accidents (36, level and can be used as an allatOmic landmark. The entire spine
107). In young children a fall from less than 5 feet can cause a should be palpated and examined, because 20% of patients with
cervical srine injury (144). Inf:1Ots ~lJ'e at risk for cervical spine cervical spine injuries have injuries at multiple levels (58). A
814 Spine

FIGURE 18-7. Clinical photograph of a patient with cervi-

cal spine injury, resulting from impact with the shoulder
harness of a seat belt. Note location of skin contusions from
the seat belt.

rhorough neurologic examinarion of borh rhe upper and lower examinations. Rectal sphincter rone and perianal sensation also
exrremiries should be performed, including srrengrh, sensarion, should be evaluated. If the child is awake and cooperarive, flex-
reflexes, and proprioceprion. An adequare neurologic examina- ion, exrension, rotation, and lateral tilt can be performed and
rion may nor be possible initially, and repeated examinations correlared wirh pain. However, rhis should nor be performed if
may be necessary. Exrremiry weakness or subrle sensory losses rhe child is nor cooperarive or is unresponsive and only afrer
may not be apparenr initially and may be found only on repeared inirial screening radiographs have been evaluared.

RADIOGRAPHIC EVALUATION
Plain Radiographs
When cervical spine injury is suspecred, radiographs of the cervi-
cal spine are indicated. There is srill no consensus on wherher
rourine radiographs of the cervical spine should be obrained in
every pediarric rrauma parienr. Some srudies have shown rhar
wirhour associared facial rrauma or specific physical findings
rhar suggesr cervical spine injury, routine cervical radiographs
produce a low yield in pediarric rrauma (42,95,133). Rachesky
er al. (133) arrempred ro idenrifY which injured children required
cervical spine radiographs. They reviewed a large series of pa-
rienrs, of whom 1.2% had documenred cervical spine injuries
and concluded rhar cervical spine radiographs were indicared if
rhe child had a complainr of neck pain, or if head or facial
rrauma associared wirh a moror vehicle accidenr were presenr.
Despire rhese srudies, rhe burden is srill on rhe rrearing physician
ro rule our cervical spine injuries. Inirial plain films should in-
clude a lareral cervical spine, open-mourh odonroid view, and
an anreroposrerior cervical spine. Oblique radiographs may be
obtai fled if abnormaliries are presenr on inirial radiographs, or
rhe rrearing physician suspecrs a cervical spine injLIIY by hisrory
or examinarion. If rhe parienr is medically unsrable, rhen a cross-
FIGURE 18-8. Clinical photograph demonstrating a soft tissue injury
that can occur from impact with a shoulder harness of a seat belt and rable lareral radiograph is sufficient unril rhe parienr's condirion
air bag inflation. perm irs a complere evaluarion. Significanr false-negarive rares of
 Chapter J 8: Cel'viwL Spine Injuries ill Children 815

23% ro 26% for single cross-cable laccr:-d radiographs have been Radiographic Evaluation of Specific Areas
reported, emphasizing che need for a complete radiographic eval- of the Spine
uacion of suspecced cervical spine injuries (9,148). Lateral Aexion
Atlantooccipital Junction
and extension views can be obtained, but only wich careful super-
vision and only after stacic films have noc shown any obvious The arlantooccipital inrerval is the most difficult ro assess be-
abnormalicies. The child must be alerc and cooperacive, so it cause of the lack of discreet and reproducible landmarks on
may not be possible ro obcain chese studies in a young, frightened radiographs. The occipical condyles should rest within the
child. depressions of the Facets of the atlas. The interval between che
Eva.luacion of cervical spine radiographs should proceed sys- occipita.! condyles and the superior margin of the facet joints of
tematically and should include evaluacion of anrerior and posce- the arlas should be approximately 3 mm, and iF the interval is
rior verrebral body alignmenr, inrerspinous discance, and spino- more than 5 mm, an adanrooccipital disruption may be present
laminar line. The absence of cervical lordosis on a latera.l film (43,125). The interval between the basion (the anterior conical
may be a normal finding in children and does not necessarily margin of the foramen magnum) and che cip of the dens should
indicate a cel'vical spine injury (31). The prevcrtebral soFc tissue be less chan 12 mm (25). Another measuremenr co evaluate rhe
space should be evaluated for increased swelling. An increase in arlantooccipital junction is che Powers racio, which assesses the
the preverrebra.! soft tissue space may be a subrle finding of relative position of the skull base ro the arias (Fig. 18-9). A line
possible ligamenrous Ot bony injury. This soft tissue space may drawn from the basion ro the anrerior cortex of the posterior
be altered by inspiration, crying, and infection, bur a measure- arch of Cl is measured, and this discance is divided by the
ment of less chan 6 mm at C3 is considered normal. distance of a line drawn from the opisthion (the posterior cortical
The inrerpretation of the plain films tequires knowledge of margin of che foramen magnum) to the posterior cortex of che
normal spine variations. This is particularly true with the neuro- anterior arch of C1. A normal value should be less than 1 and
central synchondrosis and growth plates. Knowing when these more than 0.7. A value of more chan 1 suggescs anrcrior subluxa-
should be prcsenr and when they should not is imporrant so tion of che arlancooccipita.! joint. A value of less than 0.7 suggests
that they are noc mistaken for an occult fracture (Table 18-2). posterior subluxation of the arlancooccipital joint. However, the
basion is not always visible on plain radiographs. The Wacken-
heim line, which is drawn along the poster'ior aspecc of the clivus,
probably is the most easily identified line to decermine disrup-
tion of the arJantooccipital joint (Fig. 18-10) (J 08). If che line
TABLE 18-2. NORMAL OSSIFICATION CENTERS does not inrersecc the tip of che odonroid tangenrially and if chis
AND ANOMALIES FREQUENTLY line is displaced anteriorly or posteriorly, disruption or increased
CONFUSED WITH INJURY

Avulsion fracture
Apical ossification center of the odontoid
Secondary ossification centers at the tips of the transverse and
spinous processes
Fractl:Jre
Persistence of the synchondrosis at the base of the odontoid
Apparent anterior wedging of a young child's vertebra'i body
Normal posterior angulation of the odontoid seen in 4% of
normal children
Instability
Pseudosubluxation of C2-C3
Incomplete ossification, especially of the odontoid process,
with apparent superior subluxation of the anterior arch of
C1
Absence of the ossificaton center of the anterior arch of C1,
in the first year of life may suggest posterior displacement
of C1 on the odontoid
Increase in the atlanto-dens interval of up to 4.5 mm
Miscellaneous
Physiologic variations in the width of the prevertebral soft
tissue due to crying misinterpreted as swelling due to edema
or hemorrhage
Overlying structures such as ears, braided Ilair, teeth, or hyoid
bone. Plastic rivets used in modern emergency cervical im-
mobilization collars can simulate fracture line
Horizontally placed facets in the younger child, creating the FIGURE 18-9. The Powers ratio is determined by drawing a line from
the basion (B) to the posterior arch of the atlas (C) and a second line
illusion of a pillar fracture from the opisthion (0) to the anterior arch of the atlas (A). The length
Congenital anomalies such as os odontoideum, spina bifid a, of the line BC is divided by the length of the line OA, producing the
and congenital fusion or hemivertebrae Powers ratio. (Reprinted from Lebwohl NH, Eismont FJ. Cervical spine
injuries in children. In: Weinstein SL, ed. The pediatric spine: principles
and practice. New York: Raven, 1994; with permission.)
816 Spine

FIGURE 18-10. Drawing of Wackenheim clivus-canal line. This line is

drawn along the clivus into the cervical spinal canal and should pass
just posterior to the tip of the odontoid. (Reprinted from Menezes AH,
Ryken TC. Craniovertebral junction abnormalities. In: Weinstein SL, ed.
The pediatric spine: principles and practice. New York: Raven, 1994;
with permission.)

FIGURE 18·12. The spinolaminar line (Swischuk's line) is used to deter-

mine the presence of pseudosubluxation of C2 on C3. (Reprinted from
Copley LA, Dormans JP. Cervical spine disorders in infants and children.
JAm Acad Orthop Surg 1998;6; with permission.)
laxity abouc the adancooccipital joint should be suspected. Other
Jines such as the McGregor, McCrae, and Chamberlain are noc
as useful in the evaluation of trauma but have been useful for
identifying congenital anomalies with regard co basilar impres-
sIOn. adantoaxial joint can be divided into rhirds: one third is taken
up by the odontoid, one third by the spinal cord, and one third
is space that is available for the cord (160). Up CO 4.5 mm is
Atlantoaxial Joint considered a normal atlamo-dens interval in a child, because
the unossified cartilage of the odontoid apparendy increases the
Evaluation of the atlantoaxial joint should consist of measure-
atlamo-dens interval. Also in children, extension gives the ap-
ment of the atlanto-dens interval and the space available for the
pearance of subluxation of the anterior porrion of the atlas over
spinal cord (Fig. 18-11). Steel reported that rhe space at rhe
the unossified dens on the lateral view. This usually is a pseudo-
subluxation and does nOt represent true instability (Fig. 18-12)
(31,40,51,53).

Space available for spinal cord Upper Cervical Spine

(SAC.)
Anterior displacemenr of one vertebral body on another may
indicate a bony or ligamentous injury, but anrerior displacemenr
of as much as 3 mm at one level may be a normal finding in
1~4-'->'-- Atlantal dens interval
the upper cervical spine of a child. This pseudosubJuxation is
(A.D.!.) most common at C2-C3 and at C3-C4. The anrerior displace-
ment should only be present when the radiographs are tal<en in
flexion, and this displacement will reduce in extension. As an
aid in deciding if subluxation is physiologic or pathologic,
Swischuk and Rowe (161) and Von Torklus and Gehle (168)
described a line drawn from the amerior cortex of the spinous
process of CI EO the spinous process of C3 (Fig. 18-13). If the
anrerior cortex of the C2 spinous process misses this line by
FIGURE 18·11. Sagittal views of the atlantoaxial joint demonstrating more than 3 mm, a true subluxation should be suspected. Also
the atlanta-dens interval (ADI). The space available for the cord (SAC) when evaluating instability caused by posterior soft tissue inju-
is the distance between the posterior aspect of the odontoid and the ries, widening between Cl and C2 of more than 10 mm bervveen
posterior ring of C1. (Reprinted from Hensinger RN, Fielding JW. The
cervical spine. In: Morrissy RT, ed. Lovell and Winter's pediatric ortho- the spinous processes is indicative of a soft tissue or ligamenrous
paedics, 3rd ed. Philadelphia: JB Lippincott, 1990; with permission.) injury (2).
 Chapter /8: CervioT! Spine Injuries in C/;ildren 817

2 3 4

FIGURE 18-13. Pseudosubluxation of C2 on C3. Hypermobility is com-

mon in children under the age of 8 years. Specific measurements of the FIGURE 18-14. Normal relationships in the lateral cervical spine: 1,
movement of the vertebral bodies (thin dotted line) are unreliable, spinous processes; 2, spinolaminar line; 3, posterior vertebral body line;
whereas the relationship with the posterior elements (thick dotted line) 4, anterior vertebral body line. (Reprinted from Copley LA, Dormans
is more consistent. In flexion, the posterior arch of C2 normally aligns JP. Cervical spine disorders in infants and children. JAm Acad Orthop
itself in a straight-line fashion with C1 and C3. Note the relative hori- Surg 1998;6; with permission.)
zontal nature of the facet joints, which allows greater mobility. (Re-
printed from Swischuk LE. Anterior displacement of C2 in children:
physiologic or pathologic? A helpful differentiating line. Radiology
1977;122: 759-763; with permission.)
Special Imaging Studies
Special studies often are indicated for evaluation of pediatric
cervical spine trauma. Most cervical spine injuries can be de-
Lower Cervical Spine tected by murine plain radiographs (5). Flexion and exrension
plain radiographs often are needed to determine if any instability
Evaluation of the lower cervical spine on a lareral radiograph
is present. Tomography, computed romography (CT) scanning,
should include examination of the alignment of the spinous
CT myelography, magnetic resonance imaging (MRI), bone
processes, rhe spinal laminar line, the posterior vertebral body
scanning, and cineradiography are useful adjunctive studies in
line, and the anterior vertebral body line (Fig. 18-14). These
the evaluation of cervical spine trauma. Of these, CT scanning
should aJJ be smooth curves with no step-oFfs or vertebral body
ro detect occult fractures is the most valuable in the trauma unit
translation. Loss of normal cervical lordosis may indicate spasm
sertlng.
From a cervical injury but often is a normal finding in a child
(69). Naidich's law states that at any level the interspinous
distance may be one and a half times greater than the interspi- Dynamic Studies
nous distance of tne level above or the level below. A greater Useful roo Is in evaluating pediatric cervical spine problems are
ratio indicates injury. Evaluation of a lateral cervical spine dynamic flexion and extension radiographs taken from a lateral
radiograph should include the bony anaromy as well as the view, although cineradiography occasionally may be necessary.
soft rissue spaces. Changes in the soft tissue space may warn Static lateral films should always be viewed before performing
the physician of an underlying cervical spine injury when no flexion and extension views. From the static radiographs the
abnormalities of the vertebrae or vertebral alignment are noted physician may suspect a cervical spine injury but the latera] flex-
on plain radiographs. The normal retrophalyngeal soft tissue ion and extension views lIsually will determine rhe presence of
space should be less than 6 mm at C3, and the reuotr:lcheal any instability.
space should be less than 14 mm at CG. Any increased Again, it must be emphasized that these dynamic studies
widening may be indicative of an occult bony Of ligamentous should only be performed under the direct supervision of the
injury. Adran and Kemp (1) showed thar the width of this treating physician and only in a cooperative parient. Cineradiog-
soft rissue shadow may be markedly increased in a crying raphy allows evaluation of flexion and extension and rotation
child because the pharynx is attached ro the hyoid bone and and rilt; however, it requires a high radiation dose and now is
any action displacing it forward artificially increases the width used only in rare cases. CT scanning and MRI have generally
of this shadow. Therefore, radiographs must be taken with replaced cineradiography in the definition of cervical spine inju-
the parient at rcst or during quiet respiration. ries in children.
818 Spine

Tomography can aid in idenrifying injuries that al·e not seen ate the vertebral arteries, especially in upper cervical spine rrauma
well on plain radiographs. Sagittal, coronal, and three-dimen- in young children. An MIU-enhanced technique can now be
sional rcconsrructions from CT scanning can give similar infor- used ro evaluare the vertebral arteries for injury and is not as
mation. Most of the information obtained from tomography invasive as a[[eriography. Therefore, cineradiography, myelogra-
can now be obtained with CT reconstruction views, which not phy, and arteriography have been replaced by CT and MRI,
only shows information in the axial plane, but also shows better which show better detail.
detail of any Fractures Ot bony lesions. Flexion and extension
views are possible with CT scanning to evaluate any occult insta-
bility. Sagittal, coronal, or three-dimensional reconstruction INITIAL MANAGEMENT OF CERVICAL
views can be obtained to help identify Fractures or instability SPINE INJURIES
patterns at sitcs that are not easily seen on plain radiographs.
This is most useFul in evaluating the lateral masses and occipital Care must be taken to immobilize the cervical spine to prevenr
condyles for franutes and fractute-dislocations. One should damage ro the spinal cord, especially while exrracring an injured
take care when placing the child into a CT scanner so that the child from an automobile or during rranspo[[ation. Various de-
head is not inadvertently placed in flexion because of the large vices can be used to immobilize the cervical spine during extrac-
size of a child's head relative ro the body. If this is not taken tion but should consist of splinrage of the head and neck to
into account, the neck will be placed in flexion and potentially the thorax. Any immobilization device must allow access to the
could increase dispJacemenr of an occult fracture. OFten children patienr's orophatynx and the anterior region of the neck for
under 4 years of age require sedation for CT scanning. emergency intubation or tracheostomy if necessary.
Magnetic resonance imaging has become a useFul diagnostic For rransporration the child should be placed on a backboard.
study to evaluate both soft tissue or ligamenrous injury and However, as Herzenberg et aJ. (79) have pointed out, rhe stan-
SCI\'V'ORA. MIU gives both bone and soFt tissue information, dard backboard used for adules is unsuirable for young children.
but it is most useful in evaJuating the spinal cord for occult Because the head of a young child is disproponionately large
injuries and soft tissue for occult swelling, edema, or ligamentous compared with the body, when placed on a standard board, the
injuries. C10skey et al. described this as a useFul rool for detecting child's cervical spine is in flexion. This can translate the cervical
cervicaJ spine injuries in head-injured or unconscious patienrs spine Forward into unstable fracture patterns. Herzenberg et al.
when flexion and extension views cannot be saFely obtained (32). (79) reported on 10 children under 7 years of age whose cervical
Myelography is useful in detecting abnormalities in the spinal spine had anterior angulation or translation on radiographs when
canal but has largely been replaced by MRI (Fig. 18-15). placed on a standard backboard. They recommend a backboard
Another special study is arteriography, which is used ro evaJu- with a recess so that the head can be lowered into it to obtain
a neutral position of the cervical spine. This also can be accom-
[Jlished wirh a split mattress rechnique, in which the body is
supported by two mamesses, and the head is supported by one.
Children under 6 years of age should be immobilized using a
split mattress technique or a spine board with an occipital recess
(Figs. 18-16 and 18-17) (79). One problem with rhis immobili-
zation protocol, however, is rhat it tends to reduce displaced
fraccures and makes recognition of the injury more difficult,
especially end plare Fractures, which are similar to Salter I frac-
tures in that when reduced the Fracrure line cannot be seen (Fig.
18-18) (78).
If a child needs to be placed in a halo body jacker, this
head-trunk relationship also should be remembered so that the
cervical spi ne is nor inflexion.
A large variery of pediatric cervical stabilization devices are
available, including rigid cervical collars made OUt of plastic or
soft foam (37,110). The rigid cervical colbrs give better imlllobi-
lil.arion than soFt foam collars, but [hey may cause problems
from pl·essure and often proper f1tring may be difficult. Even
the best immobilization aJlows 17 degrees of flexion, 19 degrees
of extension, 4 degrees of rotation, and 6 degrees of lateral mo-
rion (110). Huerta et a1. (84) recommended [hat these devices
be supplemenred with tape and sand bags on either side of the
head to limit [he amount of spinal motion to 3 degrees in any
direcrion. IF resusciration is required, furrher displacement of an
unstable cervical injury is a porential risk. A stud)' oFFour parients
with unstable cervical injuries who failed to be resusci[;l[ed in
FIGURE 18-15. Magnetic resonance imaging depicts a ligament tear. the emergency room showed that axial traction during the emer-
 C!Jrlpter 18: Ceruictlf Spine Injuries ill Children 819

FIGURE 18-16. A: Adult immobilized on a standard back-

board. B: Young child on a standard backboard. The relatively
large head forces the neck into a kyphotic position. (Reprinted
from Herzenberg JE, Hensinger RN, Dedrick OK, et al. Emer-
gency 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] 1989;71 : 15-22; with per-
B mission.)

gency treatment actually increased the deformity (15). Skull and pin loosening. Other complications were dural penetration,
tongs and naJo devices can be used in young children for immo- supraorbital nerve injury, and pin site scars that were considered
bilization (68), but care must be taken regarding tne amount of by rhe family to be objectionable. Despire this high complication
pressure that can be used for the Crutchfield tongs or halo pins. rate, all patients were able to wear the halo until fractllre neaJing
There are speciaJ pediatric pin sets for the Crutchfield tongs, or fusion occurred (45). A prefabricated halo vest 11as been lIsed
and if a nalo device is used, then multiple pins at a lower torque with good results in adults, and these vests can be easily fitted,
are recommended. but in children proper fit rarely is achieved and a nalo cast or
Minerva cast immobilization is an effective means ofimmobi- custOm-molded nalo vest is needed ro obtain adequate fit and
lizing the cervicaJ spine, bur to place a well-fitted cast on a young immobilization. If a casr or custom-fitted vest is not used, the
cnild requires some attention to detail. Custom-made orthoses head will be fixed in the halo and unwanted movement will take
also can be used and have the advantages of easier care and place in the vest (Figs. 18-21-18-23).
adjustability. The disadvantage is that they do not immobilize Mubarak et aJ. (112) recommended tne following sreps in
the cervical spine as well as a properly applied Minerva cast (Fig. rhe fabrication of a cusrom halo for a child: (a) the size and
18-19). Thermoplastic marerials also may cause significant skin configuration of the head are obtained with the use of a ~exible
problems from excoriation secondary to the plastic and contact Jead wire placed around tne head; (b) the halo ring is fabricated
dermatitis (Fig. 18-20). by constructing a ring 2 cm larger in diameter than the wire
The halo device, introduced by Perry and Nickel (126) in model; (c) a plaster mold of the trunk is obtained for the manu-
1959, provides immobilization of an unstable cervical spine and facture of a custom bivalved polypropylene vest; and (d) linear
also can be used for uaction in certain situations. The halo device measurementS are made to ensure appropriate lengrh of the su-
can be used to immobilize tne injured cervical spine in children, perstructu re.
but the complications seen witn the use of a halo device are much Computed tomography scanning before halo application may
more frequent in children than in adults (11,44). Dormans et help determine bone srrucrure and skull thickness and aid in
al. (44) reported a 68% complication rate with the use of halo planning pin placement to avoid a suture line, congenital malfor-
immobilization in children, most commonly pin site infection mations, and sites that may be prone to pin penetration because

FIGURE 18-17. A: Young child on a modified backboard that

has a cutout to the recess of the occiput, obtaining better su-
pine cervical alignment. B: Young child on modified backboard
that has a double-mattress pad to raise the chest, obtaining
better supine cervical alignment. (Reprinted from Herzenberg
,. \
JE, Heminger RN, Dedrick OK, et al. Emergency transport and
positioning of young children who have an injury of the cervi-
cal spine: the standard backboard may be hazardous. J Bone
B Joint Surg (Am] 1989;71.15-22; with permission.)
820 . pine

fiGURE 18-19. A 3-year-old with a fracture of the odontoid immobi-

fiGURE 18-18. Lateral radiograph demonstrating anterior displace- lized in a Minerva cast.
ment of a fracture resulting from improper immobilization of a child
on a flat spine board without an occipital recess.

A B
fiGURE 18-20. A: A child immobilized in a SOMI brace. B: Note the rash secondary to contact dermatitis.
 Chapler 18: Crn/jcll! Spine Injuries in Children 821

FIGURE 18-21. Child immobilized in halo brace after occipital cervical

arthrodesis.
FIGURE 18·23. Patient with an atlantooccipital dislocation in a halo
brace. Note the improper fitting of the vest and space between the
vest and chest wall. This allows for significant displacement of atlan-
tooccipital dislocation in the halo brace.

of skull thickness. Skull thickness in children varies gready up

to 6 years of age (97) and increases be(Ween the ages of 10 and
16 years, after which rime ir is similar to rhar in adults. Lem
found thar a 2-mm skull could be complerely penetrated with
a IGO-pound load, which is below the recommended rarque
pressure for adult skulls.
Mubarak et al. (112) recommended the use of multiple pins
at lower torque pressures in infants and children. Eight to ten
pins can be used and tightened to 2 co 4 inch-pounds, depending
on the child's age. The use of multiple pins allows significantly
less torque pressure. AJthough this technique is useful, skull de-
velopment is an important facrar to consider in halo application
in patients under 2 years of age. The halo probably should not
be used in children under 18 months of age: cranial suture inter-
digitation may be incomplete and fontanels may be open anteri-
B orly in children under 18 months of age J.nd posteriorly in chil-
FIGURE 18-22. A: Custom halo vest and light superstructure. B: In the dren under 6 months of age. If a halo is used in patients under
multiple-pin, low-torque technique, 10 pins are used for an infant halo 18 months of age, there is the potential for displacement through
ring attachment. Usually, 4 pins are placed anteriorly, avoiding the tem- the unfused suture lines.
poral area, and the remaining 6 pins are placed in the occipital area.
(Reprinted from Mubarak SJ, Camp JF, Fuletich W, et al. Halo applica-
tion in the infant. J Pediatr Orthop 1989;9:612-614; with permission.)
Technique of Halo Application
Once constructed, the halo ring is applied wi th the patient under
general anesthesia. In older children and adolescents, local anes-
822 Spine

thesia can be used. The patient is placed supine, and the head by Pang and Wilberger (122), is unique to children. This condi-
is supponed by an assistant or a cupped metal extension that rion is defined as a spinal cord injury in a patienr with no visible
cradles the head. If a metal extension is used, care should be fracture or dis.location on plain radiographs, tomograms, or CT
taken nor [0 place the neck in flexion and w maimain the proper scans.
reLHionship of the head and neck wid1 d1e [[unk. The immediate A complete or incomplere spinal cord lesion may be present,
areas of pin insenion are shaved and the skin is prepared with and rhe injury usually results from severe Aexion or distracrion
amisq)[ic solution. Selected areas in the skin and the periosteum to the cervical spine. SCIWORA is believed to OCCUt because
are infllrrared wim local anesthetic. With the help of an assistam rhe spinaJ column (venebrae and disk space) in chiJdren is more
and an applicarion device, the halo is held around the patiem's elastic rhan the spinal cord and can undergo considerable defor-
head. The halo is held below rhe area of grearest diamerer of mation without being disrupred (26). The spinal column can
rhe skull, jusr above the eyebrows, and about 1 cm above rhe elongate up ro 2 inches wirhout disruption, whereas the spinal
rips of rhe ears. The pin sites are carefully selecred so thar rhe cord ruptures wirh only one fourth of an inch of elongation.
pins enter rhe skull as nearly perpendicular as possible. The besr Spinal cord injury withour radiographic abnormaliries also
posirion for the anterior pins is in the anterolateral aspecr of the may represent an ischemic injury in some parienrs, although
skull, above the lateral tWO thirds of the orbir, and below the most are believed to be due ro a disrracrion-type injury in which
greatest circumference of the skull; this area is a relatively safe the spinal cord has nor tolerated me degree of distraction but
zone. This will avoid injury [0 rhe supraorbital and supratroch- the bony ligamentous e1emenrs have nor failed. Aufdermaur sug-
lear nerves. Care should be taken to avoid the remporalis muscle gesred another possibility (8): a fracture through a pediatric ver-
because penetration of this muscle by the halo pin can be painful rebral end plate reduces sponraneously (much like a Salrer I
and may impede mandibular morion during mastication or talk- Fracture), giving a normal radiographic appearance, although the
ing; rhe bone in this area also is very thin, and pin loosening is initial displacemenr could have caused spinal cord injUlY.
likely. Spinal cord injury without radiographic abnormalities is
The posterior pins are placed direcdy diagonal from rhe ante- more common in children under 8 years of age than in older
rior pins, if possible, and inferior [0 rhe equator of rhe skull.
children (122,124,139,169). Predisposing factors rhat may ex-
The pins are introduced rhrough rhe halo and the two diagonally
plain the increased frequency ofSCIWORA in younger children
opposed pins are rightened simultaneously. It is imporcam that
are cervical spine hypermobility, ligamentous laxiry, and an im-
rhe patient's eyes are closed while the pins are tightened wensure
mature vascular supply to rhe spinal cord. The reponed inci-
rhat the forehead skin is nor anchored in such a way as w prevem
dence of this condition varies from 7% to 66% of patienrs with
the eyelids from closing after applicarion of rhe halo.
cervical spine injuries (Sullivan's incidence of SCIWORA was
In an infam or young child, 10 pins are inserted w finger
5% ro 67%) (121,122,175).
rightness or 2 inch-pounds amerolarerally and posteriorly. If the
skull thickness is of great concern, finger tighrness only should be Delayed onset of neurologic symptoms have been reponed
used [0 prevenr penetrating rhe SklJI. In slightly older children, 2 in as many as 52% of patienrs in some series (122,139). Pang
inch-pounds of rorque should be used. In adolescems near skele- and Pollock reported 15 patiencs who had delayed paralysis after
ta] maruriry whose skull thickness is nearly rhat of an adult (as their injury (l2l). Nine had rransienr warning signs such as
determined by CT scan) wrque pressure can be increased ro as paresthesia or subjective paralysis. In all patienrs wirh delayed
much as 6 to 8 inch-pounds. The pins are secured to rhe halo onser of paralysis, the spine had nor been immobilized afrer
wirh the appropriate lock nurs or set screws. A cuswm polypro- the inirial trauma and all were neurologically normal before the
pylene vest or casr is applied as well as rhe superstrucrure after second event. This underlines rhe imponance of diligenr immo-
rhe halo ring and pins are in place. bilization of a suspected spinal cord injury in a child. Approxi-
The pins should be cleaned daily at the skin imerface with mately half of rhe young children with SCIWORA in reponed
hydrogen pcroxide or a small amounr of povidone-iodine solu- series had complete spinal cord injuries, whereas rhe older chil-
tion. The pins are rightened again 48 hours after application. If dren usually had incomplere neurologic deficit injuries that in-
a pin becomes loose after halo applicarion, it can be rerighrened volved the subaxial cervical spine (6,8,69,139).
as long as resisrance is meL If no resisrance is met, the pin should Careful radiographic evaluation is helpful in the workup of
be removed and anorher pin inserted at another site. Superficial these parients, bur MRI will show a spinal cord lesion thar often
infecrions about the pin sire can be rreated with oral antibiotics is some distance from rhe vertebral column injury. As many as
and conrinued pin sire care. IF the cellulitis persists or an abscess 5% to 10% of children with spinal cord injuries have normal
forms, rhen rhe pins should be removed. Dural puncture can radiographic results (69,75).
occur From the haJo pins. When rhis occurs the pin should be
removed and prophylactic anribiotics should be given. The dural
tear usually heals in 4 ro 5 days, ar which time the anribiotics SPINAL CORD INJURY IN CHILDREN
can be disconrinued.
Spinal cord injuries are sri II rare in children. Rang reviewed
SPINAL CORD INJURY WITHOUT spinal injuries at the Toronro Hospital for Sick ChiJdren over
RADIOGRAPHIC ABNORMALITIES 15 years and found that children constituted a small percentage
of the pariel1ts wirh acquired quadriplegia or l):uaplegia (134).
Spinal cord injury withour radiographic ahnormalities, a syn- He found rhar paraplegia was three times more common than
drome first brought to the artenrion of the medical communiry quadriplegia. When a spinal cord injury is suspected, the neuro-
 Chapter 18: em/ieat pine Injuries in Children 823

logic examination must be complete and meticulous and may sociated with breech delivery usually are in the lower cervical
rake several examinations of sensory and motor function. If an spine or upper thoracic spine and are thought to resulr from
acute spinal cord injlllY is documented by examination, rhe ad- traction, whereas injuries associated with cephalic delivelY usu-
ministration of methylprednisolone within me firsr 8 hours after ally occur in the upper cervical spine and are rhought to result
injury has been shown to improve rhe chances of neurologic from rotarion. Ir is unclear wherher cesarean section reduces
recovery (18-21). Methylprednisolone in the trearment of acute spinal injury in neonares (100); however, Bresnan and Abroms
spinal cord injuries has been shown to improve motor and sen- (22) noted thar neck hyperextension in utero (star-gazing ferus)
sory recovery when evaluated 6 weeks and 6 months postinjury in breech presentarions is likely to result in an estimated 25%
(20); however, this positive effect on neurologic recovery is lim- spinal cord injuty with vaginal delivery and can be prevented
ited to those treated within the first 8 hours of injury. The initial by delivering via cesarean section.
loading dose of methylprednisolone is 30 mg/kg body weight. Distraction rype injuries to the upper cervical spine have been
If the loading dose is given within 3 hours after injLlly, then a reponed in infants in forward-facing car seats. Because infants
maintenance infusion of 5.4 mglkg is given for 24 hours after have poor head conrrol and muscular development, if placed in
injury. If the loading dose is given berween 3 and 8 hours after a fOlward facing car sear and a sudden deceleration occurs, the
injury, then a maintenance infusion of 5.4 mg/kg is given for infant's head continues forward while the remainder of rhe body
48 hours after injury. Methylprednisolone decreases edema, has is strapped in rhe car seat, resulring in a distraction-eype injury
an antiinflammatory effect, and protects the cell membranes (66).
from scavenging oxygen free radicals (18-21). Neuromuscular control of the cervical spine in neonates and
In several series (18-21) there was a slight increase in the infants is underdeveloped, and a notmal infant cannot ade-
incidence of wound infections, but no significanr increase in quately support his or her head unril about 3 months of age.
gastrointestinal bleeding. All of these studies involved patients Infants, therefore, cannot protect their spines againsr excessive
13 years or older, so no documentation of the efficacy in young forces rhat may occur during delivery or during the months after
children exists. A combination of methylprednisolone and GM I
birrh. Skeletal injuries from obstetric ttauma are probably under-
ganglioside is being studied for its possible beneficial effect on
reported because the infantile spine is largely cartilaginous and
an injured spinal cord (61-64). GM 1 is a complex acidlike lipid
difflculr ro evaluate radiographically, especially if the injury is
found at high levels in the ceJl membrane of the central nervous
through the cartilage or cartilage-bone interface (8). A cervical
system that is thought to have a neuroprotective and neurofunc-
spine lesion shouJd be considered in an infant who is f10ppy at
tional restorative potential. Early studies have shown that pa-
birth, especially after a difficult delivety. Flaccid paralysis with
tients given both drugs have had improved recovelY over those
aref1exi;l usually is followed by a typical pattern of hyperref1exia
who had received just methylprednisolone.
once spinal cord shock is over. Brachial plexus palsies also war-
Once spinal cord injury is documented, routine care includes
rant cervical spine radiographs. MRl can sometimes be helpful
prophylaxis for stress ulcers, routine skin care to prevent pressure
sores, and initial Fo]ey catheterization followed by intermittent in this diagnosis.
catheterization and a bowel training program. Wirh incomplete Shulman er aI. (153) found arlanrooccipita.l and axial disloca-
lesions, children have a better chance rhan adults for useful re- tions at autopsy, and Tawbin (163) found a 10% incidence of
covely. Hadley et at. (69) nored that 89% of pediatric patienrs brain al1.d spinal injuries at auropsy.
wirh incomplete spinal cord lesions improved, whereas only 20% Trearment of the neonatal cervical spine is nonoperative and
of patients wirh complete injuries had evidence of significant should consist of careful realignmenr and positioning of the child
recovery. Lamineeromy has not been beneficial and can be harm- on a bed with neck support or a custom cervical thoracic orthosis.
ful (15],174) because it increases instability in rhe cervical spine. Healing of bony injuries is usually rapid and complete (159).
For example, it can cause a swan neck deformity or progressive Caffey (30) in 1974 and Swischuk (162) in 1969 described
kyphotic deformity (] 04, 154). The risk of spinal deformity afrer a child abuse syndrome called the shaken infant syndrome. Chil-
spinal cord injury has been investigared by several researchers dren have weak and immature neck muscularure and cannot
(I 0, 12,27,49,90,104). Mayfield et al. (104) found that patients support their heads when they are subjected to whiplash stresses.
who had a spinal cord injuty before their growth Spurt all devel~ Intercrania] and interocular hemorrhages can occur. This injUJy
oped spinal deformities, 80% of which were progressive. Ninery- can result in death or cercbral injury with retardation and perma-
three percent developed scoliosis, 57% developed kypflOsis, and nent visual and hearing defects. Fractures of the spinal column
18% lordosis. Sixey-one percent of these patiell(s required spinal and spinal cord injuries can occur after the violent shaking of
arthrodesis for stabilization of their curves. Onhotic manage- the child. Swischuk reported a spinal cord injury in a 2-year-
ment usually is unsuccessful, but in some patients it delays the old rhat was rhe result of violenr shaking thar produced a cervical
age ar which arthrodesis is necesso'uy. Lower extremity deformi- fracture dislocation rhar spontancously reduced (162).
ties also may occur, such as subluxarions and dislocations about
the hip. Pelvic obliquity can be a significant problem and may
result in pressure sores and difficuley in seating in a wheelchair. OCCIPITAL CONDYLAR FRACTURE

EONATAL INJURY Occipital condylar fractures are rare, and rheir diagnosis requires
a high index of suspicion, especially in parients who are uncon-
Spinal column injUlY and spinal cord injury can occur during scious or have a closed head injury or cranial nerve injUlY. CT
birth, especially during a bteech delivelY (117,163). Injuries as- with multi planar reconstrucrion usually is necessary to esrablish
824 Spine

the Jiagnosis. Three types of occipital condylar fraccul'es have

been described: type 1, impaction fracture; type U, basilar skull
fracrure extending into the condyle; and type !II, avulsion frac-
tures. An avulsion fracture is the only type of occipital condylar
fracture that is unstable. Type I injuries are the result of axial
compression. Type II injuries occur after a direct blow. Both
type I and II occipital condylar fractures can be treated with
a cervical orthosis. Type III or avulsion fractures require halo
immobilization or occipitocervicaJ arthrodesis (3).

ATLANTOOCCIPITAL INSTABILITY
I
Atlantooccipital dislocation was once thought to be a rare fatal
injury found only at the time of autOpsy (Fig. 18-24) (8,16,
24,153). This injury is now being recognized more often, and
children are surviving (44,123,158). This increase in the survival
rate may be due to increased awareness and improved emergency
care with resuscitation and spinal immobilization by emergency
personnel. AtiantooccipitaJ dislocation occurs in sudden deceler-
ation accidents, such as motor vehicle or pedestrian-vehicle acci-
denes. The head is thrown fOlward, and this may cause sudden
cranioverrebral separation.
The adaneooccipital joint is a condylar joine that has little A
inherent bony stability. Stability is provided by the ligaments

FIGURE 18-25. Craniovertebral dislocation. A: Lateral view shows ex-

tensive soft tissue swelling. The distance between the basion and the
dens is 2.4 cm (arrows) (normal is < 1 cm). B: Line drawing made to
demonstrate the abnormal relationship between the occiput and the
upper cervical spine. (Reprinted from EI-Khoury GY, Kathol MH. Radio-
graphic evaluation of cervical trauma. Semin Spine Surg 1991;3:3-23;
with permission.)

about the joine. The primary scabilizers are the paired alar liga-
menes and the tectorial membrane (a coneinuation of the poste-
riot longitudinal ligaml:l\t). In children, this articulation is not
FIGURE 18-24. Patient with atlantooccipital dislocation. Note the for-
ward displacement of the Wackenheim line and the significant anterior as well formed as in adults and it is less cup shaped. Therefore,
soft tissue swelling. there is less resistance to translationaJ forces (8,16,24,25,153).
 Chapter 18: CerlJica/ Spine Injuries in Children 825

A B
FIGURE 18-26. Atlantooccipital joint measurement points 1 through 5 demonstrated on normal cross-
table lateral skull radiograph in an 8-year-old (A) and a 14-year-old (B). (Reprinted from Kaufman RA,
Carroll CD, Buncher CR. Atlantooccipital junction: standards for measurement in normal children. AJNR
1987;8:995-999; with permission.)

Diagnosis may be difficult, because arlamooccipiral disloca- graphic measurement is the dens-basion interval. If the inte-rval
tion is a ligamenwus injury. Ahhough patiems with this injury measures more than 1.2 cm, then disruption of the arlanwoccip-
have a hiswly of trauma, some may have no neurologic findings. ital joint has occurred (25,129). Donahue et aJ. (43) described
Others, however, may have symptoms such as cranial nerve in- an occipital condylar facet distance of more than 5 mm from the
jury, vomiting, headache, wrticollis, or moror or sensory deficits occipital condyle to the C1 facet as indicative of arlantooccipital
(24,29,33,74,81,123). Brainstem sympwms, such as ataxia and injulY. They recommended measuring this distance from five
vertigo, may be caused by vertebrobasilar vascular insufficiency. reference points along the occipital condyle and the Cl facet
Unexplained weakness or difflculry in weaning off a ventilaror (Fig. 18-26).
after a closed head injUlY may be a sign of this injury. Magnetic resonance imaging also is useful in diagnosing at-
The treating physician must be awal'e of radiographic fi ndings lanrooccipital dislocation by showing soft tissue edema and liga-
associated with arlamooccipital dislocation. A significant mem injury or disruption.
amount of anterior soft tissue swelling usually is present.
Radiographic findings that aid in the diagnosis of arlantooc-
cipital dislocation are the Wackenh.eim line, Powers ratio,
dens-basion interval, and occipital condylar distance. The
Wackenheim line is drawn along the clivus and should intersect
tangentially the tip of the odontoid. A shift anterior or posterior
a OPERATIVE TREATMENT

of this line represents either an anterior or posterior displacement Because arlantooccipital dislocation is a ligamentous injury, non-
of the occiput on the arias (Fig. 18-25). This line is probably operative treatment usual1y is unsuccessful. Although Georgo-
the most helpful bcClusc ir is reproducible and easy ro idenrify on poulos et al. (65) did report successful halo stabilization, immo-
a lateral radiograph. The Powers ratio is determined by drawing a bilization in a halo should be used with caution: if rhe vest or
line from the basion ro the posterior arch of the arias and a cast portion is not fined properly, displacement can increase
second line from the opisthion w the anterior arch of the arias. (Fig. 18-27). Traction should be avoided for the same reason.
The length of line BC is divided by the length of the line OA, Surgical stabilization is the recommended treatment (99). Poste-
producing the Powers ratio. A ratio of more than 1.0 is diagnos- rior arthrodesis can be performed in situ, with wire fixation or
tic of anterior adanrooccipital dislocation. A ratio of less than fixation with a contoured Luque rod and wires. If the CI-C2
0.7 is diagnostic of posterior arlamooccipital dislocation. Values articulation is stable, arthrodesis should be only from the occiput
between 1.0 and 0.7 are considered normal. Another radio- to C 1 so that C 1-C2 motion is preserved (57). Some research-
826 Spine

A B
FIGURE 18-27. A: Lateral radiograph of a patient with atlantooccipital dislocation. Note the increase
in the facet condylar distance. B: Lateral radiograph after occipital (1 arthrodesis.

ers have expressed reservations abom the chance of obtaining Occiput to C2 Arthrodesis
fusion in the narrow adanwoccipital inrerval and have recom-
Arthrodesis without Internal Fixation
mended arthrodesis from the occiput w C2. If stability of the
Cl-C2 arriculation is questionable, arthrodesis should extend In younger children in whom the posterior elemenrs are absent
to C2 (l06). at C 1 or separation is extensive in the bi f1d part of C I posteriorly,
For a patienr who presenrs very late with an unreduced dislo- posterior cervical arthrodesis from the occiput to C2 with iliac
cation, an in situ arrhrodesis is recommended. DiBenederro and crest bone graft is performed using a periosteal flap from the
Lee (41) recommendcd arthrodesis in situ with a suboccipital occiput w provide an osteogenic tissue layer for the bone graft
craniccwmy w relieve posterior impingement. (Fig. 18-28) (93).
Instability at the atlantooccipital joint is incrcased in patients A halo is appl ied after the patienr is anesthetized, endotra-
with Down's syndrome as well as those with a high cervical cheal intubation is obtained, and aJI anesthesia lines are in place.
arthrodesis below the a;xis. These patients may be at risk of devel- For younger children, 6 w 10 pins with lower pressure wrque
oping chronic instability parrerns and are at higher risk of having are used in the halo (Fig. 18-21); in older children, 4 pins can
inst~lbility after trauma. be lIsed.

A,B C,D
FIGURE 18-28. Technique of occipitocervical arthrodesis used when posterior arch of (1 is absent. A:
Exposure of the occiput, atlas, and axis. B: Reflection of periosteal flap to cover defect in atlas. C:
Decortication of exposed vertebral elements. D: Placement of autogenous cancellous iliac bone grafts.
(Redrawn from Koop SE, Winter RB, Lonstein JE. The surgical treatment of instability of the upper part
of the cervical spine in children and adolescents. J Bone Joint Surg lAm) 1984;66: 403; with permission.)
 Chapter 18: Cervical Spine Injuries in Children 827

A radiograph is obtained to evaluate the position of the head rim of the foramen magnum, a high-speed diamond bur is used
and cervical spine in the prone position with the halo in place. to create a trough on either side of the proruberance, making a
The radiograph also aids in identifYing landmarks and levels, ridge in rhe center (Fig. 18-29A). A towel clip is used to make
although once rhe skin incision is made, the occiput and spinous a hole in this ridge through only the ourer table of bone. A 20-
processes can be palpated. gauge wire is looped through the hole and around the ridge,
A straight postetior incision is made from the occiput to then another 20-gauge wire is looped around the arch of the
about C3, with care not to expose below C2 to avoid extension atlas. A third wire is passed through a hole drilled in the base
of the fusion to lower levels. An epinephrine and lidocaine solu- of the spinous process of the axis and around this srrucrure,
tion is injected into the cutaneous and subcutaneous tissues to giving three separate wires to secure the bone grafts on each side
help control local skin and subcutaneous bleeding. The incision of the spine (Fig. 18-29B).
is deepened in the midline to the spinous processes of C2. Once A thick, slightly curved graft of corticocancellous bone of
identified, the level of the posterior elements of C1 or the dura premeasured length and width is removed from the posterior
is more easily found. iliac crest. The graft is divided horizontally into two pieces, and
After C2 is identified, subperiosteal dissection is carried prox- three holes are drilled into each graft (Fig. 18-29C). The occiput
imally. Extraperiosteal dissection is used to approach the occiput is decorticated and the grafts are anchored in place with the
(Fig. lS-28A). The dura is not completely exposed; if possible, wires on both sides of the spine (Fig. 18-290). Additional can-
any fat or ligamentous tissue present is left intact. The interspi- cellous bone is packed around and between the two grafts. The
nous ligaments also should be left intact. wound is closed in layers over suction drains.
The occipital periosteum is mobilized by making a triangular Either a rigid cervical orthosis or a halo cast is worn for 6 to
incision directly on the posterior skull, with the apex posteriorly 15 weeks, followed by a soft collar that is worn for an additional
and the broad base over the foramen magnum region. A flap of 6 weeks.
3 or 4 cm at the base can be created. With subperiosteal eleva-
tion, the periosteum can be reflected from the occiput to the
Occipitocervical Arthrodesis
spinous processes of C2 (Fig. 18-28B). The apex of the flap is
sutured to the spinous process of C2 and is attached laterally to The positioning of the patient and the procedure are performed
any posterior elements that are present at Cl or other lateral with the patient under general anesthesia and with monitoring
soft tissues. After the periosteum is secured to the bone and any of the somatosensory-evoked potentials (Fig. 18-30). A halo ring
rudimentary C1 ring is exposed subperiosteally, a power bur is is applied initially with the patient supine. Subsequently, the
used to decorticate the occipur and any exposed portions of C 1 patient is carefully placed in the prone position, the halo is
and C2 (Fig. 18-28C). secured to the operating table with a halo-positioning device,
Iliac crest bone graft is harvested, and struts of iliac bone are and the alignment of the occiput and the cervical spine is con-
placed across the area on the periosteal flap (Fig. 18-280). No firmed with a lateral radiograph. The midline is exposed from
internal fixation is used other than sutures to secure the perios- the occiput to the second or third cervical vertebra. Particular
teum. The wound is closed in a routine fashion, and a body care is taken to limit the lateral dissection to avoid damaging
jacket or cast is applied and attached to the halo. The halo cast the vertebral arteries.
is worn until radiographs show adequate posterior arthrodesis, In patients who need decompression because of cervical ste-
usually in 8 to 12 weeks. nosis or for removal of a rumor, the arch of the first or second
cervical vertebra (or both) is removed, with or without removal
of a portion of the occipital bone to enlarge the foramen
Arthrodesis with Triple-Wire Fixation
magnum.
In older adolescents in whom the posterior elements of C 1 and Four holes, aligned transversely, with two on each side of the
C2 are intact, a triple-wire technique, as described by Wertheim midline, are made with a high-speed drill through both cortices
and Bohlman (171), can be used (Fig. 18-29). The wires are of the occiput, leaving a I-em osseous bridge between the two
passed through the outer table of the skull at the occipital protu- holes of each pair. The holes are placed caudal to the transverse
berance. Because the transverse and superior sagittal sinuses are sinuses. A trough is fashioned into the base of the occiput to
cephalad to the protuberance, they are nor endangered by wire accept the cephalad end of the bone graft. A corticocancellous
passage. graft is obtained from the iliac crest and is shaped into a rectan-
Stability of the spine is obtained preoperatively with cranial gle, with a notch created in the inferior base to fit around the
skeletal traction with the patient on a turning frame or cerebellar spinous process of the second or third cervical vertebra. The
head rest. The patient is placed prone, and a lateral radiograph caudal extent of the intended arthrodesis (the second or third
is obtained to document proper alignment. The subcutaneous cervical vertebra) is determined by the presence or absence of a
tissues are injected with an epinephrine solution (l : 500,000). previolls laminectomy, congenital anomalies, or the level of the
A midline incision is made extending from the external occipital instability. On each side, a looped 16- or 18-gauge Luque wire
protruberance to the spine of the third cervical vertebra. The is passed through the bur holes and looped on itself. Wisconsin
paraspinous muscles are sharply dissected subperiosteally with a button wires (Zimmer, Warsaw, Indiana) are passed through
scalpel, and a periosteal elevator is used to expose the occiput the base of the spinous process of either the second or the third
and cervical laminae, with special care to stay in the midline to cervical vertebra. The wire that is going into the left arm of the
avoid the paramedian venous plexus. At a point 2 cm above the graft is passed through the spinous process from right to left.
828 Spine

A B

c D
FIGURE 18-29. Technique of occipitocervical arthrodesis used in older adolescents with intact posterior
elements of C1 and C2. A: A bur is used to create a ridge in the external occipital protuberance, and
then a hole is made in the ridge. B: Wires are passed through the outer table of the occiput, under the
arch of the atlas, and through the spinous process of the axis. C: Corticocancellous bone grafts are placed
on the wires. D: Wires are tightened to secure grafts in place. (Redrawn from Wertheim 5B, Bohlman
HH. Occipitocervical fusion: indications, technique, and long-term results. J Bone Joint Surg (Am] 19B7;
69' 833; with permission.)

The graft is placed into the occipital trough superiorly and about be in a cervical collar after surgery, avoiding the need for halo
tne spinous process of the verrebra that is to be at the caudal immobilization.
level of the arthrodesis (the second or third cetvical verrebrae). The base of tne occiput and the spinous processes of the
The graft is precisely contoured so that it fits securely into the upper cervical vertebrae are approached through a longitudinal
occipital trough and around the inferior spinous process before midline incision, which extends deep within the rebtively avas-
the wires are tightened. The wires are subsequently crossed, cular intermuscular septum. The entire field is exposed subperi-
twisted, and cur. An intraoperative radiograph is made at this osteally. A template of the intended shape of the stainless steel
point to assess the position of the graft and the wires as well as rod is made with the appropriate length of Luque wire. Two
the alignment of the occiput and the cephalad cervical vertebrae. bur holes are made on each side, about 2 cm lateral to the
Extension of the cervical spine can be controlled by positioning midline and 2.5 cm above the foramen magnum. Care should
of the head with the halo frame, by adjustment of the size and be taken to avoid the transverse and sigmoid sinus when making
shape of the graft, and to a lesser extent by appropriate tightening
these bur holes. At least 10 mm of intact conical bone should
of the wires.
be left between the bur holes to ensure solid fixation. Luque
wires or Songer cables are passed in an extradural plane through
the two bur holes on each side of the midline. The wires or
Occipitocervical Arthrodesis with Contoured Rod cables are passed sublaminar in the upper cel-vical spine. The
and Segmental Wire
rod is bent to match the template; this usually will have a
Occipitocervical arrhrodesis using a contoured rod and segmen- head-neck angle of about 135 degrees and slight cervical lordo-
tal wire has the advantage of achieving immediate stability of the sis. A Bend Meister (Sofamor/Danek, Memphis, Tennessee,
occipitoctl-vical junction (Fig. 18-31). This allows the patient to U.S.A.) may be helpful in bending the rod. The wires or cables
 Chapter 18: Cervical Spine InjurieJ in Children 829

A c

B
FIGURE 18·30. Occipitocervical arthrodesis. A: Four bur holes are placed into the occiput in transverse
alignment, with two on each side of the midline, leaving a 1-cm osseous bridge between the 2 holes
of each pair. A trough is fashioned into the base of the occiput. B: 16- or 18-gauge Luque wires are
passed through the bur holes and looped on themselves. Wisconsin button wires are passed through
the base of the spinous process of either the second or third cervical vertebra. The graft is positioned
into the occipital trough and spinous process of the cervical vertebra at the caudal extent of the arthrode-
sis. The graft is locked into place by the precise contouring of the bone. C: The wires are crossed, twisted,
and cut. The extension of the cervical spine can be controlled by positioning of the head with the halo
frame, by adjustment of the size and shape of the bone graft, and to a lesser extent by tightening of
the wires. (Reprinted from Dormans JP, Drummond OS, Sutton LN, et al. Occipitocervical arthrodesis in
children. J Bone Joint Surg [Am) 1995;77: 1234-1240; with permission.)
830 Spine

c D
FIGURE 18-31. A-D: Occipitocervical arthrodesis using a contoured rod and segmental wire or cable
fixation. (A and B reprinted from Warner We. Pediatric cervical spine. In: Canale ST, ed. Campbell's
operative orthopaedics. St. Louis: Mosby Yearbook, 1998; with permission.)

are secured ro the rod. The spine and occiput are deconicated caused by an axial load applied ro the head. The force is transmit-
and aurogenous cancellous bone grafting is performed. ted through the occipital condyles ro the lateral masses of CI,
causing a disnlption in the ring of Cl, usually in two places,
with fractures occurring both in the anterior and posrerior rings.
FRACTURES OF THE ATLAS In children an isolated single fracture of the ring can occur with
the remaining fmerure hinging on a synchondrosis. This is an
Fracture of rhe ring of Cl OcfFerson fracture) is not a common imponam distinction in children because often fractures occur
injury in children 05,86,102,109,114,136,165). This injUlY is through a normal synchondrosis and tbere can be plastic defor-
 'hopter 18: CervicaL Spine Injuries ill Children 831

odontoid fracrures in children were [he result of moror vehicle

accidents, with the child fastened in a forward-facing sear. The
sudden deceleration of rhe body as it is strapped into rhe car sear
while the head continues [0 rravel forward causes rhis fracrure.
Mos[ odontoid injuries are anteriorly displaced and usually
have an intacr anterior periosteal sleeve that provides some srabil-
icy (0 [he fracrure when immobilized in extension and allows
excellent healing of [he fracrure (7,137,142,149). Grow[h dis-
rurbances are uncommon after this type of fracrure. This syn-
chondrosis normally closes at about 3 to 6 years of age and adds
litrle ro [he longitudinal growth of C2.
Most ohen the diagnosis can be ascertained by viewing the
plain radiographs. Anteropos[erior radiographs usually appear
normal, and rhe diagnosis musr be made from lateral radiographs
because displacemenr of rhe odontoid usually occurs anteriorly.
Plain radiographs sometimes can be misleading when the frac-
rure occurs through [he synchondrosis and has spomaneously
reduced. When this occurs rhe fracture has the appearance of a
FIGURE 18-32. Radiograph of an atlas fracture. nondisplaced Salter I fracture. CT scans with rhree-dimensional
reconstruction views may be needed ro fully delineate the injury
(150). MRl also may be useful in nondisplaced fracrures by
detecting edema around the injured area, indicating that a frac-
marion of the ring. This distinction can be seen on plain radio- ture may have occurred. Dynamic flexion and extension views
graphs, with fracrures appearing rhrough whar appears to be ro demonstrate instability may be obtained in a cooperative child
normal physes. As rhe lareral masses separate, [he transverse liga- if a nondisplaced fracture is suspected.
ment may be ruptured or avulsed, resulting in Cl and C2 insta- Odontoid fractures in children generally heal unevenrfully
bility (109) If rhe two lareral masses are widened more [han and rarely have complications. Neurologic deficits rarely have
7 mm beyond the borders of the axis on an anteroposrerior been reponed after rhis injury, except by Odem e[ al., who
radiograph, rhen an injury ro the transverse ligament is pre- described neurologic injuries in 8 of 15 patiems, although most
sumed. Injury to (he transverse ligament may be from a ruprure were stretch injuries ro the spinal cord at the cervical thoracic
of the ligament or an avulsion of [he ligament attachment to junction and not at the level of the odontoid fracture.
Cl. Jefferson fractures may be evident on plain radiographs, bm Trea[menr of odonroid fractures is by closed reduction (usu-
CT scans are superior at demonstrating this injLllY. CT scans ally extension or slight hyperextension of [he neck), although
also may be used to follow the progress of heal ing. complete reduction of the translation is not necessalY. At lease
T teatmem consists of immobilization in an orthosis [Phila- 50% apposition should be obtained ro provide adequate cervical
delphia collar or sternal occipital mandibular immobilizer alignment, then the patient should be immobilized in a Minerva
(SO.1vU)], Minerva cast, or halo brace. If there is excessive widen- or halo cast or CUStom orthosis. This fracture wiH heal in about
ing (>7 mm), halo traction followed by halo btace or cast immo- 6 ro 8 weeks. Af[er bony healing, stability should be documented
bilization is recommended. Surgery rarely is necessa,y to stabilize by flexion/extension lateral radiographs. Once the Minerva cast
these fracrures (Fig. 18-32). or halo is removed, a soft collar is worn for 1 ro 2 weeks. If
an adequate reduction cannot be obtained by recumbency and
hyperextension, [hen head halter or halo traction is needed.
ATLANTOAXIAL INJURIES Rarely, manipulation under general anesthesia is needed for ir-
reducible fractures (Fig. 18-33). Surgery with internal fixation
Odontoid Fractures
rarely has been teporred, due to the good results that are achieved
Odomoid fractures are one of the most common fracrures of with conservative treatment in children (57,67,130,135,141).
the cervical spine in children (07), occurring at an average age
of 4 years (45,146). The unique fearure of odontoid fracrures
Os Odontoideum
in children is [hac the fracrure mosr commonly occurs through
[he synchondrosis of C2 distally a[ rhe base of rhe odontoid. Os odontoideull1 consists of a round ossicle that is separated
This synchondrosis is a cartilage line ar rhe base of rhe odontoid from [he axis by a transverse gap, which leaves the apical segment
and looks like a physeal or Salrer I injury. wirhou[ suppOrt. Fielding e[ al. (51,53) suggested that this was
A fracrure of [he odontoid usually is associated with head an unrecognized fracture at the base of [he odonroid. Some
(rauma from a motor vehicle accident or a fall from a height, studies have documented normal radiographs of the dens with
al[hough i[ also can occur after trivial head trauma. Radiographs abnormal radiographs after trivial trauma. This can be explained
should be obtained in any child complaining of neck pain. Clini- by a disrrac[ion force being applied by the alar ligamems, which
cally, the child will complain of neck pain and resisr attempts pulls the rip of the fractured odontoid away from the base and
to extend the neck. Oden[ et al. (l18) reported [hd[ 8 of 15 produces a nonunion.
832 Spine

FIGURE 18-33. A and B: Lateral radiograph and CT reconstruc-

tion view of odontoid fracture through the synchondrosis of
A C2. Note the anterior displacement.

The presentation of an os odontoideum can be variable. Signs fracrure in which rhe space is thin and irregular insread of wide
and sympwms can range from a minor w a frank compressive and smooth. The amounr of instability should be documenred
myelopathy or verrebral arrery compression. Presenting symp- on lareral flexion and exrension plain radiographs rhar allow
wms may be neck pain, wrricollis, or headaches caused by local mcasuremenr of both the anrerior and posterior displacemenr
itritation of the arlanwaxial joint. Neurologic sympwms can be of the arias on rhe axis. Because the ossicle is fixed ro the anterior
transienr or episodic after trauma ro complete myelopathy arch of C 1 and moves with the anrerior arch of C 1 borh in
caused by cord compression (46). Symproms may consist of flexion and extension, measurement of the relationship of Cl
weakness and loss of balance with upper moror neuron signs, ro rhe free ossicle is of Jirrle value bCC<lllSC rhey move ;1S a unit.
although upper mowr neuron signs may be completely absent. A more meaningful measuremenr is made by projecring lines
Proprioceptive and sphincter dysfunction also are common. superiorly from the body of rhe axis ro a line projecred inferiorly
Os odomoideum usually can be diagnosed on rourine cervical from the posterior border of the anrerior arch of the arias. This
spine radiographs, which include an open mouth odontoid view gives more information as ro rhe stabiliry of C1-C2. Anorher
(Fig. 18-34). Lateral flexion and extension views should be ob- me,lsurement rhar is velY helpful is space available for rhe cord,
tained ro derermine if any instability is present. Wirh os odon- which is the disrance from rhe back of rhe dens ro the anrerior
roideum there is a space between the body of the ;L'(is and a border of the posrerior arch of C 1.
bony ossicle. The free ossicle of the os odonroideum usually is Recommended rrearmenr is posrerior arrhrodesis of C I ro
half rhe size of a normal odonroid and is oval or round wirh C2. Before anhrodesis is arrempred, rhe inregriry of rhe arch of
smooth scleroric borders. The space differs from that of an acute C I must be documenred by CT scan. Incomplete developmenr
 Chapter 18: Cervical !:'pine II/juries in Children 833

A B
FIGURE 18·34. Lateral radiograph (A) and open-mouth odontoid radiograph (B) demonstrating os
odontoideum. (Reprinted from Warner We. Pediatric cervical spine. in: Canale ST, ed. Campbell's opera-
tive orthopaedics. St. Louis: Mosby Year Book, 1999:2817; with permission.)

of the posterior arch of Cl is uncommon bm has been reponed

to Occur wjth increased frequency in patjenrs with as odon-
toideum. This may necessitare an occipital to C2 arthrodesis for
stability. IF a Cl-C2 arthrodesis js perFormed, one must be
careFul not to oven'educe the odonroid and cause posterior trans-
lation. Care also must be taken in positioning the neck at the
time of arthrodesis and when tightening the wires iF a Gallie or
Brooks arthrodesis is perFormed to prevent posterior translation
(Figs. 18-35 and 18-36).

Traumatic Ligamentous Disruption

The transverse ligament is the primary stabilizer of an imact
odontoid against Forward displacement. Secondary stabilizers
consist of the apical and alar ligamems, which arise From the
tip of the odontoid and pass co the base of the skull. These also
stabilize the adancooccipital joinr indirectly (80). The normal
distance from the anrcrior cortex of the dens co the posterior
correx of the amerior ring of C1 is 3 mm in adults and 4.5 mm
in children. In children iF the distance is more than 4.5 mm,
disruption of the transverse ligament is presumed. The spinal
canal at Cl is large compared with other cervical segmems and
accommodates a large degree of roration and some degree of
pathologic displacement without compromising the spinal cord.
SteeJ has expressed this as a rule of thirds. The spinal canal at FIGURE 18-35. Posterior translation of atlas after C1-C2 posterior ar-
C I is occupjed equally by the spinal cord, odonroid, and a Free throdesis.
834 Spine

A B

FIGURE 18-36. A: Lateral radiograph of traumatic C1-C2 insta-

bility. B: Note the increase in the atlanto-dens interval. C: Lateral
c radiograph after C1-C2 posterior arthrodesis.
 Chapter 18: Cervical Spine Injuries in ChiLdren 835

space, which provides a buffer zone to prevent neurologic injury.

Steel found that anterior displacement of the atlas that exceeds .- - \
,
(
\

a distance equal to the width of the odontoid may place the

spinal cord at risk (160).
Acute rupture of the transverse ligament is rare and reportedly
occurs in fewer than 10% of pediatric cervical spine injuries (98,
107). However, avulsion of the attachment of the transverse
ligament to Cl is more common.
A patient with disruption of the transverse ligament usually
has a history of cervical spine trauma and complains of neck
pain, often with notable muscle spasms. Diagnosis is confirmed
on lateral radiographs that demonstrate an increased atlanto-
dens interval. An active flexion view may be required to demon-
strate instability in cooperative patients with unexplained neck
pain or neurologic findings. CI scans are useful to demonstrate
avulsion of the transverse ligament from its origins to the bony
ring of Ct.
AJthough rarely used, conservative treatment of acute trans-
verse ligament injuries has been reported. Fot acute injuries,
reduction in extension is recommended followed by surgical sta-
bilization of Cl and C2 and immobilization for 8 to 12 weeks
in a Minerva cast, a halo brace, or cervical orthosis. Flexion
and extension views should be obtained after stabilization to
document stability. FIGURE 18-37. Technique of atlantoaxial arthrodesis (Brooks-Jenkins).
A: Wires are inserted under the atlas and axis. B: Full-thickness bone
grafts from the iliac crest are placed between the arch of the atlas and

a OPERATIVE TREATMENT
the lamina of the axis. C and 0: The wires are tightened over the graft
and twisted on each side. (Redrawn from Brooks AL, Jenkins EB. Atlan-
toaxial arthrodesis by the wedge compression method. J Bone Joint
Surg (Am] 1978;60: 279; with permission.)
Atlantoaxial Arthrodesis
Technique of Brooks and Jenkins
The supine patient is intubated in the supine position while still with the head supported by traction, maintaining the head-tl1-
on a stretcher, and is then placed prone on the operating table, orax relationship during turning. A lateral cervical spine radio-
with the head supported by traction; the head-thorax relation- graph is obtained to ensure proper alignment before surgelY. The
ship is maintained at all times during turning (23) (Fig. 18-37). skin is prepared and draped in a sterile fashion, and a solution of
A lateral cervical spine radiograph is obtained to ensure proper epinephrine (l : 500,000) is injected intradermally to aid hemos-
alignment before surgery. The skin is prepared and draped in a tasis.
sterile fashion and a solution of epinephrine (l : 500,000) is in- A midline incision is made from the lower occiput to the
jected intradermaUy to aid hemostasis. level of the lower end of the fusion, extending deeply within
Cl and C2 are exposed through a midline incision. Using
an aneulysm needle, a mersiline suture is passed from cephalad
to caudad on each side of the midline under the arch of the
atlas and then beneath the lamina of C2. These serve as guides
to introduce twO doubled 20-gauge wires. The size of the wire
used varies depending on the size and age of the patient. Two
full-thickness bone grafts approximately 1.25 X 3.5 cm are har-
vested from the iliac crest and beveled so that the apex of the
graft fits in the interval between the arch of the atlas and the
lamina of the axis. Notches are fashioned in the upper and lower
cortical surfaces to hold the circumferential wires and prevent
them from slipping. The doubled wires are tightened over the
graft and twisted on each side. The wound is irrigated and closed
in layers over suction drains.

Technique of Gallie FIGURE 18-38. Wires are passed under the lamina of the atlas and
through the spine of the axis and tied over the graft. This method is
The supine patient is intubated while on a stretcher (59) (Fig. used most frequently_ (Reprinted from Fielding JW, Hawkins RJ, Ratzan
18-38). The prone patient then is placed on the operating table SA. J Bone Joint Surg (Am] 1976;58: 400; with permission.)
836 Spine

the relatively avascula.r midline structures, the intermuscular sep- of more than 10 mm. In patients with less than 10 mm of
tum, or ligamentum nuchae. Care should be tal<en not w expose translation and a neurologic deficit or history of neurologic
any more than the area to be fused to decrease the chance of symptoms, surgical stabilization also may be indicated. Once
spontaneous extension of the fusion. By subperiosteal dissection, surgical stabilization is needed, the treating physician must un-
the posterior arch of the atlas and the lamina of C2 are exposed. derstand the increased risk of complications (i.e., pseudarthrosis)
The muscular and ligamentous attachments from C2 are re- in this patient population. Segal et al. (145) reported a high
moved with a curet. Care should be taken w dissect laterally complication rate after posterior arthrodesis of the cervical spine
along the atlas w prevent injury to the vertebral arteries and in patients who have Down's syndrome. Six of ten patients devel-
vertebral venous plexus that lie on the superior aspect of the oped resorption of the bone graft and associated pseudarthrosis.
ring of Cl, less than 2 cm lateral to the midline. The upper Other complications in this patient population after attempted
surface of Cl is exposed no farther Jarerally rhan 1.5 cm from posterior arthrodesis were wound infection, dehiscence of the
the midline in adulrs and 1 cm in children. Decorrication of operative site, instability of adjacent motion segments, and neu-
Cl and C2 generally is not necessalY. From below, a wire loop rologic sequelae (152).
of appropriate size is passed upward under the arch of rhe arias
either directly or with the aid of a mersiline suture. The mersiline
suture can be passed with an aneurysm needle. The free ends Atlantoaxial Rotatory Subluxation
of the wire are passed rhrough the loop, grasping the arch of
Arlanroaxial rotatory subluxation is a common cause of child-
Cl in rhe loop.
hood totticollis. This condition is known by several names such
A corricocancellous gtaft is taken from rhe iliac cresr and
as rotatory dislocation, rotatOry displacement, rotatOry subluxa-
placed against the lamina of C2 and rhe arch of Cl beneath the
tion, and rotatOry fixation. Atlantoaxial rotatory subluxation
wire. One end of the wire is passed rhrough the spinous process
probably is the most accepted term used, except for long-stand-
of C2, and the wire is twisted on irself to secure rhe graft in
ing cases (3 months), which are called rotarory fixation.
place. The wound is irrigared and closed in layers with suction
A significant amount of motion occurs at the atlantoaxial
drainage tubes.
joint; half of the roration of the cervical spine occurs there.
Through this range of motion at the CI-C2 articulation, some
Atlantoaxial Instability Associated with children develop atlamoaxial rotarory subluxation. The two most
Congenital Anomalies and Syndromes common causes are rtauma and infection; the mosr common
cause is an upper respiratoty infection (Gtisel's syndrome) (1n).
Although acute atlantoaxial instability in children is rare, chronic
Subluxation also can occur after a retropharyngeaJ abscess, ton-
atlantoaxial instability occurs in certain conditions such as juve-
sillectomy, phalyngeopJasty, or trivial trauma. There is free
nile rheumaroid arthriris, Reiter's syndrome, Down's syndrome,
blood flow between the veins and lymphatics draining the phar-
and Larsen's syndrome. Bone dysplasia-such as Morquio's pol-
ynx and the periodontoid plexus (124). Any inflammation of
ysaccharidosis, spondyloepiphyseal dysplasia, and I<niest's syn-
these structLlres can lead ro attenuation of the synovial capsule or
drome-also may be associated with atlantoaxial instability, as
transverse ligament or borh, with resulting instability. Another
well as os odonroideum, K1ippel-Feil syndrome, and occipitaliza-
potential etiologic facror is the shape of the superior facers of
tion of the atlas (28,73,75,92,94, Ill).
the axis in children. Kawabe (88) demonstrated that the facets
Certain cranial facial malformations have high incidences of
are smaller and more steeply inclined in children than in adults.
associated anomalies of the cervical spine, such as Aperr's syn-
A meniscus-like synovial fold was found between Cl and C2
drome, hemifacial microsomy, and Goldenhar's syndrome
that could prohibit reduction after displacement has occurred.
(152). Treatment recommendations are individualized based on
the natural hiswry of the disorder and future risk ro the patient.
AJthough there is little literature on cervical spine instability in
Classification
each of these syndromes, there has been considerable interest in
the incidence and treatment of atlanwaxial instability in children Fielding and Hawkins (54) classified atlantoaxial rotatory dis-
with Down's syndrome (35,38,131,132,167). placements into four types based on direction and degree of
Some Down's syndrome patients have CI-C2 instability of rotation and translation (Fig. 18-39). Type 1 is a unilateral facet
more than 5 mm. The Committee on Sports Medicine of the subluxation with an intact transverse ligament. This is the most
American Academy of Pediarrics issued a policy statement (35) common and benign type. Type 2 is a unilateral facet subluxa-
asserting that Down's syndrome patients with 5 [Q 6 mm of tion with amerior displacement of 3 ro 5 mm. The unilateral
instability should be restricted from participating in spores that amerior displacemem of one of the lateral masses may indicate
carry a risk of stress to the head and neck. The Special Olympics an incompetent transverse ligament with potencial instability.
organization has placed even greater restrictions on particular Type 3 is bilateral anterior facet displacement with more than
spores (156). Davidson found that neurologic signs were more 5 mm of anterior displacement. This type is associated with
predictive of impending dislocation than the radiologic criteria. deficiencies of the transverse and secondary ligamenrs, which
Nearly all the patients with actual dislocations that he reviewed can result in significant narrowing of the space available for the
had at least several weeks of readily detectable physical signs cord ar the atlanroaxiallevel. Type 4 is an unusual type in which
before dislocation occurred (38). the arias is displaced posteriorly. This usually is associated with
Surgical stabilization is indicated for patienrs with translation a deficient dens. AJthough types 3 and 4 are rare, neurologic
 'hapter /8: Cervical Spim Injuries in Children 837

Type I Type II

Type III Type IV

FIGURE 18-39. Classification of rotary displacement. (Reprinted from

Fielding JW, Hawkins RJ. Atlantoaxial rotary fixation. J Bone Joint Surg
{Am} 1977;59:37; with permission.)

involvement may be present or instantaneous death can occur.

Both types must be managed with great care.
FIGURE 18-40. Child with rotary subluxation of C1 on C2. Note the
direction of head tilt and rotation of the neck.
Signs and Symptoms
Clinical findings include neck pain, headache, and a cock-robin
position of rotating to one side as well as lateral flexion to the
other (Fig. 18-40). When rotatOry subluxation is acute, the child eral mass and the dens also will be asymmetric. On the lateral
resists attempts to move the head and has pain with any attempts view, the lateral facet appears anterior and usually appears wedge
at correction. Usually they are able to make the deformity worse shaped instead of the normal oval shape. The posterior arches
but are not able to correct it. Associated muscle spasms of the of the atlas may fail to superimpose because of head tilt, giving
sternocleidomastoid muscle occur predominantly on the side of the appearance offusion of Cl to the occiput (occipitalization).
the long sternocleidomastoid muscle in an attempt to correct Flexion and extension lateral views are recommended to exclude
the deformity. If the deformity becomes fixed, the pain subsides instabi Iity.
but the torticollis and the decreased range of motion will persist Cineradiography has been used for the evaluation of arlan-
(52). If rotatolY fixation has been present for a long time in a toaxial rotatOry subluxation (50,54,80). This technique is lim-
small child, plagiocephaly sometimes can be noted. Neurologic ited in the acute stage, because pai n restricts the motion necessalY
abnormalities are extremely rare, although a few cases have been for a satisfactolY study. With atlantoaxial rotatory fixation, cine-
teported. radiography may be helpful in confirming the diagnosis by dem-
onstrating that the atlas and axis are rotating as a unit. However,
this technique requires high radiation exposure and generally
Radiographic Findings has been replaced by CT scanning (7,45,54,60,128). CT should
Adequate radiographs may be difficult to obtain because of the be performed with rhe hC:lJ and body po~itioned as close to
associated torticollis and difficulty in positioning the head and neutral as possible. This will show a superimposition of Cion
neck. Anteroposterior and open mouth odontoid views should C2 in a rotated position and will allow the degree and amount
be taken with the shoulders flat and the head in as neutral a of malrotation to be quantified. Some researchers have recom-
position as possible (10J). Lateral masses that have rotated for- mended dynamic CT scans taken with the patient looking to
ward appear wider and closer to the midline, whereas the oppo- the right and the left to diagnose rotatOty fixation (127). Three-
site lateral mass appears narrower and farther away from the dimensional CT scans also are helpful in identifying rotat01Y
midline on this view. One of rhe facet joints may be obscured subluxation (140). MRl is of little value in this condition unless
because of apparent overlapping. The distance between the lat- there are neurologic findings (Fig. 18-41).
838 Spine

A ( B

D
FIGURE 18-41. A and B: Odontoid view and lateral cervical spine radiograph of rotary subluxation of
C1 on C2. C: Note the asymmetry on the open-mouth odontoid view. D: CT and CT reconstruction
documenting rotary subluxation.

Differential Diagnoses sponraneoLlsly over a few days before medical arrenrion is sought.
If roratory subluxarion has been presem for a week or Jess, a soft
Diffc:remial diagnoses include torricollis caused by ophrhalmo-
collar, ami-inflammatory medicarion, and exercise program are
logic problems, srernoc1eidomasroid tighrness from muscular
indicated. If rhis fails to produce improvemem and rhe symp-
rorricollis, brainsrem or posrerior fossa rumors or abnormalities,
toms persist for more rhan a week, head halrer rraction should
congeniral verrebral anomalies, and infections of rhe verrebral
be iniriared. This can be done eirher ar home or in rhe hospiral,
column.
depending on rhe social siruarion and rhe severiry of symproms.
Muscle relaxams and analgesics also may be needed. Phillips and
Hensinger (127) found rhar if rotatory subluxarion was present
Treatment
for Jess than 1 month, head halrer traction and bed resr were
T rearmen t depends on the duration of rhe symproms (127). usually sufficient 1'0 relieve symptoms. If rhe subluxarion is pres-
Many parienrs probably never receive medical rrearmenr, be- em for longer rhan a momh, successful reducrion is nor very
cause symptoms may be mild and rhe subluxarion may reduce likely (29). However, halo rraction can srill be used to rry ro
 Chapter 18: Cervical Spine Injuries in Children 839

reduce the subluxation. The halo allows increased tracrion level of the neurocenrral chondrosis. Later fijms showed ossifica-
weight to be applied without inrerfcring with opening of the tion within the synchondrosis gap.
jaw or causing skin pressure on the mandible. While the traction Treatmenr should be symptomatic with immobilization in a
is being applied, acrive rotation to the right and left should be Minerva cast, halo, or cervical orthosis for 8 to 12 weeks. Trac-
encouraged. Once the atlantoaxial rotatory subluxation has been tion is not needed to reduce this fracture and may even produce
reduced, motion has been restored, and the reduction is docu- potentially dangerous distraction. Pizzutillo et al. (128) reported
menred by CT scan, the patient is mainrained in a halo vest for 6 that four of five patients healed with immobilization. If union
weeks. If reduction cannot be maintained, posterior arianro<L"Xial does riot occur, posterior arthrodesis or anrerior arthrodesis can
arthrodesis is recommended. Even though inrernal rotation and be performed [Q stabilize th is fracture.
alignment of the arias and axis may not be restored, successful
fusion should result in the appearance of normal head alignment
by relieving the muscle spasms that occurred in response to the
malrotation. Posterior arthrodesis also is recommended if any SUBAXIAL INJURIES
signs of instability or neurologic deficits secondary [Q the sublux-
ation are present, if the deformity has been presenr for more Fractures and dislocations involving C3 through C7 are rare
than 3 months or if conservative treatment of 6 weeks of immo- in children and infants (85,87,105,151) and usually occur in
bilization has failed. teenagers or older children. Lower cervical spine injuries in chil-
dren as opposed to those in adults can occur through the cartila-
Hangman's Fracture ginous end plate (39). The end plate may break completely
through the cartilaginous portion (Salter type I) or may exit
Bilateral spondylolisthesis of C2, or hangman's fractures, also through the bony edge (Salter type Il). Usually the inferior end
may occur in children (170). The mechanism of injury is forced plate fractures because of the protective effect of the uncinate
hyperexrension. Most reportS of this injury have been in childten processes of the superiot end plate (8).
undet the age of2 years (48,56,128,138). This injury probably
occurs more frequently in this age group because of the dispro-
portionately large head, poor muscle control, and hypermobility.
Posterior Ligamentous Disruption
The possibility of child abuse also must be considered. Patients
present with neck pain and resist any movement of the head Posterior ligamentous disruption can occur with a flexion or
and neck. There should be a positive histoty of trauma (Fig. 18- distraction injUlY [Q the cervical spine. The patienr usually has
42). point tenderness at the injury site and complains of neck pain.
Radiographs reveal a lucency anrerior to the pedicles of the Initial radiographs may be normal except for loss of normal
axis, usually with some forward subluxation of C2 on C3. One cervical lordosis. This may be a normal finding in young chil-
must be sure this is a fracture and not a persistenr synchondrosis dren, but should be evaluated for possible ligamentous injury
of the axis. Matthews et al. (103), Nordstrom et al. (116), and in an adolescent. Widening of the posrerior interspinous distance
Smith et al. (155) have reporred similar cases of persistent syn- is suggesrive of this injury. MRl may be helpful in documenring
chondrosis of the axis. CT scans showed the defect to be at the ligamentous damage.

FIGURE 18-42. Lateral radiograph of patient with traumatic (2 spondylolisthesis (Hangman's fracture).
840 Spine

With posterior ligamemous disruption, gradual displacement results in loss of vertebral body height. This can be detecred on
of one segment on the other can occur, and secondary adaptive a lateral radiograph. Because vertebral disks in children are more
changes in the growing spine may make reduction difficult. Pos- resilient than the vertebral bodies, rhe bone is more likely to be
terior ligamentous injuries should be protected with an extension injured. Compression fractures are stable injuries and heal in
orthosis, and patients should be followed closely for the develop- children in 3 to 6 weeks. Many compression fractures may be
ment of instability. If signs of instabiliry are present, then a overlooked because of the normal wedge shape of the vertebral
posterior arthrodesis should be performed. bodies in young children. Immobilization in a cervical collar is
recommended for 3 to 6 weeks. Flexion and extension films to
Compression Fractures confirm stability should be obtained 2 to 4 weeks after injury. In
children under 8 years of age. rhe vertebral body may reconstirute
Compression fractures, the most common fractures of the subax- itself with growth, alrhough Schwarz et al. (143) reporred that
iaJ spine in children, are caused by flexion and axiaJ loading rhar kyphosis of more rhan 20 degrees may not correct with growth.

c D
FIGURE 18-43. A and B: Lateral radiograph of a patient with so-called perched facets. demonstrating
a facet dislocation. C and D: Lateral and anteroposterior radiograph after reduction and posterior ar-
throdesis.
 Chapter /8: Cervical Spille Injuries i/1 Children 841

Associated injuries can include anterior teardrop, laminar, and tion is created with craction and reduction. If reduction cannot
spi nous process fractures. be easily obtained, open reduction and arthrodesis are indicated.
Complete bilateral facet dislocation, although I'are, is more un-
stable and has a higher incidence of neurologic deficit (Fig. 18-
Unilateral and Bilateral Facet Dislocations 43). Trearmenr consists of reduction and stabilization wirh a
posterior arthrodesis.
U nilatetal facet dislocations and bilateral facet dislocations are
the second most common injuries in the subaxial spine in chil-
dren. Most occur in adolescents and are similar (0 adult injuries.
Burst Fractures
The diagnosis usually can be made on anteroposterior and lateral
radiographs. In children the so-called perched facet is a true Although rare, burst fractures can occur in children. These inju-
dislocation. The cartilaginous componems are overlapped and ries are caused by an axial load. Radiographic evaluation should
locked. On the radiograph, the facet appears perched because consist of anteroposterior and lateral views. CT scans aid in
the overlapped cartilage caJ1not be seen. Unilateral facet disloca- derecting any spi nal canal compromise from retropulsed fracture

A B

FIGURE 18-44. A, B, and C: Anteroposterior and

lateral radiograph and (T scan of patient with a
c minimally displaced burst fracture of (5.
842 Spine

fragments and occulr laminar fracrures. [f no neurologic deficir

or significant canal compromise is present, then treatment con-
sists of traction followed by halo immobilization. Anterior ar-
rhrodesis rarely is recommended in pediatric patients except in
the rare patient with a bursr fracture and significant canal com-
promise (147). Anterior arrhrodesis destroys rhe anterior growrh
porential; as posrerior growth continues, a kyphoric deformiry
may occur (Fig. 18-44).

Spondylolysis and Spondylolisthesis

Spondylolysis and spondylolisrhesis of C2 rhrough C6 have been
reponed. These injuries can occur from eirher a hyperexrension
or flexion axial loading injury. Associated anterosuperior avul-
sion or compression fracrures of rhe verrebral body may occur.
FIGURE 18-46. Alternative fixation method for posterior arthrodesis
The diagnosis usually is made on plain radiographs rhar show of C3-0. A 16-gauge wire is placed in a figure-of-eight pattern around
a fracture line through rhe pedicles. Oblique views may be neces- two threaded Kirschner wires passed through the bases of the spinous
processes of the vertebrae to be fused. (Reprinted from Hall JE, Sim-
sary ro berrer identifY rhe fracture line. CT scanning may be mons ED, Danylchuk K, et al. Instability of the cervical spine and neuro-
useful in differentiating an acure fracture from a normal syn- logical involvement in Klippel-Feil syndrome: a case report. J Bone Joint
chondrosis. Treatment consisrs of immobilization in a cervical Surg [Am] 1990;72: 460; with permission.)

orrhosis or halo brace. Surgical srabilizarion is recommended

only for truly unstable fractures or nonunions. Neurologic in-
volvement is rare.

~
_.: ..
. - .
_. _' " z. .' .....
__ "

.. ' ,-.

"- . . ~. " '

.
" :. . .,:. .'
.-
c

FIGURE 18·45. Technique of posterior arthrodesis in subaxial spine levels C3-C7. A: A hole is made in
the spinous process of the vertebrae to be fused. B: An 18-gauge wire is passed through both holes and
around the spinous processes. C: The wire is tightened. D: Corticocancellous bone grafts are placed.
(Redrawn from Murphy MJ, Southwick WOo Posterior approaches and fusions. In: Cervical Spine Research
Society. The cervical spine. Philadelphia: JB Lippincott, 1983; with permission.)
 Chapter 18: CervicaL Spine injuries in Childrell 843

a OPERATIVE TREATMENT
11. Baum JA, Hanley EN jr, Pullekines J. Comparison of halo complica-
rions in adulrs and children. Spine 1989; \ 4:251-252.
\ 2. Bedbrook GM. Correcrion of scoliosis due w paraplegia susrained in
pediarric age group. Paraplegia 1977; 15:90-96.
Posterior Arthrodesis 13. Birney TJ, Hanley EN. Traumaric cervical spine injuries in chlldhood
and adolescence. Spine 1989; 14: 1277-1282.
General anesthesia is administered with the patient supine (Fig. 14. Bernini EP, EkFanre R, Smalrino F, Tedeschi G. Angiugraphic srudy
18-45). The patient is turned prone on the operating table, with on rhe wrrebral aner)' in cases of deFormiries of rhe occipiwcervical
care taken ro maintain traction and proper alignment of the joint. A]R 1969;107:526-529.
head and neck. The head may be positioned in a head rest or 15. Bivins HG, Ford S, Bezmalinovic Z, er aJ. The eFFecr of axial rracrion
during owrracheal imubarion of rhe trauma vicrim wirh an unstable
mainrained in skeletal traction. Radiographs are obtained ro con-
cervical spine. Ann Emerg /Vied 1988; 17:25-29.
firm adequate alignment of the vertebrae and ro localize the 16. Bohlman HH. Acurc fracrures and dislocarions of rhe cervical spine.
vertebrae to be exposed. Extension of the fusion mass can occur ] Bone Joint Surg {Am] 1969;61: 1 119-1 142.
whcn extra vertebrae or spinous processes are exposed in the 17. Bohn 0, Armsrrong 0, Bccker L, er al. Cervical spine injuries in
cervical spine. A midline incision is made over the chosen spi- children.] Trauma 1990;30:463-469.
18. Brackcn MB. Trea(lnent of acure spinal cord injury wirh merhylpred-
nous processes, and the spinous process and lamina are exposed
nisolone: resulrs of a mulri-center randomized clinical trial.] Nelll'O-
subperiosteally ro the facet joines. If the spinolls process is large Imumil 1991;8(suppl 1):47-50.
enough, a hole is made in the base of rhe spino LIS process with 19. Bracken MB. Pharmacological rrearmenr of acure spinal cord injury:
a rowel clip or Lewin clamp. An 18-gauge wire is passed through currem Slatus and Future projecrs.] El1/C1g Med 1993;11 (suppl I):
this hole, looped over the spinous process, and passed through 4.3-48.
the hole again. A similar hole is made in the base of the spinous 20. Bracken MB, Shepard MJ, Collil1S WF, er al. A randomized controlled
trial of merhylprednisolone or naloxone in rhe rrc:uml'!H of aClire
process of the inferior vertebra ro be fused, and the wire is passed
spinal cord injury: resulrs of rhe Second National spinal Cord Injuty
through this vertebra. The wire is then passed through this hole, Srudy. N Engl] iVied 1990;322:1405-1411.
looped under the inferior aspect of the spinous process, and then 21. Brackm M13, Shepard MJ, Collins WF, er al. Merhylprednisolone
passed back through the same hole. The wire is tightened and and naloxone rrearment afrer acure spinal cord injury: one year Folio\\'-
corticocancellous bone grafts are placed along the exposed lam- up data. Resulrs of rhe Seconu Narional Acure Spinal Cord InJu,y
Study./ Neuromrg 1992;76:23-31.
ina and spinolls processes. The wOllnd is closed in layers. If the
22. Bresnan MJ, Abroms IF. Nconar;ll spinal cord transeCtion secondary
spinous process is roo small ro pass wires, then an in situ arthrod- ro inrraurerine hyperexrension of neck in breech presentarion.] l'edi-
esis can be performed and external immobilization used. atr 1974;84:734-737.
Hall et al. (71) used a 16-gauge wire and threaded Kirschner 23. Brooks AL, Jenkins EB. Adanroaxial arrluodesis by rhe wedge
wires. The threaded Kirschner wires are passed through the bases compression medlOd.] Bone Joint Surg {Am] 1978;60:279-290.
24. Bucholz RW, Burkhead WZ. The parhological amromy of Faral ar-
of the spinous processes of the vertebrae ro be Fused. This is
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followed by a figure-oF-eight wiring with a 16-gauge wire (Fig. 25. Bubs 01, Firz CR, Johnson DL. Traumaric adanro-occipiral disloca-
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28. Burke SW. hench HG, Roberts JM, er aJ. Chronic adanroaxial insra-
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118. Odem T, Langlais ], Glorion C, er al. Fracrures of rhe odomoid rior arthrodesis of rhe cervical spine in pari ems who have Down syn-
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846 Spine

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 FRACTURES OF THE THORACIC
AND LUMBAR SPINE
RANDALL T. LODER
ROBERT N. HENSINGER

AN TOMY TREA ME T
CIASSlr:ICATIO AND MECHANISM OF I JURY Spinal Cord and Root Injury
Flexion Fracrure Treatmenr
Disrracrion and Shear
Compression (Slipping of rhe Verrebral Apophysis)
PROG OS,- A D COMPLICATIO S
Growrh Anesr
SIGNS A 0 SYMPTOMS SpinaJ Cord and Roar Injury
Spinal Cord and Roor Injury Orher Spinal Injuries
RADIOGRAPHIC FI DI GS

Pediarric spinal fracrures represem 2% (Q 5% of all spinal injuries include an increased carrilage-bone rario, rhe presence of sec-
(49,71). Mosr spinal fractures in children occur in the cervical ondary ossification cenrers, and sofr rissue hyperelasriciry. In
spine, but severe and seriously disabling injuries do occur in rhe infancy and early childhood, rhe verrebral bodies are largely carri-
rrlOracolumbar spine. Fracrlll'es of rhe thoracic and lumbar spine laginous, and the inrerverrebral disk spaces appear radiographi-
are rare in children compared with their frequency in adulrs. cally to be larger rhan rhey are (Fig. 19-1). Wirh maturarion rhe
The acrual incidence of thoracolumbar spinal injuries, however, ossificarion cenrer of rhe centrum enlarges and rhe cani-
may be rwice thar reponed; scatistics are skewed toward more Jage-bone rario reverses.
severe injuries because many patients wirh mild injuries are never In infants, horizonral conical shadows of lessened densiry
admitted (Q a hospital (5,71). exrend inward from barh rhe anterior and posterior walls of rhe
TI1e locarion of rhe fracrure and the mechanism of injury verrebraJ bodies and can be confused wirh a fracrure (Fig. 19-
vary wirh rhe age of the child. Neonates are more prone ro 1) (I38). The posterior indenrarion represents rhe foramen for
cervical injuries rhan to dorsal or lumbar injuries (74). Thoraco- rhe posrerior arteries and veins in rhe verrebral wall; ir is presenr
lumbar spinal fractures in infants may be caused by child abuse, in all verrebrae and ar all ages. The more noriceable anrerior
whereas children in rhe first decade of life usually susrain rhese conical shadow represenrs a large sinusoidal space wirhin rhe
injuries from motor vehicle accidents, eirher as a pedestrian or verrebra. This anrerior norch usually dis:lppears by I year of 3l!-C
passenger, or from faUs from heighrs (23,49,53,62). Thoraco- wirh ossificarion of rhe anrerior and lareral walls of rhe verrebral
lumbar spinal fracrures in children over 10 years of age rypically bodies.
occur in sporrs and recrearional activities (such as tobogganing The venebral apophyses are secondary cenrers of ossificarion
and bicycling), as well as moror vehicle accidenrs (57,70,71, rhar develop in rhe carrilaginous end plares ar rhe superior and
102,124). Injuries from gunshot wounds also are increasing in inferior surfaces of rhe verrebral bodies. Because rhey are rhicker
frequency. ar rhe periphery rhan ar rhe cenrer, rhey appear as rings during
early ossificarion and are called ring apophyses. These apophyses,
ANATOMY equivalenr ro rhe epiphyses of long bones, are separared from
rhe vertebral bodies by narrow cartilaginous physes. Equal supe-
Cenain anaromic fearures in children thar influence the radio- rior and inferior verrical growth of the venebral bodies occurs
graphic appearance of the spine, as well as rhe rype of fracrures, ar rhese physes. The verrebral physes appear radiographically
berween rhe ages of 8 and 12 years and may be confused wirh
avulsion fractures before rhey fuse wirh rhe venebral bodies by
Randall T. Loder: Shriners Hospital for Children, Deparrment of Orrho-
approximarely 21 years of age.
paedic Surgery, University of Minnesora, Minneapolis, Minncsora.
Robert N. Heusinger: Secrion ofOrrhopaedic Surgery, Department of Sur- In children, the elasriciry of the disks and venebral bodies
gay, University of Michigan, School of Medicine, Ann Arbor, Michigan. far exceeds rhar of rhe neural elemenrs. In rhe cervical spine,
848 Spine

Flexion
Hyperflexion injuries with compression are more common than
distraction, shear, or subluxation-dislocation injuries (62,63).
In immarure spines, the intact disks are more resistam to venica]
compression than are the vertebral bodies. During compression,
the vertebral body collapses before the normal disk fails. Because
of this, few children have posterior herniated disks, ,uxl hernia-
tion occurs only with signiflcanc loading injuries such as weight-
lifring and gymnastics or reperitive rrauma (30). Herni;1ted disks
associared with incervertebr;11 disk calcification have been rarely
reported (84, J 03).
When a verrebra is slowly vertically loaded, the ll1;1jor distor-
tion is a bulge in the vertebral end plale, with only a slight
change of the annulus and no alteration in the shape of rhe
nucleus pulposus (112). The bulging of the end plate forces
blood out of the cancellous bone, which normally is a shock-
absorbing mechanism. \Vith funher compression, the end plate
fractures, nuclear materia! ruptures inco the \rerrebral body, and
the [wo vertebrae move closer (Fig. 19-2). If the spine is already
flexed when compression is applied, as in tobogganing, the blood
is already squeezed out of the vertebral body, the shock-absorb-

FIGURE 19·1. The radiograph of a normal spine in a 10-week-old in-

fant. The superior and inferior vertebral end plates and vertebral
apophysis are cartilaginous. Thus, the apparent widening of the inter-
vertebral spaces is relative to the ossific portion of the vertebrae. The
anterior and posterior notching of the walls of the vertebral body are
due to normal vascular channels and may be confused with fracture.

the vertebral column can be stretched up to 2 inches without

disruption, whereas the spinal cord tolerates only 1/4 inch. This
elasticity partially accoums for the occurrence of spinal cord
injury without radiographic abnormality (SCIWORA) in
younger children (9,71,99,J47). By the age of 10 years, the
mechanical and anatomic characteristics of the bony thoraco-
lumbar spine approach that of an adult, and fracture patterns
become the same.

CLASSIFICATION AND MECHANISM OF

INJURY
FIGURE 19-2. Radiograph of a 5-year-old girl who sustained compres-
The three main mechanisms of thoracolumbar spinal fraerures sion fractures of three vertebrae from a sledding accident. Note reversal
arc Hexion with or without compression, dim'anion, and shear. of the normally convex end plate, as well as breaking and wedging of
the bodies. Overlapping of the spongiosum may appear as increased
Pure compression may cause slipping of the vertebral apophysis, density. The child was asymptomatic within 6 weeks, and complete res-
which occurs only in adolescems. titution of vertebral height can be expected.
 Chapter /9: Fractures of the Thoracic and Lumbar Spine 849

A
FIGURE 19·3. The radiograph of a lS-year-old girl who sustained an
injury to the vertebral body from tobogganing, with fracture of the
apophyseal ring (arrow) and displacement anteriorly.

ing properties are decreased, and less force is required ro injure

the spine (Fig. 19-3) (57).
In older children, th.e nucleus pulposus is no longer fluid,
and compression forces are cransmined th.rough the annulus,
resulting in either tearing of the annulus with a diffuse collapse
of the venebral body due ro buckling of its sides or a marginal
plateau fracture (12). Stronger compression forces applied more
rapidly may cause a bursting eype of injury, similar to that in
adulrs (Fig. 19-4).
The vertebral disks of children are more elastic than those of
adults, and transmit compression forces as a wave through multi-
ple levels (63,70,112). This is reflected by the clinical fact that
mlJtiple compression fractures, usually in the mid-thoracic ro
mid-lumbar area (49,53,63), are more common in children (Fig.
19-2) rban in adults (49,53,63).
Chance fractures, described by Chance in 1948 (25), were
more clearly defined by Smith and Kaufer (23) as a lumbar
spinal injury associated wirh sear belrs. Forward flexion over the
belt produces distraction of the posterior vertebral elements and
anterior compression, leading to disruption of the interspinous
ligaments, ligamentum flavum, and facet capsules. This injury, B
previously uncommon in children, is increasing with the more
FIGURE 19-4. A: The radiograph of a lS-year-old girl who was involved
frequent use of lap belts because of child resrrainr laws (6,66). in a motor vehicle accident, sustaining multiple compression fractures,
The middle and anterior columns may fail through either sofr wedging of L1, and anterior buckling of L4 and LS. B: The same patient
tissues (posterior longitudinal ligament and disk) or bone (verte- 6 months later. There is persistence of disk space narrowing at T12 to
L1. Complete remodeling of this injury is not expected, because she is
bral body or end plate). If the fulcrum of rotation is slightly near the end of skeletal growth. She was treated conservatively and is
posterior to the anterior margin of the vertebral body, there may asymptomatic.
850 Spille

TYPE A TYPE B

r-
! '
I '

TYPE C TYPE D

FIGURE 19-5. Seat-belt fracture patterns in skeletally immature chil-

dren. Type A is a bony disruption of the posterior column extending
just into the middle column. Type B is an avulsion of the posterior ele-
ments with facet joint disruption or fracture and extension into the
apophysis of the vertebral body. Type C is a posterior ligamentous dis-
ruption with a fracture line entering the vertebra close to the pars
interarticularis and extending into the middle column. Type D is a poste-
rior ligamentous disruption with a fracture line traversing the lamina
and extending into the apophysis of the adjacent vertebral body.
(Adapted from Rumball K, Jarris J. Seat-belt injuries of the spine in
young children. J Bone Joint Surg [Br] 1992;74:571-574; with permis-
sion.)

be a slighr componenr of vertebral body compression aneeriorJ)'.

More commonly, however, rhe fulcrum poine is anrerior [Q rhe
verrebral body and rhe anrerior e1emenes fail in disrracrion. B
Pediarric Chance fractures are of four types (Fig. 19-5) (1 18).
FIGURE 19-6. The radiograph of a newborn with complete disruption
A reverse Chance fracrure (a hyperextension injury) also has been at 13-T4. The child was a breech delivery with cephalopelvic dispropor-
described in infants and children (38,91), rarely with enuapment tion, leading to a difficult extraction. A: Anteroposterior view. B: Lat-
eral view, demonstrating that the fracture extended through the carti-
of bowel (113). A fracrure through rhe posterior elements alone
lage end plate. The child is completely paraplegic at the 13-T4 level
withom lumbar body fracrure also has been reported in children and has paralysis of the right hemidiaphragm.
and adulrs (I).

Distraction and Shear Compression (Slipping of the Vertebral

Apophysis)
In children with violent injuries, such as those sustained from
being hit by a car, thoracolumbar spine injuries are caused pri- Slipping of rhe vertebral apophysis usually occurs in adolescent
marily by shear forces (7). The vertebrae typically fracture boys, wirh trauma ric displacement of a lumbar verrebral ring
rhrough rhe end plate apophyses (Fig. 19-6). These injuries also apophysis inro rhe spinal canal and associared disk prorrusion
may be associated with flexion and rotarion, which leads to shear- (.35,126,132). These injuries rypically arise from rhe posrcrior
ing and ofren traumatic spondylolisthesis (Fig. 19-7). inferior rim of L4 and less commonly from rhe inferior rim of
 Chapter 19: Fractures of the Thoracic and Lumbar Spine 851

A B

FIGURE 19-7. The radiograph of a 13-year-old Boy Scout who

sustained this lumbar fracture when a tree fell directly across his
back during a severe thunderstorm. A: The anteroposterior view
demonstrates a shear-type injury with a fracture-dislocation of
L4 to LS lamina. B: The lateral view demonstrates a traumatic
spondylolysis at the L4-L5 level. C: Lateral tomograms demon-
strated severe disruption of the pedicle and facet. C
852 Spille

TYPE I TYPE II TYPE III

FIGURE 19-8. Schematic representation of the three types of avulsion fractures. In type I (left), an
arcuate fragment ,is found, but no osseous defect is seen at the posterior rim of the vertebral body.
Type II (middle) is an avulsion fracture of the posterior rim of the vertebral body that includes a rim of
bone. The fragment is not arcuate, and it is thicker than in type I. The sharply avulsed osseous edge is
recognized on computed tomography. Type III (right) is a localized fracture posterior to an irregularity
of the cartilage end plate. The osseous defect anterior to the fragment, as depicted on computed
tomography, is larger than the fragment. (Adapted from Takata K, Inoue 5-1, Takahashi K, et al. Fracture
of the posterior margin of a lumbar vertebral body. J Bone Joint Surg (Amj1988;70:589-594; with
permission.)

L3 or L5. The age and circumsrances under which rhis injulY abdominal injury (20%) ro rhe spleen and liver, pelvis, urinary
occurs :ue analogous ro rhose in parienrs wirh slipped capiral rracr, or chesr (2.61, 109.119,129,130,144); 50% ro 90% of chil-
femoral epiphysis (22), which suggesrs rhar rhe verrebral end dren with lap bell' injuries have inuaabdominal injuries (6,44,
plare is more susceprible ro shear forces during rhe period of 118), mosr commonly smalJ bowel ruprures and rraumaric pan-
rapid growrh. Borh chronic and acure forms have been described, creari tis. Some researchers (48,118) have reponed rhar abdomi-
and rhe problem is ofren erroneously diagnosed as a hernia red nal injuries are so severe as ro dominate rhe early clinical picrure
disk because of rhe similarity of symproms (35,126). Many pa- and resulr in late detecrion of spinal fracwres. Marked sofr rissue
ricnrs (38%) wirh slipped verrebral apophyses also have lumbar swelling, bruising. and renderness along rhe posrcrior spinal area
Scheuermann's disease (35), perhaps because rhe preexisring are signs rhar a spinal fracrure may have occurred. Ecchymosis
marginal Schmorl's node weakens rhe edge and leads ro a slip in a lap bell' disrriburion should alerr rhe clinician ro rhe possibil-
of rhe apophysis (126). iry of a Chance Fracrure (Fig. 19-9) (122).
Slipping of rhe apophysis can be classified inro rhree types Slipping of rhe venebral apophysis typically is caused by a
according ro radiographic appearance (Fig. 19-8) (132): rraumaric incidenr such as weighr lifting, gylllnasrics, or shovel-
ing (22). Acure slipping produces signs and symproms similar
Type I: Separarion of rhe posrerior rim of rhe involved vene- ro rhose of a cenrral herniared nucleus pulposus, including neu-
bra. A calcified arc is seen on computed romography (CT) scan rologic findings such as muscle weakness, absenr reflexes, and
wirh no evidence of associared large bony fracture. This type is posirive srraighr-Ieg raising (126). Lare findings are similar ro
mosr common in children 11 ro 13 years of age. rhose of spinal srenosis.
Type II: Avulsion fracrure of parr of rhe venebral body, annu-
lar rim, and canilage. This rype is mosr common in adolescenrs
and young adulrs 13 ro 18 years of age.
Type Ill: More localized injury rhar includes smaller posrerior
irregulariries of rhe carrilaginous end plare. This is mosr common
in young adulrs over rhe age of 18 years.
A type IV injUlY spans rhe enrire lengrh and breadrh of the
posrerior verrebral margin between rhe end plares (37).

SIGNS AND SYMPTOMS

In a child who is awake and cooperarive, complainrs of pain
may poinr ro spina] injury. In older children, pain and renderness
of rhe spine usually are preseru, and inability ro walk and muscle
spasms ofren are presenr wirh unsrable spinal injuries. In a child
wirh polvrrauma, a signiticanr verrebL\1 fracrurc may be over- FIGURE 19-9. An abdominal contusion from a lap belt, or the "seat
belt sign." (Reproduced from Jarvis JG. Seat belt fractures. In: Letts RM,
looked (80). Innocuous-appearing fracrures of rbe lumbar or ed. Management of pediatric fractures. New York: Churchill Living-
rboracic rransverse processes are ofren associared wirh serious stone, 1994; with permission.)
 Chapter 19: Fractures of the Thoracic and Lumbar Spine 853

Spinal Cord and Root Injury areas are almost equally involved (33). Neurologic loss is more
often complere in younger children (birth to 8 years of age), in
The most serious diagnostic error is failure co recognize complete
whom thoracic lesions tend to be neurologically complete more
or parcial paralysis. Neurologic evaluation of a frightened, hurt,
often (92%) than in adolescents (50%). Lumbar lesions are rare
uncooperative child is difficult. Gross flexion or reflex with-
and tend to be incomplete in all age groups (33). By definition,
drawal of the limbs may mimic voluntary movement. Stimula-
no disruption, malalignment, or other bony abnormalities are
tion and handling of the child may produce crying, leading to
seen on plain radiographs. Physiologic disruption of the spinal
a false assumption that sensation is intact. Serial observations
cord is not necessarily associated with anatomic disruption. The
over time may be necessary co determine the patient's true neuro-
exact pathoanatomy is not truly known. Magnetic resonance
logic status.
imaging (MRI) is most useful to study the cord and disk-liga-
Binh injuries to the spinal cord should be suspected in a
ment complexes and correlates with clinical outcome (45). The
floppy infant or a child with a nonptogressive neurologic lesion
outcome for patients with SCIWORA is primarily determined
after a difficult delivery. The single most important finding is
by the initial neurologic status. Approximately 25% have lare
the demonstration of a sensory level. Somatosensory-evoked po- deterioration of neurologic function.
tentials may be helpful (11). Treatment is can troversial. Pang (99) recommended brace
Nine percent to 15% of all spinal cord injuries occur in chil- immobilization for 3 months, but in his series, no child had
dren and are rwice as frequent in boys as in girls (33,62,71). instability at initial evaluation and only one child later developed
Boys lOco 15 years of age are at greatest risk for spinal cord instability demonsuated by flexion-extension radiographs (99).
injury (3). Young children usually have injuries at the cervico- Without documented radiographic instability, the biomechani-
thoracic junction that result in more severe neurologic injury, cal usefulness of brace immobilization is questionable, although
but they also have more potential for recovelY than do older Pang suggests that bracing treats "incipient instability." In chil-
children. Adolescents with thoracolumbar fractures are more dren, normal stability is seldom regained after ligamentous spinal
likely to have rransient or incomplete neurologic deficits that injuries are allowed to heal with simple immobilization, and
resolve or improve (49). spinal fusion usually is needed. It seems unlikely that SCIWORA
Delayed onset of paraplegia (2 hours co 4 days) may indicate would behave differently regarding instability, incipient or
a vascular insult to the spinal cord (26). The injUiY is rypically otherwise. Regardless of whether brace immobilization is used
at the mid-portion of the thoracic spine (watershed area) and or nor, close follow-up of neurologic funcrion is necessary. Any
usually is associated with a blow to the chest or abdomen, result- sign of instability on flexion-extension radiographs afrer 3
ing in shock or profound hypotension from internal injuries. months of bracing is an indication for surgical stabilization.
This generally results in complete and permanent paraplegia. Neurologic injuries are uncommon with Chance fractures,
In older children, vertebral fractures are the most frequent although in one series 3 of to children had paraplegia (118).
cause of neurologic injury (83%) (71). Fracrure-dislocations at This may be related to the higher center of gravity in children
the rhoracolumbar junction are the most common injuries tbat results in an increased moment arm and greater distraction
(36%), with the remainder berween T4 and L2 (49,62,63,71). of the neurologic strUC[llres.
The risk of neurologic injury increases with canal narrowing:
spinal canal stenosis of 35% at Tll-T12, 45% at Ll, and 55%
RADIOGRAPHIC FINDINGS
at L2 and below are significant factors for neurologic impairment
(52).
The radiographic appearance of a spinal injury depends on the
Recent evidence about burst fractures has suggested that the force and mechanism of injury. Compression can cause changes
degree of neurologic injury correlates primarily with the energy ranging from slight flattening of the normal I)' convex end plates
of the injulY, with no correlation co the amount of osseous or to frank wedging of the vertebrae. A zone of increased density
canal disruption. This suggests that the neurologic injulY occurs in the vertebral body may overlap the ttabecular bone (53,61).
at rhe time of trauma rather than as a result of pressure in the Damage to multiple vertebrae is usually present (the maximum
canal due co remaining osseous fragments (81). Further investi- reported number is 11), bur clinically observable kyphosis is
gation is necessary to clarify the contributions of canal stenosis uncommon unless there is a fracture-dislocation (53). True ftac-
and the energy of the injury in the etiology of neurologic damage ture lines are seldom seen in prepubertal children. Avulsed verre-
from thoracolumbar spine fracwtes. bral corners, common in adults, are rare in children (43). If the
Spinal cord injUIY without radiographic abnormality has been amount of force is significant, the end plate ruptures and the
reported co occur in 5% to 55% of all pediatric spinal cord disk is extruded inro the vertebral body, forming a Schmorl's
injuries, usually in children under 10 years of age (9,43,49,71, node, typically in the lower rhoracic and upper lumbar verrebrae
76,99,100,117,147). The immature, elastic spine is much more (10).
deformable than that of an adult. Momentary displacement from Adult fracrure patterns, such as subluxation or fracture-dislo-
external forces can endanget the spinal cord without causing cation, which are uncommon in children (Fig. 19-10), are more
radiographic disruption of bone or ligaments. Four major factors common in adolescents (Fig. 19-11). As in adults, CT scans and
are believed to be involved: hyperextension, flexion, distraction, sagittal reconstructions are more accurate than plain x-rays in
and spinal cord ischemia from direer cord conrusion or vascular derecting posterior arch fracwres (Fig. 19-12) and rerropulsed
insufficiency (82). The neurologic deficit ranges from complete bone with spinal canal narrowing (15,42). The CT CUtS muse
cord transection co parrial cord deficits; the cervical and thoracic (Jext continues on page 855))
854 Spine

A B

c D
FIGURE 19-10. This 7-year-old boy was a restrained passenger involved in a motor vehicle accident and
sustained a fracture-dislocation at L1-L2. A: Lateral. B: Anteroposterior. There was a complete absence
of neurologic function below L1 on admission. He underwent open reduction and internal fixation that
night with instrumentation and fusion from T10 to L3. C: Lateral. D: Anteroposterior. At follow-up some
3 years later, he has significant motor recovery, with motor strength being 4/5 psoas, quadriceps. and
hamstring; 3/5 triceps surae; 2/5 extensor hallicus longus; and 1/5 tibialis anterior. He is ambulatory with
ankle-foot orthoses. (Courtesy of Gregory Graziano, M.D.)
 Cbnpter J 9: Fractures of the Tboracic and Lumbar Sphu 855

A B

c D
FIGURE 19-11. This 16-year-old girl was involved in a motor vehicle accident, sustaining a fracture-dis-
location at L2-L3 with complete loss of neurologic function. The initial radiographs Ilateral (A) and
anteroposterior (B)J demonstrate a fracture with significant kyphosis at L2-L3. Also note that the frac-
ture involving the posterior elements of L3 extends inferiorly nearly into L4. This created a very unstable
situation, and the clinician elected to proceed with instrumentation and fusion. The preoperative com-
puted tomography scan shows a three-column injury (C). Also note the L3 laminar fractures (D). (Figure
continues.)
856 Spine

E F

FIGURE 19·11. (continued) The preoperative magnetic resonance image (T2-

weighted) shows an area of increased signal (arrow), representing acute cord
edema, as well as an area of decreased signal (arrowhead), representing acute
intraspinal hemorrhage (E). At surgery, hooks could not be placed on the lamina
of L3 due to fracture, as noted on the preoperative computed tomography scan.
For this reason, the clinician elected to proceed with instrumentation from L1
to L4 using pedicle screws. Due to the marked disruption and instability noted
at the time of posterior spinal fusion, the clinician also elected to perform an
anterior fusion from L2 to L4. The postoperative radiographs are shown [lateral
G (F) and anteroposterior (G)]. (Courtesy of Frances Farley, M.D.)
 ClMpter /9: Fract'JIres o.{ the Thoracic and Lumbar Spine 857

A B

c D
FIGURE 19-12. This 17-year-old girl was an unrestrained passenger in a school bus involved in a motor
vehicle accident. The rear tire blew out at a speed of 70 mph, causing the bus to rollover several
times. She was unconscious for a short period of time, but on arrival in the emergency department she
complained of chest pain. Physical examination was pertinent for a sternal contusion, a nontender
spine, and a normal neurologic examination of the lower extremities. Chest and spine radiographs
demonstrated a fracture of T5. The lateral radiograph demonstrates a marked compression of T5 and
kyphosis at TS-T6 (A). The anteroposterior radiograph demonstrates a compression of T5, with pedicular
widening (B). The computed tomographic scan shows fractures of the laminae (Cl, along with retropul-
sion of bone into the canal (D). (Figure continues.)
 858

FIGURE 19-12. (continued) Due to the kyphosis, ret-

ropulsion of bone, and three-column injury, a poste-
rior spinal fusion with distraction instrumentation was
performed. Radiographs 1 year after surgery demon-
strate correction of the kyphosis [lateral (E)] with a
E,F normal frontal alignment [anteroposterior (F)].

AB D

FIGURE 19-13. Slipped vertebral apophysis in a 15-year-old with back pain,

hamstring tightness, and symptoms suggestive of spinal stenosis. A: Lateral
radiograph at the lumbosacral junction demonstrates a Schmorl's node and
bony changes in the posterior portion of the apophysis of L4. B: The com-
puted tomography scan demonstrates a Schmorl's node formation and a
fracture of the apophysis with subluxation into the spinal canal. C: The com-
puted tomography scan reconstruction of the same lesion. D: Magnetic reso-
nance imaging demonstrates slipping of the vertebral apophysis as well as
c the intervertebral disk, with encroachment of the spinal canal.
 Chapter /9: FrflCtures of the Thoracic and Lumbar Spine 859

A,S c
FIGURE 19-14. This 17-year-old boy was involved in a motor vehicle accident sustaining a bony Chance
fracture. A: The lateral spine radiograph shows the fracture line (arrow) through the posterior elements
and the vertebral body. B: The anteroposterior radiograph also shows the fracture and gap through
the posterior elements (arrow). C: The sagittal reconstruction from the computed tomography scan
clearly shows the fracture line through the posterior elements.

be ar righr angles 1'0 rhe verrebral bodies or rhe lesion will be eral hyperinrensiry, consistenr with contusion. Parienrs wirh eype
confused wirh a pseudofracrure (15). In children wirh slipped I patterns rarely have improvemem in Frankel grade, whereas
vertebral apophyses, CT scanning (35,126) shows a small bony those wirh eypes II and III parrerns frequently improve at leasr
fragmenr (rhe edge of rhe vertebral end plare) within rhe spinal one Frankel grade (13).
canal (Fig. 19-13). MRl shows a large anterior exnadural impres-
sion (or rarely even a complere block) from rhe slipped apophysis
and pronuded disk (22,115). TREATMENT
Chance fractures in children usually are in the mid-lumbar
Spinal Cord and Root Injury
spine (Ll-L3) insread of the rhoracolumbar junction as in
adulrs. Routine lareral radiographs are best for making rhe diag- The second Narional Acure Spinal Cord Injury srudy published
nosis (Fig. 19-14) and should be obrained in any child believed in 1990 (18) recommended thaI' merhylprednisolone be given
to have abdominal injury caused by a seat bell' (139). Avulsion within the first 8 hours of injury co improve neurologic recovery.
of spinous processes ofren exrends over several verrebral levels, Unfortunately, rhe youngest parienr in thaI' study was 13 years
ofren with anterior compression fractures. CT scans eypicalJy do old, so the outcome of these recommendations in younger chil-
not demonsrrare rhis injury because rhe curs are in rhe same dren is unknown. The follow-up study (19) furrher defined the
plane as rhe horizontal fracrure-dislocarions but can provide doses and time inrervals, but here again the youngest patient in
furrher informarion abour the presence of imracanal bony frag- rhat study was 14 years old. Neverrheless, we do recommend
ments or injury co rhe osseous posrerior arch. If injury co the rhe adminisrration of methylprednisolone in patients with acute,
gasrrointesrinal nacr is suspecred, appropriare imaging should blunt spinaJ cord injuries. The initial loading dose is 30 mg/kg
be performed. body weight. If the loading dose is given within 3 hours after
Magneric resonance imaging is berter rhan CT scanning or injury, then a maintenance infusion of 5.4 mk/kg is given for
myelography for evaluation of spinal cord or cauda equina inju- 24 hours afrer injllly; if the loading dose is given 3 co 8 hours
ries in children (13,16,69,133), and obviares rhe need for in- afrer injury, rhen a maintenance infusion of 5.4 mk/kg is given
uathecal injection of contrast dye thaI' is necessary for a myelo- for 48 hours afrer injury. It must be remembered rhat dlcse
gram. However, false-negative and false-posirive MRI results recommendations were developed for rhose who had susrained
may occur. The presence of spinal insrrumemation is not a con- blum trauma. There is some evidence that the administration
traindicarion co rhe MRl scan. Three eypes of MRl parterns are of merhyJprednisoJone in penerrating spinal cord injulY may
seen on T2-weighred images of acute spinal cord injuries. Type actually impair recovery of neurologic function (107). Finally,
1 is a decreased signal consistenr wirh acute intraspinaJ hemor- rhe adminisrrarion of merhylprednisolone is associared with a
rhage, eype II is a brighr signal consistent wirh acute cord edema, higher complication rate, especially pneumonia and sepsis (19,
and eype III is a mixed signaJ of cennal hypoimensity and periph- 41), but withour an increase in morraliey (19).
860 Spine

racture Treatment fully log-rolled prone Onto rolls on a Standard operating table.
Suspension-rype frames (such as the Hall-Relron frame) should
Permanent disk space narrowing and spontaneous inrerbody fu-
not be used because this may allow excessive lumbar sag in an
sion are uncommon after spinal injuries in children, because
already unstable spine and possibly increase neurologic damage.
the healthy intervertebral disks rypically transmit forces to the
The legs and distal lumbar spine should be placed directly over
vertebral bodies (65). This, along with the presence of the rib
the break of the opera ring table ro allow some extension of the
cage in the thoracic spine, makes a Stronger case for nonoperative
legs and diseal lumbar spine during the reduction maneuver.
treatment of spinal injuries in children than in adults. Approxi-
The entire spine and iliac crests are prepared and draped in
mately cwo thirds of spinal ftactures in children are seable.
standard fashion. A pOSterior midline incision is made over the
Flexion Injuries injured vertebral levels. Often ehe gap becween the spinous pro-
cesses is easily palpable or ecchymosis is seen. I f the level cannot
Simple compression fractures heal quickly with litrle tendency be localized clinically, an intraoperative lateral radiograph should
for further progression. Sympromatic treaement wieh a shore be taken before the incision is made (Fig. 19-15A). Dissection
period of bed resr or immobilization with a case or orthosis is carried sharply down to the level of the thoracolumbar fascia.
usually is sufflcienr for mild injuries. In studies comparing cast- Dissection must be executed carefluly because the injury causes
ing with bed reSt, the rype of treatmenr did nor affect the out- severe disruption of the thoracolumbar fascia and paravertebral
come, and most children were asymptomatic in 1 to 2 weeks muscularure. Incising the subcutaneous fat alone often makes
(62,63,88). Posterior tenderness in the area of the fracture occa- the dura visible through the disrupted area.
sionally persists but usually does not pose any serious problem When the thoracolumbar fascia is reached, the paravertebral
(62). Symproms may persist for some time after end plate frac- muscles are carefully elevated subperiosreally from the spinous
cure and disk herniation inro the vettebral body but usually processes of the two disrupted vertebrae. The laminae and dis-
resolve with conservative tteatment.
rupted facet joinrs are exposed by careful lateral disseCtion. Only
The brace used for treatmenr of a flexion injUlY (compression
the injured levels should be exposed to prevent fusion of unin-
fracture) can be of twO rypes. The first is a Jewitt brace made
volved levels or iatrogenic instabiliry. The interspinous ligamenrs
of a metal frame with a stemal and pubic anterior pad and a
connecting the disrupted vertebrae to the normal cranial and
posterior vertebral pad. The lateral screw connection is used to
caudal vertebrae should nor be removed or violated in any way
secure and adjust the brace. The second rype is a polypropelene
(removing these ligamems can create an iatrogenic ligamenrous
"clamshell" brace with Velcro closure and foam lining. The
instabiliry at the uninjured levels). Normal facer joints also must
brace is molded ro fit the patient, and the anrerior shell comans
nor be violated. Large hemaromas are often encounteted during
rhe sternum and pubis to prevenr kyphosis.
this portion of the procedure; frequent use of warm saline in·iga-
If hyperextension is required, it can be best obtained in a
tion wirh careful dissection allows safe exposure of the disrupted
cast with extension across the hip joint ro a "pantaloon," if
facet joints. Small pieces of bone avulsed from the spinous pro-
extension of the lower lumbar spine is required. A Risser table
or adapted spica table is needed ro apply these body caSts. cesses and a compJetely rorn ligamentum flavum are often en-
counrered in the disrupted area. The disrupted ligamenrum fla-
Chance Fractures vum is carefully removed without violating the dura. Here again,
frequent and copious use of warm saline irrigation will make
If the injUly is truly bony in all columns, closed reduction with the disseCtion easier by lysing the hematoma and elevating tissues
reconstitution of lordosis and cast immobilization are appropn- off the dura. The disrupteJ and frayed facet capsules are re-
ate. If the injury is ligamentous, operative reduction with fusion moved, as well as any bony fragments in the area of the facets
is indicated, because ligamenrous disruptions do nor heal wlth- that might prevent anaromic reduction.
our instabiliry. Glassman et a1. (46) reponed that brace treatment A gradual and genrle reduction is begun by grasping the sepa-
failed only in patients with an initial kyphosis of more than 20
rated spinous processes with rowel clips and gradually reducing
degrees, and they advocate immobilization if kyphosis is less
the kyphosis. The reduction of rhe disrupted facets is evaluated
than 20 degrees. In their series, all children with successful brace
by visual inspection. Spinal cord-evoked porentials musr be care-
treatmenr had a decrease in kyphosis over time because the po-
fully monitored during the redUCtion maneuver. RedUCtion
tential for anrerior growth remained. \'V'hen operative treatment
often can be facilitated by extending the leg portion of the table
is required, the rype of fixation depends on the age of the child.
and bringing the diStal lumbar fragmenr into lordosis. With
In small children, simple interspinous wiring can be suppJe-
small awls or rowel clips, holes are made ar rhe bases of the
menred by posroperative cast immobilization. In adolcscenrs,
spinous processes of the two disrupted vertebrae. The holes
standard compression insrrumenration can be used.
should be carefully placed to ensure thar the dural sac is not
penetrated. A flgure-of-eight wire is passed through the holes.

a OPERATIVE TREATMENT
The wire is tightened and a lateral radiograph is taken to confirm
reduction, using both the facet joints and interspinolls distance
ro confirm anatomic reduction (Fig. 19-15B). If the reduction
Interspinous Process Wiring of . is not adequate, the wire is further tightened until an anatomic
Ligamentous Chance (Lap-Belt) Injury reduction is achieved. The wire is rhen CUt and bent. The articu-
Anesthesia is induced with the patienr supine, and appropriate lar cartilage of the facet joints is destroyed at the level of the
spinal cord monitoring leads are placed. The child is then care- fusion, and an autogenous bone graft is placeJ at the levels to
 ChapiN 19: Fractures o/the Thoracic (/lid Lumbar Spine 861

A B

c D
FIGURE 19-15. Chance fracture. A-E: This 5-year-old girl was a back-seat passenger involved in a motor
vehicle accident at a high rate of speed. She wore a seat belt and sustained a type 8 Chance fracture.
The lateral radiograph intraoperatively obtained for localization of the level for purposes of incision
placement (A). Note the overlying marker. At L2-L3 note the increased disk space posteriorly with
kyphosis and interspinous distance widening, as well as the avulsion fractures of the spinous processes
of L1 and L2. The intraoperative lateral radiograph after interspinous wiring, confirming reduction of
the kyphosis, interspinous widening, and facet joints (8). Lateral (C) and anteroposterior (D) radiographs
9 months later showing maintenance of the reduction and a solid fusion mass. (Figure continues.)
862 Spine

E F

G H
FIGURE 19-15. (continued) E-H: This 9-year-old child was a restrained passenger in a motor vehicle
crash and sustained a type B Chance fracture [anteroposterior (E) and lateral (F)]. which was also associ-
ated with a small element of shear, as noted by the slight lateral and more obvious posterior displace-
ment of L1 on L2. He was completely hemiparetic. He underwent a posterior compression type of instru-
mentation [anteroposterior (G) lateral (Hl]. Two months later, he had complete neurologic recovery.
(E-H courtesy of William Warner, Jr., M.D.)
 Chflpta J9: Fmetlll"£'s of the Thomcic and Lurnbar Spine 863

be fused. To minimize the risk of stenosis, either a local fat graft tion and instrumentation position. Depending on rhe degree of
or gelatin sponge is placed over the exposed dural sac before the intraoperarive stabiJiry and compliance of th.e parienr, either no
bone graft is placed. immobilization or a rhoracolumbosacral onhosis is used.
[f the spinous processes are tOO small to place the wire through
drill holes, the wire can be placed around the spinous processes.
Distraction and Shear Injuries
With a small Kenison rongeur, a small trough is made in the
base of the spinous process, superiorly at the superior vertebrae Unstable injuries, such as vertebral subluxation or fracrure-dis-
and inferiorly at the inferior vertebra. The interspinous ligaments location, should be reduced (21,63,65,88). The child should be
connening the disrupted vertebrae to the normal cranial and placed on a turning frame or at complete bed resr with log rolling
caudal vertebrae should not be removed or violated in any way. until the acure symproms subside, and then operarive reducrion
The spinous processes are then wired together in a figure-of- and flxarion should be performed. In children with neurologic
eight fashion by placing the wire in the troughs in the spinous injury, rhe fracture should be reduced promprly, especially if the
processes. neurologic injury involves the conus medullaris and nerve roots.
After routine closure, the child is carefully rolled supine and Children with bursr fracrures that result in kyphosis and spinal
a pantaloon spica cast is applied, with care LO maintain lumbar canal narrowing of more rhan 25% are ar risk of further canal
lordosis. Radiographs are taken after the cast has hardened, and compromise, and early correction and decompression should be
then the child is awakened. considered (21).
These adult fracrure patterns usually occur in adolescents.
Sponraneous inrerbody rusion seldom occurs; clinicians should

a OPERATIVE TREATMENT
nor rely on such fusion to provide long-term srabiliey (63,88).
The spinal canal and vertebral elemcnts are the same size as
in adults, and adult insrrumenration is used for reducrion and
stabilization (Figs. 19-11 and 19-12). All instrumentation musr
Compression Instrumentation of
be accompanied by posterior spinal fusion at least one level above
Ligamentous Chance (Lap-Belt) Injury
and below the level or levels of injury. In older children wirh
In an older child or adolescent, compression instrumentation severe neurologic deficirs, extending the fusion co the sacrum co
can be used (Fig. 19-15C), usually obviating the need for postop- prevent late onset of paralytic scoliosis is rarely advocared (76).
erative cast immobilization. The same inrraoperative positioning Some injuries that are stable in adulrs may be progressive in
and exposure as for inrerspinous wiring are used. After removal children. Severe crushing or the vertebral body and end plate
or the disrupted and frayed facet capsules, ligamentum flavum, (burst fracrures), wirh or without disruption of the posterior
and bone fragments in the area of the facets, instrumentarion is supporting ligamenrs or laminectOmy, is analogous to ;:. Salrer-
begun. A c1aw-eype construct is made using rwo laminar hooks Harris eype IV injury of rhe vertebral apophysis. Growth arrest
(one on the right and one on the left of the spinous process) in leads to progressive kyphosis (88). Early recognirion, reducrion,
a downgoing fashion over the lamina at the mOSt superior level, stabilizarion, and fusion prevent lare deFormity and neurologic
and twO laminar hooks (again one on the right and one on rhe compromise.
lert of the spinous process) in an upgoing fashion over the lamina The indications for immediate surgical decompression (49)
at the most inferior level. If the superior hooks are at the level are rhe s:lme as in adults: an open wound and progressive neuro-
or the spinal cord or conus, the right and left hooks can be logic deficit in an incomplete spinal cord injury. Reduction of
placed at successive laminar levels instead of at the same level an unstable fracrure-dislocation is a relative indication. Lami-
to minimize the decrease in inrracanal space owing to the nectomy is seldom helpful, especially in childten without bony
sublaminar hooks. Again, the interspinous ligaments connecting injury (49,65). It accentuates an already unstable condition,
the disrupted vertebrae ro the normal cranial and caudal verte- which may lead to progressive deformiey (146) such as kyphosis,
brae should not be removed or violated in any way. lr the instru- which is difflcult ro manage (72,76). Iflaminecromy is necessary,
menration is of the CorreJ-Dubousset eype, all the hooks should it should be accompanied by a short segment fusion.
be closed.
Rods of approptiate length are measured and inserted into the
Slipped Vertebral Apophysis
hooks. Gradual compression is applied, alternately compressing
right and left sides. The adequacy of reduction of the disrupted Surgical treatment is nearly always needed. Lamineccomy and
racets is evaluated by visual inspection. Spinal cord-evoked po- decompression with removal of rhe bony ridge and disk give
temials are carefully monirored during the reduction maneuver. excellent results (22,126). Disk removal alone is not sufflcient
A lateral radiograph is taken to confirm reduction, using both to relieve the nerve root impingement (22).
the facet joints and interspinous distance to veri~' anatOmic re-
duction (Fig. 9-15E). After confirmation of reduction, the hooks
are firmly tighteneJ,~nro the rods, and a fusion is performed as PROGNOSIS AND COMPLICATIONS
previously described. When possible, crosslin king should be used
Growth Arrest
berween the rwo rods.
After routine closure, the patient is carefully rolled supine Progression of the vertebral body deformiey is uncommon in
and r:ldiographs are t:lkcn to confirm ll1:1intenance of rhe reduc- children, unless the injury is Llnstable, such as a fracrure-disJoca-
864 Spine

tion, or a neurologic deficit is present. The vertebral bodies have same problems as an adult with spinal cord rnjury: increased
great potential for restoration because of the stimulation of verte- susceptibility to long bone fractures, hip dislocation, pressure
bral growth and overgrowth (53,63). In children who are under sores, joint contractures, and genitOurinary complications (9). In
10 years of age or have a Risser sign of 0 or I at the time of addition, a child is likely ro develop progressive spinal deformity
injury (106), the vertebral body tends ro rerum to its normal (scoliosis, kyphosis, and lordosis) (Fig. 19-16) (9). For many
shape, even after multiple compression fractures, and kyphosis children, the original vertebral injury often is overshadowed by
is uncommon (62,63,65,69,70,71). However, complete recon- the severity of these late spinal deformities (9). Scoliosis erodes
stirution is possible only if the nucleus pulposus does not pro- the ability to sit easily, and in young children pelvic obliquity
trude into the vertebra (62). The vertebral end plate is the area may lead to subluxation of the hip and ischial pressure sores
of active growth, and if ir is damaged, little subsequent correction (72,76).
of the deformity will occur. The undamaged adjacent vertebra In children (girls under 12 and boys under 14 years of age),
usually compensates for asymmetric growth of a damaged verte- the incidence of progressive spinal deformity after traumatic par-
bra, especially in the thoracolumbar area, and significant scoliosis aplegia is 86% to 100% (9,86). The onset of curvarure has been
seldom occurs (62). Spontaneous interbody fusion is rare in reporred to occur in children as young as 3 years (9). The fracture
children; the interposed, undamaged, interverTebral disk is seldom determines the direction of cutvature; rather, most chil-
thought to block this process (63,71,112). dren develop a long paraJytic thotacolumbar curve thought to
be caused by the influence of gravity and the uneven forces of
spasticity (72). A long thoracolumbar kyphosis reverses the nor-
Spinal Cord and Root Injury
mal lumbar lordosis (76,86). Increased lumbar lordosis is less
The most devastating complication of thoracolumbar spinal in- common (18%) and usually is associated with hip flexion con-
juries is pataplegia. A child with a spinal cord injLllY has the rractures in an ambulatory patient (72,86). Progt'ession of the

A B
FIGURE 19-16. The radiograph of a 9-year-old girl who sustained a motor vehicle accident and poly-
trauma. There were no radiographic vertebral fractures, but she was a complete paraplegic at T10,
believed to be due to a vascular injury and hypotension. A: The anteroposterior radiograph at 11 years
of age demonstrates a mild collapsing type of scoliosis. B: By 13 years and 9 months of age, the curve
had increased to 50 degrees despite aggressive orthotic management. This scoliosis required surgical
instrumentation and fusion.
 Chapter /9: Fractures of the Thoracic find Lumbar Spin£' 865

spinal curvature is directly related fO the age of the child, the most often in the metatarsals and tibia in children. Grier et al.
degree of spasticiry, and the level of the lesion (76,86). Children (47) reported stress fractures of the sacrum in twO children,
with more proximal injuries are more likely to have a progressive both of whom had pelvic pain and positive FABER (flexion,
deformity than are those injured at or below the level of the abduction, external rotation) tests. A bone scan can be used to
conus medullaris (9). localize the pain, and the diagnosis is confirmed by CT scanning.
In adolescents who are near skeletal maturity at the time of Treatment is nonoperative.
injury, spinal deformiry is more often caused by the fracture-dis-
location itself (86). Progressive kyphosis and pain at the fracture Systemic Diseases
sire are common (42%), especially after laminectomy (72,86).
If the kyphosis is progressive, long-rerm neurologic sequelae may Spontaneous collapse of a single vertebral body, especially in a
develop, with furrher loss of function from tenting of tbe neural child between the ages of2 and 6 years (%), suggests the possibil-
structures over the kyphos. This is another reason for early surgi- ity of an eosinophilic granuloma (Fig. 19-(7). Usually there is
cal stabilization of these fractures in adolescents (86). complete collapse of the body (vertebra plana), and the lyric
Treatment of scoliosis should be initiated soon after the in- appearance typical of this lesion in other areas of the skeleton
jury, before a severe curve develops. Total-contact underarm is rarely seen. The intervertebral disk is not affected. An adjacent
plastic orrhoses have been helpful in at leasr temporarily control- soft tissue mass is uncommon and, if present, suggests an infec-
ling the collapsing paralytic curve. Treatment recommendations tious process (such as tuberculosis or a bacterial process) or Ew-
are similar ro rhose for idiopathic scoliosis. Curves of less than ing's sarcoma, instead of eosinophilic granuloma. The prognosis
40 to 45 degrees may be conrrolled by bracing, or at leasr surgery is excellent, with some reconstitution of the height of the verre-
can be delayed until furrher spinal growth has occurred and the bral body and little residual deformiry. However, complete re-
child is of optimal age (74,76). For curves of more than 45 to constitution rarely occurs.
50 degrees, surgical stabil ization should be performed. In one MlJtiple vertebral collapse is common in patients with
series (86), 68% of children required surgical correction. Chil- Gaucher's disease, mucopolysaccharidoses, leukemia, and neuro-
dren wirh severe or rigid curves may require anterior release with blastoma (4,40,89,108). The abnormal cells displace the normal
or withour halo-wheelchair traction. Segmental instrumenra- bone-forming elements, and the vertebra becomes structurally
tion, such as HarringtOn or Luque rods with sublaminar wiring, weak and collapses with minor trauma. Usually these children
or the newer rotational systems (such as Cotrel-Dubousset) are have visceral as well as skeletal involvement at other sites. A bone
used, along with arthrodesis. The child should be quickly mobi- scan and skeletal survey should be obtained to identify these
lized after surgery to avoid the problems associated with long other sites. Typical symptoms are persistent pain in the region
periods of bed rest (such as pneumonia and decubiti in insensate
areas).
Wirh the advent of MRJ, the "rare" posttraumatic syringo-
myelia is being discovered with increasing frequency (13). Symp-
roms can develop many years afrer injury (4.5 years average),
even as late as 15 years (141). Pain is the inirial symptom in
over half of the children, followed by progressive neurologic loss
as demonsrrated by sweating below the level of the original le-
sion, loss of motor funcrion, and changes in the deep tendon
reflexes (141). The best method to detect syringomyelia is MRl,
and some researchers have recommended that an initial baseline
MRI be obtained [Q make later detection of syringomyelia easier
(13,83).

Other Spinal Injuries

The fractures discussed in the preceding sections are acute rrau-
matic injuries. Fractures or fracture-like conditions of the rho-
racic and lumbar spine in children can result from causes other
rhan acute tmuma, including repetitive stress, systemic disease
rhar creates pathologic bone, socieral mechanisms of trauma
(such as child abuse and gunshot wounds), spondylolysis and
spondylolisthesis, and lumbar and dorsolumbar Scheuermann's
disease.

Stress Fractures
FIGURE 19·17. The lateral radiograph of a girl 2 years and 1 month
Srress fracwres (31) are caused by abnormal or repetirive loading of age with eosinophilic granuloma of T12. Note the vertebra plana
of normal bone. They typically occur in young active individuals, with maintenance of the disk space height.
866 Spine

A B
FIGURE 19·18. Gaucher's disease. The illness is progressive with increased storage of the abnormal
metabolite and structural weakening of the vertebral elements. A: Normal appearance of the thoraco-
lumbar spine at 5 years of age. B: At 8 years of age a spontaneous compression fracture of L1 has
occurred. The patient sustained many similar fractures until her death 3 years later.
 Chapter /9: Fractures of the Thoracic and Lumbar pine 867

osreogenesis imperfecra (Fig. 19-20). However, rhese children

usually have rhe rypical srigmala, such as long bone fragiliry,
exrremiry deformiry, and blue sclera. Progressive spinal deformi-
ries of scoliosis and kyphosis are common in severely involved
children. Compression fracrures wirh kyphosis also can be caused
by cerrain conditions associared with systemic osreoporosis, such
as cysric fibrosis, or as a consequence of treatmenr, such as corri-
costeroid-induced osteoporosis in children with severe juvenile
rheumatoid arthritis (114,137).
Compression fracrures also occur in patients with idiopathic
juvenile osteoporosis (Fig. 19-21), an unusual acquired systemic
condirion characterized by profound osteoporosis in otherwise
normal prepuberral children, rypically berween rhe ages of 8 and
15 years (68). The condition may be confused wirh osreogenesis
imperfecra; however, ir is of limired durarion, usually 1 to 4
years, and is followed by nearly normal restoration of rhe skele-
ron. Osreoporosis is evidenr radiologically, and fracrures occur
wirh minimal trauma. There is no family hisrary, and parients
do not have the blue sclera, wormian bone skull changes, or
poor teeth characrerisric of osteogenesis imperfecta (68). Inirial
complaints are usually relared 1'0 the spine, and if rhe condition
is recognized, early rrearmenr with a Milwaukee brace improves
rhe appearance and reduces the amount of kyphosis and
residual deformiry. An even rarer osreoporosis is associared
with heparin use, and compression fracrures rarely occur in
children with severe cardiac disease rhar requires long-term
heparin treatment to prevent rhromboembolic phenomena
(Fig. 19-22).

Spinal Fractures Caused by Child Abuse or Gunshot

Wounds
Vertebral injuries caused by child abuse are less common than
injuries of rhe exrremities (131). Spinal injuries are usually
caused by nyperfJexion and may be simple compression of rne
FIGURE 19-19. The lateral radiograph of a 13-month-old infant evalu- venebral bodies, avulsion of the secondaq cenrers of ossification
ated for delay in motor milestones and subluxation of the hips. Note
of the spinous processes, or, less frequently, nemiation of the
the beaking of the T12 vertebral body. This finding is compatible with
storage diseases such as mucopolysaccharidoses, mucolipidoses, or hy- nucleus pulposus into the vertebral body. Fracture-dislocations
pothyroidism. In this situation, further clinical and laboratory investiga- (Fig. 19-23) or kyphosis secondary ra severe disruptions are rare,
tion is required. This particular child was diagnosed with Hurler's syn-
(27,34,73,131), alrhough there are striking examples ofT12-Ll
drome on the basis of laboratory studies.
subluxation-dislocation wirh complete paraplegia from spank-
ing (32,110). Tnese are actually Salrer-Harris rype I fractures of
rhe vertebral centrum from the cal-tilaginous end plate and may
mimic a central nervous sysrem rumor (24). There are no radio-
of rhe collapse. Neurologic complicarions are rare. In children graphic vertebral changes specific for the bartered child syn-
wirh leukemia rhe peripheral leukocyre counr may be normal drome. Kleinman and Marks (73) found rnree main patrerns:
despire verrebral involvemenr and collapse (89). (a) compression, usually no more rhan 25% of tne anrerior half
In parienrs wirh Gaucher's disease, rhe bone-forming ele- of tne vertebral body; (b) fracture of the anterosuperior aspect
menrs are replaced by an infilrrare of glucocerebroside-conrain- of the vertebral body with extension inro tne anterior aspecr of
ing rericulum cells. One or more verrebrae may collapse, bur a rne end plate; and (c) combined lesions. Similarly, rhe classic
gibbus is rare (Fig. 19-18). The mucopolysaccharidoses, chon- corner fracrures of the long bones are presenr in only 15% of
drodysrrophies, and lipidoses are similar 1'0 Gaucher's disease, abused children. A hign index of suspicion is more nelpful tnan
wirh cellular srorage of an abnormal merabolire and srrucrural a specific radiographic finding. The children mayexhibir other
weakness. Verrebral changes are rypically fi rsr nored ar rhe rhora- signs of neglecr, such as poor nutririon and poor hygiene.
columbar juncrion, wirh anrerior herniarion of rhe nucleus pul- Spinal injuries caused by gunshor wounds are increasing in
posus, and appear on radiographs as a "beaking" of rhe verrebral frequency. At Rancho Los Amigos Medical Center, berween
body (Fig. 19-19). Depending on rhe severiry of lhe disease, rhe 1985 and 1989, gunshor wounds in children accounted for rhe
process may involve rhe enrire spine (4). same number of spinal cord injuries as did moral' vehicle
Serial compression fracrures are common in parienrs wirh accidents (38% each). Before 1970, gunshor wounds accounted
868 pine

A B
FIGURE 19-20. Compression fractures seen in osteogenesis imperfecta. A: The lateral radiograph of
the spine at 3 years of age with compression fractures of the lumbar vertebrae. B: At age 7, compression
fractures of every vertebrae, with narrowing of the vertebral body and apparent increase of the interver-
tebral disk spaces representing disks that have retained their normal elasticity.

for only 6% of spinaJ injuries (50). Laminectomy does nor opmenral and congenital origins. Congeniral deficiency of rhe
affecr the oU[come of pariems wirh complere lesions and is sacrum and lack of inregriry of the posterior structures, on a
derrimental to rhose with incompJere lesions (127), resulting generic basis, may predispose ro spondylolysis. DevelopmentaJ
in cerebrospinJI fluid fisrulas, inFecrion, and Iare instability. Facrors such as rrauma, posrure, or certain reperirive acriviries
Thus, laminectomy is rarely needed (28,127), and the only may cau~e a srress fracture of rhe pars inrerarticularis.
indicarion for surgery is a progressive neurologic deficir (54). Spondylolysis occurs in children after vvalking ~ge. It is rare
One exceprion may be a motor lesion berween T 12 and L4, in children younger than 5 years of age and has been reported
where one series showed a significantly berter morar recovery in only one infanr (17). Ir is mosr common in children aged 7
after buller removal (140). or 8 years, suggesting rhar tl"auma is a prominent facror in rhe
eriology (8,143). Spondylolysis can only be produced by forced
hyperexrension, and laboratory tests indicare thar a high degree
Spondylolysis and Spondylolisthesis of force is required (60). Although minor rrauma is common
Spondylolysis occurs in approximarely 5% of rhe general popula- (50% of males and 25% of females) and often initiates the onset
rion. Its origin is conrroversial, with data supporting barh devel- of symptoms, seldom is rhe injury severe (56). Rarher, the onset
 Cbl/pler /9: Fractures of tbe Thoracic and Lumbar Spine 869

FIGURE 19-22. The lateral radiograph of a 15-year-old boy on long-

term subcutaneous heparin anticoagulation for a congenital cardiac
condition. Note the osteopenia of the vertebrae, the central compres-
sion fractures of the vertebral bodies, and the preservation of the inter-
vertebral disk height.

of symproms coincides closely with the adolescent growth spurt

(135).
Spondylolysis at L5-S1 is often categorized as a congenital
anomaly of the spine. Although there is no supporting embryol-
ogic or anaromic evidence for this designation, several findings
favor a congenital origin. A high rate of occurrence among family
members and certain ethnic groups has been reported by numer-
ous researchers, with an incidence of 27% to 69% in near rela-
tives versus an expected frequency of 4% to 8% in the general
population (145). There are also racial and sex differences, with
the lowest incidence in black females and the highest (6.4%)
in white males. Persons with spondylolysis have an increased
incidence of sacral spina bifida (28% to 42%) and congenital
lack of development of the proximal sacrum and superior sacral
facets (145).
B Substantial documentation supportS the theory that spondy-
lolysis represents a stress fracture of the pars inrerarricularis (77,
FIGURE 19-21. Idiopathic juvenile osteoporosis. This is a systemic con-
dition characterized by the onset of osteoporosis in an otherwise nor- 143). Some researchers have postulated rhat lumbar lordosis is
mal prepubertal child, typically between the ages of 8 and 15. A: The accentuated by the normal hip Aexion conuacrures of childhood,
patient has sustained multiple spontaneous compression fractures with focusing the force of weight bearing on the pars incerarricularis
considerable kyphosis and deformity of the vertebrae. B: Early treat-
ment with a Milwaukee brace improved his appearance and reduced and leading to gradual disruption (75). Anatomic studies suggcsr
the degree of kyphosis and residual deformity. that shear stresses are greater on the pars interarricularis when the
870 Spine

A B

c D
FIGURE 19-23. The radiographs of a 10-month-old girl with paraplegia from a thoracolumbar fracture
due to child abuse. The child presented to the emergency department with "acute onset" paraplegia.
A skeletal survey also discovered healing clavicle and rib fractures, consistent with abuse. After investiga-
tion by the Department of Social Services, the father was criminally prosecuted and subsequently incar-
cerated. A: The lateral radiograph shows anterosuperior Schmorl's nodes at T12 to L2, as well as compres-
sion of the vertebral body of L2. There is callus formation at the inferior aspect of the L2 vertebral body.
Note that the disk height is relatively preserved. B: The anteroposterior radiograph shows callus between
L2 and L3 and compression of L2. C: The magnetic resonance image (T2-weighted) shows an area of
increased signal intensity, representing cord edema (arrow). D: The magnetic resonance image (T1-
weighted) shows the protrusion of the intervertebral disk into the anterior margin of the vertebra
(arrow) with its associated compression of the body. Note the multiple levels of disk disruption and
vertebral body compression.
 Chapter 19: Fractures of the Thoracic and Lumbar Spine 871

spine is extended (75,77). In children, the pars interarticularis is (so-called spasm), and this has been attributed to nerve root
thin, the neural arch has not reached its maximal strength, and irritation; however, no objective evidence supports this conten-
the intervertebral disk is less resistant to shear (29). A fatigue tion (8,105,135). Hamstring tightness is seldom accompanied
fracture can occut at physiologic loads during cyclic flexion-ex- by neurologic signs (8,120)
tension motion of the lumbar spine (77). These stresses may be Children, unlike adults, seldom have objective signs of nerve
further accentuated by lateral flexion movements on the ex- root compression, such as motor weakness, reflex change, or
tended spine, as may occur during a back walk-over in gymnas- sensory deficit (135). Examination, however, should include a
tics (75,77). Spondylolysis is four times more frequent (II %) careful search for sacral anesthesia and bladder dysfunction. Sim-
in female gymnasts than in other girls of the same age (64); ilarly, children with spondylolysis rarely have myelographic evi-
many initially have normal radiographic results and later develop dence of disk protrusion or evidence of herniation at surgical
spondylolysis. Recent evidence has demonstrated the presence exploration (56,135).
of synovial pseudarthroses at the site of the spondylolysis, which
also communicates with the facet joint just superior to it. This Radiographic Findings
suggests that stress fractures of the pars intertarticularis due to If the radiolucent defect in the pars interarticularis is large (Fig.
repetitive trauma fail to heal because of the presence of synovial 19-24), it can be seen on nearly all tadiographs of the lumbar
fluid from a nearby facet joint; this eventually results in a spon- spine. If the defect is unilateral, as it is in 20% of patients, or
dylolysis (121). is not accompanied by spondylolisthesis, special imaging tech-
Acute spondylolysis has been reported in soldiers who carry niques may be required (78,85).
heavy backpacks or perform exercises to which they are unacclls- Oblique views show this area in relief and apart from overly-
tomed (143). In many, the defect healed with conservative treat- ing bony elements; the diagnosis is missed in 20% of young
ment, whereas others developed pseudarthrosis, persistent symp- patients if oblique views are not obtained (78). The "Scotty
toms, and the typical radiographic appearance of spondylolysis. dog" of Lachapele, with the defect appearing at the terrier's
An increased frequency of spondylolysis has been noted in teen- neck, is a helpful visual aid to those inexperienced with oblique
agers with thoracolumbar Scheuermann's disease, a condition radiographs (Fig. 19-25). In an acute injury, the gap is narrow
believed to be caused by excessive and repetitive mechanical with irregular edges, whereas in a long-standing lesion, the edges
loading on the immature spine (98). Similarly, thoracolumbar are smooth and rounded, suggesting a pseudarthrosis (Fig. 19-
kyphosis is often associated with a compensatory increase in 26). The width of the gap depends on the amount of bone
lumbar lordosis. Those performing heavy physical work, such resorption after the fracture and the degree 'of spondylolisrhesis.
as weight-lifters, lumberjacks, and football lineman, also have Less commonly, symptomatic children (26%-35%) have
been reported to be more at risk for spondylolysis (79). poorly developed or dysplastic (Wiltse type I) posterior struc-
tures (55,142). Because of anomalous development, the poste-
Signs and Symptoms rior facets appear to subluxate on the sacral facets. In children
Although spondylolysis commonly occurs in late childhood or with dysplastic posterior structures, rather than a gap or defect
early adolescence, symptoms are relatively uncommon in chil- in the pars interarticularis, the facets appear to subluxate and
dren and rarely are severe enough to require medical attention the pars interarricularis may become attenuated like pulled taffy.
during the teenage years (39,55). In a prospective longitudinal This has been called the "greyhound" of Hensinger (56); a defect
survey, only 13% of children known to have spondylolysis devel- may later appear in the center. This may be a different manifesta-
oped symptoms before 18 years of age (39). In the occasional tion of the same disease process, because both lesions are present
child who develops symptoms, the onset usually coincides with in members of the same family (145), suggesting that the spon-
the adolescent growth Spurt (56,120). dylolytie type represents an acute stress fracture of the pars inter-
Although pain is the major complaint in adults, most children articularis and the dysplastic or elongated type represents a
and adolescents do not have pain and seek medical attention chronic stress reaction with gradual attenuation of the pars.
only because of a postural deformity or gait abnormality caused Deficiency of the posterior elements is common in patients
by hamstring tightness. Pain generally is localized to the low with spondylolysis. Easily observable defects, such as dysraphic
back and, to a lesser extent, the posterior buttocks and thighs or malformed laminae, have been reponed in 32% to 94% of
(56,120). Symptoms usually are initiated or aggravated by stren- these patients, and, if discovered on routine lumbosacral views,
lIOUS activity of the spine common to oarsmen, gymnasts, divers, should prompt a more detailed radiographic investigation (145).
hockey players, tennis players, and baseball pitchers. A combina- CT scanning is rarely indicated in acute fracture of the pars
tion of these factors are present when too much weight is used interarticularis because a combination of bone scanning and
by weight-lifters performing the military press, when incorrect oblique x-rays is more reliable in detecting the lesion (16).
technique is used by gymnasts, and when swimmers or runners Spondylolysis at L4 or L3 is difficult to diagnose with CT scans
make too rapid advances. Symptoms usually are decreased by because the plane of scanning is parallel to the fracture (16).
test and limitation of activities (56,64,77). MRI should be considered if the patient's symptoms or neuro-
Physical examination may demonstrate some tenderness to logic signs do not resolve with bed rest, or if bladder or bowel
palpation in the low back. There may be some splinting, guard- dysfunction or perineal hypesthesia is present.
ing, and restriction of side-to-side motion in the low back, espe- When the diagnosis is suspected clinically but cannot be con-
cially if onset of the condition is acute. If hamstring tightness firmed radiographically (especially in the stress reaction stage
is present, forward flexion of the hips is markedly restricted. before fracture), a bone scan will be helpful, especially a single
Eighry percent ofsymptomatic patients have hamstring tightness photon emission CT scan (12,85). Small, partial, or unilateral
872 Spine

A B
FIGURE 19-24. A: The radiograph of a S-year-old girl with normal appearance of the lumbosacral
junction. B: The same person at age 1S. Spondylolysis and grade I spondylolisthesis have developed in
the interim with symptoms referable to the low back. Spondylolysis in children occurs after walking
age, but rarely before S years, and more commonly at 7 or 8 years. Onset of symptoms coincides closely
with the adolescent growth spurt.

Dysplastic .
A B
FIGURE 19-25. A: Pars interarticularis defect, or spondylolysis, as seen on an oblique view (arrow),
typically found with the isthmic type of spondylolisthesis. B: Similar oblique view of a patient with
dysplastic (congenital) spondylolisthesis, demonstrating elongation and attenuation of the pars interar-
ticularis, perhaps a prespondylolytic defect, and may represent a stress or fatigue fracture of the pars
intra rticu la ris.
 Chapter 19: Fractures of the Thoracic and Lumbar Spine 873

A B
FIGURE 19-26. The radiograph of a 13-year-old boy who felt a snap in the low back during a swimming
race turn. A: Spondylolysis of the pars interarticularis is seen (arrow). The narrow, irregular appearance
suggests recent injury. B: Despite cast immobilization, the fracture did not heal. The appearance 6
months later demonstrates blunting of the bone ends and widening of the gap. However, the patient
was asymptomatic.

Fracrures can be overlooked on x-rays, bur bone scans demon- Feets. A bone scan may be helpful to diFFerentiate a continuing
strate an area of increased bone turnover caused by healing of process From one of a long duration (77).
the Fracture. Bone scanning may demonstrate increased uptake In children in whom the spondylolysis is of long durarion,
in patienrs with only 5 ro 7 days of symptoms 001, 136). Later, healing is unlikely, but symproms usually respond ro conserva-
up ro I year aher onser of symptoms, bone scanning is helpFul tive measures (56). Resrricrion of vigorous acrivities and back
ro distinguish between parients wirh an esrablished nonunion and abdominal srrengthening exercises usually are successful in
(cold bone scan) and r.hose in whom healing is still progressing conrrolling mild backache and hamsrt'ing tightness (55). Pariems
(hot bone scan) and who may beneflr From immobilizarion (77, wirh more severe or persisrenr complainrs may require bed rest,
(36). Bone scanning is nor recommended in parients whose cast or brace immobilization, and nonnarcoric analgesics (28).
symproms are of more rhan 1 year's durarion or who are asymp- Hamstring tighrness is an excellenr clinical guide to rhe success
romaric (136), unless a bone tumor (such as osreoid osreoma), or Failure of the rrearment. Most children have complere relieF
inFecrion, or malignancy is suspected. of symptoms or only minimal discomforr at long-rerm follow-
Bone scanning is especially helpful in young arhleres whose up (135).
acrivities are highly associated wirh spondylolysis, such as gym- Any child or adolescent wirh symptoms caused by spondylo-
nastics (64). Early detecrion of rhe srress reacrion allows early lysis, especially those under 10 years of age, should be closely
trearmenr, which can shorren rhe recovery period. Bone scanning Followed For progression ro spondylolisrhesis (143). We do nOt
also can be used ro evaluare recovery and determine when an advise rhose wi rh asymptomaric spondylolysis or rhose with min-
arhlere can re[llrn ro comperirion (64). imal symproms ro restrict their activities; 7.2% of asymptomaric
young men 18 to 30 years of age have pars deFecrs and relatively
Treatment few have persistenr symptoms (92). Progression is unlikely with
In some children and adolescenrs, rhe spondylolytic defect may comperirive sportS activiries (94). Thus, limirarion of acriviry in
heal with 3 to 6 monrhs' casring or bracing (rhoracolumbosaCl"al a growing child does nor seem justified (55). Ir must be empha-
orrhosis) iF rhere is an acute, clearly documented onser wirh sized rhar spondylolysis is rarely sympromaric in adolescence,
injury (135,136,143) or if the lesion is early in irs course (93). and caurioll is advisable in treating a child whose symproms do
Healing is more likely with unilareral deFects rhan bilateral de- not respond ro bed resr or who has objecrive neurologic ftndings.
874 ,pine

In this situation, MRJ and possibly electromyography should (13-17 years of age) and is accom panied by a period of moder-
be considered. ately severe pain with activity. Patients usually have a history of
A small percentage of young persons with spondylolysis do acute back strain or injury (14,46,87). Wassmann noted that
not respond to conservative measures or are unwilling to curtail the condition was eight times more common in "lads from the
their activities and may require surgical stabilization. If surgery COUntty" (139), and others have reported that the lumbar verte-
is necessary, a posterolateral fusion from L5 to S 1 with autoge- bral changes often are associated with hard physical labor before
nous bone graft usually is sufficienc. If spondylolisthesis is of the age of 16, suggesting that the maturing end plate and verte-
grade III or greater, the fusion usually is extended to L4 (56). bral body ate more vulnerable to increased mechanical strain
Nachemson (95) reported solid healing of the defect after bone during this period of rapid growth (14,46,139). Hafner (51)
grafting and intertransverse ptocess fusion. coined the term apprentice kyphosis, or kyphosis muscularis, and
In patients with small defects (6-7 mm) and only slight spon- he found that it occurred more commonly in boys (2: 1) between
dylolisthesis, a variety of techniques have been described for direct the ages of 15 and 17 years, duting the growth spurt. Micheli
reduction of the defect, including wiring of the transverse process (90) found similar lumbar changes in young athleres and sug-
or placement of a screw across the pars, coupled with a bone graft gested that the cause was a localized stress injury to the vertebral
(such as in a pseudarthrosis repair) (20,36,97,104). These proce- physes.
dures usually are recommended for older adolescents and young The apophyseal ossification centers first appear in the lower
adults «30 years of age) with minimal displacement and degen- thoracic region at approximately 9 years of age and fuse with
erative change (95,97). The best candidates for this method of the vertebral bodies berween the ages of 17 and 22 years. The
treatmen t are those wi th defects berween L 1 and L4 or those wi th ring is thinner in the middle than in the periphery. Increasing
multiple defects. This is an am'active alternative to the traditional the pressure in the intervertebral disk forces it through the center
transverse process fusion because it repairs the defect at one verte- of rhe end plate and into cancellous bone of the vertebral body
bral level rather than involving a second nonaffected verrebrae (Fig. 19-27) (67). The mechanism is analogous to the produc-
(20,104). In properly selected patients, 80% to 90% obtain a solid tion of Schmorl's nodes and is accompanied by narrowing of
fusion with good to excellent results. In children, the Gill proce- the disk space (59,67,111). Similarly, metabolic and neoplastic
dure or laminectomy should never be performed without an asso- diseases that lead to structural weakening of the bone are often
ciated fusion because removal of the posterior elements may lead associated with Schmorl's node formation (111). Marginal
to increased instability and spondylolisthesis. Schmorl's nodes are more often associated with trauma, and
A rare type of spondylolisthesis, acute spondylolytic spondy- central nodes are more frequent and consistent with thoracic
lolisthesis, has been described (58). This injury is caused by Scheuermann's disease (3). In experimental models, heavy lift-
high-energy trauma and is an unstable spinal injury, similar to ing, especially when seated and bending forward, increased the
a fracture-dislocation, usually in the pars interarticuJaris of L5. intranuclear pressures to the lower end of the range necessary
The so-called traumatic spondylolisrhesis (type IV) is caused to produce fracture through a normal vertebral end plate (Fig.
by a fracture in areas of the bony hook other than the pars ] 9-28) (67). Flexion-extension motion of the spine, as in row-
interarticularis, differentiating these two acute types of spondy- ers, weight lifters, and gymnasts, can produce these same forces
lolistheses. The deformity typically progresses, and some patients (Fig. 19-29) (90).
develop neurologic compromise. Because of their instability, Back pain may be present from 2 to 6 months and is increased
high risk of progression, and possibility of developing neurologic with activity, accentuated by fOlward flexion, and relieved by
compromise, these injuries should be treated operatively. Grade [ rest (14,46). Conservative treatment such as bracing usually is
deformities can be adequately treated with posterior arthrodesis; sufficient (67,125). OccasionaJly, bed rest or plaster immobiliza-
more severe deformities may require both anterior and posterior tion is required. There are no reports of children needing surgery
arthrodeses because of the greater disruption of secondary liga- for symptOms, and only a few have required correction for defor-
mentous restraints (58). mity. The vertebral changes progress slowly toward healing dur-
ing the time of remaining growrh. Schmorl's node formation
and disk space narrowing generally persist (Figs. 19-28 and 19-
Lumbar and Thoracolumbar Scheuermann's Disease 30) (87). The apophyseal fragment at the anterior margin of the
Scheuermann's disease is a common cause of thoracic kyphosis vertebral body seldom heals.
and is seldom painful. Children present with cosmetic concerns The kyphotic deformity may progress because of the anterior
and are subsequently found to have the ch.aracteristic vertebral deformation of rhe venebral bodies from the original injury or
changes. Sorenson's radiographic criterion of three or more adja- because of increased pressure on the anterior margin with cessa-
cent velTebrae wedged more than 5 degrees (125) confirms the tion of growth in that region. The kyphosis generally is not
diagnosis. End plate irregularity, Schmorl's node formation, and severe and seldom requires any specific treatment. For severe
nan'owing of the disk space are common but are nor in them- deformity in a skeletally immature patient with kyphosis exceed-
selves diagnostic. Thoracic Scheuermann's disease is typically ing 50 to 60 degrees, a Milwaukee brace is recommended (Fig.
limited to the thoracic verrebrae, spontaneous in onset, and due 19-31). Surgery is rarely needed.
to hereditary influences. Lumbar or thoracolumbar osteochon-
dritis is less common but is more often accompanied by pain (14, ACKNOWLEDGMENTS
46,139). Several researchers suggest that the lumbar vertebral
changes are the resul t of trauma (14,46,139). Lumbar or thora- The author and editor wish to thank Dr. John Herzenberg for
columbar Scheuermann's disease primarily affects adolescenrs his past contributions to this chapter.
 Chapter J9: Fractures of the Thoracic and Lumbar Spil/e 875

J.L. 15+3

A B
FIGURE 19-27. Radiographs of a 15-year-old boy with persistent back pain in the mid-lumbar region
following a weight-lifting program. A: The routine lateral view suggests mild end plate changes. B: A
lateral tomogram demonstrates Schmorl's node formation and end plate irregularity of T11. Subtle
changes on routine films may belie significant end plate changes or disk protrusion into the vertebral
body.

15+11
A B
FIGURE 19-28. A: Acute herniated Schmorl's node in a 15-year-old weight lifter with back pain and
nodes at L2, L3, and L4. B: Eight months later there has been continued growth of the vertebrae without
progressive deformity.
 876 Spine

FIGURE 19-28. C: At 21 years of age the sites of the

21+6 Schmorl's nodes are still seen, although they appear
smaller. The minimal wedging at L2 has not changed in the
c preceding 6 years.

FIGURE 19-29. A: Radiographs of a 13-

year-old boy who sustained vertebral
end plate changes at several levels while
playing football. Note the associated
spondylolysis (arrow) and mild spondy-
lolisthesis. The patient's discomfort re-
sponded satisfactorily to bracing. B: The
radiographs at age 17 years demonstrate
the continued free fragment appearance
of the vertebral apophysis at several lev-
A,S els and persistence of Schmorl's nodes.
 Chapter 19: Fraeturrs of the Thome-ic and Lumbar Spine 877

A B
FIGURE 19-30. A: Radiographs of a 13-year-old girl who sustained anterior compression of the L1
vertebra during gymnastics, with 12 degrees of wedging. She had persistent discomfort over several
months that responded to bracing. B: At 15 years of age she was asymptomatic; there has been no
remodeling of the deformity.

A B
FIGURE 19-31. Radiographs of a 15-year-old girl with persistent back pain and deformity following
gymnastics. A: Vertebral end plate changes, Schmorl's node, and gibbus at the thoracolumbar junction.
B: Treatment with the Milwaukee brace improved alignment by reducing the deformity.
878 Spine

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 LOWER
EXTREMITY
 FRACTURES OF THE PELVIS
S.TERRANCECANALE
JAMES H. BEATY

DIAGNOSIS FRACT R S OF THE SACR M

Mechanisms of Injury FRACTUR .S OF THE C CCYX
Signs and Symptoms FRACTURES OF THE IPSILATERAL RAMI
Associated Injuries FRAC URES NEAR OR SUB UXATION OF THE
Radiographic Studies and Other Imaging SYMPHYSIS PUBIS
FRACTUR S EAR OF SUBLUXATION OF THE
CLASSIFICATION SA ROILIAC JOINT
U STABLE FRACTUR- PA" TERNS
APPLIED A ATOMY
Bilateral Fractures of the Inferior and Superior Pubic Rami
Ossification Centers
Complex Fracture Patterns
AV LSIO FRACTURE Severe Multiple or Open Fractures
Mechanism of InjUlY ACETABULAR FRACTURES
Diagnosis Classi fication
Treatmenr and Prognosis Radiographic Evaluation
Treatment
FRAC RES F THE P BT OR l 'H lUM
SurgicaJ Treatment
Fractures of the Body of the Ischium
Postoperative M anagemenr
Stress Fracwres of the Pubis or Ischium
Fractllres of tne Wing of the Ilium (Duverney Fractllre) COMPLICATIONS

Pelvic fractures constitute only] % to 3% of all fractures in related exsanguination was the cause of death in only 0.3%,
children. The most imporranr aspect of treatment of these frac- whereas 3.4% of deaths Ln adults were due to pelvic fracture
tures is the reaJization tnat such a fracture is an indication that exsanguination.
significant trauma has occurred and other injuries to neurovascu-
lar suuctures, abdominal viscera, the genitourinary system, and
DIAGNOSIS
tne musculoskeletal system also may have occurred. Fractures of
the pelvis and spine are associated with the longest hospital stays, Mechanisms of Injury
the most admissions to the intensive care unit, and the highest
Most pelvic fractures in children are caused by vehicular acci-
rates of mortality in patients with multiple injuries (9,60). When
dents. From Rang's early reports (50) to more recent series (3,
a fracture of a child's pelvis is seen on an initial radiograph, it
4,5,14,27,30,33,40,52,54,61), 70% to 90% of reported pelvic
should be an indication that associated life-threatening soft tissue
fractures in children were caused by traffic accidents. Mosr ofren
injuries may be present, and tne treatment of these injul'ies
the injured child is a pedesrrian struck by a car. Avulsion injuries
should take priority over management of the fractllrc. Mortality
usually occur in athletic activities, especially gymnastics, track,
rateS in children with pelvic fractures have been reported to be
and soccer. Child abuse is a rare eriology (34,44).
as high as 25% (49), but more recent series report mortality
rates of 2% to 12% (18,27,33,52,61,63). Tn 1,254 patients with
pelvic fractures, Ismail et al. (27) reported an overall mortaJity
Signs and Symptoms
rate of5% for children and 17% for adults. In children, fracture- The evaluation of a child with a suspected pelvic fracrure begins
with a thorough histOly and physical examination. Often a child
with a pelvic fracture has concomirant multiple injuries abour
S. Terrance Canale: D"p'lrllnellf ofOnlwp""lics, L:ni\'crsiry ofTcnncssec, the head, chest, abdomen, and genitourinalY tracr, and th~sc
C\lllpbdl Clinic, Memphis, Tcnnessec.
other injuries take precedence concerning operative intervention
James H. Beaty: Department of OrthOp3edic Surgery, University of
Tennessee, Campbell Clinic, ~nd LeI1nnhclII" Childr,·,,'s Medicol Center, to srabilize the child's condition. The pelvic fracture itself often
~1l:mphisl TenIlessee. has low priority in the critical care of a child with poJyuauma.
 FRACTURES OF THE PELVIS
S.TERRANCECANALE
JAMES H. BEATY

DIAGNOSIS FRACT R S OF THE SACR M

Mechanisms of Injury FRACTUR .S OF THE C CCYX
Signs and Symptoms FRACTURES OF THE IPSILATERAL RAMI
Associated Injuries FRAC URES NEAR OR SUB UXATION OF THE
Radiographic Studies and Other Imaging SYMPHYSIS PUBIS
FRACTUR S EAR OF SUBLUXATION OF THE
CLASSIFICATION SA ROILIAC JOINT
U STABLE FRACTUR- PA" TERNS
APPLIED A ATOMY
Bilateral Fractures of the Inferior and Superior Pubic Rami
Ossification Centers
Complex Fracture Patterns
AV LSIO FRACTURE Severe Multiple or Open Fractures
Mechanism of InjUlY ACETABULAR FRACTURES
Diagnosis Classi fication
Treatmenr and Prognosis Radiographic Evaluation
Treatment
FRAC RES F THE P BT OR l 'H lUM
SurgicaJ Treatment
Fractures of the Body of the Ischium
Postoperative M anagemenr
Stress Fracwres of the Pubis or Ischium
Fractllres of tne Wing of the Ilium (Duverney Fractllre) COMPLICATIONS

Pelvic fractures constitute only] % to 3% of all fractures in related exsanguination was the cause of death in only 0.3%,
children. The most imporranr aspect of treatment of these frac- whereas 3.4% of deaths Ln adults were due to pelvic fracture
tures is the reaJization tnat such a fracture is an indication that exsanguination.
significant trauma has occurred and other injuries to neurovascu-
lar suuctures, abdominal viscera, the genitourinary system, and
DIAGNOSIS
tne musculoskeletal system also may have occurred. Fractures of
the pelvis and spine are associated with the longest hospital stays, Mechanisms of Injury
the most admissions to the intensive care unit, and the highest
Most pelvic fractures in children are caused by vehicular acci-
rates of mortality in patients with multiple injuries (9,60). When
dents. From Rang's early reports (50) to more recent series (3,
a fracture of a child's pelvis is seen on an initial radiograph, it
4,5,14,27,30,33,40,52,54,61), 70% to 90% of reported pelvic
should be an indication that associated life-threatening soft tissue
fractures in children were caused by traffic accidents. Mosr ofren
injuries may be present, and tne treatment of these injul'ies
the injured child is a pedesrrian struck by a car. Avulsion injuries
should take priority over management of the fractllrc. Mortality
usually occur in athletic activities, especially gymnastics, track,
rateS in children with pelvic fractures have been reported to be
and soccer. Child abuse is a rare eriology (34,44).
as high as 25% (49), but more recent series report mortality
rates of 2% to 12% (18,27,33,52,61,63). Tn 1,254 patients with
pelvic fractures, Ismail et al. (27) reported an overall mortaJity
Signs and Symptoms
rate of5% for children and 17% for adults. In children, fracture- The evaluation of a child with a suspected pelvic fracrure begins
with a thorough histOly and physical examination. Often a child
with a pelvic fracture has concomirant multiple injuries abour
S. Terrance Canale: D"p'lrllnellf ofOnlwp""lics, L:ni\'crsiry ofTcnncssec, the head, chest, abdomen, and genitourinalY tracr, and th~sc
C\lllpbdl Clinic, Memphis, Tcnnessec.
other injuries take precedence concerning operative intervention
James H. Beaty: Department of OrthOp3edic Surgery, University of
Tennessee, Campbell Clinic, ~nd LeI1nnhclII" Childr,·,,'s Medicol Center, to srabilize the child's condition. The pelvic fracture itself often
~1l:mphisl TenIlessee. has low priority in the critical care of a child with poJyuauma.
884 Lower E\'tremity

The examination of tne pelvic area begins with a visual in- reported closed head injuries in approximately 30% of patients
spection. Areas of contusion, abrasion, laceration, ecchymosis, (30,33,61). Although injury to the brain has a higher prioriry
or hemarama, especially in the perineal and pelvic areas, should and needs more immediate arrention than fractures in a child
be recorded. with polycrauma, inadequately treared pelvic fractures can result
Landmarks such as the anterior superior iliac spine, crest of in permanent disabiliry and should be trcated with expectation
the ilium, sacroiliac joints, and symphysis pubis should be pal- of full neurologic recovery.
pated. Exerting posrerior pressure on the anterior superior iliac Pelvic fractures with posterior displacement of the hemipelvis
crest produces pain at the ftacture site as the pelvic ring is or iliac wing can damage the lumbosacral plexus, as well as the
opencJ. Compressing the pelvic ring at the iliac crest from the sciatic, femoral, and obturator nerves. Neurologic examination
latera'l co the medial direction also causes pain, and crepitation of the lower extremities should be routine, and documentarion
may be felt if a pelvic fracrure is presenr. Pressure downward on of any neurologic deficit is essential.
the symphysis pubis and posteriorly on rhe sacroiliac joints Fractures of other bones are present in approximately half
causes pain and motion if there is a fracrure in the pelvic ring. of children with pelvic fractures (30,33,52,54,61). The mosr
The range of motion of the extremities, especially of the hip frequently fractured bones are the femur, tibia, and fibula. Vaz-
joint, should be determined. Occasionally, pain in the inguinal quez and Garcia (63), in a study of 79 children with pelvic
area is noted during flexion and extension of the hip if there is fractures, found that the presence of any additional fracture was
a pelvic fracture. a significant indication that head or abdominal injury also was
present and that transfusion would be required in the first 24
hours after injury. Death, thoracic injuries, and patients requir-
Associated Injuries
ing Japarotomy or an additional nonorthopaedic procedure were
Because most pelvic fractures in children result from high-veloc- twice as frequent in the group with additional fractures as in
ity rrauma, injuries other than the pelvic fracture usually are the group with pelvic fractures only. Vazquez and Garcia (63)
present. Of the 43 children with pelvic fracrures reported by suggested that this easily identifiable risk factor can help identify
Blasier et a1. (3), 25 (58%) had associated injuries, most often patients who may benefit from early transfer to a regional pediat-
multiple fracrures, closed head injuries, and spine injuries. The DC trauma center.
incidence of concomitant injuries increases with the severiry of
the pelvic fracture. Bond et al. (5) noted that the location and
Radiographic Studies and Other Imaging
number of pelvic fracrures were strongly associated with proba-
biliry of abdominal injury: 1% for isolated pubic fracrures, 15% All toO often in an emergency situation, the child's well-being
for iliac or sacral fracrures, and 60% for multiple fractures of is jeopardized in one of the least desirable emergency areas of
the pelvic ring. Poole et al. (47) suggested that the outcomes of the hospital, the radiology department. Radiographs should be
patients with pelvic fractures were determined by the associated obtained only after the patient is stabilized. Rarely do radio-
injuries rather than by the pelvic fracture. graphs on an emergency basis help the physician stabilize the
As in adults, retropetironeal hemorrhage is the most serious child. Once the patient is clinically stable, only pertinent radio-
life-threatening complication in children with unstable pelvic graphs should be ordered by the physician in charge. If special
ring disruptions. Marked cephalad displacement of the hemi- views are necessary, then the physician ordering these films
pelvis can injure the superior and inferior glureal arteries at the should be in attendance. SCOut views of the skull, chest, abdo-
sciatic notch. Injury of the iliac or femoral artery is uncommon men, pelvis, and long bones should be procured quickly.
except with open fractures involving the anterior pelvic ring In a child with a pelvic fracture, unless mere is a signifIcant
(60). McInryte et a1. (33) correlated the risk of life-threatening fracture-dislocation, multiple radiographic views can be de-
hemorrhage ro pelvic fracrure complexiry. Patients with bilateral fen·ed. When the child is stable, multiple views of the pelvis
anterior and postel·ior fracrures required rransfusions signifI- should be taken (29). With the patient supine, the pelvis has
candy more often than those with other types offracrures. Ultra- a normal tilt of 25 degrees posteriorly. Thus, taking only an
sonography or perironeaJ lavage help rule out intraabdominal anteroposterior film of the pelvis gives, in realiry, an oblique
IIlJUIY· projection, which, as in radiographs of other long bones, is not
Hemaruria has been reponed in from 34% co 57% of chil- the most desirable view. As an aid to diagnosis, a 25-degree
dren with pelvic fractlires, usually without any significant urinalY caudad (inlet) view reveals the amount of internal or external
tract injury. When hematuria is accompanied by an inabiliry to rotation deformiry or the amount of displacement. Also useful
void, blood at the urethral meatus, or abnormaliry of the pros- in determining the amount of roration in the anteroposterior
tate, genirourinalY consultation should be obtained. Most uro- plane is the 35-degree cephalad (outlet) view. The pelvis can be
logic injuries occur with fractures of the anterior pelvic ring (60). tilted into internal and external roration to determine fractures
The reported incidence of genirourinary injuries (bladder or ure- of the acetabulum and pelvic ouder. A description of these views
thral rupture, vaginal or scrotal tear, kidney injlllY) averages recommended by Judet is given in Chapter 35 of Fractures in
approximately 5%. Adults (Volume 2 of this series). Comparison views of the contra-
Children with pelvic fractures are more likely ro have head lateral apophysis may be helpful in evaluating avulsion fractures.
injuries than are adults widl pelvic fractures. Rieger and Brug Computed tomography (CT) scanning helps determine the
(52) reported head injuries ranging from mild concussion to presence of fractures and any disruption or incongruiry of the
brain death in 48% of their 54 patients, and other series [lave sacroiliac joint, sacrum, or acetabulum. Newer, rapid CT scan-
 Chapter 20: Fractures of the Pelvis 885

ners can obtain a full pelvic scan in the initial evaluation. Three-
TABLE 20-1. TORODE AND ZIEG
dimensional CT images show more clearly superior or inferior CLASSIFICATION OF PELVIC
displacement of tne hemipelvis if a pelvic ring injury is present FRACTURES IN CHILDREN
and help define the degree and direction of any acetabular dis-
placemenr or rotational deformity (20,35). Magnetic resonance I. Avulsion fractures
II. Iliac wing fractures
imaging (MRl) has the same benefits and also can delineate soft
lIa. Separation of the iliac apophysis
tissue injuries in tne pelvis (35). Occasionally, a radioisotopic lib. Fracture of the bony iliac wing
bone scan is useful for evaluating nondisplaced fractures and the III. Simple ring fractures
rare stress fracture (58,59). lila. Fractures of the pubis and disruption of the pubic
symphysis; the posterior structures remain stable
Ilib. Fractures involving the acetabulum, without a
concomitant ring fracture
CLASSIFICATION IV. Fractures producing an unstable segment (ring disruption
fracture)
IVa. "Straddle" fractures, characterized by bilateral
Quinby (49) and Rang (50) classified pelvic fractures in children inferior and superior pubic rami fractures
inro three categories: uncomplicated fractures, fractures with vis- IVb. Fractures involving the anterior pubic rami or pubic
ceral injuries requiring surgical exploration, and fractures associ- symphysis and the posterior elements (e.g., sacroiliac
joint, sacral ala)
ated with immediate, massive hemorrhage. The prognostic im-
IVc. Fractures that create an unstable segment between
portance of tnis classification is apparent, and it is useful with the anterior ring of the pelvis and the acetabulum
regard to the patienr's ultimate outcome; however, its emphasis,
as it should be in an emergency situation, is on associated soft
tissue injuries rather than on the pelvic fracture itself. Watts (64)
classified pediatric pelvic fractures according to the severity of
skeletal injury: (a) avulsion, such as epiphysiolysis (caused by
violent muscular activity); (b) fracture of the pelvic ring (crusn- in adults to include three types based on mechanism of injury:
ing injury), stable or unstable; and (c) acetabular fracture (associ- anteroposterior compression, lateral compression, and vertical
ated with hip dislocation). Torode and Zieg (61), in a retrospec- shear (Table 20-2). This classification system has been incorpo-
tive analysis of 141 children with pelvic fractures, also classified rated into the Orthopaedic Trauma Association classification,
the injuries based on the severity of the fracture; their classifica- wnich also consists of three main types: A, lesion sparing (or with
tion does not include acetabular fracrures (Fig. 20-1, Table 20- no displacement of) posterior arch; B, incomplete disruption of
I). Tile (59) modified Pennal's classification of pelvic fractures posterior arcn, partially stable; and C, complete disruption of

FIGURE 20-1. Torode and Zieg classification of pelvic fractures in children. Type I, avulsion fractures;
type II, iliac wing fractures; type III, simple ring fractures; type IV, ring disruption fractures.
886 [ower Extremity

pelvis is more malleable because of the nature of the bone itself,

TABLE 20-2. TILE AND PENNAL
the increased elasticity of the joints, and the ability of the more
CLASSIFICATION OF PELVIC
FRACTURES cartilaginous structures to absorb energy (43). Second, the elas-
ticity of the joints may allow significant displacement and result-
A. Stable fractures ant fracture in only one area rather than the traditional concept
A 1: Avulsion fractures
of a mandatoty "double break" in the ring for a displaced frac-
A2: Undisplaced pelvic ring or iliac wing fractures
A3: Transverse fractur~s of the sacrum and coccyx ture (43,50). Third, avulsion fractures of an apophysis occur
B. Partially unstable fractures more often in children and adolescents rhan in adults because
B1: Open-book injuries of the inherent weakness of cartilage compared wirh bone;
B2: Lateral compression injuries (includes triradiate injury) fractures of the acetabulum into the rriradiate cartilage also
B3: Bilateral type B injuries
C. Unstable fractures of the pelvic ring
occur more otten for the same reason (50,64). Fourth, fractures
(1: Unilateral fractures through physeal cartilage in children can ultimately cause
(1-1: Fractures of the ilium growth arrest, leg-length discrepancy, and fault), development
(1-2: Dislocation or fracture-dislocation of the (e.g., a fracture through the triradiare cartilage with resultant
sacroiliac joint
"bony bar" formation and ultimately a deficient acetabulum)
(1-3: Fractures of the sacrum
C2: Bilateral fractures, one typeB and one type ( (l,2l).
(3: Bilateral type ( fractures

Ossification Centers
The pelvis in a child consists of three primaty ossification cen-
ters: the ilium, ischium, and pubis. The three centers meet at
rhe triradiate cartilage and fuse ar approximately 16 to 18 years
TABLE 20-3. AO/ASIF CLASSifiCATION Of of age (43) (Fig. 20-2). The pubis and ischium fuse inferiorly
PELVIC fRACTURES at the pubic rami at 6 or 7 years of age. Occasionally, at approxi-
A. Stable fractures mately the time of fusion of the ischium to the pubis, an asymp-
B. Rotationally unstable fractures, vertically stable tomatic mass, rhe ischiopubic synchondrosis, is noted radio-
C. Rotationally and vertically unstable fractures graphically in this area. The child should be treated expectantly,
(1.1 Iliac fracture dnd this should not be confused with a fracture of the pelvis.
(1.2 Sacroiliac fracture-dislocation
The secondary centers of ossification include the iliac crest,
C1.3 Sacral fracture
(3 Associated with an acetabular fracture ischial apophysis, anterior inferior iliac spine, pubic tubercle,
Isolated acetabular fractures angle of the pubis, ischial spine, and lateral wing of the sacrum.
The iliac crest is firsr seen at 13 to 15 years and fuses at 15
to 17 years of age. The secondary ossification of the ischi um
is first seen at 15 to 17 years and fuses ar 19 years of age,
alrhough fusion may be as late as 25 years of age. A center
postcrior arch, unstable (Table 20-3). Numerous subtypes also of ossiflcarion may be present at the antcrior inferior iliac
are included. This detailed system is described in the chapter spine ar approximately 14 years, fusing at 16 years of age
on pelvic fractures in adults in Fractures in Adults (Volume 2, (43,64). These secondary centers of ossification and the age
Chapter 35). Silber and Flynn (55) reviewed radiographs of 133 of appearance and fusion are described so they will not be
children and adolescents with pelvic fractures and classified them confused wi rh avulsion fractures.
into two groups: immature (all physes open) and mature (closed The acetabulum contains the physes of the ilium, ischium,
triradiate cartilage). They suggested that in the immature group, and pubis that mel'ge to become the uiradiate cartilage. Intersti-
management should focus primarily on associated injuries, and tial growth in the triradiate part of the cartilage complex causes
in the mature group adult pelvic fi'acture classifications and prin- the acetabulum to expand during growth and causes the pubis,
ciples are appropriate. ischium, and ilium to enlarge as well. The concavity of the ace-
This multitude of classification systems makes comparison tabulum develops in response to the presence of a spherical femo-
of incidence, results, and complications difficult among studies ral head. The depth of the acetabulum increases during develop-
using different systems. Many recent studies of children's pelvic ment as the result of interstirial growth in the acetabular
fractures in the literature use the Torode and Zieg (61) or Tile cartilage, of appositional growth of the periphelY of this cartilage,
(2,59) classifications, or both, but the most basic classifica- and of periosteal new bone formation at the acetabular margin
tion-stable or unstable fracture-in general is the most useful (48). At puberty, three secondary centers of ossification appear
information for making treatment decisions. Most pelvic frac- in the hyaline cartilage surrounding the acetabular cavity. The
turcs in children are stable injuries. os acetabuli, which is the epiphysis of the pubis, forms the ante-
rior wall of the acetabulum. The epiphysis of the ilium, the
APPLIED ANATOMY acetabular epiphysis, (48,64) forms a large part of the superior
wall of the acetabulum. The small secondalY center of the is-
There are several important anatomic differences between the chium is rarely seen. The os acetabuli, the largest part, starrs to
pelvis of a child and that of an adult (Table 20-4). First, a child's develop at approximately 8 years of age and forms a significant
 Chnpter 20: Fmetures of the Pelvis 887

TABLE 20-4. DISTRIBUTION OF PELVIC FRACTURES IN CHILDREN

Individual Single Break Double Break Acetabulum

Campbell Clinic Series (134 Patients)"

Avulsion: 13.4% Two ipsilateral rami: Straddle: 3% Small fragment: 0.7%
Pubis or ischium: 33.6% 8.2% Malgaigne: 8.2% Linear fractures (stable): 6%
Wing of Hium: 18% Symphysis pubis: 3% Severe, multiple: Linear fractures (unstable): 0
Sacrum or coccyx: 1.5 % Sacroiliac joint: 0.7% 0.7% Secondary to central
Total: 66.5% Total: 11.9% Total: 11.9% dislocation: 3%
Total: 9.7%
Comparison with Other
Series
Dunn b (115 patients) 70% (stable) 30% (unstable) Not included
Peltier b (186 patients) 10% 39% 27% 24%
Reed' (84 patients) 60.5% 2.5% 32% 5%
Hall, Klassen, Ilistrup' (204 24.5% 18.6% 31.9% 7.8% (17.2% acetabulum and
patients) pelvis)

a Classification of Key and Conwell (see Chapter 24 in Fractures in Adults. Volume 2 of this series).
b Adult series.
C Children's series.

Space occupied
by il iac bone

Triradiate cartilage

Space occupied
by pUbic bone

A Space occupied by ischial bone

FIGURE 20-2. A: Triradiate-acetabular cartilage complex viewed from

the lateral side, showing the sites occupied by the iliac, ischial, and
pubic bones. B: Normal acetabular cartilage complex of a 1-day-old
infant. The ilium, ischium, and pubis have been removed with a curet.
The lateral view shows the cup-shaped acetabulum. (From Ponseti IV.
Growth and development of the acetabulum in the normal child. J Bone
Joint Surg Am 1978;60: 575-585; with permission.) B
888 Lower Extremity

3%

32% - - - - " &

18% ---~

"'ll:8J;;;~:t---- 38%

FIGURE 20-3. Right innominate bone of an adolescent. The os aceta- 9%

buli (OA) is shown within the acetabular cartilage adjoining the public
bone (PB); the acetabular epiphysis (AE), within the acetabular cartilage
adjoining the iliac bone; and another small epiphysis (not labeled),
within the acetabular cartilage adjoining the ischium (left). (From
Ponseti IV. Growth and development of the acetabulum in the normal
child. J Bone Joint Surg Am 1978;60:575-585; with permission.)

FIGURE 20-4. Location of pelvic avulsion fractures in four series. (Mod-

parr of the anterior wall of the acetabulum; it unites with the ified from Ferbach SK, Wilkinson RH. Avulsion injuries to the pelvis and
proximal femur. Am J Radial 1981; 137: 581-584; with permission.)
pubis at approximately 18 years of age. The acetabular epiphysis
develops in the iliac acetabular cartilage at approximately 8 years
and fuses with the ilium at 18 years of age, forming a substantial
parr of the supetior acetabular joint surface (Fig. 20-3). The
lecondar)1 center ofthe ischium, the smallest of the three, develops Mechanism of Injury
in rhe ischial acetabular carrilage at approximately the ninth year, Overpull of the sartOrius muscle, especially with the hip in exten-
unites with the ischium at 17 years, and contributes very little sion and the knee flexed, can result in avulsion fracrure of the
ro acetabular developmenr. These secondaty centers should not anterior superior iliac spine. Avulsion of the anterior inferior
be confused with avulsion fracrures or loose bodies in the hip iliac spine can be caused by excessive exerrion on the direct head
JOint. of the reetus femoris muscle, which has its origin at the inferior
iliac spine. Maximal exertion of the muscle occurs when the hip
is hyperextended and the knee is flexed. This injury occurs most
frequently in sports that involve kicking (e.g., soccer, rugby,
AVULSION FRACTURES football) and is much less common than avulsion of the anterior
superior iliac spine, possibly because the anteriot inferior iliac
Avulsion fractures of the pelvis usually occur in adolescents or spine apophysis fuses earlier than the anrerior superior iliac spine.
young adults parricipating in sports (13,19,51) and usually are Avulsion fracrures of rhe ischial tuberosity can occur wirh maxi-
caused by powerful contracrion of the attached muscle, although mal exertion by the hamString muscles at their origin (38). These
rhey can result from chronic rt:peritive traction on a developing injuries occur mosr often in adolescenrs and young adulrs during
apophysis, without acute trauma (13,19). The sartOrius muscle sports, especially gymnastics, football, and track.
atraches to the anterior superior iliac spine, the direct head of
the recrus femoris to the amerior inferior iliac spine, and the
hamstrings and adductOrs to the ischial tuberosity.
Diagnosis
Of 91 pelvic avulsion fracrures reported in 4 series (17,37, Symptoms usually include localized swelling and tenderness
53,57), 38% were ischial avulsions, 32% were avulsions of the abour the site of the avulsion fracrure. Morion is limitcd, and
anrerior superior iliac spine, and 18% were avulsions of the pain may be mild or marked. In paticnrs with chronic a'.'ldsions
anterior inferior iliac spine (Fig. 20-4). Avulsjons of the iliac caused by repetitive activity, pain and limitation of motion usu-
crest (3%) and the lesser trochanter of the femur (9%) accounted ally at'e gradually progressive. In patienrs with ischial avulsions,
for the resr. pain at the ischial tuberosity can be elicited by flexing the hip
 Chapter 20: Fractllres of ,he Pelvis 889

FIGURE 20-7. Large ischial tuberosity fracture.

FIGURE 20-5. Displaced fracture of the anterosuperior iliac spine. ther displacement is probably prevented because this is a con-
joined tendon, and the reflected head of the rectLls femoris
muscle is imact. Contralateral views can be obtained and com-
pared to ensure thar rhis fragment is not actually a secondary
and exrending rhe knee. In rhis position, if rhe hip is moved center of ossification, either rhe os acetabuJi or acetabular epi-
into abduction, more pain is elicired. Parienrs also may have physis (Fig. 20-6). With ischial tuberosiry avulsions, radiographs
pain while sirring or moving on rhe involved ruberosiry. reveal a large fragment displaced disrally compared wirh the op-
In patiems wirh amerior superior iliac spine avulsions, radio- posite ischial tuberosity (Fig. 20-7). Significant displacement is
graphs show slight displacement of rhe apophysis (Fig. 20-5). resisted by rhe intact sacrotuberous ligament.
In pariems with anterior inferior iliac spine avuJsions, radio- Because these avulsion fractures occur primarily through sec-
graphs show minimal disral displacemem of the fragment. Fur- ondary centers of ossification before the center is fused with the

A B
FIGURE 20-6. A: Anteroposterior radiograph of an anterior inferior iliac spine fracture with displace-
ment. B: Three-year follow-up shows union with no displacement and no pain.
890 Lower Extremity

A'= i ....: 4 J. • B
FIGURE 20-8. Ischial tuberosity fracture at time of fracture (Al and at 6-month follow-up (6), showing
abundant callus formation.

pelvis, primarily in adolescems and young adults 14 to 25 years avulsions had chronic pain and disability that resolved after exci-
of age (64), comparison views of the contralaceral apophysis sion of the ischial apophysis; both recurned co athletic competi-
should be taken ro ensure that what appears ro be an avulsion tion and were pain free at 5-year follow-up.
fracture is not in reality a normal adolescent anaromic variant.
The exuberant callus formation can occasionally mimic an osceo-
sarcoma. Recognition of initial deformity and fracture pattern FRACTURES OF THE PUBIS OR
is important to avoid unnecessary evaluacion, such as CT and ISCHIUM
radionudide scans, and inappropriate creacmem.
In children, pelvic rami fractures usually are caused by high-
velocity trauma and have a significant number of associated inju-
Treatment and Prognosis
ries. In our series of pelvic fractures, of 45 pubic and ischial
Usually, the only creatment necessary is a shorr period of rest fractutes, 38 were caused by vehicular accidenrs, most in eirher
with positioning of the hip to lessen strecch on che involved pedestrians or passengers in automobiles. Reed (51) reporred
muscle and subsequent guarded weight bearing on crutches for thac 45% of the pelvic fractures in che children in his series were
2 weeks or more. Fernbach and Wilkinson (17) found no de- rami fractures, and we noted a 33.6% incidence. Rieger and
crease in athlecic abili ty in their 20 patients treated conserva- Brug (52) reporred 20 (37%) "simple ring fractures" in their
tively, and they recommended surgery only for symptomacic series of 54 pelvic fractures in children, and McIntyre et al. (33)
non unions. Alchough operative treatment has not been proven reponed that 23 (40%) of 57 pelvic fractures were "rype I"
co improve resulcs, Gordon et al. (20) recommended open reduc- (unilaceral anterior) fractures. Single ramus fractures are more
cion of all "widely displaced" avulsion fractures and fLxation common than multiple rami fractures, and the superior ramus
with a threaded Kirschner wire or lag screw, depending on the is fractured more often than the inferior ramus (7,16,51,61)
size of the fragment. Lynch and Renscrom (32) also recom- (Fig. 20-9).
mended open reduction and internal fixation of large fragments In patients with isolated pubic fractures, clinical examination
displaced more than 2 cm. reveals pain and possible crepitus at the fracture site; however,
Excessive callus formation after healing, especially of ischial there should be little or no motion on deep palparion. Inlet
avulsions, may be painful and impair spons activities (Fig. 20- and ourlet radiographic views or CT scanning are helpful in
8), occasionally requiring excision of the callus formation and determining if any other pelvic fractures are present. If there is
che apophysis. Sundar and Carry (57), at 44-monrh follow-up a significant displacement of the pubic rami, a second fracture
of sports-related avulsion pelvic fractures in 24 adolescents, through the pelvic ring should be suspected, although because
Found chat 8 of 12 patienrs with ischial avulsions had significanr of the plasticiry of bone and elasticity of the symphysis and
limication of athletic abiliry, and 5 had persistem symproms. Of sacroiliac joinrs in children, more displacement can be expected
che 12 patienrs with avulsions of the amerior superior or all[erior than in adults with the same injury. Bed rest until pain subsides,
inferior iliac spine, 11 recovered completely and returned co followed by progressive weight bearing, usually is sufficienr treat-
active compecition. Two of our patients with ischial ruberosiry ment.
 hapter 20: Fractures of the Pelvis 891

A B
FIGURE 20-9. A: Stable superior pubic ramus fracture. The patient was allowed full weight bearing at
4 weeks postfracture. B: He was asymptomatic and radiography showed early callus formation.

Fractures of the Body of the Ischium Stress Fractures of the Pubis or Isch ium
Fracwre of the body of the ischium near the acetabulum is Stress fractures are rare in smaJl children, but. they do occur in
extremely rare in children. The fracrure occurs from external adolescents and young adults from chronic, reperirive stress co
force to the ischium, mosr commonly in a fall from a considera- a bony area, and during the last trimester of pregnancy. Stress
ble heighr. The fracrure usually is minimally displaced, and treat- fractures of the pubis are likewise uncommon, bur a small series
menr consisrs of bed resr and progressive weighr bearing (Fig. of sn'ess fractures, primarily in the inferior pubic rami, has been
20-10). reported. Chronic sympcoms and pain increased by stress may

FIGURE 20-10. Nondisplaced fracture

through the left ischium and contralateral
superior pubic ramus fracture (A ). Follow-
up radiograph shows mild displacement
and incongruity of the acetabulum and
complete healing of the superior pubic
ramus fracture (B). Either displacement of
the fracture fragments or premature clo-
sure of the triradiate cartilage could have
contributed to the incongruity of the femo-
B ral head in the acetabulum.
892 Lower Ext1"cmity

FIGURE 20-11. Radiograph of the pelvis of a 9-year-old child. Although the differentiation could not
be made between a fracture and fusion of the right ischiopubic ossification center at the time of the
radiograph, the patient was asymptomatic and the mass was considered a variant of normal develop-
ment.

be noted in the inferior pubic area. Radiographs may show no vented by preservation of some of the attachments of the abdom-
evidence of a fracture for as long as 4 to 6 weeks, and then only inal muscles and the hip abductors. Pain is located over the wing
faint callus formation may be visible; however, a technetium of the ilium, and motion at the fracture site also may be noted.
bone scan may reveal increased uptake (26), indicating a stress A painful T rendelenburg gait may be present because of spasm
fracture, 3 to 4 weeks before changes on radiography. Treatmenr of the hip abductor muscles.
should consist of discontinuing the activity causing the repetir.ive A fracture of the wing of the ilium may be overlooked on
stress to the area, and guarded weight bearing on crutches for an underexposed radiograph of rhe pelvis wh.ere rh.e ilium is
4 to 6 weeks. poorly secn as a large area of radiolucency. Use of a "hor light"
At approximately the time of fusion of the ischiopubic ossifI- is helpful in making rhe diagnosis (Fig. 20-12).
cation centers (age 6 to 7 years), the ischiopubic synchondrosis Treatment of an iliac wing fracture usually is dictated by (he
h:'IS been noted on radiographs and may persist for 2 to 3 years
(10,64). Radiographs of the ischiopubic junction are, at best,
difficult to interpret and may be misinterpreted as a fracture.
Caffey (10) nared this radiographically in 57% of his pediatric
patients at approximately 7 years of age. Quite often, the syn-
chondrosis is bilateral (40%). An asymptomatic synchondrosis
in a child 6 to 10 years of age should be treated as a variant of
normal development (Van Neck's disease) (62). If it causes pain
in a child older than 10 years of age, a fracture should be sus-
pected and treated as such (Fig. 20-1 I).

Fractures of the Wing of the Ilium

(Duverney Fracture)
Direct trauma may cause a fracture of rhe wing of the ilium,
but isolated iliac wing fractures are relatively tare. Reed (51)
reported an incidence of 12% in children with fractures of the
pelvis. Rieger and Burg (52) reported iliac wing fractures in only
3 (5.6%) of their 54 parients, and Mcintyre et aI. (33) reponed
only 7 (J .2%) in 57 fractures. However, this fracture can occur
with other fractures of the pelvis, and the incidence may be
slightly misleading: for example, in our series of 24 fractures of
the wing of the ilium in children, only 11 were isolated fractures.
Displacement of the fracture usuaJly occurs laterally, but it
can occur medially or proximally. Severe displacement is pre- FIGURE 20-12. Minimally displaced fracture of the left iliac wing.
 Chapter 20: FrrzrtltreJ of the Pelvis 893

A B
FIGURE 20-13. A: Severely comminuted fracture of the left iliac wing. B: Radiograph at 3-month follow-
up shows fracture healed with displacement, but the patient was asymptomatic.

associated injuries. Bed rest in a comfortable position, usually ment and occur through a sacral foramen, which is the weakest
with the leg abducted, is all that is necessary for treatment of parr of the body of the sacrum. Minimal offset of the foramen
the fracture itself. This should be followed by partial weight or offset of the lateral edge of the body of the sacrum is an
bearing on crutches until the symptOms are completely resolved. indication of sacral fracture. Lateral views ate helpful only if
Regardless of the amount of comminution or displacement, there is anterior displacement, which is rare. A 35-degree caudad
these fractutes usually unite without complications or sequelae view of the pelvis may reveal a fracture of the body of the sacru m.
(Fig. 20-13). CT scans may be useful for determining the amount of anterior
displacement, if any, in these fractures (Fig. 20-15).

FRACTURES OF THE SACRUM

FRACTURES OF THE COCCYX
Sacral fractures constitute a small portion of pelvic fractures in
children. Rieger and Brug (52) reported 2 sacral fractures and Significant soft tissue injury to rhe coccyx mal<es it difficult to
7 sacroiliac fracture-dislocations in their 54 patients. Out series determine on radiograph if a coccygeal fracture has occurred,
of pelvic fractures in childten included twO patients with sacral especially in a child. However, histOrically, trauma to the coccyx
fractures (4%), 15 and 17 years of age. Sacral fractures may is often refractory to treatment. For this reason, if clinical symp-
be slightly more common than reported, but because they are toms are sufficient, an injury to this area in a child should be
obscured by the bony pelvis and soft tissue shadows of the ab- considered a fracture regardless of whether a fracture can be seen
dominal viscera, and because they are rarely displaced, they may on radiographs.
be overlooked (Fig. 20-14). These fractures are significant be- Coccygeal fractures are not included in most large series of
cause they may damage the sacral nerves, resulting in Joss of fractures of the pelvis in adults and children, although the coccyx
bladder and bowel function. is part of the pelvis. Of our nine patients with coccygeal fractures,
Sacral fractures are best diagnosed clinically. Pain and swell- in eight the mechanism of injury was similar to that in adults:
ing may be present, usually over the lower part of the sacrum. a direct faJ! onto the buttOcks in the sitting position. There were
Rectal examination causes pain anterior to the sacrum. Occa- no associated injuries with these nine fractures. Clinically, there
sionally, the fracture fragments may be felt. Repeated bimanual was immediate, severe pain in the area of the coccyx in all pa-
rectal examination with attempts at redUCtion should be avoided tients. Pain on defecarion may be present as well as pain on rectal
because a tear in the rectum may occur. examination. Because radiographic identification is difficulr, the
The fractures are difficult to see on radiographs. The fracture diagnosis should be made clinically by digital rectal examination.
can be oblique, but most are uansverse with minimal displace- Exquisite pain may be elicited, and an abnormal mobility of the
 894 Lower Extremity

A B
FIGURE 20-14. A: Radiograph suggesting comminuted nondisplaced linear sacral fracture on the left.
B: At 6-week follow-up, radiograph shows definite evidence of linear sacral fracture.

FIGURE 20-15. A: A 15-year-old boy with an obviolls frac-

ture of the left acetabulum and symphysis pubis diastasis,
and a questionable and ill-defined sacral fracture. B: Com-
puted tomography scan reveals a comminuted displaced sac-
A ral fracture.
 Chapter 20: Fractures of the Pe/vi,' 895

Considerable force is necessary to cause this fracture parrern,

and ocher associated fractures should be expected. A general
evaluation should be followed by examination of the pelvis and
lower extremities, with special arrention ro abrasions, contusions,
lacerations, and ecchymosis about the pelvis. Palpation reveals
discomfort anteriorly, and crepitus at the fracture site may be
noted.
Various methods of treatment have been advocated for adults,
such as bed rest, lower limb traction, and pelvic sling. However,
in children, the fracture almost always unites with adequate re-
modeling of even the most displaced fractures. For this reason,
short-term bed test followed by progressive weight bearing on
crutches on the involved side is all that is necessary (Fig. 20-
17).

FRACTURES NEAR OR SUBLUXATION

OF THE SYMPHYSIS PUBIS

Isolated injuries in the symphysis pubis area are rare, primarily

because they usually occur in association with disruption of pos-
terior Structures such as the sacroiliac joint. Although significant
force appears to be necessary ro disrupt or fracture the symphysis
pubis, isolated disruption of rhe symphysis can occur (64). Usu-
ally, there is some normal elasticiry at the symphysis in adults
(0.5 mm in men, 1.5 mm in women), and there is probably
even more in children, depending on skeletal maturity.
FIGURE 20-16. Lateral radiograph with the hips maximally flexed re- Clinically, exquisire pain is present anteriorly at the symphy-
veals displaced coccygeal fracture in a 14-year-old boy. sis; the legs are externally rotated and often pain is worse in the
supine position than in the side-lying position (64). Motion of
the hips in f1exion, abduction, external rotation, and extension
is restricted and painful (fabere sign).
coccygeal fragments may be noted. Acute symproms may abate Radiographs may reveal subluxation and widening of the
at 1 ro 2 weeks, but in our patients symptoms while sitting symphysis pubis, as if opening a book. Offset may be superior,
persisted for an average of 4 weeks. inferior, anterior, or posterior (Fig. 20-18). Furthermore, a frac-
Lateral radiographs of the coccyx with the hips f1exed maxi- ture near or inro the symphysis may produce an equivalent sub-
mally may reveaJ the fracture (Fig. 20-16). The coccyx may luxation of the symphysis pubis (Fig. 20-19). Because of the
appear ro be acutely angulated as a variant of normal, and a variable normal separation of the symphysis in children of differ-
fracture may not be seen, or the normal acute angularion may ent ages, the amount of traumatic separation may be difficult
be interpreted as a fracture or dislocacion. ro evaluate. Watts (64) suggested radiographs with and without
In all nine of our patients, the fracture was identified. Treat- lateral compression of the pelvis. More than 1 cm of di fference
ment consisted of an inf1ated doughnut cushion in three pa- in the width of the symphysis pubis berween the rwo views
tients. decreased activity in three patients, and no treatment in suggesrs a symphysis pubis separation.
three patients. The longest period of active treatmenr was 6 We saw a child wirh anterior pubic pain and obvious widen-
weeks (average, 4 weeks). Unlike adults with trauma to the coc- in.g of the symphysis pubis after a moving vehicle accident. On
cyx, none of these children had prolonged impairment or psy- radiographs, it appeared that the child had an isolated disruprion
chological overtones. of the symphysis pubis; however, when an adequate hisrory was
obtained and physical examination. was performed, it was appar-
ent that the child had been treated for exstrophy of the bladder
FRACTURES OF TWO IPSILA RAL with congenital widening of rhe symphysis. The lesson learned
RAMI should be obvious: "If all else fails, examine the patient."
Treatment of isolated fractures or subluxations of the sym-
Fractures of the pubic rami, which are more common than any physis pubis should consist of bed rest, usually in a side-lying
other pelvic fracture in children, may be stable bilateral fractures position, especially if other injuries are present. Unilateral Buck's
or ipsilateral fractures of the superior and inferior rami. Ipsi- traction may relieve pain, but it rarely improves alignmenr of
lateral fractures, although stable, may produce an increased inci- the fracture or subluxation. Application of a spica cast in the
dence of associated injuries ro abdominal viscera, especially the lareral position with lateral compression may also reduce the
bladder (16). displacement and decrease hospitalization (64)
896 Lower E>::tremit)'

FIGURE 20-17. A: Ipsilateral left pubic rami fractures

with a contralateral right superior rami fracture. B: At
2-year follow-up, nonunion of the ipsilateral rami frac-
B tures is evident, but the patient is asymptomatic.

FIGURE 20-18. Mild symphysis pubis subluxation with su-

perior displacement. At 4-year follow-up, the patient is
asymptomatic.
 Chapter 20: Fmctures 01 the Pelvis 897

FIGURE 20-19. Fracture adjacent to the symphysis pubis with equivalent symphysis pubis separation.

FRACTURES NEAR OR SUBLUXATION reduction and internal fixation, one with open reduction but
OF THE SACROILIAC JOINT no internal fixation, and one with external fixarion. Disabling
]ong-rerm symptoms persisted from incomplete neurologic re-
Fractures near or sublw~ation of the sacroiliac joint are rare, covel)' in SIX.
isolated injuries, pwbably even less common than isolated frac-
tures at the weaker symphysis pubis. More commonly, disrup-
tion of the sacroiliac joinr occurs wirh fractures or dislocations
UNSTABLE FRACTURE PATTERNS
of the anterior porrion of the pelvis, causing an unstable injury
of the pelvis. Sacroiliac dislocations differ from those in adults
Unstable pelvic fracture combinations usually are of three types:
in several ways. In children, fractures rend (Q be incompJere
because of parrial rearing of rhe amerior sacwiliac ligamems • Double vertical pubic rami fracrures (srraddle or floaring frac-
and rhe thick posrerior periosreum (43). A subchondral fracture tures) or dislocations of the pubis that occur as an anterior
rhrough srructuraJly weak zones of carrilage may leave rhe sacroil- double break in the pelvic ring anteriorly
iac joinr intacr (J 5). Associared vascular and neurologic injuries • Double fractures in rhe pelvic ring anreriorly and posreriorly,
are common (23). through the bony pelvis, sacroiliac joint, or symphysis pubis
Subluxation or fracture of the sacroiliac joint should be sus- (Malgaigne fractures)
pected with high-velociry ([auma and injury (Q rhe posrerior • Multiple crushing injuries rhat produce ar leasr twO severely
aspecr of the pelvis near the sacroiliac joint. In parienrs wirh rhese comminuted fractures in the pelvic ring
injuries, the fabere sign is markedly posirive on rhe ipsilareral side
(15,23). Comparison views of both sacroiliac joinrs should be
carefully evaluared to determine any asymmetry of the wings of
Bilateral Fractures of the Inferior and
rhe ilium with more separarion ar rhe sacroiliac joint (Fig. 20-
Superior Pubic Rami
20). Any offser of rhe disral articular surface of rhe sacrum and
ilium on radiography is an indicarion of sacroiliac joint disrup- Bilateral fractures of both the inferior and superior pubic rami
tion. Oblique views for comparison ofborh sacroiliac joilHs ofren (srraddle fractures) cause a floating anterior arch of (he pelvic
are beneficial. Because of the rariry of rhis suhluxation or frac- ring that is inherently unsrable (Fig. 20-22), as does dislocation
ture, multiple views, including inlet and outlet views, and axial of (he symphysis pubis with fracrures of borh ipsilareral pubic
CT scan may be necessary to ensure that there is no anterior rami. This fracture patrern frequently is associated wirh bladder
fracture (Fig. 20-21). or urerhra disruprion.
Bed rest and guarded weight bearing on crurches is probably Bila(eral fractures of the inferior and superior pubic rami
all the treatment needed for isolated subluxations or fractures. can occur in a fa I. 1 while straddling a hard object or by lareral
Heeg and Klasen (23) reported sacroiliac joint dislocations in compression on rhe pelvis. The floating fragment usually is dis-
18 children, 10 of whom had extensive degloving injuries of rhe placed superiorly, being pulled in rhis direction by the recrus
posterior pelvis. Ten were rreared nonoperatively, six wirh open abdominis muscles (64). Radiographically, an inler view mosr
898 Lower [;':<,:tremity

FIGURE 20·20. Separation of the left sacroiliac joint

with asymmetry of the wings of the ilium. A: Careful
scrutiny of the radiograph reveals contra lateral pubic
rami fractures. B: At 2-year follow-up, the sacroiliac
B joint is slightly wide, but the patient is asymptomatic.

accurately determines the amount of true displacement of dIe Complex Fracture Patterns
floati ng fragmen t.
Fractures and dislocations of the posterior arch (posrerior ro the
In a child, regardless of the amoum of displacemem, the
acetabulum) combined with antetior ipsilateral or contralateral
fracture should heal and remode'ling can be expected. Because
rhis fracture docs not involve the weight-bearing ponion of the Fractures or dislocations of the anterior arch [Malgaigne (36)
pelvis, ir does nor cause leg-Iengrh discrepancy. Skeletal [[action Fracrures; Fig. 20-23] result in instability of the hemipelvis and
is unnecessary, and a pelvic sling is con[[aindicated because of acetabulum. These unsrable fractures are associated with rerro-
rhe possibility that compression will cause medial displacement perironeal and inrraperironeal bleeding. Bilateral anterior and
of the ilium (64). posterior Fractures are the most likely Fracture pattern ro cause
Treatment should consist simply of bed rest in the semi- severe hemorrhage. Initial [[eatment usually involves replace-
Fowler position wirh flexion of the hips to relax the abdominal ment of blood volume and stabilization of the child's overall
musculature. If the fracrure was caused by lateral compression condition before treatment of the pelvic fractures (60).
forces, the lateral decubitus position is contraindicared for fear Three mechanisms of injUlY have been implicated in these
of medial displacement of the ilium. fractures and fracture-dislocations: anteroposterior compression
 Chapter 20: Fmctttres of the PeLvis 899

FIGURE 20-23. An unusual Malgaigne fracture; fracture extends

through the ilium into the sacroiliac joint with ipsilateral pubic rami
FIGURE 20~21. Fracture of the superior pubic ramus; occult fractures fractures.
of the ipsilateral sacrum and the sacroiliac joint at the distal articular
surface also are present.

B
FIGURE 20·22. A: Classic example of a straddle fracture in a 16-year-old girl. B: At 6 weeks after injury,
abundant callus formation is present and the fractures have healed.
900 Lower Extremity

FIGURE 20-24. A: A 6-year-old child with a Malgaigne

fracture with right sacroiliac joint displacement and
multiple (four) pubic rami fractures. B: Four weeks
after injury. C: At 5-year follow-up, complete remodel-
c ing is present.
 Chapter 20: Fractures of the Pelvis 901

Forces, lareral compression forces, and, wirh rhe hip fixed in pelvic Fractures, especially in children with polyrrauma, and Gor-
exrension and abducrion, indirecr Forces uansmirted proximally don et a!. (20) suggested external fIxation or open reduction and
along rhe Femoral shaft. inrernal fixation in children older rban 8 years of age because
Aside from the physical signs usually associared wirh pelvic hip spica casting is poorly rob·ated in older children. Stilerro
Fractures, leg-Iengrh discrepancy and asymmerry of the pelvis also er al. (56) reponed good results aFrer open reduction and internal
may be presenr because of rhe displacemenr of the hemipelvis. IF fixation of unstable pelvic fracture in two toddlers. AO small-
rhe measured distance From rhe umbilicus to the medial maJleo- Fragmenr instrumentation was used in both. These surgeons rec-
Ius is unequal For the twO exrremities, and the disrance From the ommended protection in a spica cast for 6 to 8 weeks, wirh
anrerior superior iliac spine to rhe medial malleolus is rhe same, removal of the implants at rhar time. Occasionally, open reduc-
pelvic obliquiry or displacemenr is presenr rather rhan rrue leg- tion and inrernal fixarion of severely malaligned Fracrures may
lengrh discrepancy. Inlet and ourler radiographic views and CT be indicated. However, because of the potential surgical compli-
scanning reveal the amount of pelvic displacement. cations, open reduction of pelvic fractures in children should
Numerous uearmenr regimens have been successFul, depend- not be underraken casually by rbe inexperienced surgeon.
ing on the type of Fracture and the amount of displacemenr.
For Fractures wirh mild displacement, bed rest in rhe lateral
recumbent position may be all rhar is necessary. IF lareral dis- • AUTHORS' PREFERRED
placement is severe, closed manipularion in rhe lareral decubirus \..~ TREATMENT
position and spica casting can be used, as described in Chaprer
35 in Volume 2 of rhis series. IF the displacement is cephaJad Treatmenr is more likely ro be conservative in younger children
only, skeleraJ uaerion or even skin uaction can be used in a and operative in juveniles and adolescents. For roddlers, we pre-
small child. OccasionalJy, manipulation under anesthesia may Fer to use bed rest and distal Femoral skeletal traction on rhe
be required. Afrer successFul manipulation of rhe Fragments, rtac- displaced side of the bemipelvis. Tbe younger rhe child, the
tion on the involved side can be used to mainrain rhe reduction. more likely that rraction will be adequate treatment and the
Open or percutaneous exrernal fixation of the pelvis with pins pelvis will remodel. Open reduction and internal fixation rarely
incorporated in a disrracrion or compression device has been are required in a young child unless severe (> 3 cm) displacement
advocated to allow accurate reducrion of the Fracrure or disloca- of the sacroiliac joinr cannot be corrected with traction. Com-
rion, early ambulation (non-weight bearing), and decreased pain bining open reducrion and internal fixation wirh external fixa-
secondary to insrabiliry. tion may be necessary in a chi ld older than 8 to 10 years of age
Schwarz er al. (54), in a long-rerm (2 to 25 years) Follow- with an unsrable fracture and severe polytrauma (Fig. 20-25).
up of 17 children with nonoperatively treated unsrable pelvic The technical principles are idenrical ro tbose used For unstable
Fracrures, reporred unsarisFactOry results in 8 due to pelvic asym- pelvic Fractures in adults (see Chaprer 35, Volume 2). In older
metry. They emphasized rhar reduction of pelvic ring fractures adolescents, treatmenr should follow the guidelines For rhe rrear-
should be as anatomic as possible because healing in malposition ment of adult Fractures (see Chapter 35, Volume 2), including
causes poor resulrs. Nierenbel·g et a1. (42), however, reporred a combination of internal and external fixarion For Fracture stabi-
excelJenr or good resulrs aFrer conservative ueatment of 20 un- lizarion and early mobilization.
stable pelvic Fracrures in children despite radiographic evidence
of deformity. They suggesred thar treatment guidelines For un- Severe Multiple or Open Fractures
srable pelvic Fracrures are not the same For children as For adults,
and recommended rhat external or inrernal fixarion should be In patients with crushing injuries, disrorrion of the pelvis is
used only when conservarive methods Fail. severe and, in addition ro multiple breaks in the pelvic ring,
Operative rreatment of pelvic Fractures in children is nor wu- apparent or occult fractures of the sacrum may be present, with
rinely recommended (3) because (a) exsanguinating hemorrhage or withoUt neurologic involvement. Massive hemorrhage is com-
is unusual in children, so operative pelvic stabilization to control mon, and only rarely does a child survive this major insult (39,
bleeding rarely is necessary (3,41); (b) pseudarduosis is rare in 64). The parient is usually in hypovolemic shock, and emergency
children and fixation is not necessary to promote healing (51); measures outlined previously in this chaprer may be necessary.
(c) the thick periosteum in children tends to help stabilize the Nthough total disruprion of the pelvis is apparenr on radio-
fracrure, so surgery usually is not necessary to obtain stability graphs, usually one hemipelvis is partially intact. In general, each
(51); (d) prolonged immobilization usually is not necessary For complex Fracture needs a special treatment regimen; however,
fracture healing (42); (e) significant remodeling can occur in tbe trearment ourlined For unsrable fracture patterns usually can
skeletally immarure patients (18) (Fig. 20-24); and (f) long- align the pelvis. Treatment may have ro be by trial and error,
term morbidity afrer pelvic Fracture is rare in children (18,41). wirh serial radiographs and CT scans ro evaluare rhe progress
Operarive fixation may be indicated to facilitate wound ueat- of realignment.
ment in open fractures, conuol hemorrhage during resuscitation, The patient should be stable without evidence of a drop in
allow patient mobiliry and make nursing care easier, prevent blood volume beFore any operative intervention, either closed
deformity in severely displaced Fractures that may not heal or or open external fixation or open reduction, is underral<en.
adequarely remodel, improve overall patienrcare in patients wirh These severe multiple Fractures abour rhe pelvis are imporranr
polyrrauma, minimize risk of growth disruprion, or restOre arric- because the mobile fracture fragmenrs may penetrare visceral or-
ular congruiry. gans (e.g., rhe bladder or abdominal viscera), lacerare rhe abdomi-
Keshishyan ct al. (29) advocated external fixation of complex nal vascular tree, or cause neurologic involvement (Fig. 20-26).
902 Lower Extremity

FIGURE 20-25. A: Multiple trauma in this 12-year-

old child included three fractures of the pubic rami,
disruption and fracture of the sacroiliac joint on the
right, and a femoral shaft fracture on the right. B:
Computed tomography scan shows fracture of the
ilium and disruption of the sacroiliac joint. C: After
open reduction and internal fixation of the sacroil-
iac joint and closed intramedullary nailing of the
femoral shaft fracture. Note femoral nail inserted
c through the greater trochanter.
 Chapter 20: Fractures of the Pell/is 903

FIGURE 20-26. A and B: Complex open type IIiC pelvic

fracture in a 3-year-old boy. Vascular (femoral artery and
vein) and neurologic injuries also were present. Multiple
debridements were required. as were colostomy and vesi-
costomy. The fractures of the wing of the ilium and pubic
rami were fixed with small screws. C: One year after injury.
(Courtesy of Dr. Gerry Clancy, Children's Hospital, Denver,
c CO.)
904 Lower Extremit)'

These acute injuries should take precedence over realignmenr Radiographic Evaluation
of the pelvic atchirecture, alrhough if possible during emergency
Anteroposterior and lateral views may not adequately show the
surgery such as a laparoromy, pelvic stabilization should be
amount of displacement of acetabular fragmencs after fracture.
achieved quickJy wit~ a combination of inrernal and external
Inlet, oudet, and 45-degree oblique Gudet) views ofren are neces-
fixation as needed while the patient is under general anesthesia.
sary to appreciate che amounc of displacemenr. CT scanning can
In particular, the application of an external flxator may decrease
be used to determine the amounr of acetabular displacemenr
blood Joss by stabilizing mobile, bleeding bone fragments (1,58,
(Fig. 20-27) and to determine if any retained fragmenrs in the
'59).
acetabulum are preventing an accurate concencric reduction
Open pelvic Fractures are rare in children. Mosheiff et al.
(lJ). Three-dimensional CT teconstructions can give an excel-
(40) reponed that 13% of 116 pediatric pelvic fractures seen
Jenc view of the overall fracrure pattern, but ofren undetestimate
over a 12-year period were open injuries. Fourteen of the 15
minimally displaced fractures.
children were struck by motor vehicles and one sustained a gun-
After reduction of a l1ip dislocation, radiographs of both hips
shot wound. Five children with srable fractures were treated
nonoperatively, and 10 with unstable fractures were n'eated with should be carefully compared to ensure that the teduction is
external fIxation (5), inrernal ttxation (2), or combined external not incongruous. Subtle signs of an incongruous reduction with
and internal fixation (3). Three of the children died because of retained osseous or cartilaginous fragmenrs, an inverted limbus,
uncontrollable hemorrhage (("vo patiems) and chest injul)' (one or enrrapped soft tissues include minimal widening of che joint
patient). Eleven of the 12 surviving children had deep wound (wichom rraction applied) and asymmetry of Shenton's line
infection or sepsis, and 3 had premature physeal closure. Mos- compared with the opposite hip (11) (Fig. 20-28). If there is
heiff et a1. (40) emphasized that the tteatment of the soft tissue any doubt about rhe concentriciry of the reduction, CT or MRI
injuries depends on stabilization of the pelvis and that externaJ is indicated.
fixation alone is insuflicienr for most open pelvic fractures.

Treatment
ACETABULAR FRACTURES The aim of treatmenr For acetabular Fraccures in children is the
same as for adults: to restore joint congruiry and hip stability.
Acetabular ftactures constitute only 1% to 15% of pelvic frac-
Treatmenc guidelines in general follow those for adults. Bed rest
tures in children, making them very uncommon. The mecha-
or non-weight-bearing ambuJation with crutches can be used
nism of injul)' of acetabular fractures in children is similar to
for nondisplaced or minimally (~I 1ll111) displaced fi:actures.
that in adults: the fracture occurs from a force transmirred
Because weight-bearing forces must not be transmitted across
through the femotal head. The position of the leg with respeCt to
the fr:1ccure, crutch ambulation is appropriate only For older
the pelvis and the location of the impact determine the Fracture
children who can be relied on to avoid putting weight on the
pattern; the magnitude of the Fotce determines the severiry of
injured limb. Non-weight bearing usually is conrinued for 6 to
the fracture Ot fracwre-disJocation. Patiems with high-energy
8 weeks. In younger children, this may be shol'Cened to 5 or 6
injuries usuaUy have major associated injuries, whereas isolated
weeks, and in adolescenrs (older than 12 years of age), p:.mial
acetabular fractutes can occur from low-energy forces.
weighc bearing should be continued For 3 to 4 more weeks. For
fractures in which displacement can be reduced to less than 2
Classification mm, skeletal cracrion with a traction pin in the distal Femur can
Watts (64) described a classification of acetabular fractutes in be used. Because traction must be maintained for 5 to 6 weeks,
chiJdren that consisted of four types: (a) small fragmenrs that this option usually is not feasible in older children or adoJes-
most often occur with dislocation of the hip, (b) linear ftactutes cems.
that occur in association with pelvic fractures without displace- Gordon et a!. (20) recommended accurate reduction and in-
ment and usually are stable, (c) linear fractures with hip joint ternal fixation of any displaced acetabular fracture in a child.
instahility, and (d) fractures secondal)' to cenrral Fracture-dislo- They noted that the presence of incomplete fractures and plastic
cation of the hip. More recencly, however, acetabular Fractures defonnation may maJ<e accurate reduction diFficult or impossi-
in both adults and children usua.lly are classified by the system ble; they recommended chat incomplete fractures be completed
of Lerournel and Juder (28,31). A more comprehensive classifi- and that osteotomies of the pubis, ilium, or ischium be made
cation is based on the AO comprehensive fracrures cLlssification, j f necessal)' for accurate reduction of the acetabul urn. Inch ildren
which groups aJl fracrures inroA, B, and C rypes with increasing with open physes, all periacetabular metallic implams should be
scvcril),. Type A acetabular fracwres involve a single wall or removed 6 co 18 months aFter surgery.
column; type B Fractures involve both columns (transverse or Improved outcomes with early «24 hours) fixation of ace-
T-types) and a ponion of the dome remains actached co the tabular Ftactures in adults has been reponed (46), and Gordon
inract ilium; and type C fractures involve both columns and et a!. (20) noted that early fixation is especially Imporranr
separare the dome fragmel1C from the axial skeleton by a fracture to prevent malunion in young patients in whom heaJing is
rhrough the ilium. Both of these classification systems are dis- rapid.
cussed in more detail in Chapter 35, Volume 2 of this series In addition, anatomic aligllmenr of the triradiate carcila"c
(Fract7treS in Adults). should be obuined in children. Linear growth of the acerabulu~
 Chapter 20: Frrlctures of the Pelvis 905

A B

FIGURE 20-27. A: Traumatic dislocation with a small ac-

etabular fragment. B: After reduction, a small fragment
is visible, but it is not impeding hip congruity or function.
C: At 12 weeks after injury, computed tomography scan
reveals that the fragment is from the posterior acetabu-
lum, with mild displacement of the acetabulum poste-
c riorly.

FIGURE 20-28. A: Posterior hip dislocation in a 5-year-old girl. B: Nonconcentric

reduction. Note widened joint space on left compared with right hip. Posterior open
A reduction revealed infolded labrum and a flap of capsule.
906 Lower Extremity

FIGURE 20-29. A: Fractures of the left superior and in-

ferior pubic rami and the left ilium with injury to the
right triradiate cartilage in a 5-year-old boy. B: Three
years after injury, the pubic rami fractures are healed
and remodeling has occurred, but acetabular dysplasia.
widening of the "teardrop." and mild subluxation are
evident in the right hip. C: At 15 years of age. the se-
quelae of the mild triradiate cartilage injury are still
c apparent. but he is not symptomatic.
 Chapter 20: Fractures of the Pelvis 907

occurs by interstitial growth in the triradiate part of the

TABLE 20-5. SURGICAL EXPOSURE FOR
cartilage complex, causing the pubis, ischium, and ilium to
OPERATIVE FIXATION OF
enlarge. The depth of concavity of the acetabulum is in ACETABULAR FRACTURES
response to the presence of a spherical femoral head and
increases during development as a result of interstitial growth Fracture
Type Exposure
in the acetabular canilage. Cessation of growth of all or parr
of the rriradiate cartilage occurring secondary to fracture may Anterior column Ilioinguinal
result in a dysplastic acetabulum. or wall
Acetabular dysplasia secondary to growth arrest (bony bridge) Posterior Kocher-Langenbeck
column or
of the rriradiate cartilage has been reponed after trauma to the
wall
acetabulum (Fig. 20-29). Heeg et al. (22,24,25) reponed acetab- Transverse Ilioinguinal (or extended lateral)
ular deformity and subluxation of the hip in two of three patients T-shaped Ilioinguinal and Kocher-Langenbeck (or
with premature fusion of the triradiate cartilage. Peterson and extended lateral)
Robertson (45) reported formation of a physeal osseous bar Anterior column Ilioinguinal
and posterior
in a 7-year-old boy 2 years after fracture of the lateral portion hemitransverse
of the superior ramus at the junction with the triradiate Both columns Ilioinguinal (or extended lateral)
cartilage. After excision of the osseous bridge, the physis
remained open. Although the injured physis closed earlier From Gordon RG. Karpik K, Hardy S, et al. Techniques of operative
than the contralateral side, there was only a slighr increase reduction and fixation of pediatric and adol'escent pelvic fractures.
Oper Tech Orthop 1995;5:95-14; with permission.
in the thickness of the acetabular wall and lateral displacement
of the femoral head. Peterson and Robertson emphasized that
early recognition and treatment are essential, before premature
closure of the entire physis and development of permanent
osseous deformity.
Bucholz et al. (8) noted twO main patterns of physeal disturb-
increased the incongruity of the hip joint and led to progressive
ance in nine patients with triradiate cartilage injUiT a Salter-
subluxation. These researchers found that acetabular reconstruc-
Harris type I or II injury, which had a favorable prognosis for
tion was frequently necessalY to correct the gtadual subluxation
continued normal acetabular growth, and a Salter-Harris type
of the femoral head.
V crush injury, which had a poor prognosis with premature
closure of the triradiate cartilage caused by formation of a medial
osseous bridge (Fig. 20-30). In either pattern, the prognosis de-
pended on the child's age at the time of injUlY. In young chil-
Surgical Treatment
cL'en, especiaJly those younger than 10 years of age, acetabular The surgical approach varies according to the pattern of the
gtowth abnormality was common and resulted in a dysplastic fracture and the ditection of the displacement as determined on
acetabulum. By the time of skeletal matutity, disparate growth the preoperative radiographs and CT scans (20) (Table 20-5) .

.II

~
Ii Ii
,I ) / )
f
I:
&'
(f, I
,I
(
f j (ft /
I;

~ ~ ~ ~
A
r
B
I( C
f
D
If
FIGURE 20·30. Types of triradiate cartilage fractures. A: Normal triradiate cartilage. B: Salter-Harris
type I fracture. C: Salter-Harris type II fracture. D: Salter-Harris type V (compression) fracture. (Redrawn
from Scuderi G, Bronson MJ. Triradiate cartilage injury: report of two cases and review of the literature.
Gin Orthop 1987;217: 179-189; with permission.)
908 Lower ExrremitJ

A B
FIGURE 20-31. A: Fracture of the wing of the ilium with extension into the dome of the acetabulum
in a 3-year-old boy. B: After reduction and fixation with two cannulated screws. (From Habacker T,
Heinrich SO, Dehne R. Fracture ofthe superior pelvic quadrant in a child. J PediatrOrthop 1995;15: 69-72;
with permission.)

A B
FIGURE 20-32. A: Anterior column plate and additional anterior wall "hook" plate. B: Posterior wall
buttress plate and hook plate. (From Gordon RG, Karpik K, Mears DC. Techniques of operative reduction
and fixation of pediatric and adolescent pelvic fractures. Oper Tech Orthop 1995;5:95-114; with permis-
sion.)
 Cllrtpter 20: Fractllres of the Pelvis 909

Fractures of the posterior wall or posterior column can be ap- Postoperative Management
proached through a Kocher-Langenbeck approach with the pa-
Small children can be immobilized in a spica cast for 6 weeks.
tient either in the lateral decubims position (isolated posterior
wall fracmre) or supine (associated posterior column fracture).
lf radiographs show adequate healing at that time, the cast
is removed and free mobility is allowed. In an older child
Anterior column injuries can be approached through an ilioingu-
inal approach. Some transverse fracmres may require an extended wi th stable fixation, crutches are used fot protected weight
iliofemoral approach, but this is rare in children (12). The ex- bearing for 6 to 8 weeks. If radiographs show satisfactory
tended lateral approaches, which include the extended iliofem- healing, weight bearing is progressed as tolerated. Rerum ro
oral and triradiate approaches, should be avoided as much as vigorous acrivities, especially competitive spons, is delayed for
possible because of the risk of devascularization of the ileum and at least 6 months.
heterotopic bone formation (21).
The surgeon should be familiar with ]udet's (29) treatise
on the operative reduction of acetabular fractures and with
Letournel's wotks befote performing this surgery. For smaller
COMPLICATIONS
children and smaller fragments, Watts (64) recommended
threaded Kirschner wires for reduction. In larger children, Because of the remodeling potential in young children, loss of
cannulated screws may aid in reduction and provide secure reduction and malunion usually are not problems. Reported
fixation (Fig. 20-31). Small-fragment reconstruction plates, complications include premature triradiate cartilage closure.
appropriately conwured, also can be used. Gordon et al. (20) avascular necrosis, traumatic arthritis, sciatic nerve palsy, heter-
described the addition of a small (rwo- or three-hole) "hook otopic myositis ossificans about the acetabulum and pelvis
plate" for small or comminuted ftagments (Fig. 20-32). Be- after acetabular fractures (Fig. 20-33), and pelvic asymmetry
cause operative procedutes about the hip may be necessary at long-term follow-up of female patients. Because this asym-
later, the hardware in a child may be removed in this situa- meny may cause maternal dystocia during childbearing, pel-
tion. vimetry is recommended before pregnancy. Rieger and Brug
Brown et al. (6) described the use of CT image-guided fixa- (52) reponed one female patient who required cesarean section
tion of acetabular fracmres in 10 patients, including bilateral because of ossification of the symphysis pubis after nonopera-
posterior wall fractures in a 14-year-old girl. They cite as advan- tive treatment of an open-book fracture. Schwarz et al. (54)
tages of image-guided surgery reduced operating time (approxi- reported leg-length discrepancies of 1 to 5 cm in 10 of 17
mately 20% reduction), less extensive surgical dissection, re- patients after nonoperative tteatment of unstable pelvic frac-
duced fluoroscopic time, and compatibility with traditional tures; 5 complained of low back pain at long-term follow-
fixation techniques. Most important, it allows accurate and safe up. Nine of 10 patients with lumbar scoliosis also had low
placement of screws and pins for acetabular fixation. back pain.

A _~ _

FIGURE 20-33. Central fracture-dislocation of the hip with injury to the triradiate cartilage in a 15-
year-old boy. Note distraction and incongruous reduction. A: During skeletal traction after reduction
of the hip dislocation. (Figure continues.)
910 Lower EY:tremity

FIGURE 20-33. (continued) B: Six months after injury.

C: Two years after injury, he has chondrolysis, mild avas-
cular necrosis of the femoral head, and an ankylosed
c hip.

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injury in children with pelvic fractures'; Tl-auma 1991 ;31:1 169-l173.
1. Alonzo JE, Horowitz M. Use of the AO-A5IF external f,xaror in chil- 10. Caffey.l P. Pediatric x-ray diagnosis: textbookfOr s/udems andpractitioncrs
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2. Barislam E, Arc', Y, Germiyanoglu C, er al. Role of Tile c1assJficarion Publishers, 1978.
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3. lllasicr RD, ;v1cArcc J, Whire R, et al. Disruption of rhe pelvic ring J 2. Carnesalc PG. F.xtensi!e approach ro the acetabulum. In: Crenshaw

in pediarric parienrs. Clill O;-thop 2000;.376:87 -9~. AH, cd. Ci/l'llpbell;- operative orthopaedics, 8th cd. Sr. LOllis: Mosby-
4. I310unt WP. Frftrtllm ill children, 2nd ed. lhlriJnore: Williams & Wil- Year Book, 1992:83-85.
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6. Brown GA, Willis MC, Firoozbakhsh K. et al. Compured romography J Surg 1935;30:69-82.
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2000;370:21.9-226. iliac joinr trauma in children.J ComplttAssis/ TonlOgr 1985;9:352-356.
7. llryan \Xlj, Tullos HS. Pcdiarric pelvic fraClures: review of 52 pariencs. 16. Dunn AW, Morris HD. Fractures and dislocations of the pelvis.} Bone
} 'JiWli'rlll 1')7');19:79')-805. ./oiruS/ligAm 1968;50:1639-1648.
8. Bucholz RW, Flaki M, Ogden JA. Injury ro rhe acerabular rriradirtre 17. Fel'l1bach SI<, Wilkinson RH. Avulsion injuries to the pelvis and proxi-
physeal cartilage. J BOllc Joillt S,lIr JIm 1982;61:600-609. mal femur. AmJ RadioL 1981;137:581-584.
 Chapter 20: Fractures of the Pelvis 911

18. Garvin KL, McCarthy RE, Barnes CL, et al. Pediatric pelvic ring frac- 41. Musemeche CA, Fischer RP, Cotler HB, et al. Selective management
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21. Hall BB, Klassen RA, Ilstrup OM. Pelvic fractures in children: a long- 44. Pendergrast NC, deRoux SJ, Adsay NV. Non-accidental pediaTric pel-
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22. Heeg M, de Ridder VA, Tornetta PIlI, et al. Acetabular fractures in 45. Peterson HA, Robertson RC. Premature partial closure of the triradiate
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28. JudeT R, J uder), LeTOurnel E. Fractures of The aceTabulum: classificaTion 51. Reed MH. Pelvic fractures in children. ] Can Assoc Radiol 1976;27:
and surgical approaches for open reduction.] BoneJoint Surg Am 1964; 255-261.
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29. Keshishyan RA, Rozinov VM, Malakhov OA, eT al. Pelvic polyfractures 336:226-239.
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327-329. 55. Silber JS, Flynn JM. Changing patterns of pediatric pelvic fractures
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] Pediatr Orthop 1992;12:621-625. pelvis in children who have multiple injuries. ] Bone Joint Surg Am
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 FRACTURES AND TRAUMATIC
DISLOCATIONS OF THE HIP IN
CHILDREN
R. DALE BLASIER
LAURIE O. HUGHES

FRACTURES OF THE HIP HIP DISL CATIONS IN IILDRE

Diagnosis Diagnosis
Classification Classification
Unusual fracrure Pa((erns Unusual fracture Patterns Associated with Hip Dislocation
Surgical and Applied Anatomy Surgical/Applied Anatomy
Trcatmenr Treatmenr Options
Surgical Procedures Surgical Procedures
Postoperative fracture Care Posrreducrion Care
Complications Complications
Stress Fracrures

FRACTURES OF THE HIP co heal, their importance lies in the frequency and severity of
complications, including AVN, coxa vara, premature physeal
Fractures of the head and neck of the femur in children are closure, limb length discrepancy and occasionally nonunion. Be-
exceedingJy rare, accounring for fewet than 1% of all pediatric cause the hip is developing in the growing child, deformities can
fractures (24). In comparison, the prevalence of fracrures of the progress with age.
hip in children is Jess than 1% of that in adults. Therefore, most
orthopaedic surgeons will treat only a few such fractures in a
lifetime (6).
Diagnosis
The pattern of fracture a.nd thus the classification in children Mechanism of Injury
differ from those in adults. Because of the weak proximal femotal
Hip fractures in children can be caused by axial loading, rorsion,
physis, a rransphyseal separation can occur in children. Transcer-
hyperabduction, or a direct blow ro the hip. AJmost all hip
vical and ccrvicotrochanreric fractures have an extremely high
fractures in children are caused by severe, high-energy trauma.
risk for avascular necrosis (AVN) and coxa vara compared with
This is in marked contrast ro hip fractures in the elderly, in
their adult counrerparcs. Imerrrochanreric fractures are mechani-
whom minor rorsional forces acring on osteoporotic bone cause
cally similar in both groups, alchough in childten involvemem
most hip fractures. The proximal femur in children, except for
of the gteater rrochanreric apophysis can resulc in premature
the proximal femoral physis, is extremely strong, and high-en-
closure.
ergy forces, such as from moving vehicle accidems and high falls,
The proximal femoral physis is at risk in hip fractul"e and
are necessary ro cause fracture (9).
has obviolls implications for fracture care and prognosis. If the
proximaJ physis is damaged, coxa vara or coxa breva may develop
with further growth regardless of fracture alignment. Conversely, Examination
if the greater trochanter apophysis fuses prematurely as a result
of trauma, coxa va.lga may develop (4). Clinical examination usually reveals pain in the hip and a short-
ened, externally rotated extremity. With a nondisplaced or stress
AJthough hip fractures in children can generally be expected
fracture of the femoral neck, the patient may be able ro bear
weight with a limp and may only demonstrate hip or knee pain
with extremes of rar<ge of motion, especially inrernal rotation.
R. Dale Blasier and Laurie O. Hughes: Arbn"lS Children's Hospital, /\. good qualit), anteroposterior pelvic radiograph will provide a
L.ittk Rock, Arkansas. comparison view of rhe opposite hip if a displaced fractute is
914 Lower Extremit)'

suspecred. A cross-cable lareral radiograph should be considereel

ro avoid further displacemenr and unnecessary discomfort [0 the
patienr from an attempt ar a frog-leg lateral view. Any break or
ofT;cr of rhe bony trabeculae near Ward's rriangle is evielence of
a nonJisplaced or impacted fracrure.
Nor all fracrures can be derecrecl on plain radiographs early.
::;pecial srudies may be required ro reveal an occult fracrure. A
raclioisoropic bone scan 48 hours after the onset of symproms
may show increased uprake at rhe fracrure site. The rypical mag-
neric resonance imaging (MRl) appearance of a fracrure is a
linear black line (low signal) on all sequences surrounded by a II
Iligh signal band of bone marrow edema and hemorrhage. The
low signal represenrs rrabecular impacrion. MRf may detecr an
occult hip fracture within the first 24 hours after injury (17).
In a patient wirh posmaumaric hip pain wirhout evidence
of a fracture, other diagnoses musr be considered, includi ng syn-
oviris, hemanhrosis, and infecrion. A complere blood counr,
eryrhrocyre sedimenrarion rare, C-reactive protein, and rempera-
ture are helpful. Ulrrasonography can be used ro derecr Auid in
the joint. If necessary, aspiration should be performed. A bloody
aspirare establishes the diagnosis of fracrure, whereas a serous or
suppurarive aspirate suggesrs synoviris or infection, respectively.
In children under 5 years of age, c1evelopmenral coxa vara can
be confused wirh an old hip fracrure (4). III IV

FIGURE 21-1. Delbet classification of hip fractures in children. I, transe-

piphyseal, with or without dislocation from the acetabulum; II, transcer-
Classification vical; III, cervicotrochanteric; and IV, intertrochanteric.
Pediarric hip fractures are classifIed by the method of DeibeL
Its simplicity anduniformiry allow accurare descriprion and re-
porting of results of each fracrure by type. Type I is a transepi-
physeal separation, wirh (type IA) or without (type IS) disloca-
tion of the femoral head from the acetabulum. Type ][ is a
rranscervical fracture. Type III is a cervicorrochanreric fracture.
Type IV is an intertrochanteric fracrute (8) (Fig. 21-1). Subrro-
chanreric fracrures are not included in rhis classification and are
discussed in Chapter 22.

Type I
Transphyseal frac£llres occur rhrough rhe proximal femoral phy-
sis (Fig. 21-2). Such fracrures arc rare, consriruting 8% of femo-
ral neck fracrures in children (Hi). True rransphyseal fractures
tend ro occur in young children after high-energy trauma (S,
12) and are different from unstable slipped capital femoral
epiphysC's of rhe preadolescenr, which probably occur as a result
of a subrle endocrinopathy. In rhe absence of a history of signifi-
cane rrauma in a young child, battered child syndrome should
be susl'C'cced (lH). Rat'ely, rhis injury occurs during a difficulr
delivery or attemprcd closed reducrion of a rraumaric dislocation
of the hip in adolescents (16). Approximately half of rype I
fractures are associarcd wirh a dislocation or the capital femoral
epiphysis. In such caSl'S, the outcome is dismal because of A\IN
and premarure physeal closure in virtually 100% of patients (5,
12).
Type I Fractures in children under 2 or 3 years of age have
a berrn prognosis chan in older children. A\IN is unlikely, al- FIGURE 21-2. Type I transphyseal fracture of the left proximal femur
in a 3-year-old patient with spina bifida. Superior translation of the
rhough coxa vaLl, coxa breva, and premacure physeal closure can metaphysis with the head remaining in the acetabulum is typical of a
cause subsequent leg lengrh discrepancy (18,23). type IA fr actu re.
 Chapter 2/: Fractures flnd Traumatic Vi.,Locations afthe Hip iu Children 915

Type /I and AVN after this fracture are exceedingly rare. Coxa vara and
premature physeal closure have rarely been reporred (5,16,19,
Transcervical fracrures account for 46% of fracrures of rhe head
24,25).
and neck of rhe femur in children (6). In three large series,
77% of all type II fractures were displaced (6). Nondisplaced
fracrures have a berrer prognosis and a lower rate of AVN than
displaced fractures, regardless of treatment (5,24). The risk of Unusual Fracture Patterns
AVN is thought by most investigatots to be directly related to Type I fracture in a neonate deserves special attention. This
the initial displacement of the fracture, although a few have injury is exceedingly rare, and, because the femoral head is nor
hypothesized an imraarricular hemarthrosis with tamponade (5, visible on plain radiographs, the index of suspicion must be high.
16) as rhe etiology of vascular impairment. An affected jnfanr holds the extremity flexed, abducted, and
externally rotated. A strong suspicion, pseudoparalysis, and
Type III shonening are keys to the diagnosis. The differential diagnosis
includes septic arthritis and hip dislocation. Plain radiographs
Cervicotrochanreric fractures are, by definition, located at or
may be of assistance, but ultrasonography is useful if the diagno-
above the anterior intertrochanteric line and are the second most
sis remains in doubt. Plain radiographs may show a high riding
common eype of hip fracture in children, comprising about 34%
proximal femoral metaphysis on the involved side, resembling
of fractures (I 6). The incidence of AVN is 20% to 30%, and,
a dislocation. Ultrasonography shows the cartilaginous head in
as in eype IJ fractures, the risk of AVN is directly related to the
the acetabulum with dissociation from the femoral shaft. The
degree of displacement at the time of injury (6). Premature
diagnosis can be missed if there is no histol)' of ([auma (such
physeal closure occurs in 25% of patients and coxa vara in 14%
as in child abuse) or if there is an ipsilateral fracture of the
(16). Displaced rype III fractures are similar to rype II fractLIl'es
femoral shaft (l).
in regard to the development of complicarions. Nondisplaced
Stress fractures are caused by repetitive injury and resulr in
rype III fracrures have a much lower complication rate than
hip or knee pain and a limp. Pain associated with long distance
displaced fractures.
running, marching, or a recent increase in physical activity is
suggestive of stress fracture. Close scrutiny of high-qualiry radio-
Type IV
graphs may identify sclerosis, conical thickening, or new bone
Intertrochanteric fractures accounr for only 12% of fractures of formation. Undisplaced fraccures may appear as faint radiolucen-
the head and neck of rhe femur in children (6). This fracture cies (Fig. 21-3).
has the lowest complication rate of all four types. Nonunion An acute unstable slipped capital femoral epiphysis may be

A B
FIGURE 21-3. A: This 5-year-old boy jumped off his bunk bed and subsequently complained of right
hip pain and limp. Anteroposterior radiography yielded normal findings. B: Careful examination of the
frog-leg lateral radiograph revealed a nondisplaced femoral neck fracture. Symptoms resolved after 4
weeks in a spica cast.
916 Lower Extremit)'

confused with an acute rype I fracture of the proximal Femur;

however, a slipped capital femoral epiphysis is caused by an
unJerl)'ing abnormaliry of the physis and occurs aFrer trivial
trauma, usually in preadolescents, whereas type 1 fractures usu-
aJ Iy occur in young children.
D Cartilage

h'acture after minor trauma suggests weakened bone. Intrin-

n
~
New bone
sic bone disease, tumors, cyStS, and infections may weaken the
bone. IF rhe trauma is significlIlt, but the history is not cons is- o Bone fluorescent Irom
accumulated tetracycline
rent, nonaccidenral trauma must always be considered (2,28).
It is easy to miss hip fractures that are overshadowed by more
o Marrow cavity

dramatic or painful injuries. Radiographs of the proximal femur

should be examined c:lrefull)' in patients with femoral shaft frac-
tures bec:luse ipsil:ttcr:ll fracrure or dislocation of the hip is not FIGURE 21-5. Drawing of a frontal section through the upper end
unusual (1). of the femur of a 14-week-old pig injected 8 weeks previously with
tetracycline (50 mg/kg). Diagram depicts the contribution of the capital
femoral physis and greater trochanteric physis to new bone formation.
(Reprinted from Edgren W. Coxa plana. A clinical and radiological inves-
Surgical and Applied Anatomy tigation with particular reference to the importance of the metaphyseal
changes for the final shape of the proximal part of the femur. Acta
Ossification of the femur begins in rhe 7th fetal week (12). In Orthop Scand 1965;84(suppl):24; with permission.)
e:lrl)' childhood, on!ly a single proximal femoral physis exists (Fig.
21-4A and B). During the first year of life, the medial ponion
of this physis growst;rster than the lateral, creating an elongated
femoral neck by 1 year of age (Fig. 21-4C). The capital femoraJ Vascular Anatomy
epiphysis begins ro ossify at approximately 4 months in girls and
5 ro 6 months in boys. The ossificuion center of the trochanteric Because of the frequency and sequelae of AVN of the hip in
apophysis appears at 4 yeal's in boys and girls (16) (Fig. 21-40). children, the blood supply has been studied extensively (7,23,29,
The proximal femoral physis is responsible for the metaphyseal 30). Postmortem injection and microangiographic studies have
growth in the femoral neck, whereas the trochanteric apophysis provided clues w the vascular changes with age. These observa-
contributes ro the appositional growth of the greater trochanrer tions are enumerated as follows:
and less to the metaphyseal growth of the femur (20) (Fig. 21-5).
Fusion of the proximal femoral and trochanteric physes occurs at 1. The vessels of the ligamentum teres are of virtually no impor-
about the age of 14 in girls and 16 in boys (5). The confluence tance. They contribme little blood supply ro the femoral head
of the greater trochanteric physis with the capital femoral physis until age 8, and then only about 20% as an adult.
along the superior femoral neck (Fig. 21-4E) and the unique 2. At birth, the branches of the medial and lateraJ circumflex
vascular supply ro the capital femoraJ epiphysis make the imma- arteries (metaphyseal vessels) traversing the femoral neck pre-
ture hip vulnerable to growth derangement and subsequent de- dominately supply the femoral head. These arteries gradually
formiry after a fracture. diminish in size as the cartilaginous physis develops and forms

A-C 4 months 1 year 4 years 6 years D,E

FIGURE 21-4. The transformation of the preplate to separate growth zones for the femoral head and
greater trochanter. The diagram shows development of the epiphyseal nucleus in the proximal end of
the femur. A: Radiograph of the proximal end of the femur of a stillborn female, weight 325 g. B-E:
Drawings made on the basis of radiographs. (Reprinted from Edgren W. Coxa plana. A clinical and
radiological investigation with particular reference to the importance of the metaphyseal changes for
the final shape of the proximal part of the femur. Acta Orthop Scand 1965;84(suppl):24; with permission.)
 Chapter 21: Fractures and Traumatic Dis/owtiom o/the Hip in Children 917

Posterior superior branch protecrive cuff of muscularure. Open hip fracture is rare. In rhe
\ absence of associated hip dislocarion, neurovascular injuries are
Lateral cervical ----I(C.~~ rare afrer hip fracrure and are more likely co occur during surgery.
ascending artery
The lateral femora! cutaneous nerve lies in rhe imelval be-
Posterior
inferior (\veen rhe rensor and sarrorius muscles and supplies sensarion
.V branch ro the lareraJ chigh. This nerve must be idemifled and preserved
during an anrerolatcral approach co rhe hip. The femoral neuro-
-Medial circumflex vascular bundle is separated from rhe anterior Ilip joinr by the
~
femoral artery iliopsoas. Thus, any rerracror placed on the anterior acerabular
)2 \ rim should be carefully placed deep ro rhe iliopsoas co protect
Lateral circumflex rhe femoral bundle. Inferior and medial ro rhe hip capsule, cours-
femoral artery
ing from rhe deep femoral arrery coward rhe posterior hip joinr,
FIGURE 21·6. Arterial supply of the proximal femur. The capital femo- is the medial Femoral circumflex arrery. Placement of a discal
ral epiphysis and physis are supplied by the medial circumflex artery Hohmann rerracror roo deeply can rear chis artery, and comro!
through two retinacular vessel systems: the posterosuperior and poster-
oinferior. The lateral circumflex artery supplies the greater trochanter of the bleeding may be difficulr.
and the lateral portion of the proximal femoral physis and a small area The sciarjc nerve emerges from the sciatic norch benearh rhe
of the anteromedial metaphysis.
piriformis and courses superficial eo the exrernal rorarors and
rhe quad raws medial ro the grearer rrGchancer. The nerve is
rarely seen ar hip fracture surgelY, bur placemenr of a Hohmann
retracror dorsalJy and distally, simultaneous wirh exrernal IOra-
a barrier [har p[evenrs penerrarion of rnese vessels ineo rhe tion of rhe leg, can damage ir.
femoral head. This meraphyseal blood supply is virrually non-
exisrenr by age 4.
3. When rhe meraphyseal v ssels diminish, rhe lareral epiphyseal Treatment
vessels predominare and rhe femoral head is primarily sup-
Type I
plied by rhese vessels, which bypass rhe physeal barrier.
4. Ogden Dared rhar rhe lareral epiphyseal vessels consisr of cwo Fracwre rrearmem is based on rhe age of rhe child and Fracrure
branches, rhe posrerosuperior and posreroinferior branches srabiliry afrer reducrion. In roddlers under 2 years of age wirh
of the medial circumAex anery (Fig. 21-6). Ar rhe level of nondisplaced or minimally displaced fracrures, simple spica cast
rhe inrernochanreric groove, rhe medial circumflex anery immobilizarion is likely to be successful. Because the fracrure
branches ineo a rerinacular arrerial sysrem (rhe posrerosuper- tends to displace ineo varus and exrernal rorarion, rhe limb
ior and posreroinferior arteries). These aneries penerrare rhe should be casred in mild abducrion and neurral roration to pre-
capsule and rraverse proximally (covered by rhe rerinacular vem displacemenr. Displaced fractures in coddlers should be
folds) along rhe neck of rhe femur to supply rhe femoral head reduced closed by genrle rraction, abducrion, and inrernal rora-
peripherally and proximally to rhe physis. rion. If rhe fracture "locks on" and is stable, casring wirhol\(
5. Capsulocomy does nor damage rhe blood supply co rhe femo- fixarion is indicated. If rhe fracrure is nor stable, it should be
ral head, bur violarion of rhe imenrochameric norch or rhe fixed wirh small smoorh pins that access rhe femoral neck and
Jareral ascending cervical vessels may render rhe head avas- cross the physis. If casting wirhour flxarion is done, repear radio-
cular. graphs should be raken wirhin days ro look for displacemenr
6. Ar abour 3 ro 4 years of age, rhe lareral posrerosuperior vessels because the likelihood of successful repeat reducrion decreases
appear co predominare and supply rhe enrire anrerior lareral rapidly wirh time and healing in a young child (Fig. 21-7).
ponion of rhe capiral femOl·al epiphysis. Older children should always have operative fix.arion even if
7. The posreroinferior and posrerosuperior aneries persisr
rhe fracrure is undisplaced because rhe complicarions of lare
rhroughour life and supply rhe femoral head.
displacemenr may be grear. Smoorh pins can be used in young
8. The ll1ulriple small vessels of rhe young coalesce wirh age ro
children, bur cannulared screws are bener for older, larger chil-
a limired number of larger vessels. As a resulr, damage co
dren. Fixarion should cross rhe physis inco rhe capical femoral
a single vessel can have serious consequences; for example,
epiphysis. Irreducibiliry mandares an open reducrion and inrer-
occlusion of rhe posrerosuperior branch of rhe medial circum-
nat fixarion. Posroperative spica casr immobilization is manda-
flex anery can cause AVN of rhe anrerior law·al porrion of
(Ory in all bur rhe oldesr and mosr reliable adolescenrs. Fixarion
rhe Femoral head (4).
may be removed shortly after fracrure healing (8-12 weeks) co
enable furrher growrh in younger parienrs.
Closed reducrion of type IB fracrure-dislocarions should be
Soft Tissue Anatomy
anempted, wirh immediate open reduction if unsuccessful. In-
The hip joim is enclosed by a rhick fibrous capsule. Tense he- ternal flxarion is mandaroly. The surgical approach should be
manhrosis afrer inrracapsuJar fracrure may ramponade rhe as- from the side co which rhe head is dislocared, generally posrero-
cending celvical vessels and may have implicarions in rhe devel- lateral. Parenrs must be advised in advance abour rhe risk of
opment of AVN. The hip joinr is surrounded on all sides by a AVN.
 918 Lower Excremit),

A B

c D

FIGURE 21-7. A: A 16-month-old boy with a type I fracture of the left

hip. Note widening of the left femoral physis. B: Lateral radiograph at
injury. Instability of the physis is apparent. C: Anteroposterior radio-
graph after 1 month in spica cast. 0: At 2 years postinjury, the patient
has mild coxa valga and coxa breva. E: At 10 years postinjury, coxa breva
secondary to premature physeal closure is evident. Note the over-
E growth of the greater trochanter.
 Chapter 21: Fractures and Traumatic DislocatioJ1J of the Hip in Chilclren 919

Type /I and Type 11/ Gentle closed reduction of displaced fractutes is accomplished
wjth the use of longitudinal traction, abduction, and internal
Displaced neck fractures should always be treated with anatomic
rotarion. Open reduction is FrequemJy necessary for displaced
reduction and stable imernal fixation w minimize the risk of
late complications. In t\'vo large series, the prevalences of coxa Fracrures and should be perFormed via a Watson-Jones slHgical
vara and nonunion were high in displaced transcervical fractures approach.
treated with immobilization but without internal fixation (5, Internal fixation with cannulated screws is performed
19). Much lower prevalences of these r\NO complications have through a small later:)1 incision. Three screws should be placed
been documented in patients treated with anawmic closed or iF possible. One screw should be placed low along rhe calcar,
open reduction and internal fixation (5). and twO above, spaced as widely as possible (3). Occasionally,
Internal fixation is also recommended by mosr investigawrs the small size oFthe child's Femoral neck will accommodate only
for nondisplaced transcervical fractures (16), because the risk of two screws. Care should be taken to minimize dtill holes in the
late displacement in such Fracrures far outweighs the risk of subtrochanteric region because they increase the risk of subtro-
percutaneous screw fixation, especially in young children (3). chanteric fl·actute. IF possible, screws should be inserted shorr
Nondisplaced rype II fractures in children under 5 years of age of the physis in type III Fractures; however, if physeal penetration
can be managed with spica casting and close Follow-up (10,19), is necessal)' for purchase, it must be done (Figs. 21-8 and 21-
but fixation remains preferable. Even then, close follow-up IS 9). The risks of premature physeal closure and trochanteric over-
necessary ro prevent varus displacement in the cast. growth are much less than those of nonunion, pin breabge,

A 8

FIGURE 21-8. A: A girl 4 years and 4 months of age with a type II

fracture of the left femoral neck. Anteroposterior pelvis film at presen-
tation shows a displaced femoral neck fracture. B: Three weeks postin-
jury. Smooth pins were chosen to minimize the risk of physeal damage.
C: Six years after fracture. Mild coxa valga is evident, possibly from
damage to the growth zone on the superior femoral neck in this young
c child.
920 Lower Extremity

A B

c D
FIGURE 21-9. A: This boy 4 years and 9 months of age sustained a type III femoral neck fracture in a
motor vehicle accident. B: Lateral radiograph at presentation. C: Three months after anatomic open
reduction and internal fixation with two screws, sparing the physis. D: Lateral radiograph on the same
date.

and AVN. Trearmem of rhe fr<lnure is rhe fil"S[ priority, and been shown [Q have a complicarion rare similar [Q rhar for rype
any subsequem growrh disrurbance and leg lengrh discrepancy II fracrures and should be rrea[ed similarly. Fixa[ion generally
(U.o) are secondary. does no[ need [Q cross [he physis in type nr fractures.
Nondisplaced cervicouochameric franLl[es can be treared ad- In a more dis[al cervicouochameric fracwre, especially in a
equarely in an abdunion one and one-half spica casr wirh close child over 5 years of age, a pediatric hip compression screw can
follow-up (16). Displaced cervicouochameric fracwres have be llsed for more secure Jixa[ion. Considerarion may be given
 Chapter 21.' Fractures d/lel Tmlllrlatic Dislocatill/H of the Hip il1 Chi/dml 921

A B
FIGURE 21·10. A: A girl 3 years and 7 months of age with type IV intertrochanteric right femurfracture.
B: Three months after fixation with a pediatric sliding hip screw.

ro capsuloromy or aspiration of the joinr co eliminate tense he- tel' screws, in adolescents. For fixation of type-IV fracrures, pedi-
marrhrosis at the time of surgery. Spica casting is routine, except atric-size hip-compression screws should be used in children and
in older reliable children. Hardware removal at 6 to 12 monrhs adult-size hip-compression screws, in adolescents.
after fracrure union will avoid bony overgrowth of the hardware. A hip-spica cast should supplemenr internal fixation in all
patients who are less than ten years old. Fracrures of the neck
of the femur in children who are twelve years old or more are
Type IV treated in a manner similar co that used in adulrs: no poscopera-
Good results can be expected after dosed treatment of most tive cast is used and early walking with crutches is encouraged.
intenrochanreric fracrures, regardless of displacement. Traction For patients who are between the ages of ten and twelve years,
and spica cast immobilization are effecrive (16). Failure to main- the necessity for a poscoperative cast is Jess clear-cut. If stability
tain adequate reduction and polytrauma are indications for inrer- of the fracture fixation is questionable, or if compliance of the
nal fixation. Children old enough to use crutches or those with patient is doubtful, a hip-spica cast should be used.
multiple injuries can be treated with open reduction and internal Because the femoral bone in chi Idren is harder than the osteo-
fixation (Figs. 21-10 and 21-1 I). A pediatric hip screw provides pOl'otic bone in elderly patients, pre-drilling and pre-tapping are
the most rigid internal fixation for this purpose. necessary for insertion of all screws.
Finally, growrh of the femur and the contribution of the
proximal femoral physis are important; however, this physeal
Surgical Procedures conrribution ro growth is only 13 per cent of the entire extrem-
When an operation is indicated, several factors must be evaluated ity, or three co four millimeters per year on the average. Once
before the method of inrernal fixation and the operative proce- the decision for internal fixation of a fracture of the head or
dure are selected (Table 21-1). Perhaps the most important con- neck of the femur is made, stable fixation of the fracture is a
sideration is the age of the patient. For discussion, three age- higher priority than preservation of the physis. If stability is
groups have been established arbitrarily: infantile (younger than questionable, the internal fixation device should extend into the
thtee years), juvenile (three co eight years), and adolescenr (older femoral head for rigid, stable fixation, regardless of the type of
than eight years). fracture or the age of the child.
For younger and smaller patienrs, the operation should be
done on a radiolucent operating table rather than on a fracture
Anterolateral Approach
table, which is more appropriate for older and larger adolescents.
For internal fixation of types 1, II, and III fracntres of the If closed ('eduction is successful, a 5- co 4.5-cm lateral incision
femoral neck, smooth pins may be used in infants; cannulated is made distal to the greater trochanter apophysis for insertion
4.0-millimeter screws, in children; and cannulated 6.5-millime- of pins or cannulared screws. An anterior approach through rhe
922 Lower Extremity

A,B C
FIGURE 21-11. A: A 14-year-old boy who fell from a tree swing sustained this nondisplaced left intertro-
chanteric hip fracture. B: Lateral radiograph shows the long spiral fracture line. C: Three months postfixa-
tion with an adult sliding hip screw.

Warson-Jones interval is often used for open reducrion. A lateral longitudinal capsuloromy is made along the anrerosuperior fem-
incision is made over the proximal femur, slighrly anterior to oral neck. A transverse incision may be added superiorly for
the greater rrochanrer (Fig. 2 J -12A). The fascia lata is incised wider visualization (Fig. 21-120).
longitudinally (Fig. 2] -12B). The innervation ohhe tensor mus- Alternatively, a bikini approach can be used through the
cle by the superior gluteal nerve is 2 ro 5 cm above the grcarer Smith-Petersen interval. Care should be raken ro identify and
rrochanter and care should be wken not ro damage this innerva- prorect the lateral femoral cutaneous nerve. The sarrorius and
tion. The tensor muscle is reAected anteriorly. The inrerval be- recrus muscles can be detached ro expose the hip capsule. Medial
rween the gluteus medius and the tensol' muscles will be used and inferior retracrors should be car'efully placed ro avoid damage
(Fig. 21-12C). The plane is developed between the muscles and co rhe femoral neurovascular bundle and medial femoral circum-
the underlying hip capsule. [f necessary, the anreriormost fibers flex artery, respectively. Care must be taken nor ro violate the
of the glureus medius tendon can be detached from the trochan- intertrochanteric notch and the lateral ascending vessels.
rer for wider exposure. After clearing the anrerior hip capsule, Under di recr vision, the fracture is reduced and guidewires
are p~sseJ from the lateral aspect of the proximal femur up
rhe neck perpendicular to the fracrure. Wires are passed either
through rhe incision or percuraneollsly if a bikini approach is
used. Smoorh wires can be used as definitive fixation in toddlers
TABLE 21-1. SURGICAL TIPS AND PEARLS FOR or as guides for drilling if cannulated screws are used. The choice
FRACTURES IN CHILDREN
of internalfJxation should consider the child's size and age. For
Anterolateral approach inrernal fixation of types I, II, and III fractures, smooth pins are
Age 0-3 yr-smooth pins, 5/64-inch or 3/32-inch appropriare in children under 3 years of age, cannulared 4.5-
Age 3-8 yr-cannulated 4.5-mm screws mm screws in children 3 to 8 years of age, and 6.5-mm cannu-
Age 8+ yr-6.9 or 7.3-mm cannulated screws
lated screws in children over 8 years of age. For fixation of rype
Type IV fractures
<8 yr-pedi hip compression screw IV fracwres, simple screw fixation is inappropriare. A pediarric-
>8 yr-adult hip compression screw size hip compression screw is appropriate in patients under 8
Always predrill and tap before inserting screws years of age, and an adulr-size hip compression screw may be
Avoid crossing physis if possible, but cross physis if necessary for lIsed in older children and adolescents. Because the femoral neck
stability
Age <10 yr-hip spica for 6-12 wk
in children is denser and harder rhan the osteoporotic bone in
elderly parients, predrilling and rapping are necessary before the
inserrion of screws.
 'hapter 2/: Fractures and Traumatic DUocat;om of the Hip in Children 923

A B

c D

FIGURE 21-12, Watson-Jones lateral approach to the hip joint for open reduction of femoral neck
fractures in children. A: Skin incision. B: Interval between gluteus medius and tensor fasciae. C: Dissection
carried proximally. D: Completed exposure.
 924 Lower Extremity

Postoperative Fracture Care mately 30% based on nine series in the literature (6,16,22). It
is rhe primary cause of poor results after fractures of the hip in
Hip spica casting is used after internal fixation in moSt patients
children. The risk of AVN is related w the extem of initial
under 10 years of age. The cast should ['emain in place for 6 w
displacement of the fracture and to the damage to the blood
12 weeks depending on age. For children over 12 years of age,
supply at injury. The risk of AVN is highest after displaced type
no poswperative cast is used, and eady walking with crurches
IB, type H, and type III fractures (16) (Fig. 21-13). Although
is encouraged, as in adults. For children 10 w 12 years of age,
prompt reducrion of displaced fractures may be of some benefit,
the use of a postoperative cast depends on the stability of fracture
its worth has not been proven. Increased intraarticular pressure
flxarion and the patiem's compliance. If either is in doubt, a
caused by fracture hemawma may be related to AVN after intra-
single hip spica cast is used. Formal rehabilitation usually is
unnecessary unless there is a severe persistent limp, which may capsular fracture, and evacuation of this hemarchrosis may de-
be due w abducwr weakness. Stiffness rarely is a problem in the crease the AVN rare (16,22,27). Aspirating the hemaroma from
absence of AVN. the hip capsule may decrease the intracapsular pressure and in-
crease blood 80w w the femoral head (6,22) or may have no
effecr (]6,21). If a child is going w have an anestheric for trear-
Complications mem of a fracture, aspiration of the hematoma can easily be
accomplished. Open reduction results in capsular evacuation at
Avascular Necrosis
capsulotomy, or a small capsulowmy can be made if a srraighr
Avascular necrosis is the most serious and frequent complication lateral incision is used after unsuccessful closed reduction.
of hip fractures in children. Its overall prevalence is approxi- Avascular necrosis has been classified by Ratliff as foHows:

A B

c D
FIGURE 21-13. A: A 14-year-old girl with a type II fracture of the left femoral neck. 8: After fixation
with three cannulated screws. C: Seven months after injury. Avascular necrosis with collapse of the
superolateral portion of the femoral head. D: After treatment with valgus osteotomy.
 Chapter 2/.' Fraclures and TrIll/malic Dislocations of the Hip in Children 925

FIGURE 21-14. Three types of avascular necrosis. (Re-

printed from Ratliff AHC. Fractures of the neck of the
femur in children. J Bone Joint Surg [Br] 1962;44 : 528; with
II III permission.)

type I, involvement of the whole head; type II, partial involve- candy lower in series in which internal fixation was used afrer
ment of the head; and type III, an area of AVN from the fracture reduction of displaced fractures (5). Coxa vam may be caused
line (Q the physis (24) (Fig. 21-14). Type I is the most severe by malunion, AVN, premature physeal closure, or a combination
and most common form and has the poorest prognosis. Type I of these problems (Fig. 21-\6). Severe coxa vara raises rhe greater
probably results from damage to all of the lateral epiphyseal trochanter in relation to the femoral head, causing shortening
vessels, type II from localized damage to one or more of the of the extremity and mechanical disadvantage of the abductors.
lateral epiphyseal vessels near their insertion into the anterolat- The result is an abductor lurch. If the child is over 8 years of
eral aspecr of the femoral head, and type III from damage to age, the neck shaft angle is 1\ 0 degrees or less, and coxa vara
rhe superior meraphyseal vessels. Type III is rare but has a good has been persistent for more than 2 years, subtrochanteric valgus
prognosis (24). osteotomy may be considered to restore limb length and abduc-
Avascular necrosis causes pain and limitation of motion. As tor strength (16).
early as 6 weeks after injury, plain radiographs may reveal de-
creased density of the femoral head with widening of the joint
space. Fragmentation and collapse of the femoral head occur Premature Physeal Closure
late. Technerium bone scanning with pinhole collimation may
Premature physeal closure has occurred after approximately 28%
show decreased uptake in the involved femoral head early in the
of fractures (16). The risk of premature physeal closure j ncreases
course of AVN. With revascularization, changes may be variable.
with penetration by fixation devices or when AVN is present.
Signs and symptoms of AVN usually develop within the first
It is most frequent in patients who have type II or III AVN (24,
year after injury, but sometimes as late as 2 years (16,25). Pa-
25) (Fig. 21-16).
tients should be followed with plain radiographs for at least 2
The capital femoral physis contributes only 1.3% of the
years after fracture to rule out late onset of AVN. MRl reveals
growth of the entire extremity and normally closes earlier than
AVN within a few days of injury (see the subsection on Avascular
mosr of the other physes in the lower extremity. As a result,
Necrosis later under Hip Dislocations in Children). IfMIU does
shortening due to premarure physeal closure is nor significanr
nor reveal AVN within 6 weeks of injury, ir is unlikely to de-
except in very young children (16,18). Treatment for leg length
velop. The long-term results of AVN are poor in over 60% of
discrepancy is only indicared for significant discrepancy (2.5
parients (5,10,13). There is no clearly effective rrearment for
cm or more projected at maturity) (16). Rarely, rrochanreric
posttraumatic AVN in children (16,25). Older children (> 10
epiphysiodesis may be used in progressive coxa vara.
years of age) tend [Q have worse outcomes than younger children.
Ongoing investigative research includes the role of core de-
compression, vascularized fibular grafting, and the trapdoor pro-
Nonunion
cedure. Results of the procedures in few reported patients must
ultimately be compared with the natural healing of untreated Nonunion occurs infrequently, with an overall incidence of 7%
AVN. Remodeling can occur over many years and is more likely of hip fractures in children (16). Nonunion is a complication
in younger children than in older ones. Degenerative arthrosis in of femoral neck fracture and is nor generally seen afrer type 1
older children is generally irreversible. Valgus intertrochanteric or type IV fractures. The primary cause of nonunion is failure
osteotomy may improve coxa vara and leg length discrepancy if to obtain or maintain an anatomic reducrion (5,16). After femo-
there is reasonable congruence in adduction of the hip preopera- ral neck fracture in a child, pain should be gone and bridging
rively (Fig. 2\-15). new bone should be seen at the fracture site by 3 months afrer
injury. A computed tomography (CT) scan may be helpful to
look for bridging bone. If no or minimal healing is seen by 3
Coxa Vara
months, the diagnosis of nonunion is established. Nonunion
The prevalence of coxa vara has been reported [Q be approxi- should be treated operatively as soon as possible. Either rigid
marely 20% ro 30% in nine series (16), alrhough ir is signifl- internal fixation or subtrochanteric valgus osreotomy should be
 926 Lower Extrtrnity

A B

c o
FIGURE 21-15. A: A girl9 years and 4 months of age with Ratliff type I avascular necrosis of the femoral
head. B: Lateral radiograph on the same date. The patient has had a previous acetabular osteotomy for
containment. C: Two years after valgus osteotomy. D: Lateral radiograph on same date. Note that some
remodeling of the femoral head has occurred.

performed ro allow compression across rhe fracrure (Fig. 21-17). Stress Fractures
Because rhe approach necessary for bone grafring is exrensive, ir
Suess fracrures of rhe femoral neck are unusual in children, Only
should be reserved for recalcirranr cases. Inrernal fixarion should
13 cases have been reponed in rhe English-language lirerarure.
exrend across rhe sire of rhe nonunion, and spica casr immobili-
The rariry of such franures underscores rhe need for a high index
zarion should be used in all bur rhe mosr marure and cooperarive
ofsuspicion when a child has unexplained hip pain, because early
adolescenrs.
diagnosis and aearmenr are essenrial ro avoid complere franure
wirh displacemenr.
Other Complications
Mechanism
Infeerion is uncommon afrer hip fracrures in children. The re-
poned incidence of 1% (5,19,24) is consisrem wirh rhe ex peered S[t'ess fracrmes of rhe femoral neck in children resulr from reperi-
infecrion rare in any closed fraerure [t'eared surgically wirh open rive cyclic loading of rhe hip, such as rhar produced by a new
reducrion and inrernal fixarion, or increased acriviry, A recenr increase in rhe repetitive acriviry
Chondrolysis is exceedingly ral'e and has been reponed only is highly suggesrive of the diagnosis, Long disrance running,
in one series ar a rare of50% (13). Cal'e musr be raken ro avoid [I'ampoline use, and scooter usc are examples of such acriviries.
persisrenr pJacemenr of hardware inro rhe jOilH, which can cause Underlying merabolic disorders rhar weaken rhe bone may pre-
rhis condirion. dispose ro srress fracrure. In aclolescenr female ar!lleres, amenor-
 Chapter 21. Fracrures and Traumatic Dislocations of the Hip ill Children 927

A B

C D
FIGURE 21-16. A: A 12-year-old boy with a type III left hip fracture. Poor pin placement and varus
malposition are evident. B: The fracture united in mild varus after hardware revision. C: Fourteen months
after injury. Collapse of the weight-bearing segment is evident (Ratliff type II avascular necrosis). D: Six
years postinjury. Coxa breva and trochanteric overgrowth are seen secondary to avascular necrosis,
malunion, and premature physeal closure.
928 Lower ExtremifJl

A B

c D
FIGURE 21-17. A: A 15-year-old girl with a markedly displaced type" femoral neck fracture. B: She
underwent open reduction and internal fixation with two 7.3-mm cannulated screws and one 4.5-mm
cannulated screw. Primary bone grafting of a large defect in the superior neck also was performed. C:
Radiograph at 5 months showing a persistent fracture line. D: Six weeks after valgus intertrochanteric
osteotomy. The fracture is healing.
 hapter 2/: Fractures find Traumatic DislowtiullS of the Hip in Children 929

rhea, anorexia nervosa, and osteoporosis have been implicated

in the development of stress fractures of rhe femoral neck (14).
IHip pain I
The usual presentation is that of progressive hip or groin pain
with or withour a limp. The pain may be perceived in the thigh
!
Hx & PE
or knee, and the pain may not be so severe as ro preclude the consistent with
offending activity. In the absence of displacement, examination stress fracture
typically reveals slight limitation of hip motion with increased
pain, especially with internal roration. Usually, plain radiographs
-
1
reveal the fracture, bur in the first 4 to 6 weeks after presentation,
plain films may be negative. If there are no changes or only
Bone scan
Radi0F'h'~
lineat sclerosis, bone scan will help identi~' the ri·acture. MRl
has been documented as a sensitive test for undisplaced Fractures - + Undisplaced I I Displaced I
of the femoral neck because impaction of rhe bony trabeculae
appears on both T1 and T2 images as a linear black signal (21).
~ stress fracture stress fracture

If a sclerotic lesion is seen on plain tadiographs, the differential

IObserve I r
diagnosis should include osteoid osteoma, chronic sclerosing os- Non weight I Reduce fracture I
teomyelitis, bone infarct, and osteosarcoma. Other causes of hip bearing until Internal fixation
full ROM
pain, including slipped capital femoral epiphysis, Legg-Calve-
without pain
Perthes disease, infection, avulsion injuries of rhe pelvis, and
eosinophilic granuloma should be considered. Stress fracture
unrelieved by rest or treatment may progress with activity to Fracture Advance
1
complete fracture with displacement (26). For this reason, progression; weight bearing
delayed
f+-
prompt diagnosis and treatment are important. as tolerated
or nonunion

Classification Spica cast

or internal
1
Healed Ie
Devas classified femoral neck stress fractures into two types:
fixation
compression fractures and tension fractures. The compression
type appears as reactive bone formation on the inferior cortex FIGURE 21-18. Treatment algorithm for hip pain in children and ado-
without cortical disruption. This type tarely becomes completely lescents with a history and physical examination compatible with a
stress fracture. (Reprinted from St. Pierre P, Staheli LT, Smith lB, et
displaced but may collapse into a mild varus deformity (1 J). al. Femoral neck stress fractures in children and adolescents. ) Pediatr
Compression types have recently been reported to progress to Orthop 1995;15.470-473.
complete fracture without early treatment (26). The tension type
is a transverse fracrure line appearing on the superior ponion of
the femoral neck (11). TI1is type is inherently unstable because
the fracture line is perpendicular to the lines of tension and to all the complications of type II and type III displaced femoral
fractures heal best under compression. Tension Stress fractures neck fracwres.
have not been reponed in children but may occur in the skele-
tally mature teenager (26). HIP DISLOCATIONS IN CHILDREN
Hip dislocations in childten are relatively uncommon. They can
Treatment occur in young children under age 5 as a result of seemingly
Compression type fractures generally can be treated wirh a pe- trivial trauma (32,37,43,46,51). The child's acetabulum at that
riod of non-weight bearing on crutches. Partial weight bearing age is primarily soft pliable cartilage, and there is generalized
can be allowed at 6 weeks and full weight bearing at 12 weeks ligamentous laxity that allows hip dislocation. Dislocations in
if pain is resolved and there is radiographic evidence of healing. older children usually require significant trauma because the ace-
In small or uncooperative children, spica casting may be neces- tabulum is bony and less resilient and the ligaments are stiffer
sary. Displacement into varus, however minimal, mandates in- (37,43,46,51). Most hip dislocations in children can be reduced
ternal fixation. Tension fractures are at high risk for disphcc- easily and will heal satisfactorily (46,5J), although the possibiliry
ment and should be treated with in situ compression fixation of latc problems exists (50). Difficulties after hip dislocation can
using cannulated screws (Fig. 21-18). include neurovascular injury, concomitant fracrure, irreducibil-
ity, nonconcentric reduction, A VN, coxa magna, arthrosis, and
recurrent dislocation.
Complications
Coxa vara is the most common complication of untreated
Diagnosis
compression type fractures. Acute displacement of this type also The mechanism of injury dictates the direction of hip disloca-
has been described. Once displaced, the stress fracture is subject tion. Postnior dislocations are the most common (32,50,51)
 930 Lower Extremity

c
B

FIGURE 21-19. A: Not all children have severe pain with dislocation. An 8-year-old com-
plained of pain and had difficulty walking after wrestling. Because of knee pain, a knee
immobilizer was placed at an outside facility. B: The leg length discrepancy had gone
unnoticed. C: The thigh was markedly shortened on the dislocated right side. 0: Closed
reduction was easily achieved under anesthesia. Thigh length was restored. She made
an unremarkable recovery. D
 Chapter 2/.· FraCTures and TrflU/'fwtic Dislocations of the IIip in Children 931

and generally occur when a force is applied ro the leg with the posed between the femoral head and acerabulum. MRl is espe-
hip flexed. Anterior dislocations generally occur through a com- cially helpful io noocooceortic reducrions \-vhen rhe Initial direc-
bination of external rotation and abduction. rion of dislocation is unknown. Soft rissue injury will dicrare
The affected child has pain and inabiliry ro ambulare. Chil- the surgical approach.
dren sometimes feel rhe pain in the knee rarher than in rhe hip Spontaneous reducrion may occur afrer hip dislocation (47),
(Fig. 21-19). The hallmark of the clinical diagnosis of dislocation and rhe diagnosis will be missed if it is not considered. The
of the hip is abnormal positioning of the limb, which is nor presence of air in rhe hip joinr, which may be detectable on CT
seen in fracture of the femur. With posterior dislocarion, rhe scan of the pelvis, is evidence rhar a hip dislocarion has occutred
rhigh tends to be flexed, adducted, and inrernally rotated. The (36). Dislocation and sponraneous reduction wirh interposed
grearer trochantet is proximal ro irs normal posirion, and the rissue can occur and lead to lare arthropathy if untreated (47).
femoral head is often palpable in rhe glureal region. If rhe hip Widening of rhe joi nt space on plain radiographs suggests rhe
is dislocared anteriorly, rhe extremiry is generally exrended, ab- diagnosis. In patients wirh hip pain, a history of trauma, and
ducred, and exrernally rorated. Posterior dislocarions of rhe fem- widening of rhe joint space, consideration should be given to
oral head can damage the sciaric nerve, and funerion of rhis MRI or arthrography to rule out dislocarion wirh spooraneous
nerve should be specifically tesred afrer injury. Anterior disloca- relocarion incarcerating sofr tissue. [f incarcerared soft rissues or
rions can damage rhe femoral neurovascular bundle, and femoral osseous cartilage fragments are found, open reduerion is required
nerve function and perfusion of rhe limb should be assessed. to obtain concentric reducrion of rhe hip.
Plain radiographs usually confirm the diagnosis. Radiographs
should be examined for fraerure of rhe acerabular rim and proxi-
mal femur, which may be associared with dislocarion. Ipsilareral
Classification
femoral fracrure has been described in a few parients (50). CT Hip dislocations in children generally are classified as anterior
scanning is useful for evaluaring the acetabulum and may be or posrerior depending on where rhe femoral head lies afrer
useful in localizing intraarticuJar bony fragments afrer reducrion dislocarion. Posterior dislocarions are much more common than
(44) (Fig. 21-20). The identification of nonbony fragments is anterior dislocarions and tend to occur as a resulr of an a..,'(ial
difflcul r by CT without rhe use of concomirant arthrography force on rhe femur applied toward the hip wirh the hip in flexion.
(44). MRl is useful for evaluaring soft rissues thar may be inter- Dashboard injury is a frequent cause. The limb assumes a posi-

A B
FIGURE 21-20. A: A girl 13 years and 11 months of age sustained a left posterior hip dislocation in
a motor vehicle accident. B: Computed tomography scan after reduction showed intraarticular bony
fragments. (Figure continues.)
932 Lower Extremity

c
FIGURE 21-20. (continued) C: At open reduction and capsulorrhaphy, the bony fragments were re-
moved. Suture anchors were used to reattach capsule to bone. Ten months postinjury, there is no sign
of avascular necrosis. Heterotopic ossification is seen.

tion of shortening, internaJ rotation, and adduction (Fig. 21- a dislocation of the hip. Failure to appreciare rhe presence of
21). hip dislocation may lead to inadequare treatment. If soft rissue
Anterior dislocations can occur superiorly or inferiorly and has been interposed in the hip joint, chronic arthropathy may
result from forced abduction and external rotation. In extension, result. In a child with posttraumatic hip pain without obvious
the hip tends to dislocate anteriorly and superiorly. The limb deformity, the possibility of dislocarion-relocation must be con-
appears shortened, the thigh is positioned in external roration sidered. Radiographs should be obtained ro rule our joint space
and extension and the femoral head is palpable in the groin. If widening and undisplaced fracture.
the hip dislocates with the leg flexed, the femoral head tends to Another consideration afrer reduction of hip dislocations is
dislocate inferiorly. The leg is held in abduction, external rota- interposed tissue. Afrer reduction, hemarthrosis may initially
tion, and flexion, and the femoral head is palpable near the cause the hip joint to appear slightly wide (49). Wirh rime, the
obturator foramen (Fig. 21-22). hip should seat and the increased iliofemoral disrance should
Fracture-dislocation of the hip involving the femoral head subside (Fig. 21-24). If it fails to a[Jpear concentric after a few
or the acetabulum is much more unusual in children than in days, the possibility of interposed soft tissue must be considered
adults. Older adolescents may sustain adult-type fracture-disJoc- (39,43.47,52).
ations of the hip, and these are best classified by the methods
of Thompson and Epstein and of Pipkin.
Surgical and Applied Anatomy
The hip joint is highly specializ.ed. Although capable of bearing
Unusual Fracture Patterns Associated with
body weight, the hip still provides a tremendous range of mo-
Hip Dislocation rion, surpassed only by the range of motion of the shoulder.
There are several pitEllis in rhe diagnosis of hip dislocations in The architecture of the hip joint is highly specializ.ed and is
children. It is always important to look for associated fractures. centered on the spherical femoral head, which resides in the
In older children, it is important to evaluate the posterior rim bony acetabulum. The relatively narrow femoral neck increases
of the acetabulum after posterior dislocation to rule out fracture the range of motion possible ar the hip joint in flexion, extension,
(Fig. 21-23). Fractures ar other sites in the femur must be consid- abduction, and circumduction. A larger diameter neck would
ered. Ir is important to obrain radiographs thar show the entire impinge on rhe acerabular rim ar exrremes of morion.
femur to rule out ipsilateral fracture. Fractures of the femoral Conrainment of rhe hip joint is assured by several factors.
head are distinctly unusual in children, but separation of the The bony socket physically constrains rhe femoral head and is
capital femoral epiphysis and femoral neck fracture have been further deepened by rhe surrounding fibrocartilaginous acerabu-
reported in association wirh dislocation of the hip. lar labrum. In young children, the socket and labrum are largely
Another pitfalJ is the possibility of spontaneous relocation of cartilaginous and flexible. In older children, a larger proporrion
 Chapter 21: Fractures and Traumatic Dislocations of the Hip in Child/'en 933

A B

FIGURE 21-21. A: A girl 4 years and 7 months of age presented with a

posterior dislocation of the left hip. B: Frog-leg lateral radiograph at
injury is shown. C: Eight months after successful closed reduction, radio-
c graphic appearance is normal.

A B
FIGURE 21-22. A: An ll-year-old girl sustained anterior inferior dislocation of the hip. B: Immediate
closed reduction was concentric.
934 Lower Extremity

A B

c
FIGURE 21-23. A: A 12-year-old boy was tackled from behind in football. The right hip was dislocated.
Reduction was easily achieved, but the hip was unstable posteriorly as a result of fracture of the posterior
rim of the acetabulum. B: The fracture and capsule were fixed via a posterior approach. C: Oblique view
shows reconstitution of the posterior rim.

of rhe socker and rim is hard bone. Inrimare comacr berween provide acrive extrinsic srabiliry by maintaining consranr rension
rne carrilaginous surfaces of rhe round head and rhe socker, in acl"Oss rhe hip joinr, which pushes rhe head inro rhe acerabulum.
rhe presence of joinr fluid, provides a sucrion fir. In an inracr These muscles, which provide rhe power for sranding and loco-
joinr, considerable force is required to disrupr rhis union. The morion, acr around rhe fulcrum cenrered ar rhe hip. Efflcienr
srrong fibrous joinr capsule funher conrains rhe hip joinr. The rransmission of muscle forces requires hip srabiliry.
capsule is flexible enough ro allow exce.llenr range of morion, bur In order for rhe hip co dislocare, considerable force or me-
secure enough to mainrain rhe hip reduced excepr for exrreme chanical advanrage is required co overcome rhese resrrainrs. The
circumsrances. The ligamenrum reres does nor provide any sra- capsule musr be rorn or srrerched. This will be deformed or
biliry co rhe hip. The muscles rhar span rhe hip joim funher disrupred ar rhe rime of dislocarion. The ligamenrwn reres is
 Chapter 21: Fractures find Traul'r/fuic Dislocations of the Hip in ChiLdren 935

A B

FIGURE 21-24. A: A boy 10 years and 3 months of age sustained an

anterior dislocation of the hip in football. B: The hip was easily re-
duced. The joint space was initially widened, probably due to hemar-
throsis but normalized in a few days. C: At 4 months postinjury, the
c radiographic appearance was normal.

likely ro be (Orn, but this does not appear (0 result in any Jong- erally, closed reduction should be attempted initially. Successful
term sequelae. closed ['eduction can be achieved with intravenous or intramus-
cular sedation in the emergency room in many patients (49).
Complete muscle rela;'Cation is required for others, and this is
Treatment Options
besr provided in the operaring room with a general anesthetic.
The immediate goal in the treatment of a dislocated hip is to Open reduction is indicated if closed reduction is unsuccessful
obtain concentric reduction as soon as practically possible. Gen- or incomplete.
936 Lower Extremity

Several methods of closed reduction have been described. grees. Once tne gluteal fascia lata is incised, the femoral head
Stimson described a maneuver for reducrion of posterior disloca- can be palpated benearh or within rhe substance of ehe gluteus
tion of the hip. It is also referred to as the gravity method of maximus muscle. The fibers of the gluteus maximus can then
Stimson. In this method, the patient is placed prone with the be divided by blunt dissection, exposing ehe femoral head. The
lower limbs hanging over the edge of a table. Two persons are paeh of cUslocation is followed through rhe shorr external rotatOr
required to perform !\his maneuver. An assistant stabilizes the muscles and capsule down to the aceeabulum. The sciatic nerve
pelvis by applying pressure downward from above. The manipu- lies 011 the shorr external rotatorS and should be inspected. It
1:1[or holds the affected knee and hip flexed 90 degrees and ap- may be necessary to detach the shorr external rotatOrs in order
plies gende downward pressure in an auempt to bring the poste- to see inside ehe joinr capsule.
riorly dislocated head over the posterior rim of the acetabulum Anterior dislocations should be approached th rough an ante-
and back inro the socker. Gende inrernal and external rotation rior approach. This can be done through a bikini incision that
may assist in the reduction. uses the interval between sartOrius and tensor fascia lata. The
Allis described a maneuver in which the patient is placed deep dissection follows the defect created by ehe femoral head
supine and rhe reducing surgeon stands above the patient. For down to the level of the acetabulum.
this reason, either the patient must be placed on the floor or Ae the time of open reduction, rhe femoral head should be
the surgeon must climb ontO ehe operaeing table. The knee is inspecred for damage, scuffing, or fracturing. Before reduction,
flexed to relax the hamstrings. While an assistant stabilizes ene the aceeabulum should be inspected and palpated for similar
pelvis, the surgeon applies longitudinal traction along the axis damage. Any intraarricular fragments should be removed. The
of the femur and gently manipulates the femoral head over the labrum and capsule should be inspected for repairable tcars.
rim of the acetabulum and back into the socker. Labral fragmencs that cannot be securely replaced should be
Bigelow described a manipulative teducrion in which the pa- excised, but repair should be attempted. hequently, the labrum
tient lies supine and an assistant provides downward pressure or hip capsule is entrapped in the joint. The femoral head should
on the pelvis. The surgeon grasps the ipsilateral limb at the ankle be dislocated and any inrerposed soft tissue extracted. The la-
with one hand, puts the opposite forearm behind rhe knee, and brum or capsule may be tied for ease in removal. Obstacles to
applies longitudinal traction in the axis of the femur. Internal reduction should be ceased out of the way and the traumaeic
rotation, adduction, and flexion of 90 degrees or more take the defecr enlarged if necessary. The hip joint is then reduced uncleI'
tension off the Y ligament and allow rhe surgeon to bring the direct vision. Radiographs should be eaken to confirm concentric
femoral head to the level of the acetabulum, posteriorly. The reducrion. If the joint appears slightly widened, repeat investiga-
femoral head is then levered into the acetabulum by abducting, tion must rule out inrerposed eissue. Slight widening may be
externally rotating, and extending the hip. This is a more forceful due to fluid in the hip joint and this should serrk our over the
maneuver than the others and may cause damage to the arricular next few days. The capsule is repaired if possible. Closure is
surGKes of hip or even fracrure the femoral neck, so it should routine.
he used with great caurion. Open fractures should be treated wirh immediate irrigation
A technique called the reverse Bigelow maneuver can be used an.d debridement. The surgical incision should incorporate and
for anrerior dislocation. In this technique, the hip is held in enlarge the traumatic wound. Inspection should proceed as de-
partial flexion and abduction. One of rwo reduction methods tailed above. Capsular repair should be artempted if rhe hip joinc
may be used. The first is a lifting method in which a firm jerk is nor conraminated. The wound should be left open or should
is applied to the thigh, which may result in reduction. If that be well drained to prevenc invasive infection. As in all open
fails, traerion is applied in the line of the thigh and ehe hip is fractures, inrravenous antibiotics should be administered and
then sharply internally rotated, adducted, and extended. This repeat wound care performed as needed.
manipulative method may result in reduction but also risks frac-
ture of rhe femoral neck.
\\!ith any type of dislocation, eraceion along ehe axis of the Postreduction Care
thigh coupled with gentle manipulation of the hip ofeen effeces
After reduction, treatment should be symptomatic. Generally a
rcduceion aftcr satisfactory relaxation of the surrounding mus-
shorr period of recumbency, until the pain subsides, can. be fol-
cles.
lowed by return ro ambuJation with crutches if necessary. Bed
If satisfactory closed reducrion cannot be obtained using rea-
rest, spica casting, skin traction, and non-weight bearing have
sonable measures, it is appropri:He to proceed wi eh open reduc-
nor been proven to be beneficial (43,50,5 I). After open reduc-
tion to remove any obstructing soft tissues.
tion with substanrial capsuJorrhaphy, immobilization or a spica
cast may be indicated for a period of 6 weeks to allow capsular
Surgical Procedures healing. Physical therapy is nO[ roueinely necessary. Return to
full activities is encouraged.
Open reduction of a poseerior dislocarion should be performed
through a posterolateral approach. The patient is positioned in
the lateral decubitus position wieh the dislocated side upward.
Complications
The incision is centered on and jusr posterior to ehe greater
trochanter and goes up into rhe butcock. Generally a straight Most hip dislocations in children will be treated and resolved
incision can be made with the hip flexed approximately 90 de- wiehour sequelae. Complicarions are rare.
 Chapter 21: Fractures and Traumatic Dislocations of the Hip in Children 937

Vascular Injury If AVN develops, pain, loss of motion, and deformity of the
femoral head are likely (31). AVN in a young child resembles
Impingement on the femoral neurovascular bundle has been
Perrhes' disease and may be treared like Perrhes' disease (31).
described after anterior hip dislocation in children, and this may
Priorities are to maintain mobility and containment of the femo-
occur in 25% of patients (50). If there is femoral artery occlu-
ral head to maximize congruity after resolution. AVN in older
sion, the hip should be relocated as soon as possible to remove
children should be treated as in adults and may require hip
the offending pressure from the femoral vessels. If relocation of
fusion, osteotomy, or reconstruction, as discussed following fem-
the hip fails to restore perfusion, immediate exploration of the
oral neck fractures.
femoral vessels by a vascular surgeon is indicated.

Recurrent Dislocation
Nerve Injury
Recurrence after traumatic hip dislocation is rare bur occurs
The sciatic nerve may be damaged after a posterior dislocation
most frequently after posterior dislocation in children under 8
of the hip in 2% to 13% of patients (35,50,51). Usually the
years of age (33,38) or in children with known hyperlaxity
nerve is directly compressed by the femoral head. The treatment
(Down's syndrome, Ehlers-Danlos disease). The incidence is es-
is expedient relocation of the hip. Nerve function returns sponta-
timated at no more than 3% (46). At surgical exploration of
neously in most patients (35,43). The nerve does nor need to
these hips, recurrence has been found to result from either laxiry
be explored unless open reduction is required for other reasons.
or a defect in the capsule (33). Recurrence can be quite disabling
If sciatic nerve function is demonstrated to be intact and is lost
and in the long term may result in damage to the articular sur-
during the reduction maneuvet, the nerve should be explored
faces due to scuffing. Arthrography is recommended to identify
to ensure that it has not displaced into the joint. Other nerves
a capsular defect or redundancy (33). Prolonged spica casting
around the hip joint rarely are injured at dislocation. Treatment
(at least 3 months) may stop recurrence (53), but exploration
is generally expectant unless laceration or incarceration is sus-
with capsulorrhaphy is a more rapid and reliable solution (33,
pected. If so, exploration is indicated.
38,53). In older children, recurrent dislocation can occur as a
result of a bony defect in the posterior rim of the acetabulum
Avascular Necrosis similar to that in adults and may require posterior acetabular
reconstruction.
Avascular necrosis occurs in about 10% of hip dislocations in
children (40,50). Prompt relocation of the hip, especially within
24 hours, may decrease the incidence of this complication (37, Chondrolysis
50). The risk ofAVN is probably related to the severity of initial
Chondrolysis has been reponed after hip dislocation in up to
trauma (50). The cause is unknown. It may result from damage
6% of children (40,43,45,46) and probably occurs as a result
to ascending vessels Ot increased intracapsular pressure (49). The
of articular damage at the time of dislocation. Chondrolysis can-
type of postreduction care has not been shown to influence the
not be reversed by medical means, and treatment should be
rate of AVN.
symptomatic. Antiinflammatory medicines and weight-relieving
Early technetium bone scanning detects AVN as an area of
devices should be used as needed. If the joint fails to reconstitute,
decreased uptake. This is best seen on pinhole collimated images.
fusion or reconstruction should be considered.
After a few weeks, with the onset of revascularization and reossifl-
cation, the uptake may appear normal or even increased.
Magnetic resonance imaging detects avasculatity of the capi- Coxa Magna
tal femoral epiphysis as loss of signal on Tl-weighted images
(48). Findings on T2-weighted images are abnormal but of vari- Coxa magna occasionally occurs after hip dislocation. The re-
able signal intensity. poned incidence ranges from 0% to 47% (40,45,46). It is be-
After hip dislocation, rourine screening for AVN by bone lieved to occur as a result of posttraumatic hyperemia (46). In
scan or MRI cannot be strongly recommended for several rea- most children, this condition is asymptomatic and does not re-
sons. Even if a perfusion defect is detected, there is no known quire any treatment (46). There is no intervention that will
rreatment that will reverse it. Secondly, MRI may be falsely prevent coxa magna.
negative if performed within a few days of injury (48). Funher-
more, hips with abnormal bone scan and MRI weeks after injury
Late Presentation
may not develop sympmmatic AVN. In fact, a large proportion
of perfusion defects seen on MRI spontaneously resolve after Not all hip dislocations in children cause severe or incapacitating
several months (41,48). symptoms. Ambulation may even be possible (Fig. 21-19). As
Ifhips are followed by serial radiographs for AVN, it is recom- a result, treatment may be delayed or the diagnosis missed, and
mended that they be studied for at least 2 years after dislocation shortening of the limb and contracture are well-established, mak-
because radiographic changes may appear late (32). IfMRI yields ing reduction difficult. Prolonged heavy traction will sometimes
notmal findings 4 to 6 weeks after injury, no further study is effect reduction (42). Preoperative traction, extensive soft tissue
necessary because the risk of developing symptomatic AVN is release, or primary femoral shortening should be considered if
miniscule (48). open reduction is required. Open reduction will likely be diffi-
938 Lower Extremity

cult and will nor always be successhd. Even if rbe hip srays 18. ]erre R, Karlsson J. Ourcome arrer rransphyseal hip Fractllres. lielll
Orthop Scaud 1997;68:235-238.
reduced, progressive anhroparhy may lead ro a sriff and painful
19. Lam SF. f'racwres or rhe neck or rhe remur in children. j liMe joint
hip. The likelihood of a good resulr decreases wirh rhe durarion Surg (Am) 1971;53:11(,5-1179.
of dislocarion. 20. bngenskiold A, S;1!cnius P. Fpiphyseodesis or the grearer trochanter.
Aela Orrhop ,)'((II!tll967;38:199-219.
21. Maruenda ]1, Barrios C, Gomar-5ancho F. Inrracapsuhr hip pressure
Interposed Soft Tissue after remora.1 nL'ck rranure. Uin Orlhop Rei Res 1997:340: 172-180.
Inrerposcd rissues may cause nonconcenrric reducrion or resulr 22. Ng GP, Cole WG. Ufccr or carll' hip decompression on rhc frequency
oravascular m'crosi, in children wirh rrauures ofrhL' neck or the rL'mur.
in complere failure of closed reducrion. Muscle, bone, articular
["jUl] 1996;27:419-421.
carrilage and labrum have been implicated (34,37,39,43,52). 23. Ogden.Il\. Changing parrerns or proximal Femoral vasculariry. j Bone
CT arrhrography or MRl provides informarion on obstacles ro joint Surg (Am] 1974;56:941-950.
complcrc reduction and the direcrion of rhe inirial dislocarion 24. Ratlilf AHC. Fracrures or rhe neck or the remur in children. j BOIIl'
(39,52). Open reducrion generally is necessary ro clear impeding ]oim Surg {Br} 1962;44:528-542.
25. R;Hlirf AHC. Complications afrer fracrures or the femoral neck in chil-
rissues from rhe joint (34,39,43,46,52). Untreared nonconcen- dren and their treatmenr. In Proccedings of the British Orrhopaedic
rric reduction may lead to permanent degenerarive anhropathy Associarion. J Bone joillt Stllg IBi) 1970;52: 175.
(47). 26. St. Pierre P, Sraheli LT, Smith JB, er al. Femoral neck stress rracrures
in children and adolescents. j Pediatr Onhop 1995; 15:470-473.
27. Soto-Hall R, Johnson LH, Johnson RA Variations in the ilHra-articular
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1964;46:509- 516.
28. Swischuk LE. Irrirable inrant and lefi lower exrremiry pain. Pediatr
Hip Fractures in Children Emog Care 1997;13:147-148.
1. Alho A. Concurrent ipsilatcral rracrures or rhe hip and femoral sharr. 29. Truera ]. Tbe normal vascular anatomy of rhe human remoral head
Acta Or/hop SctIJld 1996;67:19-28. during growth. j Bone joint Surg (Br) 1957;39:358-39.3.
2. Ashwood N, \'V'ojcik AS. Traumatic separarion or the upper femoral 30. Truera], Morgan ]D. The vascular conrribllrion ro osteogenesis.] Bone
epiphysis in a 15-month-old girl: an unusual mechanism or injury. joillt SI{ig (Br) 1%0;42:97-109.
fnjury 1995;26:695-696.
3. Bray T]. Femoral neck rracture fixation. Gin Orthop Rei Res 1997;
339:20- 31. Hip Dislocations in Children
4. Canale ST, Beaty]H. Pelvic and hip rractures. In: Rockwood CA ]r,
Wilkins KF., Be;lt}' ]H, cds. Fl'I1<'1l1res in childreu, 4rh ed. Philacklphia: 31. BarquCl" A. NatLlral hisrory of avascular necrosis following rraumatic
Lippillcorr-Ravcll, 1996: 1109-1193. hip dislocarion in childhood. A review or 145 cascs. flew O)'/hop Smnd
5. Canale ST, Bourland WL. Fracrure or the neck and intertrochanreric 1982:53:815-820.
region or the remur in children. j Sane joint Surg (Am] 1977;59: 32. Barquet I\. Traumatic hip dislocation in childhood. Acta Or/hop Scand
431-443. 1979;50:549-553.
6. Chellg ]CY, Tang N. Decompression and srable intcrnal fixarion or 33. Barquer A. Recurrenl traumatic dislocation or rhe hip in childhood. j
femoral neck rracrures in children can a/leC( rhe outcome. j Pi,diatr Trauma 1980;20: 1003- 1006.
Onhop 1999;19:338-343. 34. Canale ST, Manugian AH. Irreducible traumaric dislocarions or rbe
7. Chllng SMD. The arterial supply or rhe developing proximal end or hip. j Bone joint Surg (Am) 1979;61:7-14.
the hunJ;lll femur in childhood. A teport or six cases. Ai/il SlOg 1928; 35. Epstein He. Tr;1Urnatic dislocarions or rhc hip. C!in Orthop Ref Res
88:902-907. 1973;92:116-142.
8. Colonna Pc. Fracrure orthe neck orrhe remur.j BonejoinrS/Ii;( (/11!1; 36. Fairbairn K], Mulligan ME, Murphey MD, et al. Gas bubbles in the
197(,;58% 1-970 hip joinr on CT: an indicarion or recenr disloc;1rion. /l]N 19%: 166:
9. Currey ]0, Bllrlc-r G. Ivlechanical properties of bone tissue in children. 472-473.
J BOlle joilil Surg I/lm] 1975:57:810-814. 37. Funk F]. Traumatic dislocarion or the hip in children. ] Bone joim
10. Davison BL, Weinsrein SL. Hip rracrures in children: a long-term SlIIg (Am) ] 962;44: I 135-l145.
rollow-up srudy. J I'diatr Orthop 1992; 12:355-358. 38. Gaul RW. Recurrenr rraumaric dislocarion or rhe hip in children. Uill
J I. Devas M B. Srrcss rracrurcs of rhe remoral neck. J Bone joint Stag (Br) Or/bop Rei Res 1973;90:107-109.
1965;47:728-738. 39. Gennari ]M, Merror T, Bergoin V, et al. X-r8)' transparency inrerposi-
12. Edgren W. Coxa plalla. A clinical and radiological invesrigation wirh rions 'lfrer reduction of rraumaric dislocations of the hip in children.
parricllbr rererence to rhe imporrance or the meraphyseal changes ror Eur j Pedi(/l1' Surg 1996;6:288-293.
rhe final shape or rhe proximal parr of the femur. Acta Orthop Scand 40. Glass A, Powell HOW. Traumaric dislocarion of rhe hip in children.
Slippi 1965;84:1-129. An analysis of forry-seven patients. ] BOJle Joint SUig IBi} 196 1;43:
1.3. Forlin E, Guille ]T, Kumar 5], er al. Transepiphyseal rracrures or rhe 29-37.
neck of rile femur in vel)' young children. j I'dia/r Orchop 1992; 12: 4 I. Godley DR, Williams RA. Tr8umatic dislocarion or rhe hip in a child:
503-509 usefrdness or 1VIR!. ())'/hopedir.f 1993; 16: 1145-1147.
14. Haddad F", Balin S. Hill RA, et al. Displaced stress fracrure of rhe 42. Gupta RC, Shravat BP. Reducrion or neglecred rraumaric dislocation
remoral neck in an acri"e amenorrhoeic adolescenr. Br j Sp01'fS /Vied or rhe hip by heavy mcrion.j SOllljoim Smg lAm! 1977;59:249-251.
1997;31:70-75. 43. H,"nilroll PR, Broughton NS. Traumatic hip dis!ocatinn in childhood.
15. Hansman CF. Appearance and rusion or ossiflcarion cenrers in rhe j Pedilltr Orthop 1988; 18:691-694.
human skeleton. AjR ! 962;88:476-482. 44. Hernandez R], POZl1:1nski AK. CT ('vnlllation or pediatric hip disorders.
16. Hughes LO, Beary ]H. Currenr conceprs review: fractures or the head Orthop elill North Am 1985;16:513-541.
and neck or rhe rcmm in children. J Balle joint Surg (Am] 1994;76: IfS. Hougarcl K, Thomsen PB. Traumatic hip dislocarion in children. Fol-
283-292. low up or n cases. Or/hopedics 1989; 12:37')-378.
17. Ingari .IV, Smirh DK, Aurdemorre TB, er al. Anatomic signilJClllCe or 46. Offierski CM. Traumatic dislocarion or rhe hip in children. j BOlle
nugneric resonanc.e imaging findings in hip rracture. eLiu Orthop fir! joill/Surg (Sri 1981;63:194-197.
Rfs 1996;332:209-214. 47. Olsson 0, Lanclin LA, Johansson A Traumaric hip dislocarion with
 Chapter 21: Fractures and Traumatic Dislocations of the Hip in Children 939

spontaneous reduction and capsular interposirion. Acta Orthop Scand Society. Traumatic dislocation of the hip in children. Final report. J
1994;65:476-479. Bone Joint Surg (Am) 1968;50:79-88.
48. Poggi JJ, Callaghan ]], Sprirzer CE, er aI. Changes on magneric reso- 51. Schlonsky], Miller PRo Traumatic hip dislocations in children.] Bone
nance images after traumatic hip dislocation. Clin Orthop Ref Res Joint Surg (Am) 1973;55: 1057-1063.
1995,319:249-259. 52. Shea KP, Kalamachi A, Thompson GH. Acetabular epiphysis-labrum
49. Rieger H, Pennig D, Klein W, Grunert ]. Traumatic dislocation of entrapment following traumatic anterior dislocation of the hip in chil-
the hip in young children. Arch Orthop Trauma Surg 1991;110:114- dren. J Pediatr Orthop 1986;6:215-219.
117. 53. Wi1chinsky ME, Pappas AM. Unusual complications in traumatic dis-
50. The Scientific Research Committee of the Pennsylvania Orthopaedic location of the hip in children. J Pediatr Orthop 1985;5:534-539.
 FEMORAL SHAFT FRACTURES
JAMES R. KASSER
JAMES H. BEATY

A ATOMY Leg Lengrh Discrepancy

MECHA ISM OF I JURY Angular Deformiry
Rorarional Deformi ry
DIA 'NOSIS Delayed Union
RADIOGRAPHIC FIN or C· Nonunion
Muscle Weakness
CLA SIFICATIO
Infecrion
TREATME T Neurovascular Injury
Pavlik H;lIness Compartmenr Syndrome
Immediare Spica Casring
Tracrion and Casring SPECIAL FRACTURE OF THE FEMORAL
ExrernaJ Fixation SHAFT
Inrramedullary Fixation Meraphyseal (Subrrochanreric and Supracondylar) Fracrures
Open Reducrion and Inrernal Fixarion wirh Plare and Open Femoral Fracrures
Screws Femoral Fracrures in Parienrs wirh Merabolic or
COMPLICATIONS OF FEMORAL SHAFT Neuromuscular Disorders
FRACTURES Floating Knee Injuries

Femoral shaft fractures, including subtl"ochanreric and supracon- laly nailing, have become available to help decrease impairment,
dylar fractures, represenr approximately 1.6% of aU bony injuries increase convenience, and decrease cost of care,
in children. The male: female mio of femoral fracture is 2.6: l
with a bimodal disrribution (10,12,17). The first peak occurs
in early childhood, the second in mid-adolescence. A review of
ANATOMY
rhe Ma,yland Hospital Discharge Database by Hinron er al. (14)
confirmed the bimodal distl"iburion with peak incidences ar 2
Children's bone changes from primarily weak woven bone to
and 12 years of age. The annual rate of femoral shaft frac[Ure
stronger lamellar bone through remodeling during childhood
in children was 1 per 5,000. In Switzcrland, rhe incidence of
(26). Strength also is increased by a change in geometry (Fig.
pediatric femoral shafr fracwre is 1 per 2,000 per year (5).
22-1). The increasing diameter and area of bone result in a
Alrhough femoral shafr fractures are dramatic and disabling
markedly increased area moment of inertia, leading to marked
injuries, both to rhe patieIH and the family, most unite rapidly
increase in strength. This progressive increase in bone strength
without significanr complications or sequelae. Not many years
helps explain the bimodal distribution of femoral fracrures. In
ago, tranion and casting were standard treatmenr for all femotal
early childhood, the femur is relatively weak and breaks under
shafr fractures in children. and femoral fractures ranked high in
load conditions reached in normal play. In adolescence, high-
duration of hospitalization for a single diagnosis (13). More
velociry trauma is required [Q reach the stresses necessary for
recently. a variery of rherapeuric alrernarives, such as external
fracrure.
fixation, compression placing, and flexible or locked intramedul-

MECHANISM OF INJURY
James R. Kassel': Departmenr of Orrhopoedic Surgery, H~rvard School of
Medicine, and Children's Hospirol Medical Cenrer, Bosron, Mossochuserrs.
The etiology of femoral fractures in children varies with the age
James H. Beaty: Departmenr of Orrhopaedic Surgery, University of
Tennessee. Campbell Clinic, and LeBonheur Children's Medicol Ccnrer, of the child. In children younger than walking age, up to 80%
Memphis. Tennc:'scc. of femotal fracrures may be caused by abuse (1, 11,27); in chil-
942 Lower Extremity

often benign lesions such as nonossif)'ing fibroma, aneurysmal

bone cyst, unicameral cyst, or eosinophilic granuloma. Patho-
50
logic femoral fractures rarely occur in patienrs with osteosarcoma
or Ewing's sarcoma (Fig. 22-2).
45
Stress fractures may occur in any location in the femoral shan
(6,15,22). Most occur in adolescents involved in sportS acriviry,
40 such as football, lacrosse, and track. Although uncommon (4%
.:'
of all stress fractures in children), femoral shaft srress fraccure

j
35 should be considered in a child wirh thigh pain because an unrec-
ognized scress fracrure may progress to a displaced femoral frac-
30 ture. As the number of young children involved in arhlerics
>
:::0 increases, srress fraccureswill become more frequem (4). Bilareral
m
25 > femoral stress fractures were reponed in a roJJerblade enehusiasr,
3' refleecing a departure from the traditional sportS recognized as
20 3 being related to this injury (28).
~
An unusual femoral fracture reported in infancs is a greenstick
15 fracture of the medial distal femoral metaphysis that occurs when
rhe parem falls on a child who is straddling the parene's hip. It
10 is irnportane to recognize this fracture because it occurs in infancs
B~;':W"'"
at an age when abuse is the leading cause of femoral fracture.
"';;;;:::~:;~"- "i:::~~~~t
5 The fracture is caused by bending of the femur, which produces
a compression injury to the medial cortex. This injury is nor
consisrent wirh abuse and may confirm a parent's descriprion
2 3 4 6 8 10 20 of a fall as the cause.
AGE (years)
FIGURE 22-1. The shaded area represents cortical thickness by age DIAGNOSIS
group. This rapid increase in cortical thickness may contribute to the
diminishing incidence of femoral fractures during late childhood. (Re-
Most parienes with femoral shaft fractures are unable to walk
drawn from Netter FH. The Ciba collection of medical illustrations. Vol.
8. Musculoskeletal system. Part I. Anatomy, physiology, and metabolic and are in extreme pain with an obvious fracture. The diagnosis
disorders. Summit, NJ: Ciba-Geigy, 1987; with permission.) is more difficult in parients with multiple trauma or head injury,
and in nonambulatory, severely disabled children. A physical
examination usually is sufficiene to document the presence of a
femoral fracture. Swelling, instability, crepitance, and tenderness
dren under 4 years of age, up to 30% of femoral fractures may
usually are present. In patients lacking sensation (myelomenin-
be caused by abuse. Blakemore et a1. (3) reponed that in 42
gocele), swelling and redness may simulate infecrion.
children 1 to 5 years of age who had femoral fractures, a history
The entire child must be carefully examined. Hypotension
of a fall was present in 34. Although the history was considered
rarely results from an isolated femoral fraccure. Waddell's criad
suspicious for intentional injury in 14 patienrs, only 1 patienr
of femoral fracture, incraabdominal or intrathoracic injury, and
had a documented abuse-related injury. Older children are Ull-
head injLllY are associared with high-velocity automobile injuries.
likely to have a femoral shaft fracture caused by abuse, because
Multiple crauma with head injury may dictare a change in man-
their bone is sufficiently strong to [Olerare forceful blows or is
agement of the femoral shafr fraccure (20,23).
able to resist torque without fracrure. In older children, femoral
The hemodynamic significance of femoral fracture has been
franures are most likely to be caused by high-enel'gy Injuries,
studied recently by twO groups (8,21). Hematocrit levels below
such as motor vehicle accidenrs, which account for over 90%
30% rately occurred in the absence of multiple system injury.
of femoral fractures in this age group (9,12,20). Gunshot
Hemodynamic instabiliry was always associated wirh multisys-
wounds are an increasingly common cause of femoral fractures.
tem injury. A declining hematocrit should nor be attributed to
Pathologic femoral fractures are relatively rate in children,
closed femoral fracture uncil other sources of blood loss have
but they may occur because of generalized osteopenia in infants
been eliminated (8,21).
or young children with osteogenesis imperfecta. A femoral frac-
rure in a young child with no histOry suggestive of abuse or
significam trauma should suggest the possibiliry of osteogenesis RADIOGRAPHIC FINDINGS
impel'fecta (19). Radiologic evaluation is often insufficient [Q
diagnose osteogenesis imperfecta, and skin biopsy, collagen anal- Radiographic evaluation should include the encire femur, as well
ysis, and bone biopsy may be required to make a definitive diag- as the hip and knee, because injulY of rhe adjacent joincs is
nosis. Generalized osteopenia also may accompany neurologic common. Femoral shafr fractures may occur with inrerrrochan-
diseases, such as cerebral palsy or myelomeningocele, leading [eric fractures of rhe hip, fractures of the femoral neck, and
to fracture with minor trauma in osteopenic bone (10,16,25). dislocation of the upper end of the femur (2,7). Distal femoral
Pathologic fractures may occur in patienrs wirh neoplasms, mosr fractures may be associated with physeal injury about rhe knee,
 Chafw' 22: Femoral Shaft Fractures 943

A B
FIGURE 22-2. A: Femoral fracture through a poorly demarcated. mixed, osteoblastic, osteolytic le-
sion-an osteosarcoma. B: Sclerotic borders of this lesion in the distal femur are typical of a pathologic
fracture through a nonossifying fibroma.

knee ligament Injury, meniscal tears (29), and ribial fracrures injury is documented and is pan of the description of the frac-
(J 8). ture. The most common femoral fracture in c11ildren (over 50%)
Plain radiographs generally are sufficienr for making rhe diag- is a simple transverse, closed, noncomminLlted injUlY.
nosis. Bone scanning and magnetic resonance imaging (MRI) The level of the fracture (Fig. 22-3) leads ro charactetistic
occasionally may be helpful in the diagnosis of small buckle displacement of the fragments based on the attached muscles.
fracrures in limping children or stress franures but usually are With subtrochanteric fractures, the proximal fragment lies in
not necess~llY. Comminution Or nondisplaced "bunerfly" frag- abduction, Aexion, and external rotation. The pull of the gastroc-
menrs, second fracrures, joinr dislocations, and pathologic le- nemius on the distal fragmem in a supracondylar fracture pro-
sions should be considered. duces an extension deformity, which may make the femur diffi-
Roach and Hoschl (24) described diffuse uptake of radionu- cult ro align.
clide tracer throughout an enrire femoral shaft in an 18-momh-
old child. This is significam because it demonstrates that radio-
TREATMENT
nuclide uptake may nor be limited to the isolated area of the
ftacture but may involve the entire shaft of the bone in a vet'y
Treatment of femoral shaft fractllres in children is age depen-
young child. A similar finding has been shown in plastic deFor-
dent, with considerable overlap bervveen age groups (Tabk 22-
mation of the forearm in young children.
1). The child's size and bone age also must be considered, as
well as the cause of the injulY. Whether the femoral fracture is
CLASSIFICATION an isolated injury or pan of poJytrauma inAuences rreatmem
choices. Economic concerns, the family's ability to care fm a
Femoral franures are classifLed as (a) transverse, spiral, or child in a spica cast or exrernal fixator, and the advantages and
oblique; (b) comminuted or noncomminured; and (c) open or disadvantages of any operative procedure also are imporram fac-
closed. Open fractllres are c1assifted according ro Custilo's sys- tOrs. In adolescents, rhe psychologic implications of treatment
tem (J 3). The presence or absence of vascular and neurologic should be considered. Prolonged hospitalization alters the ado-
944 Lower ExtremilJI

lescene's self~image and interrupts social and educational devel-

opmene. Especially in older children, the disadvanrages of non-
operative ueatment-time in traction or a cast, economic and
social impacr on the family-must be carefully weighed against
the potential complications of a surgical procedure: infection,
refracture after t'emoval of fixation, neurologic injury, limb
shonening or overgrowth, and avascular necrosis of the femoral
head.
The comparative economics of nonoperative and operative
ueatmene of femoral shaft fracrures have been evaluated by sev-
eral researchers, but no dear consensus has been reached. Reeves
et al. (57) reponed that the cost of nonoperative treatment was
46% 11igher rhan that of operative treatment, even considering
the necessity for a second surgical procedure for implane re-
moval. Newton and Mubarak (53) analyzed the financial aspects
of femoral shaft fracture ueatment in 58 children and adoles-
A B c D
cents and determined that total charges were lowest for those
ueated "vith early spica casting and highest for those treated with

E~--~
skeletal traction or intrameduUary nailing. Similarly, Coyte et
al. (35) found the COSt of surgical treatment (external fixation)
to exceed that of early spica casting in all cases. Stans and Mor-
rissy (65), in evaluating the cost of treating femoral fractures in
FIGURE 22-3. The relationship of fracture level and position of the
chilcit'en 6 to 16 years of age, found that all surgical tl'eatments
proximal fragment. A: In the resting unfractured state, the position of cost approximateJy the same. This cost was three times that of
the femur is relatively neutral due to balanced muscle pull. B: In proxi~ early spica cast management and essentially equivalene to trac-
mal shaft fractures the proximal fragment assumes a position of flexion
(iliopsoas), abduction (abductor muscle group), and lateral rotation tion, folJowed by spica case. In all cost studies related to femoral
(short external' rotators). C: In mid~shaft fractures the effect is less ex~ fracture, the determinanes of increased COSt are (a) cost of fixation
treme because there is compensation by the adductors and extensor device, (b) cost of the operating room, and (c) cost of hospital
attachments on the proximal fragment. D: Distal shaft fractures pro~
duce little alteration in the proximal fragment position because most days for recovety. Nark and Hofflnger (55) showed that hospital
muscles are attached to the same fragment providing balance. E: Supra~ profit was highest in the traction group, despite charges being
condylar fractures often assume a position of hyperextension of the equivalene to the surgical group, because the actual hospi tal re-
distal fragment due to the pull of the gastrocnemius.
sources required were significantly less. In a study by Yandow
et al. (70) comparing COSt of traction to immediate spica in
young children, equivalene results occurred witn 83% greater
charges in the traction group. Cenainly, cost is a factor, but it
should not be the overriding consideration in discussions of
TREATMENT OPTIONS FOR
treatment options with the family.
TABLE 22·1.
FEMORAL SHAFT FRACTURES IN In infants, newborn to 6 months of age, femoral fractures
CHILDREN AND ADOLESCENTS usually are reasonably stable because of thick periosteum. Fat·
stable proximal or mid-shaft femoral fractures, simple splinting
Age Treatment
or a Pavlik harness is all that is required. For unstable fractures
Birth to 24 mo Pavlik harness (newborn to 6 mol in infancy, a simple splint can be tried, but usually the femur
Immediate spica cast cannot be adequately treated in this manner. We have found
Traction ~ spica cast that a Pavlik harness with a wrap atound the thigh, as described
24 mo to 5 yr Immediate spica cast
by Wilkins, is beneficial. For femoral fracrures with excessive
Traction ~ spica cast
Externalfixa~ion (rare) shortening (> 1-2 cm) 01' angulation (> 30 degrees), spica cast-
Flexible intramedullary rod (rare) ing may be required. Traction rarely is necessary in this age
6-11 yr Traction ~ spica cast group.
Flexible intramedullary rod In children G months to 6 years of age, immediate or early
Compression plate
External fixation spica casting is the ueatment of choice for femora.! fracrures with
12 yr to maturity Flexible intramedullary rod less than 2 cm of initial shortening (Fig. 22-4). Femoral fractures
Compression plate with more than 2 cm of initial shortening or marked instability
Locked intramedullary rod and fracrures [hat cannot be reduced with immediate spica cast-
External fiY.ation ing require 3 to 10 days of skin or skeletal traction. Skeletal
stabi Iii.ation by external fixation generally is reserved for chi Idren
Treatment choices are influenced by polytrauma (vs. an isolated with open fractures or !TIultiple trauma. IntramedullalY rodding
femoral shaft fracture) or open fractures with soft tissue trauma.
is used in children with metabolic bone disease that predisposes
to fracture or after mulriple fracrures, such as in osteogenesis
 Chrlpter 22: Femora! Shrift Frrlctures 945

A B
FIGURE 22-4. A: Three weeks after immediate spica casting of isolated femoral shaft fracture in 3-year-
old child. B: Three months after injury, fracture is healed in good position.

imperfecta. Larger children in whom reduction cannot be main- as a standard procedure, but the recognized risks of avascular
tained with a spica cast occasionally may benefit from flexible necrosis and growth disturbance have led ro limited use of this
intramedullary rodding or traction. as a standard technique.
T reatmenr offemoral fractures in children 6 to 11 years of age
is highly controversial. For stable, minimally displaced fractures,
Pavlik Harness
immediate spica casting usually produces satisfactory results;
however, in large children with unstable comminuted fractures, In a newborn wirh a femoral fracrure, one is faced with a very
traction followed by application of a casr brace or spica cast may small child, a thick periosteum, and a remarkable remodeling
be necessary. Because of the COSt and the social problems that potential. Stannard, Christensen, and Wilkins (64) popularized
may accompany management of a child in a spica cast, enthusi- the use of the Pavlik harness for the treatment of this fracture.
asm for skeletal fixation has increased in recent years. Skeletal This treatment is ideal for a proximal or mid-shaft femur fracture
fixation frequently is used in children with multiple trauma, that occurs as a birth-related injury. In a newborn infant in
head injury, vascular compromise, floating knee injuries, or mul- whom a femoral fracture is noted in the intensive care unit or
tiple fractures. Treatment options should be discussed with the nursery, simple padding or immobilization of the femoral with
parents before choosing the method of fracture fixation, even a soft splint can be tried. For a stable fracture, this approach
for isolated fractures. may be sufficient and will allow intravenous access to the feet
Enthusiasm for treatment that decreases hospital stay has led if needed. If the fraerure remains angulated, a Pavlik harness can
ro the use of external fixation and flexible jnrramedullalY nails be applied with the hip in moderate flexion and abduction. This
in children 6 years of age through maturity. Compression plating often helps align the distal fragment with the proximal fragment
has been reintroduced as a technique with low risks and signifi- (Fig. 22-5). Reduction can be aided by a wrap around the thigh
cant benefit in the management of pediatric femoral fractures. if greater scability is needed. The reduction is easily evaluated
Even home traction has been recommended as a low-cost alter- in the sagittal plane with a lateral radiograph, but evaluation of
native for management wirh satisfacrory outcome. In older chil- angulation in the coronal plane (varus-valgus) is more difficult
drl'l1 and adolescents, antegrade rodding has been recommended because of hypcrfkxion. Srannard et al. (64) reported acceptable
946 Lowei' Extremity

FIGURE 22-5. A: This infant had a birth-related left femoral fracture.

B: An anterior-posterior splint was used but ended at the fracture site,
only increasing the angulation. C: A Pavlik harness reduces the fracture
c by flexing the distal fragment.
 Chapter 22: FemoraL haft Fractures 947

alignment in all patients with less than 1 cm of shortening. In

fractures occurring in infancy, management may include evalua-
tion for underlying metabolic bone abnormality or abuse. Once
these have been ruled out, a stable fracture should be managed
using a simple splint. Unstable fractures should be managed
using a Pavlik harness and a small wrap around the thigh, with
immediate spica or traction reserved for the rare fracture that
cannot be managed with simpler means because of failure to
align the fracture or excessive shonening.

Immediate Spica Casting

Immediate spica casting, popularized by Irani et al. (46) and
Stabeli et aJ. (62), is indicated for isolated femoral shaft fractures
in children under 6 years of age unless (a) shonening of more
than 2 cm is present, (b) massive sweHing of the thigh is noted,
or (c) associated injuries are present. Its primaty advantages are
simplicity, low cost, and generaHy good results based on leg
length equality, healing time, and motion (38,45).
Hughes et al. (42) evaluated 23 children ranging in age from
2 through 10 years who had femoral fractures treated with imme-
diate spica casting to determine the impact of treatment on the
patients and their families. The greatest problems encountered
by the family in caring for a child in a spica caSt were transpona-
tion, cast intolerance by the child, and keeping the child clean.
Although most child ten did not attend school while in the cast,
no child was required to repeat a grade and no permanent psy-
chological effects were reponed by the parents. The researchers
found that ovetall treatment in a spica cast was much easier for A,B
families of preschool children than for those with school-age
FIGURE 22-6. A: Immediate spica casting of isolated femoral shaft frac-
chiJdren: healing time was faster, younger children were lighter, ture in an 8-year-old child; shortening on initial radiograph was 2 cm.
time until independent walking was shorter, and families of B: Four months after injury, shortening of 2 cm is seen with this healed
fracture.
younger children had more preexisting care arrangements for
them. They tecommended counseling and planning with the
family before cast application if possible.
Ulgen et al. (44), in a series of 114 isolated femoral fractures
in children under 6 years of age, found that 90 degree/90 degree especially in comminuted fractures. Ahhough shortening and
(90/90) spica casting was successful in 86% without cast change angulation can occur in a spica cast, excessive deformity can be
or wedging, based on tolerance of shortening less than 1.5 cm detected with weekly radiologic and clinical evaluations during
and angulation less than 10 degrees. Of the 20 patients requiring the first 2 EO 3 weeks after injUlY. Minimal shortening is accepr-
spica change, only 2 healed with unacceptable position (> 2 cm able bur should nor exceed 2 cm (Fig. 22-6). This is best mea-
of leg length discrepancy). One of these overgrew by 1. 5 cm sured on a lateral radiograph taken rhrough the cast. If follow-
and the othet was lost to follow-up. Illgen et aJ. used an immedi- up radiographs reveal significanr varus (> J 0 degrees) or anrerior
ate spica regardless of initial shortening and placed the child in angulation (>30 degrees), rhe cast may be wedged. However,
traction only if unacceptable shortening occurred. Shortening Weiss et al. (69) noted that wedging of 90/90 spica casrs can
requiring spica cast change was associated with a knee flexion cause peroneal nerve palsy, especially during correction of valgus
angle of less than 50 degrees. Similar excellent results have been angulation. For unacceptable position, the Fracture can be ma-
reported by Czerrak and Hennrikus (36) using the 90/90 spica nipulated and a new cast applied, or the cast can be removed
cast. and rhe patient placed in traction EO regain or maintain length
Thompson et al. (67) described the telescope test in which (Fig. 22-7). Angular deFormity of up EO J5 degrees in the coronal
patients were examined with fluoroscopy at the time of reduction plane and up to 30 degrees in the sagirral plane may be accepr-
and casting. If more than 3 cm of shortening could be demon- able, depending on the patient's age (Table 22-2). Finally, if
strared with gentle axial compression, traction was used rather shortening exceeds 2 cm, traction or an external fixator can be
than immediate spica casting. By using the telescope test, these used.
researchers decreased unacceptable results (>2.5 cm of shorten- Shortening and angulation occur most often in fractures asso-
ing) from 18% ro 5%. ciated with polytrauma and rhose with loss of the periosreal
Martinez et al. (47) reported excessive shortening and angular sleeve (9,10). Fry et al. (10) found that 50% (12 o(23) of closed
deformity in 26 of 5 J patients after immediate spica casting, femoral shaft fractures caused by high-energy trauma in children
948 Lower Extremity

A B
FIGURE 22·7. A: Unacceptable position of fracture in spica cast in a 2-year-old child. B: With manipula-
tion, application of a new spica cast, and cast wedging, this angulation is corrected.

under 10 years of age required repeac reduccion or other treat- has been recommended: the more proximal che fracture, che
ment to correcc excessive shortening or angulacion chat occurred more flexed the hip should be (62).
after inicial reduction; only 8% (2 of24) of low-energy fractures An alcernative to the standard hip-knee excended spica is dle
required repeat closed reduccion. 90/90 spica casc or the sitting spica cast (48,50). A siuing spica
The posicion of che hips and knees in cbe spica casr is cancro- cast (Fig. 22-8), wich the hips and knees ser in about 90 degrees
versial. Spica casc application wich che hip and knee extended and of flexion, is the easiest and perhaps che most effeccive cast for
che bottom of the foot cuc our to prevent excessive shortening has femoral fractures in preschool-aged children, unless the fractute
been described (49). Varying the amounts of hip and knee flex- cannot be maintained in this position. The child is placed in a
ion in che spica cast based on the position of che fracture also sitting position with the legs abducted about 30 degrees on either
side. The synthetic material used for the cast gives it sufficient
strength so chat no bar is required berween rhe legs. This nor
only allows the child co be carried on the parenr's hip buc also
aids in toilecry needs, making bedpans unnecessary. Also, rhe
TABLE 22-2. ACCEPTABLE ANGULATION child can sic upright during rhe dely and can attend school in a
wheelchair.
Varus! Anterior!
Valgus Posterior Shortening
Age (degrees) (degrees) (mm) Spica Cast Application: Technique
Birth to 2 yr 30 30 15 The child is taken co the operacing room 01' plasrer room where
2-5 yr 15 20 20 anesthesia or sedacion is administered. A shorr leg casr is applied
6-10 yr 10 15 15
11 yr to maturity 5 10 10
wirl1 che foot in neutral posicion (Fig. 22-9A). Ex:rra padding
and a felt pad are placed in rhe area of rhe poplireal fossa. The
cast is then exrended to a long leg casr wich the knee held in
 Chapter 22: Femoral Shaft Fractures 949

weeks (1 mm per day) to reestablish acceptable length (Fig. 22-

10).
Generally, the spica cast is worn for 4 to 8 weeks, depending
on the age of the child and the severity of the soft tissue damage
accompanying the fracture. After the cast has been removed,
management should include skin care in young children and
crutch-assisted or walker-assisted ambulation in older children.
Arnbulation is accomplished with weight bearing as tolerated.
Stiff knees and weak hamstrings and quadriceps should be iden-
tified after the child begins to walk and a physical therapy pro-
gram should be started if needed. Long-term follow-up for leg
length evaluation, range of motion, and quadriceps weakness
should be maintained.
An alternative to extend the use of early spica cast treatment
into an older age group and unstable fractures is the incorpora-
tion of a supracondylar traction pin into the spica cast. In a series
reported by Sahin et al. (60), this technique was demonstrated to
be effective in children 1 to 10 years of age. The clinicians
accepted no more than 15 mm of shortening at the time of spica
cast application, and obtained satisfactory results in all patienrs.

Traction and Casting

Since as early as the eighteenth century, traction has been used
for management of femoral fractures. The French used the Hip-
pocratic method of traction and coaptation splinting in exten-
sion. The English, influenced by POll (56), treated patients on
their side with the hip and knee flexed. In 1861, Buck (32)
introduced simple horizontal traction. Vertical overhead traction
FIGURE 22-8. A 90 degree/gO degree spica cast allows a small child to with the hip flexed 90 degrees and the knee straight was intro-
be carried on the parent's hip. The child can be placed in a sitting posi-
tion in a chair or on the toilet in this type of cast.
duced by Bryant in 1873 (31,33), but this often resulted in
vascular insufficiency (Fig. 22-1 I) (54), and it is now rarely used
for treatment of femoral fractures, except occasionally in infants
under 2 years of age and weighing less than 20 pounds. However,
even in this infantile age group, split Russell's traction (58) or
90 degrees of flexion (Fig. 22-9B). Because most diaphyseal frac- immediate spica casting is preferable. Modified Bryant's traction,
tures tend to fall into varus angulation while in a spica cast, a in which the knee is flexed 45 degrees, increases the safety of
valgus mold is necessary (Fig. 22-9C). The patient is then placed overhead skin traction (39). Gallows traction also has been used
on a spica table, supporting the weight of the legs with manual (41).
traction, and the remainder of the cast is applied with the hips The indications for skin or skeletal traction include (a) un-
in 90 degrees of flexion and 30 degrees of abduction, holding stable femoral fracture in a child under 6 years of age with more
me fracrure out to length (Fig. 22-9D). The leg should be placed than 2 to 3 cm of shortening, (b) femoral fraclllre that fails to
in 15 degrees of external rotation to align the distal fragment maintain proper length and alignment in a spica cast in a child
with the external rotation of the proximal fragment. After the under 6 years of age, and (c) femoral fracture in a child 6 to 11
spica cast is in place, anteroposterior (AP) and law'a! radiographs years of age, without multiple fraclllres, head trauma, or severe
are obtained to ensure that length and angular and rotational soft tissue or vascular injuries, who is able to cooperate with a
alignment are maintained. period of bed rest and spica cast immobilization and whose fam-
Gonex liners can be used to decrease the skin problems of ily prefers no surgely. The limit of skin traction is the interface
diaper rash and superficial infection. This has been beneficial between skin and tape or skin and foam traction boot. Skin
and has justified the cost of a Gonex liner. If angulation of more complications, such as slough and blisrering, usually occur when
than acceptable limits occurs, the cast should be changed with more than 5 pounds of traction is applied. When more than 5
manipulation in the operating room. Casts can be wedged for pounds of traction is required, or simply for ease in patient
less than 15 degrees of angulation. If shortening of more than management, skeletal traction can be used to maintain alignmel1l
2 cm is documented, the child should be treated either with (30).
cast change, traction, or conversion to external fixation with Skeletal traction also can be used in adolescents with commi-
lengthening. When conversion to external fixation is required, nuted proximal femoral shaft and interrrochal1leric fractures in
we recommend osteoclasis at the time of the application of the whom secure fixarion cannot be obtained without risk of vascular
external fixator with slow lengthening over a period of several compromise to the proximal femur. In general, however, skeletal
950 Lower Extremity

A B

FIGURE 22-9. Application of a 90 degree/90 degree spica cast. A: Generous pad-

ding is applied over the foot, and a pad is placed on the popliteal fossa to prevent
injury to the peroneal nerve and popliteal vessels. B: A long leg cast is applied
with the knee flexed 90 degrees. C: A mold is placed over the apex of the fracture,
generally correcting a varus deformity into slight valgus. D: Using a standard spica
table, a one-and-a-half spica cast is applied with the hip flexed 90 degrees and
c abducted 30 degrees.
 Chapter 22: Femoral Shaft Fractures 951

A,S c
FIGURE 22-10. A: This 8-year-old child with a femur fracture was treated with an immediate spica cast.
B: After 3 weeks of immobilization, unacceptable shortening (2.2 em) was noted. C: Closed osteoclysis
and lengthening with an external fixation device resolved the problem with length achieved by callus
distraction.

FIGURE 22·11. Adverse effect on limb circulation

by overhead traction as detailed by Nicholson. A:
Incremental increase in hydrostatic pressure neces-
sary for limb perfusion due to increasing limb
length. B: Hyperextension ofthe knee occurs ifthe
infant moves to the foot of the bed, stretching the
popliteal artery. C: Extrinsic compression of wrap-
ping to maintain traction tapes aggravates the
problem. Any or all of these factors contribute to
the risk of overhead traction. (Redrawn from Ni-
cholson J, Foster R, Heath R. Bryant's traction: a
A provocative cause of circulatory complications.
lAMA 1955; 157: 4118; with permission.)
952 Lower Extremit)'

A,B C
FIGURE 22-12. Tibial epiphyseal injury in association with tibial pin traction treatment for a femoral
fracture. A 14-year-old boy sustained a femoral fracture that was treated by tibial skeletal traction. Two
years later the fracture was well healed but 2.5 cm short. A recurvatum deformity of the same side was
apparent. A: An apparent fusion of the tibial tubercle. B: The bridge was confirmed by tomography. C:
Bridge resection was performed with free fat interposition. A marker was placed to facilitate subsequent
evaluation of growth. A tibial pin, if used, should be inserted posterior to the anterior aspect of the
tibial tubercle.

traction is not recommended for children 12 years of age or with a local anesthetic or general anesthesia should be given
older because of significant incidences of shortening and angulal· before the traction pin is inserted (Fig. 22-13B). Th.e location
malunion. of pin inserrion is one finger breadth above the patella with the
The disml femur is the location of choice for a traction pin knee extended or JUSt above the Rare of the distal femur (Fig.
(30,37,59). A1dlough proximal tibial rraction pins have been 22-l3e). A smaJJ puncture wound is made over the medial side
recommended by some cJinicians (43), growth arrest in the prox- of the femur (Fig. 22- I 3D). A medial-to-lateral approach is used
imal tibial physis and subsequent recurvarum deformity have so that the traction pin does nor migrate into the area of the
been associated wich rheir use (Fig. 22-12). Also, k.nee ligament femoral arrery that runs th.rough Hunter's canal on rhe medial
and meniscal injuries that sometimes accompany femoral frac- side of the femur. A traction pin between 3/32 inch. and 1/8
tures are aggravated by the chronic pull of traction across the inch is chosen depending on the size of the child. The pin is
knee. The rare indication for a tibial traction pin is a child in placed parallel to the joint surface (30) to help maintain align-
whom fracture configuration or skin problems prevent place- ment while in traction. After tne pin protrudes through the
ment of a femoral traction wire and in whom no knee injury is lateral cortex of the femur, a small incision is made over the tip
presenr. of the pin. The pin is then driven far enough through [he skin
In a group of 45 patients with femoral fractures, Stanitski et ro allow fixation with a traction bow (hg. 22-13F). If 90/90
al. (63) calculated the radiation dose received by the patienr traction is used, a short leg cast is laced with a ring through irs
while in traction. The average dose· before casting was 0.699 mid-portion ro suppOrt the leg. Alternatively, a sling ro support
rad. Although this is a significant radiation exposure, it was not the calf may be used. If a sling is used, heelcord stretching should
excessive compared 10 that received by patients managed with be performed while in traction.
other methods of treatmenr, particularly wnen inrraoperative After the skeletal traction pin has been placed in the distal
femur, rracrion is applied in a 90/90 position (the hip and knee
exposures are considered. However, radiation exposure during
flexed 90 degrees) (Fig. 22-14) or in an oblique position (the
treatment must be considered.
hip flexed 20-60 degrees). If the oblique position is chosen, a
Thomas splint or sling is necessary to support the leg. The frac-
ture may be allowed ro begin healing in traction, and radiographs
Femoral Traction Pin Insertion: Technique
should be obtained once or twice a week ro moniror aJignmenr
After preparation of the thigh circumferentially from tne knee and lengrh. In a child under 10 years of age, the ideal fracture
to the mid-thigh, the limb is draped in a sterile manner. The position in traction should be up to 1 cm of shorrening and
knee is held in the position in whicll it will remain during trac- sligh[ valgus alignment ro coumeract the tendency to fall infO
tion; that is, if 90/90 traction is being used, the rraction pin varus in [he cast and the evenrual overgrowth that may occur
should be inserted with the knee bent 90 degrees (Fig. 22-13A). (average 0.9 cm). If this method is used for adolcsccms (11 years
The patient either should be sedated and the wound treated 01" older), normal length should be maimained.
 Chapter 22: Femoral Shaft Fractures 953

~
~
A Il- ----rr=

B,C D

FIGURE 22-13. Insertion of femoral

skeletal traction pin. A: The limb is held
in the 90 degree/90 degree position by
an assistant. B: A site just superior to the
adductor tubercle is surgically prepared,
both medially and laterally. C: Local an-
esthesia is applied in the skin and peri-
osteum on both sides of the limb. D: The
skin is penetrated with a scalpel. E: A
threaded Steinmann pin is introduced
at the level 1 cm proximal to the adduc-
tor tubercle. F: Dressing and traction
E,F bow in place.
954 Lower Extremity

technique, a traction pin is placed in the distal femur and then

incorporated in a cast brace. The traction pin is left long enough
ro be LlScd for maintaining traerion while the patient is in the
cast brace or traction is applied di rectly to the cast. The patient
is allowed ro ambulate in the cast brace starring 3 days after
application. Radiographs ate taken of the fracwre in the cast
brace to documenr rhat excessive shortening is not occurring.
The patient then is returned ro traction in the cast brace until
satisfacrory callus is present ro prevent shortening or angular
deformity with weight bearing. The technique was not eFfecrive
in older adolescents with mid-shaft fractures but achieved excel-
lenr results in children 5 ro 12 years of age. The average hospital
stay was 17 days.

Complications of Traction and Casting

FIGURE 22-14. In 90 degree/90 degree traction, a femoral pin is used Comparative stud ies and retrospective reviews have demon-
and the lower leg and foot are supported with a short leg cast or a
sling. s[l'ated unsatisfactory results in. a small, yet significant, percent-
age of patients treated wirh skeletal tracrion (43,57,97,102). It
is clear that traction remains an excelJenr method of treatment
of femoral shah fracrures in children under 12 years of age,
but other methods are easier at more convenient with the same
Technique Tips
outcome.
Threaded pins, although more difficult ro remove, are preferable
ro smooth pins because of their secure fixation wirhin the bone
without side-ro-side movement; however, rhey have a slightly
higher incidence of skin interface complications.
External Fixation
Aronson et aJ. (30) found that obliquely placed femoral trac- External fixation of femoral shaft fractures offers a fast conven-
tion pins were associated with an increased incidence of varus ient method to align and hold the fractured femur. It is the
or valgus angulation. Pins for skeletal traerion should be placed method of choice when severe soft tissue injLIIY lS present and
parallel ro the axis of the knee joint, and in children over 11 may be considered in any patient where rraditional closed meth-
years of age the fracrure should be reduced without shortening. oels of managemenr are not appropriate (104). In heael-injured or
multiply injured parients and those with open fraGures, external
Postoperative Care fixation offers an excellent method of managemenr. Wagner was
Prolonged traction of 3 weeks or more followed by knee immo- an early advocare of monolateral frame fixation and developed
bilization in a spica cast is well rolerated by young children. In an external fix<lrion and lengthening device. Aronson and T ursky
children over 12 years of age or in children weighing over 100 (7l) in 1987 reponed their early experience with 44 femoral
pounds, maintaining the knee in 90 degrees of flexion for a fractures [I'eated wi th primary external £xation and early weight
prolonged period of time may lead ro knee stiffness and a diffi- bearing. Most patients returnecl to school by 4 weeks after frac-
cult period of rehabiliration (4.1). Cast braces, either with a trac- ture and had full knee motion by 6 weeks after the fixawt was
tion ,}in or after a period of traction, rillow erirly knee motion. removed. In this early study, end-on alignment was the goal and
Polycentric hinges, fiberglass wds, or hinge cables should be overgrowth was minimal. Following early enthusiasm for the
used to prevent malalignmenr between the cast brace and the use of external devices, the 1990s saw some \ovaning interest in
knee that restricts motion. their use because of complications with pin track infections,
Alternatives for rreatment after traction application include scarring, and refracture. With other methods of skeletal fixation
(a) a 2- ro 3-week period of tracrion until callus formation is such as flexible intramedullary rodding, the use of external fixa-
apparent and the fractute is stable beforL' pin removal and appli- tion devices for primary treatment of femoral fractures has de-
cation of a spica cast or cast brace (32,34.49,52,61); (b) early clined.
incorporation of a traction pin into a spica cast; and (c) incorpo- Bar-On et al. (72) compared external fixation wirh flexible
ration of a traaion pin into a casr brace with intermittent trac- intramedulla,y wdding in a prospective randomized study. They
tion to maintain length until callus formation is presenr (40). found that the early posroperative course was similar but thar
Each of these methods has advantages, COStS, and risks, and a rhe time ro retLJrn ro school and to resume full activity was Jess
clear "best Illethod" cannot be identified. with intramedullary fixarion. Muscle strength was better in the
flexible intramedullary Nxation group at 14 months after frac-
rure. Parental satisfaction was also significantly better in the
Results of Traction and Casting
flexible inrramedullalY rodding group. Bar-On et al. (72) recom-
In a study by Gross et a1. (40), 72 children with femoral fractures mended that external fixation be reser'Veci fa I' open or severely
were treated with early CaSt brace/traction management. In this comminured fl·acrures.
 Chapter 22: Femoral Shaft Fractures 955

Fixator Design
The design of external fIxator frames is importanr in derermining
rhe end resulr. In general, circular fixarion devices are rarely, if
ever, indicated for femoral fracrures. External fIxarion should be
performed using a monolareral or canrelever rype sysrem. The
monolareral devices are of rwo rypes (Fig. 22-15). The AO sys-
rem, in which pins can be placed ar any poinr along a bal' wirh
a special clamp holding the pins ar a righr angle ro rhe bar, has
been in common use (Fig. 22-16). The advanrage of' rhis sysrem
is rhat the srabiliry of' fIxarion is increased if' rhe fWO pins on
each side of the fracture are spread widely wim one pin close ro
rhe fracrure and one quite disrant from ir. A second longimdinal
rod can be added ro rhis sysrem to increase irs rigidiry. A second
rype of exrernal fixation system has pin clamps ar rhe end of' a
relescopic rube. The pin clamps provide easy applicarion, bur
rhe srabiliry of rhe fIxarion device is decreased because the pins
are widely separared from me fracrure. The pin clamps may be
constrained to !'Oration only (Wagner) or arrached with a univer-
sal joint to rhe barrel of rhe device (OrrhofIx) (Fig. 22-17). The
telescoping barrel provides lengrhening or dynamizarion, and
rhe universal joints provide adjusrment. Sola, Schoenecker, and
Gordon (119) found rhar resulrs were improved significantly by

B
FIGURE 22-15. Monolateral external fixation devices have (A) fixed
end clamps with universal joints (Orthofix type) or (B) pins that can be
secured at various positions on a simple rod that positions close to and
distant from the fracture site (AOj, achieving greater stability of frac-
ture fixation.

FIGURE 22-16. Application of AO external fixator. The most proximal

and distal pins are placed a few centimeters from the fracture site to
improve frame stability.
956 LOllJer Extremity

~B C
FIGURE 22-17. A: Two weeks after unilateral external fixation of a comminuted femoral shaft fracture
in an 8-year-old child. B: Clinical photograph of external fixator in place. C: Four months after fracture,
immediately after removal of the external fixator, fracture has healed in good position.

adding an auxilialY pin [Q the standard Orthofix type Frame, of a frame with a more flexible construct. Pins are more closely
providing beuer fixarion near rhe Fracture site. They reviewed clustered and placed farther from rhe fracture site, and the frame
38 Fracrures in 37 children 5 [Q 18 years of age. Six of 22 femurs irself is placed more laterally away from the femur, which does
rreared without auxiliary pins required remanipulations for loss not need to be anatomically reduced.
of reduction, whereas only 1 of the 16 frames with an auxiliary
pin required remanipulation. Although these researchers pro-
vided auxiliary pin fixarion by attaching a pin [Q the barrel of Unilateral Frame Application: Technique
the exrernal fixator wirh methylmethacryJate, other methods of Preoperative planning is mandatory. Fracture lines indicative of
intermediate pin fixation are available at this time. comminution must be recognized. There must be room between
A new variarion of external fixation device, the Orrhofix de- the rrochanteric and the distal femoral physes for the device
vice, uses a bar with pin clamps and intermedialY fixation. The chosen.
sliding clamps allow auxilialY pin fixation near the fracture sire, After appropriate anesthesia, rhe leg is prepared and rhe pa-
as well as distal pin fixation. Dynamization is allowed with this rienr is placed on a radiolucent table or a fracture rabie, depend-
device as well. Series reporring experience with this treatment ing on the preference of the surgeon and the size of the child.
of Femoral Fractures are not yer available, and because enthusiasm Either the fracture table or Fluoro table works well. We make
currently is shifting roward flexible intermedullalY rodding, large the decision based on the size of the patient and the ease with
series n'catcd with this device may not be routinely reported. which reduction can be obtained, as well as the help available.
Another technical development in external fixation has been In general, a 6:acture table facilitates reducrion and application
the use of hydroxyapatite-coated pins. The pin-bone interface of the external fixator.
was a problem with loosening with some devices. The srrength First we ny to reduce the fracture both in length and align-
of the pin-bone interface with hydroxyapatite-coated pins ap- ment. If the fracture is open, it should be irrigated and debrided
pears to be somewhat beuer, alrhough large series wirh this de- before applicarion of the external fixation device. With the frac-
vice have not yet been reporred. ture maximally aligned, fixation is begun. The minimal and
Price and others have anecdotally recommended application maximal length constrainrs charaererisric of all exrernal fixation
 Chapter 22: Femoral Shaft Fractures 957

systems must be kept in mind. The angular adjustment intrinsic complications were five refractures or fractures through pin sites.
to the fixation device needs to be dctermined. If a universal joint Skaggs et at. (117), in reviewing the use of external flxarion
at the end of the Onhofix device only allows fot 15 degrees of devices for femoral fractures ar Los Angeles Children's Hospiral,
angular correction, one cannOt expect 40 degrees of adjustment found a 12% rate of secondary fractures in 66 parients. Multivar-
aftcr application of the device. Rorarion in general is constrained iare linear regression analysis showed no correlation between rhe
with all exrernal fixation systcms once the first pins are placed. incidence of refracture and rhe fracture pattern, percentage of
Thar is, if parallel pins are placed with the fracture in 40 degrees bone contact after fixator application, type of external flxator
of malroration, a 40 degree malaJignment will exisL Rorational used, or dynamization of the fracture. A statisrically significant
correction must be obtained before placing rhe pins in the pl'Oxi- associarion was found beteen the number of cortices demonstrat-
mal and distaJ shafts of the femur. ing bridging callus on both the AP and lateral views at the time
Applicarion of the fixator is similar no matrer what device is offixator removal and refracture. Fractures with fewer than three
chosen (Fig. 22-18). One pin is placed proximally in the shaft, cortices with bridging callus had a 33% risk of refracture,
and anorher pin is placed distally perpendicular to the long axis whereas those with three or four conices showing bridging callus
of the shaft. Alignment is always ro the long axis of the shaft had only a 4% rate of refracrure. Other repons in rhe literarure
rather than to the joint surface. Rotation should be checked wirh smaller numbers, but srill substantial experience, document
before the second pin is placed because it constrains rotarion refracture rates as high as 20% with more significant complica-
but not angulation or length. After pins are correcrly placed, all tions (84,92,99,113,115,117).
fixation nuts are secured and sterile dressings are applied (Q pins. In 1997, in a follow-up of the original article by Aronson
and Tursky (71), Blasier et al. (76) reponed L39 femoral frac-
Technique Tips tures treated with external fixation between 1984 and 1993. The
Pin sizes vary with manufacturers, as do drill sizes. In gen.eral average age at treatment was 8.9 years, and the average time ro
the pin.s are placed through predrilled holes to avoid thermal healing was 11.4 weeks. Only 18 patients had definitive radio-
necrosis of bone. Sharp drills should be used. The manufacturer's graphic follow-up, wirh 15 patients demonstrating overgrowth
recommendation for drill and screw sizes should be checked averaging 8.7 mm. In the series of Blasier et al., pin track infec-
before starting the procedure. At least two pins should be placed tion was common, and there was a 2% incidence of fracture
proximally and two distally. An intermediate pin may be benefi- after removal of the device.
cial. Alrhough joint stiffness has been noted in some patients
treated with external fixation, it is relatively uncommon in chil-
Postoperative Care dren with femoral fractures unless major soft rissue injury is
Pin care is critical, and avoiding rension at the skin-pin interface present (85).
is beneficial. Large pin sites are cleaned with peroxide daily.
Showering is allowed once rhe wound is stable and there is no
Intramedullary Fixation
communicarion between the pin and the fracture hemaroma.
Anribiorics are used liberally because pin site infections are com- Since rhe introduction of intramedullary fixation of femoraJ frac-
mon and easily resolved with antibiotic treatment, usually cepha- tures, enthusiasm for this form of internal fixation has varied
losporin. The external fixation device remains until the fracture but generally increased. Although a number of techniques have
is healed. Dynamization is performed before removaJ, allowing been described over the years, the modifications introduced by
the bone to be stressed to full body weight. The device should Winquist et al. (126) and Ligier et aJ. (105) were significant. In
not be removed until three or four cortices demonstrate bridging rhe 1970s, Winquist et a!' (126) developed techniques for closed
bone concinuous on AP and lateral radiographs, typically 3 to intramedullary rodding and indirect methods of fixarion with
4 months after injury. reamed and locked fixation devices. In the 1970s and 1980s,
Ligier et al. (105) introduced a dual flexible rod system rhar
provided internal fixation offractures with an indirect reduction
Complications of External Fixation
merhod leading to less fracture stability but accelerated healing.
The mosr common complication of external fixation is pin track By the late 1980s, techniques of antegrade rodding had been
infection, which has been reponed to occur in up ro 72% of refined, and enthusiasm grew for using this procedure in younger
patiems (11 I). This complication generally is mild and easily patients. The publication by Ligier er al. (105) in 1988 of a
treated with oral antibiotics and local pin site care. Sola et a1. group of patients treated with Aexible intramedulJary rodding
(119) reported a decreased number of pin track infections after seemed contrary w the tendencies toward more rigid and more
changing their pin care protocol from cleansing wirh peroxide securc fixation. With rcports of avascular necrosis of the proxi-
to simply having the patient shower daily. Superficial infections maJ femur by Beaty (73) and others beginning in the early 1990s,
should be treated aggressively wirh pin track releases and antibi- flexible rodding (either antegrade or retrograde) for femoral frac-
otics. Deep infecrions are rare, bur if present, drainage and anti- tures has grown in favor over locked intramedullary nails. The
biotic therapy are mandawry. Any skin tenting over the pins relative safety of the technique combined with its simplicity have
should be released ar rhe time of application or ar follow-up. led to irs greater acceptance. Comparative studies by Reeves et
In a study of complications of extcrnal fixawrs for femoral a!' (57) and Kirby et at. (102) as well as retrospective reviews
fractures, Gregory et al. (91) reporred a 30% major complicarion of traction and casting, suggest that femoral fractures in adoles-
rate and a 107% minor complicarion rate. Among the major cents are better treared with intrameduIJary fixation (40,80,84,
958 Lower Extremity

A B
(Ortho fix type) (AO type)

FIGURE 22-18. Technique of external fixation. A: With traction ap-

plied and provisional reduction of the fracture obtained, the proximal
and distal pins are placed perpendicular to the long axis of the bone,
being certain that rotational alignment is satisfactory. B: Provisional
fixation is obtained by attaching the external fixation device with
single pins in place. C: The second pin is added proximal and distal,
c (Ortho fix type) (AO type)
providing secure fixation.
 Chi/pteI' 22: Femoral Shaft Fractures 959

TABLE 22-3. RESULTS OF TREATMENT OF FEMORAL SHAFT FRACTURES IN ADOLESCENTS

Average Age
No. of (Range) in Results and
Series Patients Years Treatment Complications (n)

Kirby et al. 13 12 -I- 7 Traction -I- cast Short >2.5 em (2)

(10 11-15
-I- -I- 6) Significant residua'i angulation (4)
12 12 -I- 0 Intramedullary nailing No overgrowth
(10 - 10-15 -I- 7) No significant residual angulation
Ziv et al. 17 8 -I- 3 'Intramedullary nailing No leg length discrepancy >1 em
(6-12) (9 Rush pins, 9 Kuntscher nails) Change in AID 0.5-1 em = 3 with
Kuntscher nails
Reeves et al- 41 12 -I- 4 Traction -I- cast Delayed union (4)
(9 -I- 9-16 -I- 4) Malunion (5)
Growth disturbance (4)
Psychotic episodes (2)
49 14 -I- 11 Intramedullary nailing No infection, nonunion, or malunion
(11-16 -I- 10)
Beaty et al. 30 12 -I- 3 Intramedullary nailing Overgrowth >2.5 em (2)
(10-15) AVN femoral head (1)
Aronson et ak 42 9 -I- 7 External fixation 8.5% Pin infection
(2 -I- 5-17 -I- 8) 10% Cast or reapplication
Ligier 123 10 Flexibl'e 1M rods 1 infection
(5-16) 13 wound ulcerations
2 LLD :> 2 em
Mazda 34 9.5 Flexible 1M rods 1.0 to 1.5 em overgrowth (3)
(6-17) 1.0 to 15° malalignment (2)

89,97,102,J05,122,126,128) than wich traditional traction and rods allows axial deviation with return to normal alignment. In
casting (Table 22-3). 56 patients with femoral fractures stabilized with flexible tita-
nium rods, Flynn (87) reponed 4 with angular malalignment
Flexible Intramedullary Rod Fixation of more than-,10 degrees. These angular devi;ltions tended to
occur in fracture toward the end of the bone ratber than in
Flexible intramedullary nailing of pediatric femoral fracture
diaphyseal fractures,
either with stainless steel (Ender) or citanium (Nancy) rods can
There is no series comparing tiranium to srainless-steel rods
be performed either antegrade or retrograde. The benefit of elas-
in a randomized fashion, bur both rypes of rods have high success
tic internaJ fixation is that a healthy environment for fracture
rates when judged by rates of malunion, which are less than 5%
healing with some motion leads to increased callus formation.
in most series. Gregory et al. (92) compared the use of flexible
Properly used, flexible intramedullary rods provide sufficient sta- rods (Ender) with rigid antegrade nailing and found thar both
bility in the fracture so that a cast is not needed, but they lack techniques produced sarisfactory outcomes but flexible rods re-
the rigidity of an external fixation device, which inhibits fracture quired much less operative and fluoroscopy time wirh similar
healing. This lack of rigidity and inability to Jock the flexible patient satisfaction and outcome.
rods may predispose to deformity either with angular or axial BourdeJet (97) compared retrograde and antegrade (ascend-
deviation in unstable fractures. The lack of rigidity aJso may ing and descending) flexible intramedullary rodding in a group
create an environment in which muscle spasm and postoperative of73 femoral fractures. Treatmenr was noc randomized, but rhe
pain become more of a problem than with traditional rigid intra- subtrochanteric insertion sice was preferred because there were
medullary fixation devices. fewer knee symptoms and earlier patient independence with the
Elastic nailing offemoraJ fractures carries with it a few contrO- antegrade insertion technique. The insertion site used by Bour-
versies: (a) straighc versus bent rods, (b) titanium versus steel, delet was JUSt below the level of the trochanter proximally with
(c) immobilization versus no immobilization postoperatively, a standard medial and lateral disral insertion site. An anregrade
and (d) antegrade versus retrograde insertion. rransrrochanteric approach was recommended by Carey and Cal-
Mechanical testing of femoral fracture fixacion systems pin (82), who reported excellent resulrs in 25 patienrs without
showed that the greatest rigidity is provided by an external fixa- growth arrest of the upper femur and no avascular necrosis.
cion device and the least by flexible intramedullary rodding (8. Satisfactory alignment and fracture healing were obrained in all
Snyder, personal communication). Stainless-steel rods are patients.
srJ'onger than titanium in bending tescs. Stainless-steel rods have Rerrograde intramedullary rodding with Ender rods or rira-
greater intrinsic strength and therefore are not as dependent on nium rods has been reported by Ligier et aI. (l05), Mann et al.
che opposing bend cechnique. The elastic nature of the titanium (lOG), Heinrich er aI. (95), Herscovici et al. (98), and others
960 Lower Extremity

(82,100,109). Heinrich et al. (95) recommended a 3.5-0101 postoperative use of an external support device to supplemenr
Ender nail in children G to 10 years of age and a 4.0-0101 nail the internal flexible rod has been of value in unstable Fractures.
in children over 10 years of age. Ligier and Meraizeau (l 05) In evaluating the radiograph, fracture lines that propagate
used titanium rods ranging from 3 to 4 0101 inserred primarily beyond the obvious fracrure should be noted (Fig. 22-19). In-
in a retrograde fashion. Heinrich et aJ. recommended flexible volvement of the distal metaphyseal region is a relative contrain-
inrramedullary nails for fixation of diaphyseal femoral fractures dication ro this technique. The width of the canal is measured
in children with multiple system injUlY, head injury, spasticity, at the narrowest poinr in the diaphysis on both the AP and
or multiple long-bone fracrures. After early success in this se- lateral view (Fig. 22-20), and this number is divided by 2. This
lected group of patienrs, they expanded the use of flexible incra- represents the maximal diameter rod that can be used, and gener-
medullary rods ro include isolated fractures in any patienr over ally a rod at least 0.5 ro 1 0101 smaller rhan this radius should
G years of age with a femoral fracture and pareIHS willing ro be used. Therefore, if the medullary canal measures 8 mOl, a
accept the risk of the surgical rreatmenr. External immobilization 3.0- ro 3.5-mm rod probably should be used.
with casts was rapidly disconrinued in their series. The procedure can be performed eirher on a fracture table
or on a fluoroscopy table, but reduction must be documented
with fluoroscopy beFore insertion of the rods. The procedure is
Fixation with Flexible Intramedullary Rods: described with the use of a fracture table, but in small children
Technique «80 pounds), we find this easier ro do without a Fracture rable.
The procedure has been described with AO titanium clasric rods,
Preoperative Planning
bur other devices are available and can be used with slight varia-
Patienrs in whom this method of fixation is appropriate are those
tions in procedure.
between the ages of 5 and 16 with noncomminutecl femoral
Fractures. With unstable femoral fracrure patterns, considerable Rod Bending
experience is required ro achieve satisfactory outcome with flexi- The distance From the rop of the inserted rod ro the level of the
ble incrameduHalY nailing. Posroperative cast immobilization or fracrure site is measuted, and a gentle 30-degree bend is placed

r-

A,S c
FIGURE 22-19. A: The initial anteroposterior radiography of the 8-year-old child shows an oblique
femoral fracture, but there is also a non displaced butterfly fragment (arrows). B: Flexible rods may be
used in such a case, being careful not to displace the fragment and (C) burying the rods deep in the
proximal femoral metaphysis to provide satisfactory fixation.
 Chapter 22: Femoral Shaft Fraaures 961

Retrograde Insertion
After the child is placed on the fracture rabie, the leg is prepared
and draped with the thigh (hip to knee) exposed (Fig. 22-22).
The image inrensifier is used to localize the placement of skin
incisions by viewing the distal femur in the AP and lateral planes.
Incisions are made on the medial and lateral side distal to the
insertion site in the bone. The tOp of the 3-cm incision should
be ar or just distal to the level of the insertion site, wh ich is
about 2.5 to 3 cm proximal to the distal femoral physis (Fig.
22-23). A 4.5-mm drill bit or awl is used to make a cortical
I hole in the bone.
I
I
I I
Rods are inserted from the medial and lateral side and driven
----+l~: up to the level of the fracture. The distal femoral metaphysis is
, I
I I
opened using a drill or awl at a poinr 2.5 cm proximal to the
I I distal femoral physis. The driJl is then inclined 10 degrees anteri-
I I
I I orly and steeply angled in rhe frontal plane to facilitate passage
I I
of the nail through the dense pediatric metaphyseal bone. Upon
insertion rhe rod glances off the cortex as it advances toward
the fracture site. Borh medial and lateral rods are inserted to rhe
level of rhe fracrure. At this point the fracture is reduced using
longitudinal rraction, as well as a fracture reduction tool (Fig.
22-22B). This tool is radiolucent and holds the unstable femoral
fracture in the appropriate position to allow fixation. After the
first rod is driven across the fracture, approximately 2 to 3 cm,
the second rod is driven across the fracture. The twO rods rhen
AP La! are driven into the proximal end of the femur with one driven
toward the femoraJ neck and the other toward the greater tro-
Rod size (mm) =~ - 0.5 mm = chanter. When placing the second rod across the fracture site
and rotating it, care must be taken nor to wind one rod around
FIGURE 22-20. To determine the size of titanium flexible rods to be
the other. After the rods are driven across the fracture and before
used, measure the diaphyseal internal diameter on both the anteropos-
terior and lateral views, divide by 2, and subtract 0.5 mm. Use the they are seated, fluoroscopy is used to confirm satisfactory reduc-
smaller of the number obtained from the anteroposterior and lateral tion of the fracture and to ensure that the rods have not commi-
views. AO rods range from 2.0 to 4.0 mm in diameter, in 0.5-mm incre-
nuted the fracture as they were driven into the proximal frag-
ments.
ment.
The rods are pulled back approximately 2 em, the end of
in the nail with the apex at what will be the level of the ftacture. each rod is Cut, and the rods are driven back securely into the
Next the rod tip is benr to facilitate placemenr, and to allow femur. The end of the rod should lie adjacent to the bone of
the rod to bounce off the opposite cortex at the time of insertion. the metaphysis but should be at least 1 cm distal to the insertion
This also facilitates spreading of the rods in the proximal me- hole to allow ease in larer removal. Bending the rod ends should
taphysis, either in the femoral neck or in the greater trochanter. be avoided because ir can cause a painful bursa over rhe rod
Some surgeons prefer to avoid the second bend at rhe level of end.
the fracture and use these rods as straight rods, much as in If the fracture is in the lower portion of the femur and perhaps
traditional intramedullary fixation. Although not consistenr with even jfit is diaphyseal, a proximal insertion site should be consid-
ered. The insertion site may be anterolateral just below the
the recommendation ofLascom bes, satisfactoty results have been
greater trochanter or through the lateral border of the trochanter.
achieved with this technique, especially with the stronger stain-
Through a skin incision at the level of the trochanrer, two 4.5-
less-steel rods. The rods used generally are 3.0 to 4.0 mm in
mm holes are drilled into the metaphysis just below the apophy-
diameter, depending on the size of the bone and the child. Two
sis and connected with a rongeur. The rods are inserted ante-
rods of the same size should be used, and varying sizes should
grade. The sizing of the rods and postoperative management are
be avoided.
the same as in the retrograde technique.
The technique of elasric fixation of femoral fractures as de-
scribed by Ligier et aL (lOS) requires that a bend be placed in Technique Tips
the mid-portion of the rod at the level of the fracture site. This Mazda et al. (l09) emphasized that for insertion of titanium
produces a spring effect (Fig. 22-21) that adds to the rigidiry of elastic nails, the nails have to be bene into an even curve over
the fracture fixation. The spread of the rods in opposite direc- rhe enrire length, and the summit of the curve has to be at the
tions provides a "prestressed" fixation, which increases resistance level of the fracture or very close to it in comminuted fracrures.
to bending. The opposite bends of the two rods at the level of The depth of curvature should be about three times the diameter
the fracrure significantly increase resistance to varus and valgus of the femoral canal. Flynn et al. (87) also stressed the impor-
stress, as well as torsion. tance of contouring both nails with similar gende curvatures,
962 Lower Extremity

Weight

.
/ /-.~.
I
r'· r

lJ - c
FIGURE 22-21. A: Stability from flexible rods comes from proper technique. B: Torsional stability results
from divergence of the rods in the metaphysis. C: Resistance to sagittal and coronal bending results
from spreading of the prebent rods through the diaphysis, as well as the size and material properties
of the rods. Elastic fods return to their predetermined alignment when loaded unless plastic deformation
occurs.

A B
FIGURE 22-22. A: In children weighing more than 80 pounds, the fracture table may be used to provide
traction and reduction of a femoral fracture. The leg is draped free, allowing medial and lateral rods
to be placed. B: A radiolucent reduction bar may be beneficial to reduce angular deformity when passing
the rods.
 Chapter 22: Femoral Shaft Fractures 963

which increases the motion at the fracture site and increases

quadriceps spasm. Postoperative knee motion does return to
normal, but this requires time. Full weight bearing generally
is tolerated by 6 weeks.
The rod may be removed 6 to 12 months after injury when
the fracture is fully healed, usually as an outpatient procedure.

Complications of Flexible Intramedullary Nailing

Complications are relatively infrequent after flexible inrramedul-
lary nailing. In 308 fractures reponed in six srudies (72,81,86,96,
105,108), no nonunions, infections, or occurrences of avascular
necrosis were reported. Approximately 12% of parients had ma!-
unions, most often mild valgus or varus deformiries, and approx-
imately 3% had clinically significant leg length discrepancies
A from either overgrowth or shortening. Mazda er al. (108)
B
pointed our a technique-related complication that occurred in
10 of their 34 patients: rods were left roo long and caused painful
bursae and limited knee flexion. All 10 patients had the nails
removed 2 ro 5 monrhs after surgery. In a multicenter study
thar included 58 femoral fractures stabilized wirh titanium elastic
nails, irritation of the soft tissue near the knee by the nail tip
occurred in 4 patients (7%), leading ro a deeper infection in 2
patients. This study also reported one refracture after premature
nail removal, leading to a recommendation that nail removal be
delayed until callus is solid and the fracture line is no longer
visible.

Rigid Intramedullary Rod Fixation

Problems with angular malalignmenr and maintenance of length
can be avoided with the use of rigid inrramedullary fixation.
lnrerloclcing proximally and distally to maintain length and rota-
tional alignmenr in unstable fractures, as in adults, appears to
be of benefit to some adolescents (74,78,93). Beaty et al. (73)
reported the use of interlocking inrramedullaty nails for the
treatment of 31 femoral shaft fractures in 30 patients 10 to 15
years of age. All fractures united, and rhe average leg length
c discrepancy was 0.51 em. No angular or rotational maJunions
occurred. All naiJs were removed at an average of 14 months
FIGURE 22-23. Retrograde insertion. A: The rods are inserted through after injury; no refracture or femoral neck fracture occurred after
a distal cortical hole 4.5 mm in diameter made either with a drill or an
awl 2.5 cm above the physis. B: Rods are advanced to the level of the
nail removal. One case of avascular necrosis of the femoral head
fracture site by rotating (reciprocally) or pounding with an inserter and occurred, which was thought to be secondary to injury to the
mallet. The fracture is reduced and one rod is driven across the fracture ascending cervical artery during nail insertion. A poll of the
site 3 to 5 cm. C: Then the second rod is driven into the proximal frag-
ment.
members of the Pediatric Orthopaedic Society disclosed 14 pa-
tients with avascular necrosis in approximately 1,600 femoral
fractures. Despi te the use of a "safe" rranstrochanteric insertion
site for antegrade femoral rodding, a case of avascular necrosis
choosing nails that are 40% of the narrowest diaphyseal diame-
has been reported. Buford et at. (79) showed in their MRl study
ter, and using media! and lateral starting points that are at the of hips after anregrade rodding that subclinical avascular necrosis
same level in the metaphysis.
may be present. Antegrade rodding through the trochanter or
the upper end of the femur appears to be associated with a risk
Postoperative Management of avascular necrosis in children with open physes, regardless of
For unstable long oblique fractures or comminuted fractures, chronologie age.
immobilization with a cast or traction may be of benefit. To Reamed antegtade nailing in children undet 12 years of age
decrease knee pain and quadriceps spasm, we have found the use is l10t recommended because of proximal femora! growth abnor-
of a knee immobilizer to be beneficial in the early postoperative malities (163), the risk of avascular necrosis of the femora! head
course. Physical therapy with touchdown weight bearing (56,73,110,121), the size of the proximaJ femur, and the relative
should begin as soon as the patient is comfortable. Gentle success of other treatment methods. However, Maruenda-Pau-
knee exercises and quadriceps strengthening can be begun, lino et al. (l07) reported good results using 9-mm Kunrscher
but there should be no aggressive passive motion of the knee, rods in children 7 to 12 years of age, and Beaty et at. (73)
964 Lower Extremity

reported the use of newer pediatric "intermediate" interlocking mis fossa with vigorous dissection and placemenr of anterior and
nails for femoral canals with diameters as small as 8 mm. In posterior retractors to the femoral neck also may cause injury
children 12 to 17 years of age, antegrade locked transtrochanteric to the lateral ascending cervical artery and should be avoided.
fixation may occasionally be indicated for an unstable fracture Dissenion should be limited to the lateral aspect of the greater
in a large adolescent. trochanter and not into the piriformis fossa. This prevents dissec-
Open fractures in older adolescents can be effectively treated tion near the origi n of the lateral ascending cervical artery medial
with intramedullary rodding, either as delayed or primary treat- to rhe piriformis fossa.
ment, including those caused by gunshot wounds and high- A threaded-tip guidewire is inserted into the proximal edge
velocity injuries (75,123). Antegrade intramedullary rod inser- of the greater trochanter, followed by reaming with a 9-mm
tion maintains length, prevents angular malunion and non- reamer (Fig. 22-24). A ball-tip guidewire then can be inserred
union, and allows the patient to be rapidly mobilized and dis- into the proximal femur. No dissection should be performed
charged from the hospital. However, other rechniques with fewer medial or posterior to the insertion sire. The ball-tip guidewire
potential risks should be considered. is driven across the fracture site and into tbe distal fragment to
a level JUSt proximal to the distal femoral pbysis. Progressive
Antegrade Intramedullary Nailing: Technique reaming is performed before a reamed rod or a nonreamed rod is
chosen. The smallest rod that maintains contan with tbe femoral
The child is placed either supine or in the lateral decubitus cortices is lIsed (generally 8 or 9 mm) and is locked proximally
position on a fracture table. The upper end of the femur is and disrally. Only one distal locking screw is necessary, but two
approached through a 5-cm longitudinal incision proximal to
can be used (66). Rods rhat have an expanded proximal cross-
the greater trochanter and in line with the femoral shaft. The
section should be avoided. The proximal end of the nail should
skin incision can be precisely placed after localization on both
be left slightly long (up to 1 cm) to make later removal easier.
the AP and lateral views. The gluteus maximus muscle is spread,
and the gluteus medius muscle identified. The rod should be
inserted through the gluteus medius muscle insertion in the tip Technique Tips
of the trochanter, because posterior dissection may place the Dissection should be limited to tbe tip of the greater trochanter,
vasculature proximally at risk for injury. IdentifYing the pirifor- wirhour extending to the capsule or mid-portion of the femoral

A B
FIGURE 22·24. Antegrade insertion of intramedullary nail. A: Guidewire is placed at the medial edge
of the greater trochanter, piercing the gluteus medius muscle and avoiding posterior insertion. B: Three
months after fixation of a femoral shaft fracture in an l1-year-old child with multiple trauma and a
closed head injury. A 9-mm pediatric locked intramedullary nail was used.
 Chapter 22: Femoral Shaft Fractures 965

neck. Leaving the proximal end of the nail up to 1 em long In a series of intramedullary nailing of 31 fractures, Beary et
makes later removal easier. al. (73) reported one patient with segmental avascular necrosis
of the femoral head (Fig. 22-25), which was not seen radiograph-
Postoperative Management ically until 15 months after injury. Kaweblum et at. (lO 1) re-
Nails can be removed 9 to 18 months after radiographic union poned a patient with avascular necrosis of the proximal femoral
epiphysis after a greater trochanteric fracture, suggesting that the
to prevent bony overgrowth over the proximal tip of the nail.
blood supply to the proximal femur may have been compro-
Dynamization with removal of the proximal or distal screw gen-
mised by vascular disruption at the level of the greater trochanter
erally is not necessary.
during rod insertion. Other researchers have reported single pa-
tients with avascular necrosis of the femoral head after intramed-
Complications of Locked Intramedullary Nailing ullary nailing (110,112,121). Chung (82) noted the absence of
Although good results have been reponed with this technique transphyseal vessels to the proximal femoral epiphysis and dem-
and patient satisfaction is high, problems with proximal femoral onstrated that the singular lateral ascending cervical artery pre-
growth, avascular necrosis, and leg length discrepancy cannot dominantly supplies blood to the capital femoral epiphysis (Fig.
be ignored. 22-26). He stated that all of the epiphyseal and metaphyseal

A c
FIGURE 22-25. A: Isolated femoral shaft fracture in 11 '1,-year-old child. B: One month after fixation
with an intramedullary nail, femoral head appears normal. C: Eight months after injury, fracture is
healed; note early signs of avascular necrosis of right femoral head. (Fi ure continues.
966 Lower Extremity

FIGURE 22-25. (continued) 0: Fifteen months after injury, segmental avascular

necrosis of the femoral head is evident on radiographs. E: Magnetic resonance
image shows extent of avascular necrosis of right femoral head. (D reprinted
from Beaty JH, Austin SM, Warner we, et al. Interlocking intramedullary nailing
of femoral-shaft fractures in adolescents: preliminary results and complications.
D J Pediatr Orthop 1994;14: 178-183; with permission.)

brancnes of the lateral ascending cervical arrery originate from

a single stem that crosses the capsule at the trocnanteric notch.
Because the space berween the trochanter and the femoral head
is extremely narrow in children under 8 years of age, rhis single
arrery is vulnerable to injury and appears to be so until skeletal
maruriry, regardless of chronologie age.
Townsend and Hoffinger (124) reporred no avascular necro-
sis in 34 parienrs in whom a rrocnanteric tip srarring point was
used.
Skak et al. (118), in a long-term study of 52 children and
adolescenrs with femoral fracrures treared with plating and intra-
medullary rodding, found that excessive overgrowrh was less
common wirh nailing than with plating. Three patienrs had
moderate valgus deformities of the hip and one had lare arrhrosis
after inrramedullary rodding despite using a rransrrochanreric
approach. Skak et al. (1] 8) concluded that open physes were a
conrraindication to anregrade rodding even with a rranstrochan-
reric approach. Thomerz and Handen (12 I) also documenred
an association berween avascular necrosis and anregrade rodding
in an adolescenr.
Growth abnormaliry in rhe proximal femur may occur witn
arrest of the greater trochanreric physis. Although most growtn
from the greater rrochanrer afrer 8 years of age is appositional,
Raney et al. (163) reported five patients who developed coxa
valga and mild hip subluxation from trochanreric physeal arrest
after anregrade nailing. These patients ranged in age from 9 to 13
years, suggesting rhat even in older children greater rrochanreric
physeal arrest occasionally can produce clinical problems. Beary
et al. (73) reported rwo patienrs with overgrowth of more than
FIGURE 22-26. The single ascending cervical artery (A) is the predomi- 2.5 em that required epiphysiodesis because ofleg lengrh discrep-
nant blood supply to the femoral head. The vessel is at risk during ancy.
antegrade insertion of an intramedullary rod. (Reprinted from Chung
S. The arterial supply of the developing proximal end of the femur. J The proximal femoral physis is a conrinuous carrilaginous
Bone Joint Surg [Am] 1976;58:961; with permission.) plate berween tne gteater rrochanrer and the proximal femur in
 hapter 22: Femoral Shaft Fractures 967

FIGURE 22-27. Fifteen-year-old boy 3 years after intramedullary nail-

ing of the right femur. Acetabular to trochanter distance increased by
1.5 cm; note partial trochanteric epiphysiodesis (arrow) with mild over-
growth of the femoral neck. (Reprinted from Beaty JH, Austin SM, War-
ner we, et al. Interlocking intramedullary nailing of femoral-shaft frac-
tures in adolescents: preliminary results and complications. Pediatr
Orthop 1994;14: 178-183; with permission.)

young children. Interference with the physis may result in atro-

phy of the femoral neck, placing the child at a small risk for
subsequent femoral neck fracture (16). An tegrade rodding wi th A B
reaming of a large defect also may result in growth disturbance FIGURE 22-28. A: Pathologic fracture (nonossifying fibroma) of the
in the proximal femur as well as femoral neck fracture (Fig. 22- femoral diaphysis. B: Plate fixation at the time of biopsy and bone
27). Beary et al. (73) reponed no "thinning" of the femoral grafting.
neck in their patients, which they attributed to an older patient
group (J 0- J 5 years of age) and design changes in the femoral
nail that a.llowed a decrease in the cross-sectional diameter of
the proximal ponion to 10 mm. were kept non-weight bearing on crutches for 8 weeks. There
were two plate breakages requiring revision and one requiring
spica casting to achieve healing. Modem techniques of femoral
Open Reduction and Internal Fixation with plating (14) with maintenance of the periosteum may lead to
Plate and Screws greater acceptance of this merhod of management.
Pathologic fractures, especially in the disral femoral metaphy-
Ward et al. (25), Kregor et al. (03), Fyodorov et al. (88), and
sis, creare larger areas of bone loss that can be neated with plate
Hansen (94) recommended this form of treatment in selected
fixation and immediate bone grafting to avoid protracted periods
femoral fractures. Ward et al. (25) reported the use of AO
of traction and immobilization (Fig. 22-28).
compression plates for the treatment of femoral shaft fractures
in 25 children 6 to J 6 years of age, 22 of whom had associated
fractures or multisystem injuries. Follow-up was available for 24
Technique
patients, 23 of whom (96%) had healed ftactures at an average
of J J weeks. According to these investigators, plate fixation offers Tn a sterile operating room environmenr after general anesthesia
the advantages of anatomic reduction, ease of insertion, simpli- has been given, the patient is placed on a radiolucent operating
fied nursing care, rapid mobilization wirhour casting, and appli- table and the entire extremiry is prepared and draped. The femur
cabiliry to any size femoral shaft. Disadvantages of plate fixarion is approached laterally. The vastus lareralis is renacted anreriorly
include rhe long incision necessalY and the risks of plate breakage to expose the femur. Soft tissue arrachment to rhe bone is pre-
and stress fracture after plare removal. They recommend plate served to the extent possible. Fragments are lagged into place
fixation only for children under J J years of age with closed- and secured with a dynamic compression plate. A 4.5-mm or
head injuries or muhiple trauma. All rhe patients reporred by larger compression plate is used in children (Fig. 22-29). If the
Kregor er al. (J 03) had multiple trauma, and this form of treat- fracture is ar either end of the bone, leaving insufficient bone
ment was selected ro stabilize the femoral fracture quickly and for cortical fixarion, fully threaded cancellous screws add to the
mobilize the patient. Fyodorov et al. (88) reviewed 2 J patients stabiliry of fixation and are preferable to either cortical or
in whom 4.5-mm DCP plates were used for fixation. Patients parrially threaded cancellous screws. Borh interfragmentary
968 LOI.lJer Extremity

Fyodorov, Sturm, and Robertson (88) reponed hardware fail-

ure in 2 of 23 femoral shaft fracrures [['eared with dynamic
compression plating. One was treated with revision plating and
the other with spica cast; both fractures healed uneventfully. No
other complications were noted in their parients.
Refracture is rare, and whether bone atrophy under a plate
is caused by stress shielding or by avascularity of the correx is
unknown. AJthough still somewhat controversial, the plate and
screws are generally removed at 1 year after fracture ro avoid
fracture at the end of the plate.
Quadriceps srrength after plate fixation appears nor ro be
compromised, (147) relative to inrramedullalY fixation or cast
immobilization.

~. AUTHORS' PREFERRED METHOD

V OF TREATMENT
For stable femoral fractures in children under 6 monrhs of age,
we use a posterior splint or Pavlik harness. If the fracture is
unstable, usually the proximal fragmenr is Aexed and a Pavlik
harness is the ideal device for reducing and holding the fracture.
The use of a Pavlik harness requires an attentive and complianr
caregiver. Traction with a spica cast occasionally is needed in
this group. Abuse and metabolic bone disease must be considered
in an infant wirh a femoral fracture.
In children 6 monrl1s ro 6 years of age, an immediate spica
cast with Cortex liner is almost always the treatmenr of choice.
If length or alignment cannot be maintained in an immediate
spica cast, traction followed by casting can be used. We usually
A B
use a distal femoral traction pin and place the child in a 90/90
FIGURE 22-29. A: This oblique mid-shaft femoral fracture with some
comminution in a 200-pound male occurred after an automobile acci-
or oblique position in the bed for traction. It is of note, however,
dent. B: Stable fixation with plate and lag screw construction is highly that over 95% of young children with femoral fractures can be
successful and carries no risk of avascular necrosis. managed with immediate spicas with a low complication rate
and low cosr. In children with multiple trauma, either Acxible
intramedullalY rodding or external fixation is chosen, based on
the fracture anatomy and the soft tissue injUlY.
compression and dynamic compression techniques can be used In children 6 ro 12 years of age, flexihle imramedullary rod-
ro achieve stability and anatomic alignment. ding is frequently used, most often with retrograde inserrion.
External fixation is used for unstable fracture patterns, commi-
Technique Tips nuted fractures, and fractures with severe soft tissue injUlY. Im-
mediate spica casts may be used for the mosr stable fracrures in
Soft tissue stripping should be limited, and three screws should
this age group. In children 12 years to maturity, we use flexible
be used proximal and distal to the fracture site.
intramedullary rods as our treatment of choice. In a patiem with
an unstable fracture configuration, we would use either a plate
Postoperative Management or an anregrade rod, recognizing the low but signiflcanr risk of
Protecred weight bearing is progressed ro weight bearing ro roler- avascular necrosis of the femoral head. Plating is preferable for
ance. Acrive range of motion of the hip and knee is encouraged. subtrochanreric and supracondylar fractures of the femur,
whereas intramedullalY nails are ideal for mid-shaft fractures. If
antegrade rodding is chosen, a transtrochanreric approach is
Complications of Plate Fixation
used. New methods are under development for fixation, using
Extensive dissection and periosreal stripping during plate appli- an infratrochanreric approach with a locked type of flexible rod,
cation may lead to overgrowth. Overgrowth was not a significant bur such devices are not available yer.
problem in the series of Kregor et aJ. (103), with an average
increase in length of 0.9 cm (range 0.5-1.5 cm), but Ward et COMPLICATIONS OF FEMORAL SHAFT
al. (125) reporred several patients with considerable overgrowth FRACTURES
(approximately 1 inch), and Hansen (94) reporred overgrowth
of an inch in a 12-year-old boy, suggesting rhat overgrowth is Leg Length Discrepancy
possible in children over 10 years of age. More data are necessary The most common sequela after femoral shaft fractures in chil-
on rhis issue to malce a deflnirive statement. dren is leg length discrepancy. Th.e fractured femur may be ini-
 Chapter 22: Femoral Shaft Fractures 969

tially shorr from overriding of the fragmenrs at union; growth but some have reported overgrowth to be more frequent after
acceleration occurs ro "make up" che difference, bur often this spiral, oblique, and comminuted fraccures associated with greater
acceleration conrinues and overgrowth occurs. The potential for trauma.
growth stimulation from femoral fraccures has long been recog-
nized, bue the exact cause of this phenomenon is still unknown. Angular Deformity
Growth acceleration has been attributed ro age, sex, fraccure
type, fracture level, handedness, and the amount of overriding Some degree of angular deformity is frequent aftet femoral shaft
of the fracture fragments. Age seems to be the most constant fractures in children, but this usually remodels with growth.
facror, but fractures in the proximal third of the femur and Angular remodeling occurs at the site of fraccure with apposi-
oblique comminueed fraccures also have been associated with tional new bone fOl·mation in the concavity of the long bone.
relatively greater growth acceleration. According to Staheli Differential physeal growth also occurs in response ro diaphyseal
(170), in patients over 10 years of age, shortening is more likely; angular deformity. Wallace and Hoffman (176) stated that 74%
in patients 2 to 10 years of age, overgrowth is more likely, espe- of the remodeling that occurs is physeal, and appositional re-
cially if traction has been used. modeling at the fracture site occurs to a much lesser degree.
However, this appears to be somewhat age dependent. It is clear
that angular remodeling occurs best in the direction of motion
Shortening at the adjacent joint (176). That is, anterior and posterior remod-
Because the average overgrowth after femoral fraccure is approxi- eling in the femur occurs rapidly and with little residual defor-
mately 1.5 cm, shortening of2 ro 3 cm in the cast is the maximal mity. In contrast, remodeling of a varus or valgus deformity
acceptable amounr. The maximal acceptable shottening depends occurs more slowly. The differential physeal growth in a varus
on the age of the child; for example, in a 6-year-old child, 2.5 or valgus direction in the distal femur causes compensatory de-
em may be acceptable, whereas only 1 ro 2 cm should be accepted formity, which is usually insignificant. In severe varus bowing,
in a 14-year-old approaching skeletal maturity. In patients 2 ro however, a hypoplastic lateral condyle results, which may cause
10 years of age wi th more than 3 cm of shortening after immedi- a distal femoral valgus deformity if the varus bow is corrected
ate spica casting, the cast is removed, traction is reapplied until (Fig. 22-30).
acceptable length is obtained, and then a new cast is applied.
For early shortening of more than 3 cm in a patient 11 or 12
years old, a reinsticution of traction and reapplication of the cast
also may be appropriate. If, however, the shortening is unaccept-
able at 6 weeks after fraccure, the decision must be made as
v.o.
co whether osteoclasis and distraction with external fixation is
preferable to a later limb equalization procedure (lengthening
or shortening). The trend is to correct the shorrening immedi-
ately with external fixation if possible.

Overgrowth
Overgrowth after femoral fracture is common in children 2 co
10 years of age. The average overgrowth is 0.9 cm, with a range
of 0.4 to 2.5 em (169). Overgrowth occurs whecher the fracture
is short, at length, or overpuJled in traction at the time of healing.
In general, overgrowth oecuts most rapidly during the first 2
years after fraccure and to a much lesser degree for the next year
or so (148).
T ruesdeH (173) first reported the phenomenon of overgrowth
in 1921, and many researchers since have verified che existence of
growth stimulation after fracrure (129-132,138,139,142,145,
158,159). The relationship of the location of the fracture co
growth is somewhat controvetsial. Staheli (170) and Malkawi
(154) reported that overgrowth was greatest if the fracture oc-
curred in the proximal third of the femur, whereas Henry (151)
stated that the most overgrowth occurred in ftactures in the
distal third of the femur. Other investigators have found no
relationship berween fracture location and growth stimulation
(145,151,164); Shapiro's data (169) support the lack of relation-
ship. The relationship berween fractute type and overgrowth
FIGURE 22-30. Long-standing varus deformity in the femoral shaft
also is controvetsial. In general, most researchers believe that no may lead to hypoplasia of the lateral condyle and a compensatory distal
specific relationship exists berween fracture type and overgrowth, femoral valgus deformity after correction of the varus of the shaft.
970 Lower Extremi~)1

(J)
'-

F[
c: 2
Q)
o

FIGURE 22-31. Remodeling potential of the femur during infancy. This infant sustained a femoral
fracture during a breech delivery and was placed in a spica cast but with insufficient flexion of the hip.
left: At 3 weeks union is evident with about 45 degrees of angulation in the sagittal plane and 1.5 cm
of overriding. Center: line drawing demonstrating true angulation. Right: Twelve months later the
anterior angulation has reduced to a level such that it was not apparent to the family, and the shortening
has reduced to less than 1 cm.

Guidelines for acceptable alignmenr vary widely. The range poned as a complication of traction pin or wire placemenr
of acceptable anrerior and posterior angulation varies from 30 through or near the anterior as peer of the proximal tibial physis,
ro 40 degrees in children up ro 2 years of age ro 10 degrees in excessive traction, pin track inFection, or prolonged cast immobi-
older children and adolescenrs (Fig. 22-31) (157). The range of lization (68). However, proximal ribial growrh arrest may com-
acceptable varus and valgus angulation also becomes smaller with plicate femoral shaft fracture, presumably as a result of occult
age. Varus angulation in infanrs and children should be bet""el'll injury (152). Femoral pins are preferred for traction, but if tibial
\ 0 and \5 degrees, although greater degrees of angulation may pins are required, the proximal anterior ribial physis musr be
have a satisfacrory outcome. Acceptable valgus angulation is 20 avoided (51). Femoral traction pi ns should be placed one or rwo
to 30 degrees in infants, 15 ro 20 degrees in children up ro 5 finger breadths proximal ro the superior pole of the patella to
years of age, and 10 degrees in older children and adolescems. avoid the disral femoral physis.
The muscle mass of the femur generally hides femoral deformiry If significant angular deformity is present after fracture union,
from direct observation. The acceptability of femoral deformity, corrective osreoromy should be delayed for at leasr a year unless
in general, is a direct function of the degree of difficulty in the deformity is severe enough ro impair function. This will
changing the deformity and the appearance of rhe leg. allow determination of remodeling potenrial before deciding
Late development of genu recurvatum deformity of the proxi- that surgical correction is necessary. The ideal osteoromy correers
mal tibia after femoral shaft fracwre has been most oFten re- the deformity at the site of fracwre. In juvenile patienrs, how-
 Chapter 22: Femoral Shaft Fractures 971

ever, mecaphyseal osreoromy of rhe proximal or disral femur 20

may be necessary. In adolescenrs wirh mid-shaft deformities,

diaphyseal osreoromy and fixation wirh an inrerlocking inrra-
(j)
medullary nail are preferable. .>L
Q)
Q)
15
~
Z
Rotational Deformity 0
Z
:;:) 10
According to Verbeek (174), rorarional deformities of 10 degrees
0
ro more rhan 30 degrees occur in one rhird of children after I-
W
conservative treatmenr of femoral shafr fractures. Mal kawi et al. :E
(158) found asymptomaric rotarional deformities of less than i=
5
10 degrees in two thirds of their 31 patienrs. Torsional defOl'miry
usually is expressed as increased femoral anteversion on rhe frac-
tured side compared wirh rhe opposite side, as demonsrrared by
anreversion views; a difference of more than 10 degrees has been
5 10 15
tne criterion of significant deformiry. However, Brouwer er al.
AGE (years)
(1%) challenged this criterion, ciring differences of 0 ro 15 de-
• Excludes delayed unions and pseudoarthroses.
grees in a conn'ol group of 100 normal volunreers. The accuracy
of measuremenrs from plain radiographs also has been dispured, FIGURE 22-32. Time required for union of femoral shaft fractures in
childhood and adolescence. (Redrawn from Skak SV, Jensen n. Femoral
and Norbeck er al. suggesred rhe use of compured tomographic shaft fracture in 265 children. Acta Orthop Scand 1988;59:704-707;
(CT) scanning for grearer accuracy. with permission.)
Rotarional remodeling in childhood femoral fractures is an-
orher conrroversy in rhe search for criteria on which 10 base
therapeutic judgments. According [Q Davids (143) and Braren
et al. (135), up to 25 degrees of rotarional malalignment at the
with a range from 10 to 15 weeks (Fig. 22-32). The rare of
time of healing of femoral fractures appears [Q be well tolerated
healing also is relared to sofe rissue injury and type of rrearment.
in children. In rheir parienrs with more than 25 degrees of rota-
Application of an external fixation device appears to delay callus
tional malalignmem, however, deformiry caused clinical com-
formation and slow rhe rate of healing.
plainrs. Davids found no spontaneous correcrion in his study of
Bone grafting and internal fixation wirh eirher a compression
malunions based on CT measuremenrs, but the length oHollow-
plare or locked intramedullary nail is the usual treatment for
up is insufficienr [Q state that no rotational remodeling occurs.
delayed union in older children and adolescents. Delayed union
Brouwer et al. (136) and others (133,149,162,174) reponed
slow rotarional correcrion over time. of a femoral fracrure rreated with casting in a child 1 ro 6 years
Cerrainly, in older adolescents, no significant rorarional re- of age is probably best rreated by continuing casr immobilizarion
modeling will occur. In infants and juveniles, some rotational until bridging callus forms or (rarely) by additional bone
deformiry can be accepted (146), because eitner rrue rotational grafring.
remodeling occurs or functional adaptarion allows resumprion
of normal gait. Up to 30 degrees of angular malrotarion in the
femur should result in no funcrional impairmenr unless rhere is Nonunion
preexisring rotational malalignment. The goal, however, should Nonunions of pediatric femoral fracrures are rare (156). They
be [Q reduce a rotational deformiry 10 10 degrees, based on
rend ro occur in adolescents, in infecred fracrures, or in fracrures
alignmenr of the proximal and disral femur radiographically,
with segmental bone loss or severe soft rissue loss. Mosr non-
inrerprerarion of skin and sofr tissue envelope alignment, and
unions in children are of tibial fracrures; femoral fractures ac-
correct positioning within a cast, based on the muscle pull on
count for only 15% of nonunions in children. Even in segmenral
the proximal fragmem. The distal fragmem should be lined up
fracrures with bone loss, young children may have sufficient
with the posirion of rhe proximal fragment determined by rhe
osteogenic porenrial ro fill in a signiflcanr fracture gap (Fig. 22-
muscles insened upon it (Fig. 22-3).
33) (160). For the rare femoral shaft nonunion in a child 5 to
10 years of age, bone grafring and plate-and-screw fixation have
been rraditional rrearmenr mcrhods, bur morc reccntly inserrion
D layed Union of an inrerlocking intramedullary nail and bone grafring have
Delayed union of femoral shafe fracrures is uncommon in chil- been preferred, especially in children over 10 ro 12 ycars of age.
dren. The time ro fracture union in mosr children is rapid and Roberrson et al. (166) reponed the use of extcrnal fixarors
age dependenr. In children under 5 years of age, healing usually in 11 open femoral fractures. The time ro union was delayed, bur
occurs in 4 [Q 6 weeks. In children 5 [Q 10 years of age, fracture a sarisfacroly ourcome occurred withour subsequent procedures.
healing is somewhar slower, requiring 8 [Q 10 weeks. Through- This supports the belief rhar rhe rates of delayed union and
our adolescence, rhe rime ro nealing continues to lengthen. By nonunion are low in pediatric femoral fractures, because open
rhe age of 15 years, rhe mean time to healing is abour 13 weeks, fracrures would have rhe highesr rates of delayed union.
972 Lower Extremity

Injury to the quadriceps muscle probably occurs at the rime

of femoral fracture, and long-term muscle deficits may persist
in some patients regardless of treatment. Severe scarring and
conrracture of the qmdriceps occasionally require quadri-
cepsplasry (154).

Infection
Infection may rarely complicate a closet! femoral shaft fracture,
with hematogenous seeding of the hematoma and subsequenr
osteomyelitis. Fever is commonly associated with femotal frac-
tures during the first week after injury (171), but persistenr fever
or fever that spikes exceedingly high may be an indication of
infecrion.
Pin-track infections occasionally occur with the use ofskeletal
tr<lction, but most are superficial infections that resolve with
local wound care and antibiotic therapy. Occasionally, however,
the infections may lead to osteomyelitis of the femoral metaphy-
sis or a ring sequestrum that requires surgical debridement.

Neurovascular Injury
Nerve <lnd vascular injuries are uncommon wirh femoral frac-
tures in children (140,144,153,167). An estimated 1.3% oHem-
oral fractures in children are <lccompanied by vascular injury
(140,144,153,167), such as inrimal tears, rotal disruprions, or
injuries resulting in the formation of pseudoaneurysms (168).
Vascular injury occurs most frequently with displaced Salter-
FIGURE 22-33. The effectiveness of remodeling of the femur in a child.
Harris physeaJ fracrures of the disral femur or distal metaphyseal
Left: Comminuted fracture in an 8-year-old child managed with a femo- fractures. If arteriography indicates that vascular repair is neces-
ral pin incorporated in a spica cast. The mid-fragment is markedly angu- sary after femoral shaft fracture, open reduction and internal
lated. Center: Fracture after union 12 weeks later with filling in of the
defect and early absorption of the protruding fragment. Right: Appear- flxarion or external fixation of the fracrure are recommended.
ance at age 12 with only a minimal degree of irregularity of the upper Secondary limb ischemia also has been reponed after the use of
femur remaining. both skin and skeletal tracrion. Documentation of peripheral
pulses ar rhe time of presentation, as well as throughout treat-
ment, IS necessary.
Nerve abnormalities reported with femoral fractures in chil-
dren include those caused by direct rraum<l to the sciatic or
Muscle Weakness
femoral nerve at the time of fracture and injuries to the peroneal
Weakness after femoral fracture has been described in the hip nerve during treatment. Weiss er al. (69) reponed peroneal nerve
abductor musculature, quadriceps, and hamstrings, bur persis- palsies in 4 of 110 children with femor<ll fractures treared wirh
tenr weakness in some or all of these muscle groups seldom early 90/90 hip spica casting. They recommended exrending the
causes a clinical problem. Hennrikus et al. (150) found rhat inirial short leg portion of the casr above the knee to decrease
quadriceps srrength was decreaseJ in 30% of his patients and tension on the peroneal nerve.
18% had a significant decrease demonstrated by a one-leg hop Riew et al. (165) reported 8 nerve palsies in 35 consecurive
rest. Thigh atrophy of 1 cm was present in 42% of patients. patients treated wirh locked inrramedullalY rodding. The nerve
These Jeflcits appeared to be primarily related to the degree of injuries were associated with delay in treatmenr, preoperative
initial displacemenr of the fracture. Finsen et <ll. (147) found shorrening, and boot traction. Resolution occurred in less than
hamstring and qU<ldriceps deflcirs in patients with femoral shaft one week in 6 of 8 patients.
fractures treated with either rods or plates. The natural history of peroneal nerve injury with femoral
Damholt and Zdravkovic (141) documented quadriceps shaft fractUres in children seems to be sponraneous correcrion.
weakness in approximately one third of patients with fern OI'a I In infants, however, rhe developmenr of an early conrracture of
fractures, and Viljanro et a1. (175) reported that this weakness rhe Achilles tendon is more likely. Because of the rapid growth
was presenr whether patienrs were treated operatively or nonop- in younger children, this contracture can develop quite early;
eratively. Biyani (134) found that hip abductor weakness was and if peroneal nerve injuIY is suspecred, the extremity should
related to ipsilateral fr<lcCLIre magnitude, long inrramedullary be braced until the peroneal nerve recovers. If peroneal, femoral,
rods, and, to a lesser degree, heterotopic ossification from inrra- or sciatic nerve deficit is present ar initial evaluarion of a closed
medullalY rodding. fracrure, no exploration is indicared. If a nerve deficit occurs
 Chapter 22: Femoral Shaft Fractures 973

during reduction or rreatment, the nerve should be explored.

Persistent nerve loss withour recovery over a 4- ro 6-month pe-
riod is an indication for exploration.

Compartment Syndrome
Compartment syndromes of the thigh musculature are rare, but
have been reponed in patients with massive thigh swelling after
femoral fracture and in patients treated with intramedullary rod
fixation (161). If massive swelling of thigh musculature occurs
and pain is our of proporrion ro that expected from a femoral
fracture, compartment pressure measurements should be ob-
tained and decompression by fascioromy should be considered.
It is probable that some patients with quadriceps fibrosis (164)
and quadriceps weakness (150,172) after femoral ftacture had
inrracompartmental pressure phenomenon. Vascular insuffi-
ciency related ro Bryant's traction may produce signs of compart-
ment syndrome with muscle ischemia (137). ]anzing (I55) re-
ported the occurrence of compartment syndrome using skin
traction for rreatment of femoral fractures. Skin traction has
been associated with compartment syndrome in the lower leg
in both the fractured and nonfractured side. The association of
compartment syndrome with Bryant's traction is well recog-
nized. It is important to realize that in a traumatized limb, cir-
cumferential rraction needs to be monitored closely and is con-
rraindicated in the multiply injured or head-injured child.
A B
FIGURE 22-34. Subtrochanteric fractures (A) may be treated with trac-
tion followed by a one-legged ambulatory spica cast (B).
SPECIAL FRACTURES OF THE
FEMORAL SHAFT
Metaphyseal (Subtrochanteric and
Supracondylar) Fractures tolY one-legged spica cast or a flexed hiplflexed knee spica cast,
Subtrochanteric fracrures can be rreated in traction, followed by depending on the fractlJre and healing.
either a cast brace or single spica cast (Fig. 22-34) (177). Supracondylar fractures are difficult to treat because the gas-
Sponseller (181) reported satisfactory results with conservative trocnemius muscle inserts just above the femoral condyles and
treatment of subtrochanteric fractures in children. Internal fixa- pulls the distal fragment into a position of extension (178), mak-
tion wirh plate and screw devices also can produce satisfactory ing alignment difficult (Fig. 22-3). The traditional methods of
results (179). Intramedullary fixation of subtrochanteric frac- casting and single-pin traction may be satisfactOry (Fig. 22-36).
tures in children is generally not indicared. In adolescents, there If alignment cannot be achieved using these methods, however,
is insufficient experience wirh rhis fracture ro determine at what open reduction and internal fixation or combined epiphyseal-
age intramedullalY fixation with a reconstruction-rype nail and metaphyseal traction can be used. Generally, internal fixation is
an angled transfixion screw inro the femoral neck is indicated. preferable, either with plates and fully threaded cancellous screws
Antegrade intramedullalY nail systems place significant holes in if there is sufficient metaphyseal length to allow this or with
the upper femoral neck and should be avoided. Unlike subtro- crossed smooth Kirschner wires transfiXing the fracture from the
chanteric fractures in adults, nonunions are rare in children with epiphysis to the metaphysis, as described for distal femoral phy-
any treatmem method. seal separations (180). If there is sufficient metaphyseal length,
With the admonition against intramedulialY fixation in chil- antegrade flexible rods can be used.
dren with open physes combined with the fact that nonunions
are rare, our recommendation is for traction followed by spica
casting in young children up ro approximately age 5 or 6, wirh
Open Femoral Fractures
plate and screw fixation in older children. The method of plate Open femoral fractures are uncommon in children because of
and screw fixation may be either a srraight plate with angled the large soft tissue compartment around the femur. Proper
screws in the proximal fragment (Fig. 22-35) or hip screw con- wound care, debl·idement, stabilization, and antibiotic therapy
figuration systems appropriately sized to a small child. are required to reduce the chance of infection (178).
The rraction technique should be that of 90/90 traction in External fixation of open femoral shaft fractures simplifies
which the distal fragment is flexed to align with the proximal wound care and allows early mobilization. The configuration of
fragment and spica cast treatment may be either in an ambula- the external fixator is determined by me child's size and the
974 Lower Extremity

A B
FIGURE 22-35. A: This 6-year-old boy sustained a subtrochanteric fracture of the femur. B: He was
treated with plate and screw fixation supplemented with a spica cast.

Fracture parrern. Generally, monolateral half-pin frames are satis- is recommended for repeated fractures or angular deformiry.
factory, bur thin-wire circular frames may be necessary if bone Cast immobilization is usually avoided in patients with myelo-
loss is cxtcnsive. External fixation provides good fracture control, meningocele or cerebral palsy because of the frequency of osteo-
but as always, family cooperation is requited to manage pin and porosis and refracture in these patients. If possible, existing leg
fixaror care. braces are modified for treatment of the femoral fracture. In
Plate fixation also allows early mobilization, as well as ana- nonambulatOty patients, a simple pillow splint is used.
tOmic reduction of the femoral fracture. Wound care and treat-
ment of other injuries are made easier in children with multiple
trauma. However, this is an invasive technique with the potential
Floating Knee Injuries
for infection and additional injUJy to the already traumatized These rare injuries occur when ipsilateral fractures of the femoral
soft tissues in the area of the fracture. [n emergency situations, and tibial shafts leave the knee joint "floating" without distal
rlate fixation can be used for Gustilo-Anderson type I and II or proximal bony arrachments (Fig. 22-37A). They are high-
fracrures; type HI fractutes in older adolescenrs are better suited velocity injuries, usually resulting from collision between a child
for external fixation or intramedullary nailing. Plate breakage pedestrian or cyclist and a motOr vehicle. Most children with
can occur if bone grafting is not used for severe medial cortex floating JUlee injuries have multiple rrauma, including severe soft
commll1U[lon. tissue damagc, open fractures, and often head injuries.
[n older adolescents, plating or flexible jmramedullary nailing [n general, at least one of the fractures, usually the tibia,
is especially useful. Closed nailing after irrigation and drainage should be fixed. The femoral fracture can usually then be treated
of the fracture allows early mobilization and easy wound care by the most appropriate option. Ifboth fractures are open, exter-
in patients with Gustilo-Anderson type [, II, IlIA. and IIIB nal fixation of both the tibial and femoral fractures may be ap-
injuries, bur rhe risk of avascular necrosis must be recognized. propriate. If immediate mobilization is necessary, fixation of
both fractures with external fixation, intramedullary nails,
Femoral Fractures in Patients with compression plates, or any combination of these may be indi-
Metabolic or Neuromuscular Disorders cated (Fig. 22-37B).
For patients with osteogenesis imperfecta who have potential for Letts and Vincent (I8) described five patterns of ipsilateral
ambulation, surgical treatment with Rush or Bailey-Dubow rods tibial and femoral frac[U[es and made treatment recommenda-
 Chapter 22: Femora! Shaft Fractures 975

A B

c
FIGURE 22-36. A: This 6-year-old patient sustained an unstable supracondylar fracture of the femur.
B: The fracture was managed with immediate spica casting with the knee in 90 degrees of flexion,
mandatory in such a case to prevent posterior angulation. C: Bayonet apposition is acceptable in a child
this age.
976 LOlller Extremity

FIGURE 22-37. A: Floating knee injury in a 4-year-old girl: femoral

shaft fracture, displaced physeal fracture of the distal femur, and
open (type IIIB) proximal tibial fracture. B: After external fixation of
femoral shaft fracture, closed reduction and percutaneous pinning
of the distal femoral physeal fracture, and external fixation of the
A,B open tibial fracture; a free-flap was required for skin coverage.

Type A
Diaphyseal
closed

Type B
Metaphyseal
and
diaphyseal
closed

Type C Type D Type E

Epiphyseal One Both open
FIGURE 22·38. Classification of floating knee in-
and fracture with major
juries in children. (Redrawn from Letts M, Vincent
diaphyseal open soft tissue
injury N, Gouw G. The "floating knee" in children. J Bone
Joint Surg [Br] 1986;68: 442; with permission.)
 Chapter 22: Femomf. haft Fractures 977

tions based on those panerns (Fig. 22-38). Because of the high 10. Fry K, Horfer M, Brink J. l:cmoraJ shaft fracturcs in brain-injured
cnilclrcn.} Trauma 1976;16:371-373.
prevalence of complications after closed treatment, Bohn and
J l. Gross RH, Stranger M. Causative racrars responsible ror femoral frac-
Durbin recommended open or closed reduceion and inrernal rures in infanrs and young children. } Pediatr Orthop 1983;3:
fixation of the femoral fraceure in older children. In children 34 J -343.
under 10 years of age, these investigawrs recommend 90/90 12. H~dlund R, Lindgren U. The incidence or femoral sharr rracrures in
femoral pin traction for 4 weeks, followed by 1- Y2 spica casting children and adolcscclHs.} Pediatr Orthop 1986;6:47-50.
13. Henderson J, Goldacre MJ, Fairwearher JM, er aI. Conditions ac-
until fracture union. The ribiaJ fracture was immobilized in a
counting for subsranrial rime spem in hospital in cnildren aged 1-14
below-knee cast during the traction. Bohn and Durbin listed years. Arch Dis Child 1992;67:83-86.
four situations in which operative stabilization of the femoral 14. Hinton RY, Lincoln A, Crockett MM, et al. Fracrures of the femoral
fracture is indicated: (a) a child with severe head trauma with shart ill children. Incidence, mecnanism, and sociodcmographic risk
signs of posturing, (b) an adolescent near skeletal maturity, (c) ractors.} Bone joint Surg [Am} 1999;81 :500-509.
15. Johnson AW, Weiss CB Jr, Wheeler DL. Srress rractures of the kmoral
a child with severe soft tissue injury, and (d) an inability w
shaft in arhleres-more common rhan expected: a new clinical test.
obtain acceptable closed reduction. Stabilization of the tibial /Im} Sports Med 1994;22:248-256.
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reduction cannot be obtained or mainrained and for open frac- Surg [11m} 1953;35:220-226.
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97. Herndon WA, Mahnken RF, Yngve OA, et al. Management offemo- 122. Timmerman LA, Rab GT. Inrramedullary nailing of fc-moraJ shaft
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123. Tolo Yr. External flx~tion in multiply injured children. O;'r/JO/' Clin
98. Herscovici 0 Jr, SCO(( OM, Behrens F, et al. The use of Ender nails
in femor~1 shaft fractures: what are the temaining indications?] Orthop
North Am 1990;21 :393-400.
124. Townsend DR, Hol'linger S. Inmmcdulbry nailing of femoral shaft
Trauma 1992;6:314-317.
fractures in children via the trochanter tip. C!in Ortho? 2000;.376:
99. Hull JB, Sanderson pL, Rickm~n M, et aJ. External fix~tion of chil-
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cem femur fractures.] Pediatr Orthop 1992; 12:626-632.
100. Karaoglu S, Baktir A, Tuncel M, et al. Closed Ender n~iling of adoles-
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of femoral fractures.] Bone Joint Surg (Am) 1984;66:529-539.
101. K,lweblum M, Lehman WR, Gram AD, et al. Avasculat necrosis of 127. Wiss OA, BrienWW, Stetson WB. Imerlocked nailing for rreatl11enr
the femoral head as sequela of fracture of the greater trochamer. Clin
of segmental fractures of the femur.] Bone Joint Swg [/111/7 [990;72:
Orthop Rei Res 1993;294: 193-1 95. 724-721;.
102. Kirby RM, Winquist RA, Hansen ST Jr. Femoral shaft fractures in 128. Ziv I, Blackburn N, Rang M. Femoral inrramedullary nailing in the
adolescents: a comp~rison between traction plus c~st treatment and growing child.] Trmtma 1984;24:432-434
closed imramedullary nailing.] Pediatr Ortbop 1981;1: 193-197.
103. Kregor pJ, Song KM, Roun ML Jr, et al. Plate flxarion of femoral
shaft fracrures in multiply injured children.] Bone Joint Surg 1993; Complications
75: 1774-1780.
129. Aitken AP, Blacken CW, Cinconi JJ. Overgrowth of the femoral shafr
104. Krenek C, Haas N, Walker J, et al. Treatment of femoral shaft frac-
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130. Aitken AP. Overgrowth of the femoral shaft following fracrure in
105. Ligier IN, Mctai'leau JP, Prevot J, et al. Elastic stable intramedullalY children. Am] Surg 1940;49:147-148.
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131. Anderson M, Green WT. Lengths of the f~mur and the libia: norms
1988;70:74-77. derived from orthoroemgcnogr~msof children from five years of age
106. Mann DC, Weddington J, Davenport K. Closed Ender nailing of umil epiphyseal closure. Am] Dis Child 1948;75:279-290.
femoral shaft fractures in adolescenrs. ] Pediatr Orthop 1986;6: 132. Barfod B, Christensen J. h~crures of the femoraJ sh~ft in children
651-655. with special reference to subsequent overgrowth. Acta Chir Scand
107. Maruenda-Paulino Jr, Sanchis-AJfonso V, Gomar-Sancho F, et al. im 1958; I J 6:235-250.
Orrhop 1993;17:158-161. 133. Benum 1', Fnresvag K, Hiseth K. Torsion deformities after ([action
108. Mazda K, Khairouni A, Pennecot GF, et at. Closed flexible inrramed- rreatlnenr of femoral fr~crures in children. Acta Orthop SC({l1d 1979;
ullary nailing of rhe femora! shaft fractures in children. J Perlitllr Or- 50:87-91
thoP 1997;6: 198-202. 134. Biyani A, Jones OA, Daniel CL, et al. Assessment ofhip rtbductorjimc-
109. McGraw JJ, Gregoly SK. Ender nails: ~n alternative for inrramedullary tion in relrttion 10 peritrochtlnteric heterotopic o.. sijicrltifJi! after dosed
fL'{ation of femoral shaft fractures in children and adolescenrs. Sourh femoral nailing. Swansea, England: Oepartmem of Orthopaedics,
Med] 1997;90:694-696. Morrisron Hospital.
110. Mileski RA, Garvin KL, Huurman It/W. Av~scul~r necrosis of the 135. Braten M, Terjesen T, Rossvoill. Torsional deformiry ahcr inrr~Jlled­
femoral head afrer closed inrramedullary shonening in an adolesccnr. ull~ry nailing of femora.l shaft fractures: measuremem of ~ntevcrsion
J Pedialr Orthop 1995; 15:24-26. angles in 110 patiems.] BOlle Joint Sing [Br) 1993;75:799-803.
Ill. Miner T, Carroll KL. Ourcomes of external fixation of pedianic femo- 136. Brouwer KJ, Molenaar JC, Van Linge B. Rotational deformiries ~r'rer
ral shaft fracrures. ] Pediatr Orthop 2000;20:405-410. femoral shah fractures in childhood. Acta OU/.lop Smild 1981 ;52:
112. O'M'llley DE, Mazur JM, Cummings RJ. Femoral bead avascular 81-89.
980 Lower extremity

l37. Clark MW, D'Ambrosia RD, Roberrs JM. Equinus conrracrure fol- FraClures in children rreared by the lllodified Bloum method.} Pedir1!T
lowing Bryant's rracrion. Orthopaedics] 978;] :31] -3l2. Orthop ]986;6:421-429
138. Ckmcnr DA, Colton CL. Overgrowrh of rill' femur aftcr fraCiure in 159. Meals RA. Overgrowth of the felllur ft)lIowing Fractures ill children:
childhood: an increased effecr in boys. J Bone Joint SlIrg {Br} 1986; influence of handedness. J Bone Joint Sllig [Am! 1979;6\ :38 I- 384.
68:534-536. \60. Mesko ./W, DeRosa GP, Lindscrh RE. Segmenral fCllllll' loss in chil-
139. Cole WHo Compensarory lengrhening of rhe femur in children afrer drcll. J Pedion' Orlhop 1985;5:471-474.
fracrure. Ann Surg 1925;82:609-6 I6. 161. Miller DS, Marrin L, Grossman E. Ischemic fibrosis of the lower
140. Connolly JF, Whirtaker D. Williams E. Femoral and tibial fracrures exnemiry in children. Am J Surg 1972;84:317.
combined with injuries co the femoral or popliteal artery: a rC"'iew of 162. Oberhammer J. Degree and frcquency of rotational defonnitie, afrer
rhe literature and analysis of founeen cases. J Bone Joint Sing (11m} infant fellloral fractures and their spomaneolls correcrion. Arch Orthop
197t ;53:56. hllli11rltol SlIJg 1980;97:249-255.
l4I. Oamholr 13, Zdravkovic D. Quadriceps Function following Fracrurcs ]63. Rallc)' EM, Ogden JA, Grog:lI1 DP. Premature greater trochameric
of rhe Fcmoral shaft in children. Ami Orlhop SUllid 1974;45:756. Cf)iphysiodesi.\ secolldary to ;lHramedullaly femoral rodding.J Pedirllr
\42. David Vc. Shortening and compensatory overgrowth Following frac- Or/hup 1993;13:516-520.
rures of the Femur in children. Arch Slllg 1924;9:438-449. 164. Rcynolds OA. Growrh change in fractured long bones: a srudy of
l43. Oavids JR. Rotational deformiry and remodeling aFrcr fracture of the 126 children.} Bone Joint S,llg fBI} 198] ;63:83-88.
femur in children. CliJJ Ort/Jop 1994;302:27-35. ]65. Riew KD, Sturm PF, Rosenbaum D, er '11. Neurologic complications
144. Dehne E, Kriz FK Jr. Slow arteriai le'lk consequent to unrecognized of IJediarric femoral nailing. J Pedialr Orthop 1996; I6:606-6] 2.
anerial laceration: reporr of five cases. J Balle Joint SlIIg {Am} J 967; 166. Robcrtson P, Karol LA, Rab GT. Open fracrures of the rihia and
49:372. fcmur in children. J Pet/illtr Ortbop 1996; 16:62 J -626.
145. Fdvardsen P, Syvcrsen SM. Overgrowrh of the femur after fraer,ure 167. Rosenrhal J), Gasper MR, Gjerdrum TC. et al. Vascular injuries asso-
of rhe shaft in childhood. J Bone Joint Slirg [Br} 1976;58:339-342. ciared with fractllres of rhe femllr. Anb SlIrg 1975;110:494-499.
]46. Engel GM, Sraheli LT. The narll(al niscory of (Orsion and otner Facrors 168. Shah A, Ellis RD. False anculysm complicating closed femoraJ fracrure
influencing gait in cnildnood: a srudy of rhe angle of gair, ribial rOr- in a child. Orthop Rev 1993;22: \ 265-1267.
sion, knce angle, hip rorarion and developmelH of tbe arcn in norma] 169. Shapiro F. Fractures of thc femoral shaft in children: rhe overgrowrn
cnildren. ('lin Orthop 1974;99:\2-]7. phenomenon. Acta Orthop Scand 198 J ;52:649-655.
170. Sr~heli LT. femoral and ribial growth following femoraJ shafr fracrure
]47. Finscn V, Harness 013, Ncss 0, et al. Muscle Function aFrer plated
and nailed Femoral shaft fractures. Injury 1993;24:531-534. in childhood. Gin Urthop ] 967;55:] 59-163.
148. Griffin PP, Anderson M, Grcen wi-. i::ractures of the sh3fr of rhe 17l. Sraheli l.T. Fever foJlowing trauma in cnildhood. JAiVlA ] 967; 199:
503-504
femllr in children: trc~rmcllf and reslIlrs. Ort/Jop !.lin North 11m 1972;
l72. Thomson SA, :Vbhonev Lj. Volkmann's ischemic conrmcrure and irs
3:213-224.
relationship ro fracrure' or"rne femur. J Bone Joint Surg {Br} 195] ;33:
149. Hagglund G, Hansson L1, Norman O. Correcrinn by growrh of rora-
336-347.
tional deformiry after Femoral fractllres ill children. Acta Orthop :)£<IIul
173. Truesdell ED. Inequaliry of lower cxtremiry Followillg Fracturc of rhe
1983;54:858. femoral shafr in childhood. linn S/lrg 1921 ;74:498-'500.
150. I-1ennrikus WL, Kassel' JR, Rand f, et al. The funcrion of rne quadri- 174. Verbeek H. Does rorarion,,1 deformiry following femur shaft fracture
ccps muscle after a Fracture of rhe Femur in par;ellfs who are less thall correct during growth? RecoYl5trS/lrg Trilll1//atoI1979;17:77-81.
seventeen years old. J Bone Joint Surg ]993;75:508-513. 175. Viljanto j, Kiviluow H, Paamllen M. Remockling after femoral shafr
151. Hem)' AN. Overgrowth afrcr femoraJ shaft franures i11 children_ J fracture in children. Acta Chlr Scand 1975; 141 :360-365.
Bone Joim Surg (Br} 1963:45:222. 176. Wallace ME. HoHtnan EB. Remodelling of angular deFonniry aftl'l'
]52. Hrcsko MT, Kassl'l' JR. PhyseJI arresr about the knee associared with femoral shaft fractures in children.} Bone .faint Surg {Br! 1992;74:
non-ph)'seal fr~cfLlres in rhe lower exrremiry. J Bone .foinl SlIIg (Am( 765-769.
1989;7 \:698-703.
153. Isaacson J, Louis DS, Cosrcnbader JM. Art-erial injury associared with
closed femoraJ shaFt fracrure: reporr of five cascS. J nOlle Join! SUig
Subtrochanteric and Supracondylar
(11m) 1975;57: 1147. Fracture
154. Ikpemc JO. Quadriccpsplasr)' following femoral shaft fracrures. 1;ljll':Y 177. Del .,c j, Clanton TO, Rockwood CA Jr. Closed rreatment of subrro-
1993;24: 104-108. chanreric fr:lCrures of rhe femur i/\ a modified casr brace. J Bone Join!
ISS. laming H, Broos P, Rommens P. CompanlllclH syndrome as a con' S1I/g [/I",! 1981 ;63:773.
plication of skin tranion in children with femoral fr"c(LIres.J Tmlll1lil 178. Guslillo RB. Current eonccpls in lhl' m"nagemenr or open fr"ernres.
lujury IJI(ecl Cril Care 1996:41:] 56-\58. Inslr CO//I'J(, Lect 1989;36:359-366.
]56. Lewallen RP, Peterson HA. Nonunion of long bone fractures in chil- 179. Ireland OCR, Fi.,her Ri. S'l!mochanreric Fr""ures of rhe femur in
dren: a review of 30 cases. J PedilllT Orlhop 1985;5: l35-142. children. Gin Urthop 1975;]10:157.
157. MacEwen GO, KasserJR, I Ieimich SO. PediatriC.fi'llm,res. Baltimore: 180. Shahchcraghi CH, Doroodchi HR. Supracondylar rracrure of the
Williams & Wilkins, 1993:281. femUl': closed or open reduction' J Ji'tlu;na l ')93;34:499-502.
158. Malkawi H, Snannak A, Hadidi S. Remodeling after kmoral sl1<ll'r 181. Sponsellor P. Personal communicarion, ,cries in 11J'CpnrJrion.
 FRACTURES AND DISLOCATIONS
ABOUT THE KNEE
PAUL D. SPONSELLER
CARL L. STANITSKI

PART I: EXTRAARTICULAR FRACTURES Radiographic Findings

Trearment
DISTAL FEMORAL EPIPHYSEAL FRACTURES
Prognosis
Historical Review
Surgical Anatomy FRACTURES OF THE PATELLA
Mechanism of Injury Anaromy
Classification Mechanism of InjuI)'
Signs and Symptoms Classi fica tion
Radiographic Findings Signs and Symptoms
Trearment-Overview Radiographic Findings
Postreducrion Care Treatment
Prognosis Postoperative and Postfracrure Care
Complications Prognosis
Complications
FRACTURE OF THE PROXlMAL TIBIAL EPIPHY IS
Historical Review
PART II: INTRAARTICULAR AND LIGAMENTOUS
Surgical Anatomy
INJURIES ABOUT THE KNEE
Mechanism of Injury
Classification OS' EOCHONDRAL FRACTURES
Signs and Symproms Surgical Anaromy
Radiographic Findings Mechanism of Injury
Treatment Classi fica tio n
Prognosis Signs and Symptoms
Complicarions Radiographic Findings
Merhods of Treatment
AVULSIO OF' HE TrBlAL TUBERCLE
Postoperative Care
Surgical Anaromy
Prognosis
Mechanism of Injury
Complications
Classification
Signs and Symproms FRACTURE F THE TIBIAL SPlNE
Radiographic Findings (l TERCONDYLAR EMINENCE)
Trearment Surgical Anatomy
Postreduction Care Mechanism of Injury
Prognosis C1assi fica tion
Complications Signs and Symproms
Radiographic Findings
OS ;OOD-SCHLATTER LE ION
Methods of Treatment
Surgical Anatomy
Prognosis and Complications
Mechanism of Injury
Signs and Symptoms LIGAMENT IN] RIES
Surgical Anaromy
Mechanism of Injury
Classification
Paul D. Sponseller: Department of Onhopaedic Surgery, School of Medi-
Signs and Symptoms
cine, Johns Hopkins Universiry, Balrimore, Maryland.
Carl L. Stanitski: Deparrmmr ofOnhopacdic Surgery, Medical Universiry Radiographic Findings
of South Carolin'l, Charlcsron, Sourh CaroJj"a. Methods of Treatment
982 Lower Extremity

Postoperative Care and Rehabilitation Methods of Treatment

Prognosis Postoperative Care and Rehabilitation
Complications Prognosis
Complications
KNEE DISLOCATIONS
Surgical Anatomy
MENISCAL I JURIES
Mechanism of Injury
Surgical Anatomy
Classification
Mechanism of InjulY
Signs and Symptoms
Classification
Radiographic Findings
Signs and Symptoms
Methods of T reatmel1[
Radiographies Findings
Postoperative Care
Methods of Treatment
Prognosis
Postoperative Care and Rehabilitation
Complications
Complications
PAT LLAR DfSLOCATIONS
Surgical Anatomy DISCOID MENISCUS
Mechanism of Injury Classification
Classification Methods of Treatment
Signs and Symptoms
Radiographic Findings TIBIOFIBULAR DISLOCATIO S

PART I: EXTRAARTICULAR FRACTURES occur across several zones of the physis at a microscopic level,
Fractures involving the physes around the knee are far from even in fracture patterns that are rypically considered to be be-
"routine" injuries because they have a significant risk of growth nign, such as Salter-Harris type I and II injuries.
diswrbance, which can result in shortening or angulation, or Although it has been thought that knee ligament injury does
both. Vascular injury occasionally occurs, especially with proxi- not occur with fracture through the distal femoral physis, Bertin
mal tibial injuries, and nerves and ligaments also may be dam- and Goble (7) found that 14 of29 patients with physeal injuries
aged. about the knee had ligamentous instability at follow-up. Brone
and Wroble (I5) reported three patients with Salter-Harris type
III fractures of the femoral condyle associated with anterior cru-
DISTAL FEMORAL EPIPHYSEAL ciate ligament (ACL) tears, and found twO more reported in the
FRACTURES literature. All were near skeletal maturity. An awareness of this
possibiliry and a careful examination will allow timely treatment
Historical Review of ligamentous injury.
Distal femoral physeal injuries account for 1% to 6% of all
The cause of a distal femoral epiphyseal fracture can help deter- physeal injuries (Table 23-1) and for fewer than I % of all frac-
mine the method of treatment and identify potential problems. tures in children. They are much Jess common than physeal
In hyperextension fractures, the epiphysis is displaced anteriorly injuries of the ankle or upper extremity. Most are Salter-Harris
and rhe metaphysis is displaced into the popliteal fossa, making type II injuries. Although separations through the cartilaginous
neurovascular injury possible. Reduction often is unstable be- physis would seem to be more likely than fractures through the
cause ligamentotaxis rarely is effective. Extreme knee flexion may hard corrical bone of the femoral shaft, the physis is protected
be required to tighten the anterior sofr tissue hinge. Varus-val- by its large surface area and its undulating shape.
gus fracwres (Fig. 23-1) result from an abduction or adduction In 1898, Hutchinson and Barnard (36) published one of the
force, and the posrerior periosteal' hinge is intact. In either type earliest reports of this injury. The results were dismal: of 58
of fracture, reduction should be precise because any residual patients with distal femoral physeal injuries, 22 required ampma-
V;HUS or valgus about the lmee in older children has limited tion and 10 died. The worst results were in patients with hyper-
remodeling potential. extension injuries that caused popliteal ischemia and uncontrol-
Many clinical srudies of distal femoral physeal fracrures report lable infection. Also in 1898, Poland (61) reported 114 patients
high incidences of growth disturbance, resulting in asymmetry with injuries to the distal femoral epiphysis, 24 of them boys
of length or angulation, or both (6,63,77). Growth disturbance whose legs were caught in the spokes of a moving carriage wheel
is caused by bony bridging resulting from direct physeal trauma as they swung themselves up over the tailgate. With rhe anterior
or from lack of anatomic reducrion of the physis. Several authors thigh stopped against the wagon bed, the lower leg was hyperex-
have shown that the likelihood of physeal disturbance is greater tended by the revolving wheel. The result was often an open
with significant (>50% of the width of the physis) initial dis- injury with neurovascular compromise. Appropriately, separa-
placement of the fracture (42,54,78). The complex contour of tion of the distal femoral epiphysis came to be known as the
the physis makes it possible for shearing of the fracture line to wagon-wheel injury by the end of the 19th century.
 Chapter 23: Fractures and Dislocations Abollt the Knee 983

A B

co E
FIGURE 23-1. Appearance at presentation of an 11-year-old boy who was hit by a car from the front
on the right side, sustaining a fracture-separation of both distal femoral epiphyses (A). There was apex-
posterior angulation of both sides, with varus angulation on the left side (8 and C) and valgus on the
right (D and E). (Figure continues.)

Nrer rhe beginning of rhe 20rh cemUlY, lirde was wri((en In 1960, Neer (51) reviewed 2,368 epiphyseaJ fracrures and
abour injuries co rhe disral femoral epiphysis umj] Aicken and found rhar only l% involved rhe disral femur. Seven parienrs
Magill's 1952 reporr of 15 pariems (2). Ten of rhe 15 separarions (25%) had resulram growrh disrurbance. He relared rhe severiry
occurred in parjenrs 13 to 17 years of age; all 10 were foorball of inirial displacement co early physeal closure. NeeI' rhoughr
injuries. Only 1 of che 15 parienrs had a hyperexrension injury rhar delayed closure resulred from injury to rhe epiphyseal anery.
so common in rhe days ofHurchinson and Poland. Airken and In 1962, Bassen and Goldner (4) reponed 25 parienrs wirh disral
Magill wroce, "The horse and wagon has been replaced by rhe femoral physeal injul'ies, 40% of whom experienced signiflcam
foorbalJ field as rhe source of rhis rype of injury." shonening or angular deformity.
984 Lower Extremit)'

F G
FIGURE 23-1. (continued) Both sides were treated by closed reduction, with stabilization using cannu-
lated screws on the left (F) and a percutaneous smooth pin on the right (G).

In 1973, Roberrs (64) reported 100 patiems with injuries to positive correlation between the severity of injury and premature
the distal femoral epiphysis. Two thirds of the separations re- closure of the physis. Substantial shortening developed in five
sulted from sports. Of 50 patients followed an ~lVcrage of7 years, patients despite satisfactory reduction. Growth inhibition usu-
11 had shortening of more than 2.5 cm. Of the emire group of ally was evident by 6 months after injury. Because six of their
100 fractures. no vascular injury was documented, and only patients who had shortening had Salter-Harris typc I or II inju-
I patiem had an associated nerve injUlY (a transient peroneal ries, the authors questioned the prognostic significance of the
deflci t). Salter-Harris classification as it pertained to separations of rhe
In 1974, in a retrospective review of20 patients with separa- distal femoral epiphysis.
tion of the diStal femoraJ epiphysis, Stephens et al. (76) found a In 1983, Riseborough et at. (63) in a follow-up study of 66

TABLE 23-1. COMPARATIVE INCIDENCE OF EPIPHYSEAL SEPARATIONS

IN THE LOWER EXTREMITIES

Location Nee"" Peterson b Manne

Proximal femur 1 (.5%) 4(1%)

Distal femur 28 (5%) 13 (6%) 29 (9%)
Posteroral tibia 17 (3%) 8 (4%) 12 (4%)
Distal tibia 238 (41%) 104 (52%) 282 (86%)
Proximal fibula 2 (0.3%) 1 (.5%)
Distal fibula 302 (51 %) 68 (34%)
Totals 587 195 327

a NeeI' CS II, Horwitz BS. Fractures of the proximal humeral epiphyseal plate. Clin Orthop 1965;41:24-31.
b Peterson HA, Madhok R, Benson JT et at. Physeal fractures: Part I. Epidemiology in Olmsted County,
Minn., 1979-1988. J Pediatr Orthop 1994;14:423-430.
C Mann DC, Rajmaira S. Distribution of physeal and nonphyseal fractures in 2,650 long-bone fractures in

children age 0-6 years. J Pediatr Orthop 1990;10:713-716.

 Chflpter 23: Frtl(tllreJ and Disloctltiol/5 About the Knee 985

distal femoral separations reported that 17 patients subsequently

underwent osteo[Omy for angular deformiry. They identified a
patto'n of cenrral growth arrest that supponed Brashear's hy-
porhesis (12-14) of damage [0 the germinal cells from the grind-
ing of the cenrral ridges on the proximal surface of the epiphysis
as it displaced with injury.
I
In 1995, Thomson et al. (78) reponed 30 fractures of the I
I
distal femoral physis and found that many displaced fractmes I
• I

lost reduction when immobilized in a cast. They recommended ire

i-I
internal fixation of displaced fractures.
from one century [0 the next, the clinical presentation of
\; I
, 1
:
distal femoral epiphyseal separation has changed considerably. i I
i" I
The 19th-cenrury surgeon most often found anrerior displace- I
I
ment of the epiphysis from forced hyperextension, an open in- !I

jury, neurovascular compromise, and, later, life-threatening in-

fection. The 21 st-cenruly onhopaedic surgeon usually is
prc:sc:nred with a closed injury, with displacemenr in either the
coronal or sagittal plane, caused by either a mo[Or vehicle acci-
dent or an athletic injury. CurrentJy, the main concern is prema-
ture closure of the physis leading [0 progrc:ssive angulation or
shortening, or both.

Surgical Anatomy
The epiphysis of the distal femur is larger and grows more rapidly
than any other epiphysis in the lower extremi ry. I t develops from
a single ossific nucleus. It is the first epiphysis [0 ossify and the
last [0 fuse. From birth [0 skeletal maturity, the distal femoral
physis contributes 70% of the growth of the femur and 37% of
the growth of the lower extremity. The annual rate of growth
is approximately % in. or 9 mm. The growth rate slows at a
mean skeletal age of 13 years in girls and 15 years in boys (3,
31).
FIGURE 23-2. Relation between anatomic and mechanical axes of
lower extremity and joint line. Normal value for theta is 3 degrees and
for beta 6 degrees. (From Krackow KA. Adv Orthop Surg 1983;69-88;
Bony Anatomy with permission.)
Immediately above the medial border of the medial condyle, the
metaphysis of the distal femur widens sharply to the adduc[Or
tubercle. In conrrast, the metaphysis flares minimally on the
lateral side [0 produce the lateral epicondyle. A line tangential reaches the posterior margin of the physis. Sometimes, there is
(0 the distal surfaces of the two condyles (the joint line) is ap- a shallow horizonral groove on the articular surface of each con-
proximately horizonral in an upright stance. The longitudinal dyle, marking the border between the patellar and tibial surfaces.
axis of the diaphysis of the femur inclines medially downward, This groove is more constant on the lateral condyle.
with an angle of 9 degrees from venica!. The mechanical axis The COntour of the distal femoral physis undulates from side
of the femur, formed by a line between the centers of the hip [0 side, as well as from front to back. AJthough less pronounced

and knee joints, is 3 degrees from vertical (Fig. 23-2). in humans than in some animals, there is a distinctly quadrupe-
Viewed from behind, the condyles are separated by a deep dal conftguration. On the distal surface of the metaphysis, facing
intercondylar notch. In the coronal plane, the medial condyle the physis, a midline groove from anterior [0 posterior lies JUSt
has a larger cross section; in the rransverse plane, the lateral above the intercondylar notch. A similar central groove is present
condyle is larger. in the mid line from the medial to the Lueral margins. The inter-
A large part of the surface of the distal femoral epiphysis is secting grooves divide the distal surface of the metaphysis in[O
covered by cartilage for articulation with the proximal tibia and four mamilialY processes. The corresponding proximal surface of
patella. The anterior or patellar surface has a shallow midline the epiphysis has four valleys. The interdigitating conftguration
concaviry [0 accommodate the longitudinal ridge on the under- between the distal surface of the metaphysis and the proximal
surface of rhe patella. The distal or tibial surface of each condyle surface of the epiphysis may help [0 resist shear and rorsion.
extends on either side of the inrercondyJar notch far around When subject [0 rrauma, however, the epiphyseal ridges may
OntO the posterior surface. Here, the articular cartilage nearly grind against the metaphyseal projections as a displaced separa-
986 Lower Extremity

tion occurs. In this way, germinal cells in the deeper layers of Above the popliteal space, the sciatic nerve divides inro the
the intervening carrilaginous physis may be damaged. Brashear peroneal and tibial nerves. The peroneal nerve descends poste-
(12,13) has shown rhis ro occur experimentally in simulated riorly between the biceps femoris muscle and the latetal head of
separations of rhe distal epiphyses in rar femora. the gasrrocnemius muscle ro a point jusr distal to the head of
the fIbula. The nerve is subject to stretch if the distal femoral
epiphysis is tilted into varus or rOGued medially. Moreover, rhe
Soft Tissue Anatomy
superficial course of the peroneal nerve makes it vulnerable to
The distal femoral physis is completely exrraarricular. Medially ditect pressure on the posterolateral aspect of the knee.
and I;lterally, rhe physis is exactly ar the level of rhe epicondyles,
which serve as a landmark for it. Ameriorly and posteriorly, rhe
Mechanism of Injury
synovial membrane and joint capsule of rhe knee arrach ro rhe
femoral epiphysis close to rhe perimeter of rhe disral femoral The partern of injuJY is determined by the direction of applied
physis. Anteriorly, rhe supraparellat pouch balloons up over the force as well as any other superimposed compressive at disrrac-
anterior surface of the metaphysis. On the medial and lateral tion loads. The epiphysis may be subjecr to distraction by a
surfaces of rhe epiphysis, rhe proximal arrachment of rhe synov- lam'al force ro rhe dislal femur against a fixed foot, or by hyper-
ium and capsule is separated from rhe physis by rhe inscnions extending the lower leg agJinsr a fixed thigh. An example of the
of the collateral ligaments. former injulY is a foorball player whose foot is fixed to the
The srrong posterior capsule, as well as all major supporting ground by his cleated shoe and who is hit from the side by
ligaments of the knee, are artached ro the epiphysis of rhe femur another player. The classic example of the hyperextending mech-
distal ro rhe physis. Both cruciate ligaments originate in rhe anism is, as mentioned earlier, a boy who catches his lower leg
upward-sloping roof of rhe illtercondylar notch disral to the in the spokes of a revolving wheel. A more modern example is
physis. Compression and tension forces can be transmirred across a child descending on a rrampoline while ir is recoiling from
the extended knee ro the epiphysis of the femur by taut Jigaments another child (41). Both compression and distraction forces may
(57). be imposed simultaneously on the physis at the time of injury.
The medial head of the gasrrocncmius and the plamaris mus- Physcal separation begins on the tension side and ends with an
cles originate from the poplireal surface of the distal femoral oblique fracrure through rhe metaphysis on the compression side
metaphysis proximal to rhe physis. There is some difference of (a Salter-Harris rype II injury) (68). On rhe tension side, the
opinion among anatomists (11,29,30), as to whether the lateral cartilaginous mattix is more vulnerable to distraction or avulsion
head of the gastrocnemius originares from the meraphysis or the force. On the compression side, the osseous matrix of the me-
epiphysis. Muscle pull would not seem ro be as much of a factor taphysis is more vulnerable to shear failure from loading.
as rhe pull of the ligaments in the initial displacement of the Separation of the distal femoral epiphysis also can be caused
epiphysis at the time of injury. Posterior displacement or angula- by a direct blow. The amerior surface of the epiphysis may be
tion is not common, in COntrast to displaced supracondylar fem- struck when a patient falls forward on a benr knee. One reponed
oral fracwres. Also in contrast, separation of the distal femoral distal femoral physeal separation was in a 14-year-old boy who
epiphysis with posrerior displacement can be reduced and held srruck his knee on rhe door frame as he galloped his horse
by the extended knee, with rhe tightened gastrocnemius acting through a barn (35).
as an illternal splint against rhe posterior aspect of the epiphysis Specific mechanisms of injury in recenr clinical reviews are
(2). summarized in Table 23-2. In one series, all but 2 of 15 children
hit by auromobiles were 6 to 12 years of age. In conrrast, separa-
tions from sportS injuries usually occur between 10 and 19 years
Vascular Anatomy
of age.
The popliteal arrery is close to the posterior surface of rhe distal Unusual mechanisms or underlying conditions also may
femur: only a thin layer of fat separates the artery from the cause distal femoral physcal injuries (4,73,74,77,80). Unilateral
popliteal surface of the metaphysis. Directly above the femoral or bilateral separations can occur from birth injury (16). Separa-
condyles, the superior geniculate arteries pass medially and lat- rion of this epiphysis also has been noted in infants with arthro-
erally ro lie between the femoral metaphysis and the ovcrlyi ng g'yposis multiplex congenita, presumably occurring as stiffknees
muscles. The terminal branches of the superior geniculate arter- arc passively manipulated (26). Epiphyseal separation also is a
ies emer the distal femoral epiphysis near the medial and lateral risk of manipulating a stiff knee in a normal child (71). Separa-
epicondyles. As the popJiteal artery continues distally, it lies on tions of the distal femoral epiphysis may occur in association
the posterior capsule of the knee joint between the femoral con- wirh osteomyeliris, leukemia, hemophilia, osteosarcoma, and
dyles. At this level, the middle geniculate artery branches directly myelomeningocele (27,75,82). Rodgers et al. (66) reported four
fOlward to enter the posteriot aspect of the distal femoral epi- chronic physeal fractures of the distal femur in patients with
physis. The popliteal artelY and its branches are vulnerahle ro myelomeningocele; they attributed them to chronic stress to a
injuty from the distaJ femoral metaphysis at the time of hyperex- poorly sensate limb. Kumar et al. (39) noted that physeal injuries
rension injury. An intimal rear of the artery is possible. It is in children with myelomeningocele may heal more slowly than
unlikely that the disral remoral epiphysis would be completely metaphyseal fractures and may require splinting or casting ror
shorn of irs blood supply because of the rich anasromosis sup- a longer period. Separation through a normal physis has been
plied, in parr, by the superior geniculate branches. reponed in children with congenital absence of pain (53).
 Chapter 23: Fractures and Dislocations About the Knee 987

TABLE 23-2. MECHANISM OF INJURY IN CLINICAL REVIEWS OF

SEPARATION OF THE DISTAL FEMORAL EPIPHYSIS

Nee"'- Bassettb Roberts C Stephens d Total

Sportsinj ury - 5 4 64 8 81 (49%)

Hit by automobile 9 8 15 10 42 (25%)
Falls .3 3 12 1 19 (12%)
Autoaccide[1t 3 5 1 9 (5%)
Other 4 7 4 15 (9%)

a Neer CS H. Separation of the lower femoral epiphyses. Am J Surg 1960;99:756-761.

b Bassett FH III, Goldner JL Fractures involving the distal femoral epiphyseal growth line. South Med J
1962;55:545-557. - -
C RobertSJM.Fracture separation of the distal femoral epiphysis. J Bone Joints Surg Am 1973;55A:1324.
d Stephens DC, Louis OS, Louis E. Traumatic separation of the distal femoral epiphyseal cartilage plate. J
Bone Joint SurgAm 1974;56:1383-1390.

Classification undetected. Sometimes the diagnosis is made only in retrospec[,

when subperiosteal new bone formation occurs along the adja-
Separations of the distal femoral epiphysis have been classified
cent metaphysis. If displacement is presel1t, it is usuaJly in rhe
according co the pattern of fracture, the direction of displace-
sagittal plane. Growth diswrbance may occur after Salter-Harris
mem, or the mechanism of injury. Each has specific implications
type I discal femoral injuries, comrary to the usual expecrarions
(Table 23-3). The Salter-Harris classification (68) is useful for
for Salter-Harris type I fraCtures.
description and rreatmem planning. The direction and degree
The Salter-Harris type II pattem, characterized by an oblique
of displacement may help predict the type and severity of com-
plications. Mechanisms of injulY, as well as the implications of exrension of the fracrure across one corner of the adjacent me-
growth disturbance, vaty with the patient's age. taphysis, is the mos[ common type of separation at rhe disral
femur and usually occurs in adolescents. Displacement usuaJly
is toward rhe side of the meraphyseal fragment (Fig. 23-3). The
Classification by Fracture Pattern incidence of premature growth arrest, even wirh satisfacwlY re-
duction, is significant. If asymmetric growth follows a type II
The Salter-Harris type I pattern is a separation through the distal separation, the portion of the physis undernearh the metaphyseal
femoral physis, without fracture through the adjacent epiphysis fracture usually is spared (78). Therefore, if rhe metaphyseal
or metaphysis. It occurs in newborns with birth injury and in fracture is medial, deformiry is more likely to be valgus than
adolescents, often as a nondisplaced separation. Either may go varus. If rhe meraphyseal fracwre is lateral, varus angularion is
more likely. The size of rhe meraphyseal fragmenr is proportional
to rhe amount of compression force at rhe time of injury.
A Salrer-Harris type III injury consists of a partial separation
CLASSIFICATION OF DISTAL of rhe physis, with a vertical fracrure line exrending from the
TABLE 23-3.
FEMORAL EPIPHYSEAL physis down W the articular surface of rhe epiphysis (Fig. 23-4).
FRACTURES: PARAMETERS AND The vertical fracrure line is usually in line wirh rhe intercondylar
IMPLICATIONS notch. Salter-Harris type III injuries most often are caused by
Parameter Impl icatioi1s valgus stress in sporrs and usually involve the medial condyle.
The fracrure may be nondisplaced and detected only wirh a
Anatomic Directs method of stabilization, if displaced stress radiograph. If displaced, reduction usually is unsrable and
Salter HV (does notstrongly predict growth
(II most disturbance)
requires internal fixation. A displaced type III fracture may cause
common) incongruity of rhe joint surface, especially of rhe parellofemoral
Displacemeni: Predicts risk"·of neurovascular injury articulation. Hemarthrosis occurs from dirccr bleeding inro [he
Medial joint from the articular fracture.
Lateral
Anterior
Salrer-Harris type IV injuries of rhe distal femur are uncom-
Posterior mon. A sagittal fracture line extends from rhe metaphyseaJ correx
Age Predicts severity ofgroyvth down across the physis and enters rhe articular surface of rhe
Infantile - disturbance-infantile-and juvenile have epiphysis. Even slight displacemenr of rhe fracrure fragmenr may
Juvenile risk of greatest disturbance
Adolescent
produce growrh diswrbance from form arion of a bony bridge
from rhe displaced epiphysis W the metaphysis. Therefore, ana-
tomic reducrion and internal fixarion are advised.
988 Lower t:xrremity

A B

c D
FIGURE 23-3. A and B: Anteriorly and medially displaced Salter-Harris type II fracture of the distal
femoral epiphysis in a 16-year-old football player struck on the outside of the left knee. C and 0: After
closed reduction and percutaneous fixation with crossed Kirschner wires.
 Chapter 23: Fmc/llre;- awl Dislocations Abou/ the Knee 989

A B
FIGURE 23-4. A: Minimally displaced Salter-Harris type III fracture-separation of the distal femoral
epiphysis in a 15-year-old football player hit from the front on the left knee. B: Fifteen years after injury.

Salter-Harris type V injuries (withour fracrure) are rare. Most children struck on the From of the flexed kJJee. Reduction is
commonly, (he diagnosis is made in retrospect at the time of obtained and maintained by extending (he knee.
evaluation for premature growth arrest and limb-length discrep- Medial/lateral displacemenr currently is most common, usu-
ancy or angular deFormity. ally with an associated Fracture of the adjacent metaphysis (Sal·
Even less common is an avulsion injury (0 (he edge of the ter- Hal"l"is type [I).
physis. A small Fragmenr, including a portion of the perichon-
drium and underlying bone, may be torn oFF when the proximal Classification According to Age
attachment ofrhe collateral ligament is avulsed_ This uncommon Separations of the distal Femoral epiphysis in inFants may be
injury may also lead to localized premamre growth arrest and associated with breech birth Ot child abuse (64) (Fig. 23-5).
progressive angular deformiry (34). The bony bridge usually is Most are Salter-Harris type I injuries. Clinically diFFerentiating
small, localized, and surgically accessible, and excision is appro- between an epiphyseal separation and hematogenous osteomye-
prIa(e. litis may be difficult. Ultrasonography may be used to confirm
A triplane Fracmre infrequently occurs in the distal Femur. Fracture. Older children and preadolescems usually al"e injured
Computed tomographic (CT) scans with three-dimensional in high-energy accidents such as a Fall or being hit by a vehicle.
modeling may be helpFul in idenri~ring and analyzing (44) this Associated musculoskeletal and visceral injuries are common in
lllJury. this group.
In most recenr reviews, approximately two thirds of distal
Femoral epiphyseal separations occur in adolescenrs, often from
Classification by Displacement contact spans (45,51,64). The most common patterns ate Sal-
ter-Harris rypes I and II. The potential For growth disturbance
Anrerior displacemenr of the epiphysis results From hyperexten- is lowest in this group (Fig. 23-6).
sion of the knee. The extension Force on the distal femur is
transmitted (hrough (he posterior capsule of (he knee joint. The Signs and Symptoms
mechanism is similar to that oFknee dislocations in adults. There
is an increased risk of neurovascular injury (77).
Physical Findings
Posterior displacement of the epiphysis on (he Femul" is un- The parient usually cannot walk or bear weight on the injured
common. It has been l"eported in birth injmies and in older limb immediately aFter sustaining a displaced separation of the
990 Lower E-aremitj

eype III and IV separations, in which the articular surface is

fractured. The hemarthrosis associated with other patterns of
separation may be caused by bleeding through the synovial su-
prapatellar pouch. The knee may feel tense to palpation. Aspira-
tion nearly always produces sanguineous Auid. Extravasation of
blood into the soft tissues of the distal thigh and popliteal fossa
ptoduces ecchymosis that becomes apparene within 72 hours
after injury.

Direction of Displacement
Most commonly, displacement of the epiphysis occurs in the
coronal plane, producing varus or valgus deformiry. The pro-
truding end of the metaphysis can be palpated through the distal
portion of the vastus medialis with valgus injuries, or through
the vastus lateralis with varus injuries.
With anterior displacement, the patella, riding forward on
the femoral epiphysis, becomes extremely prominent. There is
a palpable depression across the anterior thigh JUSt proximal to
the patella, and fullness in the popliteal fossa is produced by
posterior displacement of the distal end of the metaphysis. Poste-
riot protrusion of the metaphysis may pUt pressure on the popli-
teal arrelY, so that pulsations become palpable in the subcutane-
ous region of rhe popliteal fossa. Anterior displacemenr of the
distal femoral epiphysis may be indicated by prominence of the
adductor tubercle, which is displaced with the epiphysis anterior
FIGURE 23·S. Lateral radiograph of a swollen knee in a 3-month-old
girl who reportedly fell out of her crib 8 days earlier. Subperiosteal to the metaphysis.
ossification along the distal femoral shaft indicates separation of the With posterior displacement of the distal femoral epiphysis,
distal femoral epiphysis. Note evidence of fracture-separation of the
proximal tibial' epiphysis as well. Final diagnosis: abused child.
the distal end of the metaphysis is prominent on the anterior
aspect of the distal thigh directly above the patella, and the
epiphysis can be felt as a palpable Fullness in the popliteaJ Fossa.
Whatever the direction of displacement, the parella and femoral
condyles remain in line with the proximal tibia, a point useful
distal femoral epiphysis. However, witb a nondisplaced separa- in differentiating epiphyseal separation from dislocation of the
tion, such as in athletic injuries. tbe patient may be able co walle knee.
He or she may have felt a "pop" at the injulY and presumed a
ligament tear. Effusion of the knee and soft tissue swelling de-
vclop rapidly. Abrasion or laceration of the overlying soh tissues Po Iytrauma
may be a clue to the mecbanism of injury or to an open fracture.
If lhe secondalY hamstring spasm can be relaxed, instability With an open injury, the distal end of the metaphysis may cause
JUSt above the knee joint may be felt. Complete separation of a transverse laceration, most often in the lateral portion of the
the epiphysis and tear of adjacent ligaments can occur simultane- popliteal fossa. The apex of the protruding metaphysis is den-
ously. A soft end poine or crepitus may accompany the abnormal uded of periosteum.
motion after separation of rile physis. Crepitus sometimes is Whenever a diagnosis of epiphyseal separation is suspected,
abscne because the periosteum is imerposed between the me- careful neurovascular examination of the lower leg and Foor
taphysis and the epiphysls. Abnormal laxiey in a patient with should be done, including pulses, colot, temperature, capillary
negative radiographs may be caused by a nondisplaced physeal refill, and motor and sensory status. The extremity may become
injury rather than by a ligamentous tear. If the diagnosis of cyanotic jf venous return is impaired. The use of rhe Doppler
,physeal injUlY is contlrmed radiographically, Further stress or Aow meter may be helpful in evaluating circulation distal to the
displacemene of the epiphysis should be minimized. injury. Compartmental pressure recordings should be obtained
It sometimes is possible to localize tenderness to the level of if there are clinical findings of compartment syndrome (50). If
the physis, which is at approximately the same level as the upper the separation occurred in a vehicular accident, associated inju-
pole of the patella and the adduccor tubercle, both of which can ries may be present (4).
be used as reference poines. In Salter-Harris eype III and IV
fractures, tenderness is greater on the involved side of the distal
femur.
Radiographic Findings
Separation of the distal femoral epiphysis usually is accompa- Because the physis normally is radiolucent, injury is diagnosed
nied by effusion of the knee joint. This is logical in Salter-Harris by displacement, widening, or adjacent bony disruption (54).
 Chapter 23: Fractures and Dislocations About the Knee 991

A B

c D
FIGURE 23-6. A: The initial anteroposterior radiograph of a 12-year-boy who sustained an injury to
the left knee while playing football shows widening of the lateral aspect of the distal femoral physis.
B: With conhnued play, a second injury was sustained with anterior displacement of the distal femoral
epiphysis. C: Open reduction and fixation with crossed Kirschner wires was necessary because of late
presentation of injury. D: At follow-up, early closure of the distal femoral physis is apparent. ((ourtesy
of Stephen (ope, MD, Mobile, Alabama.)
992 Lower Extremity

However, a nondisplaced Salter-Harris rype I or III fracture The radiolucent line representing the physis on the antero-
without separation can be easily overlooked. Oblique views of posterior projection is approximately 3 mm thick until adoles-
the distal femur may reveal an occult fracture through the epi- cence. Diminution of the distance between the line of provi-
physis or metaphysis. Stress views should be considered if multi- sional calcification at the lower edge of the metaphysis and the
ple plain films are negative in a patient with an effusion or bony plate on the upper border of the epiphysis suggests a
tenderness localized to the physis (Fig. 23-7). compression injury to the physis, especially if reinforced by the
In a Salter-Harris type II injury, the most common pattern, clinical findings. Neer (51) pointed out that radiographic signs
a fracture line extends from the radiolucent physis obliquely of premature closure usually become evident within 6 months
through the distal femoral metaphysis. The metaphyseal fracture after injury.
line and spared segment of physis outline a triangular fragment
of bone that remains in position relative to the epiphysis. The
Treatment-Overview
size of the metaphyseal triangle tends to be larger if displacement
has occurred in the coronal plane. The objectives of treatment of separation of r.he distal femoral
A vertical fracture line extending from the arricular surface epiphysis are to obtain and maintain satisfacrory reduction, ro
of the distal femoral epiphysis into the radiolucent physis is regain a functional range of motion of the knee joint, to regain
diagnostic of a Salrer-Harris type III fracture. Usually, the epi- normal strengrh of the quadriceps and hamstring muscles, and
physeal fracture line is best seen on an anteroposterior view be- to avoid further damage to the physis.
cause it is oriented in the sagittal plane. The degree of displace- Anaromic reduction of a displaced separarion of the distal
ment in this fracture pattern may be difficult to measure unless femoral epiphysis is desirable, and the closer the patient is to
the radiographic projection is precisely in line with the plane of skeletal maturiry, the greater rhe need for exact realignment.
fracture. If the fracture pattern requires further definition to Blount (8) pointed out that residual varus or valgus deformity
determine treatment, multiple oblique views or CT scanning after reduction usually does not remodel with further growth.
may be helpful to demonstrate the fracture plane or measure Reduction of displacement in the sagittal plane may be slightly
the gap in the articular surface of the femoral portion of the less precise. Sharrard (70) stated that angulation of up to IS
patellofemoral joint. Less commonly, the vertical ftacture ex- degrees with apex anterior or posterior is well tolerated. Blount
tends through the articular surface in the weight-bearing portion wrote that a child younger than 10 years of age with posterior
of the femoral condyle. If the weight-bearing surface is involved, angulation of less than 20 degrees will not have permanent genu
it is even more important to determine the degree of displace- recurvatum, and the deformiry remodels with growth. The re-
ment. modeling potential in infants is so great that considerable dis-
A fracture line extending from the epiphyseal surface across placement can be accepted. Burman and Langsam (16) reported
the physis and up through the metaphysis is characteristic of a good results in displaced birth fractures that were merely
Salter-Harris type IV injury. Even 1 to 2 mm of displacement splinted. Most infants can be treated by supportive traction or
is signifJcant (21). Occasionally, the pattern of fracture separa- splinting, no matter how great the displacement.
tion may be difficult to outline. If needed, CT can be useful. Closed reduction usually can be performed in older children
Anterior or posterior displacement of the epiphysis is best up to 10 days after injuJY. Bohler (9) reported successful reduc-
appreciated on the lateral projection. The anteriorly displaced tion 12 days after injury, and Patterson (57) reported successful
epiphysis usually is tilted so that the distal articulat surface faces reduction in a 9-year-old girl 11 days after injury.
anteriorly. The posteriorly displaced epiphysis is rotated so that Closed reduction may fail for a number of reasons, making
the distal articular surface faces the popliteal fossa. open reduction necessary. A Salter-Harris rype lor II separation
Separation of the distal femoral epiphysis in an infant is diffi- may be irreducible by closed methods because of interposed soft
cult to see on initial tadiographs unless there is displacement tissue, usually a flap of tOrn periosteum or muscle that curls up
because only the center of the epiphysis is ossified at birth. This inside the fracture cleft. Displaced Salter-Harris type III or IV
ossicle should be in line with the axis of the femoral shaft on both separations almost always require open reduction and internal
anteroposterior and lateral views (17,18). Comparative views of fJxation to minimize disruprion of the articular surface and de-
the opposite knee may be helpful. Magnetic resonance imaging crease the likelihood of premature growth arrest. In an open
(MRl), ultrasonography, or arthrography of the knee may help injury, open reduction and fixation may be accomplished at the
to identi fy a separation of rJ1e relatively unossifJed femoral epi- time of wound debridement.
physis. AJthough growth may be adversely affected by the injury
Stress views are indicated when the initial radiographic ap- itself, further damage to the physis should be avoided during
pearance is negative bur the hisrory and physical signs suggest diagnostic stress radiography, closed reduction, or open reduc-
epiphyseal separation. Stress radiographs may be falsely negative tion. The use of general anesthesia decreases the forces across
if there is associated muscle spasm. Adequate analgesia relaxes the physis. Kurlander (40) reported a patient in whom the popli-
muscle spasm and helps protect the physis from further injury teal artery was injured at the time of closed reduction. Salter et
during examination. Some ([action should be applied ro the al. (67) stated that it is better to accept a less-than-perfect reduc-
lower leg as the knee is angulated for radiographic examination. tion and do a corrective osteotomy later than to cause further
Smith (72) reported two I5-year-old boys injured on the football damage by rough handling.
field for whom the diagnosis of distal femoral epiphyseal separa- Thomson et al. (78) showed that significantly displaced phy-
tion could be made only on stress views. seal fractures of the distal femur had a better outcome if they
 Chapur 23: Fractures and Dislocations A bout the Knee 993

A B

c D
FIGURE 23-7. A 14-year-old football player sustained a knee injury when he was tackled. A: The initial
anteroposterior radiograph shows no fracture or separation. B: Anteroposterior valgus-stress radiograph
reveals separation of the distal femoral epiphysis. C and D: Another example, age 16: such injuries may
occur even when the physes are nearly closed.
994 Lower Exrremiry

aspirarion under srerile precautions may be done. A well-molded

long leg cast is applied with rhe knee in approximately 15 [Q 20
degrees of flexion. The forces rhar caused rhe injUly should be
reversed and the intact periosteal hinge tightened. Thus, if the
metaphyseal fragment of a nondisplaced Salter-Harris type II
separation is on the lateral side of the metaphysis, the cast is
applied with three-point molding into slighr varus. If the me-
taphyseal fragment is medial, the cast is molded into slight val-
gus. AJternative methods of immobilization include a Jones
dressing, posterior splint, cylinder cast from high rhigh to supra-
malleolar level, or, most often, a single hip spica cast. The more
secure form of immobilization should be used if rhe parienr is
obese or of uncertain reliability. It must be stressed thaI' rhere
is a high chance of loss of reduction if a displaced fracture is
reduced and nor internally fixed (78). Radiographs are made 1
week after immobilization to ensure that displacement has nor
occurred.
Isometric exercises are started as soon as symptOms permit.
Srraight-Ieg raises usually are possible approximately a week after
injulY. Ambularion on crutches with touchdown gait lS comin-
ued for 3 to 6 weeks after injulY. By 4 to 8 weeks after injury,
depending on rhe parient's age, rhe cast is removed or convened
to a removable posterior splint. Thereafter, acrive range-of-mo-
tion exercises are done twice daily until normal strength and
knee motion are regained. Return to athleric activities may be
permiued when symptoms are resolved, knee range of marion
is normal, and quadriceps mass is symmetric with the opposite
side. Even wirh a nondisplaced fracture, growth inhibition may
FIGURE 23-8. Previously reduced Salter-Harris type II fracture of the
be caused by a compression force at the time of injury, and the
distal femoral epiphysis in a 13-year-old boy. After reduction, two 6.5- patient should be followed for ar least 6 months and preferably
mm cannulated screws were inserted through the large medial metaph- for 12 to 24 months.
yseal fragment for fixation.

Closed Reduction and Fixation

The technique of closed reduction depends on the direcrion and
degree of displacement of the epiphysis (Fig. 23-9). General
were internaJJy fixed. Whenever possible, fixation devices are anesthesia often is indicated to decrease associated muscle spasm
placed [Q avoid crossing the physis. In Salter-Harris type III and diminish the risk of further injUlY to the physis. Joint aspira-
separations, pins or screws may be placed transversely through tion may precede manipularion. Keeping in mind rhe imact
rhe epiphysis. In SaJrer-HalTis type II or IV separarions, pins or tether of periosreum on the side to which the epiphysis is dis-
screws are placed transversely rhrough the meraphysis, engaging placed, the first maneuver increases rhe deformiry slightly with
the rriangular fragment if ir is large enough (2 [Q 3 cm tall; Fig. traction. The proximal edge of the displaced epiphysis can then
23-8). If traversing the physis is unavoidable, smooth, small- be brought to the edge of the metaphysis on rhe same side of the
diamerer pins are used. periosteal tether. Reduction is then completed by realignmenr of
External fixation rarely is indicated for the treatment of phy- the angular deformity. Grinding of the physcal carrilage against
seal injuries about the knee because of the danger of secondary the meraphysis is rhereby avoided. The sequence of events is to
knee joinr infection (79). pull, tip, and close the separation. The maneuver should be 90%
At the time of initial evaluation and treatment planning, the traction and 10% leverage.
snorr- and long-term problems and complications are explained
to rhe patient and parents. The need for long-term follow-up is Medial or Lateral Displacement. To reduce either medial or
srresscd from the beginning of treatment. The family is berrer lateral dispLlccment of the epiphysis, the patient is placed supine.
able to comprehend rhese facts if they are presenred from the The leg is grasped with the knee in extension and the hip in slight
beginning. flexion. The thigh is fixed by an assisrant. Moderate longitudinal
rraction is exerted by a handhold on the leg above the ankle. If
rhe displacement of the epiphysis is medial, varus is increased
Nonoperative or Conservative Treatment
gently and cautiously to avoid stretching rhe peroneal nerve.
Immobilization Wirh one hand holding traction on the leg, rhe palm of rhe
A nondisplaceJ separation is immobilized [Q prevent displace- other hand is placed againsr the concave surface of rhe angulared
ment and relieve pain. If there is tense effusion of the knee joint, disral femur. The epiphysis is pushed toward the meraphysis as
 Chapter 23: Fractures find Dislocations Abolit the Knee 995

c
FIGURE 23-9. Closed reduction and stabilization of a Salter-Harris type I or II fracture. A: With medial
or lateral displacement, traction is applied longitudinally along the axis of the deformity to bring the
fragments out to length. B: For anterior displacement, the reduction can be done with the patient prone
or supine. Length is gained first; then, using a large bolster as a fulcrum, a flexion moment is added.
C: Fixation is with smooth 3-mm pins in most adolescents; the angle must be oblique so that the pins
cross proximal to the physis. Pins should engage the far cortex and may be cut off under the skin.

the leg is realigned with the thigh. Once redunion is obtained, 68). Hutchinson and Barnard (36) showed that reduction of
longitudinal uacrion is released. If traction on the leg is pre- this displacement could be more easily and surely obtained by
cluded by an associated injury ro the femur or a tear of a knee applying rraction ro the leg with the knee flexed. With the pa-
joinr ligament, a pin can be inserted rransversely across the proxi- tient supine, the hip is flexed approximately 60 degrees and rhe
mal tibia ro be used as a handle in the maneuver. Usually, how- thigh is fixed by an assistanL Longirudinal traction is applied,
ever, these associared injuries increase the risk ofloss of reduction with the knee in partial flexion. Downward pressure on rhe
and are indications for primary inrernal fixation in adolescents. epiphysis is exerred manually. Wirh conrinuing tr:l<:rion on the
The reduction is checked by anreroposterior and [areral radio- leg, the knee is flexed 45 ro 90 degrees. Prone rcducrion requires
graphs. A long leg cast or hip spica cast is then applied, wirh fewer assistanrs. If the surgeon chooses ro perform the reduction
the knee in slight flexion. External immobilization is conrinued with the patienr prone, traction is applied to the limb, an assis-
for 5 ro 6 weeks. Thereafter, the care is similar ro that for a tant pushes down on the posterior aspen of the thigh, and the
nondisplaced separarion. knee is flexed further unri I approximately 110 degrees of flexion
is reached. This sequence is similar ro that for reduction of a
Anterio1' Displacement. Anrerior displacemenr of the epiphysis supracondylar humerus fracture of the elbow.
can be reduced with rhe patienr either supine (82) or prone (62, After reduction of an anreriorly displaced epiphysis, ir is im-
996 Lower Extremit),

porranr co check the pulses in the foot and ankle. Flexion of a angle, less than 45 degrees co the long axis of the femur. The
swollen knee co beyond 90 degtees may compromise the popli- pins are cut off under the skin before application of the cast,
real vessels. The position is mainrained by temporary spliming with the knee in slight Aexion. Infection is frequent if pins in
while images are obtained. If reduction is adequate, the knee is this region ate left out through the skin for a long time.
immobilized in nexion by a long leg or hip spica cast. Bellin (5)
and Griswold (32) noted difficulty regaining extension of the Posterior Displacement. To reduce posterior displacement of
knee after prolonged immobilization in nexion. Two weeks after the distal femoral epiphysis, the patient is placed supine. The
injury, the cast is changed or modified so that the knee can be surgeon grasps the leg and exerts downward longitudinal traction
brought Ollt to 45 degrees Aexion. It is imporrant co increase while the knee is held pattly Aexed. Longitudinal traction is
the range of extension gradually during the 6- co 8-week period continued as the leg is brought up co extend the knee. An assis-
of immobilization. tant pulls up ditectly under the distal femoral epiphysis with
one hand and pushes down on the distal meraphysis of the femur
Pin Fixation. The larger the metaphyseal fragment and the with the other. Heller (33) advised placing a pin transversely
greater the displacement, the less stable the dosed reduction. If distal co the tibial tubercle. Upward pull on the tibial pin is
reducrion of the anterior displacement is unstable, percutaneous continued while applying longitudinal traction co the leg. Aitken
pin fixation is recommended. An image intensifier may be used. and Magill (2) pointed out that reduction of this type of separa-
If the metaphyseal ftagment is large enough, threaded pins or tion was best maintained by leaving the knee in extension. The
screws can be directed transversely across the metaphysis after medial head of the gastrocnemius originates from the metaphysis
reduction (Fig. 23-10). In the absence of a substantial metaphy- proximal co the distal femoral physis and acts as an internal
seal fragmem, smooth pins ate ditected through the side of each splint when held taut against the posterior aspect of the epiphysis
condyle to cross in the metaphysis proximal to the central third by the extended position of the knee. Burman and Langsam
of the physis. The closer the pins are co crossing at the fracture (16) advised immobilization without reduction for posterior dis-
site, the less stable they are. To make the pins cross at a point placement in a newborn after breech delivery. They reporred that
proximal co the fracture site, they should come in at a "high" adequate remodeling occurred, even with severe displacement.

(
\

A
FIGURE 23-10. Reduction and percutaneous screw fixation of Salter-Harris type II fracture with a large
metaphyseal fragment. A: Cannulated screws are placed closer to the physis than to the fracture line.
Two screws may be placed anterior and posterior to each other. A washer helps increase compression.
B: After both screws are in place. reduction should be maintained when pressure is removed. If deformity
recurs. the metaphyseal fragment may be unstable or the periosteum may be infolded on the contralat-
eral side.
 Chapter 23: Fractures lind Dislocations About chI' Knee 997

Operative Treatment blood permi t better inspection of the separation. An interposed

flap of periosteum may be identified between the epiphysis and
Open Reduction of Physeal Fractures
metaphysis. The periosteal flap is gently pulled out of the separa-
Open reduction is indicated fOl' displaced Salter-Harris rype III
tion with forceps or a large skin hook. Special care is taken to
or IV fractures, for all other rypes in which satisfactolY alignment
avoid any additional damage to the physis covering the proximal
cannot be obtained by closed means, or when associated injuries
mandate it (i.e., a "Aoaring knee" or ligament jnjlllY). A tourni- surface of the epiphysis. Once the muscle and periosteal flap are
quet around the pl'Oximal thigh may be used for temporary he- removed, reduction is carried out by gentle realignment. To
mostasis if it is placed proximally enough to avoid bi nding the avoid damage to the physis, instruments should not be plaCt·J in
thigh muscles under rhe in flared tourniquet. the physeal interval. Again, for unstable or irreducible frac[llres,
For an irreducible Salrer-Harris type II separation in the coro- percutaneous pinning is indicated to stabilize the fracture (56)
nal plane, a longicudinal incision is centered over the palpable, (Fig. 23-11). After closure of the wound, a long leg or hip spica
prominent end of the metaphysis. The approach fl'Om this direc- cast is applied.
tion gives direct exposure of any obstacles to reduction and For open reduction and internal fixation of a Salter-Harris
avoids disruption of the periosteal hinge. If the displacement of rype III or IV separation, an anteromedial or anterolateral longi-
the epiphysis is lateral, the metaphysis protrudes medially under rudinal incision is used (Fig. 23-12). The anterior physeal and
the distal portion of the vasrus medialis. If the displacement of articular margins of the fracture are exposed. If the fracrure is
the epiphysis is medial, the metaphysis protrudes laterally under nondisplaced, percutaneous cannulated screw fixation is indi-
the distal edge of the vascus lateralis. If the displacement is ante- cated. ]n displaced fractures, arthrotomy allows inspection of
rior, the procedure is done with the patient prone. After incision the articular surface of the epiphysis. Reduction is checked by
of the deep fascia, cLssection is continued, extending the plane noting the apposition of the articular surfaces, the physeal line
of injlllY bluntly by spreading the muscle fibers to expose the anteriorly, and rhe fracrure pattern (Fig. 23-12, arrows) and
end of the metaphysis. Irrigation and careful removal of clotted can be confirmed with Auoroscopy. Provisional stabilization is

A B
FIGURE 23-11. A: Completely displaced Salter-Harris type II fracture of the distal femur in a 6-year-old
girl whose foot was on the back of the driver's headrest when the automobile in which she was riding
was involved in an accident. B: Ecchymosis in the popliteal fossa and anterior displacement of the distal
femur are evident. Clinical examination revealed absence of peroneal nerve function and a cold, pulseless
foot. The fracture was irreducible by closed methods and required open reduction, internal fixation,
and repair of a popliteal artery laceration. (Figure continues.)
998 Lower Extremity

c D

E F
FIGURE 23-11. (continued) C and D: Three months after injury; note incomplete reduction, 25 degrees
of posterior angulation, and abundant callus formation about the fracture. E and F: Four years after
injury; note remodeling about the distal femur with normal growth of the distal femoral physis.
 Chapter 23: Fractlll'es and DisLoc(uionJ A bout the Knee 999

&11.;::::;===-\
I
I
I
I

A B

C
FIGURE 23-12. Open reduction of displaced lateral Salter-Harris type IV fracture of the distal femur.
A: Longitudinal skin incision. B: Provisional stabilization with Kirschner wires. Cortex, physis, and joint
surfaces are aligned (arrows). C: Fixation screws are inserted parallel to the physis.

obtained with Kirschner guidewires. When reduction is accom- ligament disruption. After surgery, the reduction is protected by
plished, threaded pins or screws are directed transversely across a long leg or hip spica cast.
the epiphysis in Salter-Harris type III separations (Fig. 23-13), If an associated coJiateraJ ligament injury is found, ir can be
or across the metaphysis and epiphysis in Salter-Harris type IV repaited at the time of open teduction. Internal fixation is used
injuries (Fig. 23-14). If crossing the physis with fixation is una- to aJlow early mobilization and rehabilitation of both the physeaJ
voidable, smooth pins or wires should be used. Fixation pins separation and the ligamentous injury.
usually are introduced through stab wounds adjacent to the inci- If vascular repair is indicated, a posterior modified S-shaped
sion. The pins are cut off beneath the skin. After reduction and incision or posteromediaJ incision is used to follow the course
fixation are checked by inrraoperative radiographs, the knee joint of the femoral artery (Fig. 23-15). Care should be taken during
is thoroughly irrigated and inspected for other fractures and incision because the vessel may be superficial benearh rhe skin.
1000 Lower Extremity

A B

FIGURE 23·13. A: Salter-Harris type III fracture-separation of

the distal femur. Note the vertical fracture line extending from
the physis distally into the intercondylar notch with displace-
ment. B: After reduction and fixation with two compression
screws extending transversely across the epiphyseal fragments.
Note closure and healing of the vertical fracture line in the
epiphysis, with restoration of the articular surface. C: Place-
ment of screws in the epiphysis distal to the physis and proxi-
c mal to the articular cartilage.
 hapter 23: Fractures and Dislocations About the Knee 1001

A B

FIGURE 23-14. A: Salter-Harris type IV fracture

of the distal femur in a 7-year-old boy who was
struck by a car. The fracture plane was complex
and it was significantly displaced. B: Two years
after open reduction and internal fixation,
growth was maintained, although flexion was
limited to 110 degrees. C: Six years later, limb
c lengths and angulation were equal.
1002 Lower E'(tremi~y

reduction and should be avoided to prevent injury to vascular

strucrures. I n children younger rhan 10 years of age, as much
as 20 degrees of posterior angularion is acceptable, but in patienrs
closer to adolescence, we accept only minimal anteroposterior
angulation and no more than 5 degrees of varus-valgus angula-
[Jon.
If the displacement is anterior, we perform the reduction with
the parient supine. An assisrant holds the rhigh with the hip
parrly flexed over a bolsrer. The surgeon grasps rhe leg from
behind the calf with one hand and pulls down in line with the
thigh as he or she tries to tip and close rhe epiphysis against the
meraphysis with the other hand. We check for pulses after this
maneuver. For all but minimally displaced and complerely stable
fractures, we use internal fixation wirh percuraneous pins or
screws. Smoorh pins C~~4 or %2 in.) are placed so rhar they cross
in the metaphysis, proximal to the fracture, to prevent the epi-
physis from rorating at the fracture site. In an adolescent with
a large (2 to 3 cm high) triangular metaphyseal spike (Thursron-
Holland fragmenr), we insert twO cannulated 4.0- or 6.5-mm
screws transversely to fix the spike to rhe metaphysis withour
A
crossing rhe physis. An above-the-knee cast is applied with the
FIGURE 23-15. Open reduction of distal femoral fracture with vascular knee in 5 to 10 degrees of flexion.
repair. A: Lateral view showing site of vascular injury. B: Modified S-
shaped incision follows the course of the femoral artery. We prefer open anatomic reduction for all displaced rype III
and IV fractures to prevent the formation of a bony bar, which
causes limb-length discrepancy and angular deformiry. The frac-
(Ute line, the physis, and the joint surface are observed to confirm
The hamstring tendons may be "bowstrung" around the femoral anatomic reduction (Fig. 23-16). Cannulated screws are then
meraphysis. The artery may be in spasm, occluded by inrimal inserred with eirher an open technique or percutaneously with
rear, or rorn. Afrer rhe vascular strucrures are idenrified, rhe the aid of image intensification.
fracture is reduced and stabilized before vascular repair. Open fractures or fractures caused by massive penetrating
Open separarions of the distal femoral epiphysis usually are trauma require meticulous debridement. We ny to save and
caused by hyperextension, with anrerior displacement of rhe epi- stabili7..e any viable fragmenrs of e[Jiphysis or articular surface,
physis. A wound may be presenr in rhe popliteal fossa, overlying but torally free fragmenrs are removed. Debridement is repeated
the posterior protruding end of rhe metaphysis. The patienr is as necessary, usually at 48 hours, and sofe ti,suc coverage is
placed prone wirh rhe knee slighrly flexed and rhe skin is thor- accomplished as soon as feasible.
oughly irrigated and debrided. The wound is enlarged ro allow
inspecrion of the conrenrs of rhe popliteal fossa. Muscle or peri-
osteum or borh may be interposed in the fracture site. Because Postreduction Care
the patiem is prone, reduction is obtained by bringing rhe leg
Ambulation on crutches usually is possible within a few days.
up against downward pressure on rhe distal end of the femoral
At 1 week after reduction, the patient rerurns for radiographs
shaft, while maintaining longitudinal tracrion. Internal fixarion
taken through rhe cast. If displacement has occurred, it is nor
is used ro stabilize the fracrure, especially if vascular or ligamen-
toO late to obtain reduction by remanipulation. If reduction is
rous repair is to be done. The wound is packed open, and the
maintained, straight-leg exercises are begun four times daily.
IUlee immobilized in slight flexion with a long leg or hip spica
At 4 weeks after injury, the patienr rerurns for radiographs. If
cast. Rarely, if extensive soh tissue reconsrrucrion is required, an
subperiosteal new bone [ormation is present adjacent to the me-
external flxator spanning the knee may be considered ro faciliEate
taphysis, the cast is bivalved, and the posterior porrion may
dressing changes and soft tissue reconstrucrion.
then be removed twice daily for acrive muscle-strengthening and
range-of-motion exercises, done both supine and prone. The
splint may be reapplied for ambulation with crutches. Partial
19 AUTHORS' PREFERRED METHOD weight bearing is gradually increased. At 6 to 8 weeks after in-
,~ 0 F TREATMENT jury, and at regular intervals thereafter, the patient rerurns for
reexamination to evaluate healing, range of knee motion, and
Nondisplaced fracrures are treared with above-rhe-knee casr im- the strength of thigh muscles. When range of motion and thigh
mobilizarion for 4 to 6 weeks. For displaced Salrer-Harris rype muscle strength are fully recovered, the patient may return [Q
I or II fracrurcs, we perform gende c1o,ed reducrion with the normal acrivities. At 6 months after injury, alignment, leg length,
parienr under general anesrhesia, using traction and gentle ma- and gait are evaluated with comparative radiographs of the lower
nipulation. Extreme flexion should not be necessary to maintain extremities. If alignment, leg length, and gait are within normal
 Chapter 23: Fractures and Dis!ocatiom About the Knee 1003

A B

c D
FIGURE 23-16. A: Comminuted Salter-Harris type III fracture of the distal femoral epiphysis with large
osteochondral fragments. B: Axial plane computed tomography scan demonstrates intraarticular osteo-
chondral fragments. C and D: After open reduction and internal fixation with Herbert screws. On the
lateral view, the screws appear to be protruding anteriorly in the distal femoral epiphysis, but they
actually are buried in articular cartilage. (Courtesy of Dr. William C. Warner, Jr, Campbell Clinic, Memphis,
Tennessee.)
1004 Lower Extremity

limits, the patient is dismissed from romine care but is counseled stiffness, quadriceps weakness, and persistent instability of the
[0 return for evaluation of growth 12 and 24 months after injury. knee. Delayed union or nonunion is rarely a problem, except
in patients with an underlying neuropathy such as meningomye-
Jocele. Avascular necrosis of the epiphysis has not been reponed
Prognosis
after distal femoral physeal injuries, in contrast to proximal fem-
The prognosis for separation of tne distal femoral epiphysis usu- oral physeal injuries. The reponed incidences of complications
al!,y is good. Over two thirds of the patients with this injury in five clinical reviews are summarized in Table 23-5.
are healtny adolescents (64). With appropriate treatment, they
return to normal activities within 4 to 6 months. Although as
Vascular Impairment
many as a third of patients may sustain some damage to tne
physis at the time of injury, they usually are close enough to Intimal tear and thrombosis in the popliteal artery may be caused
the end of growth to make shortening or angulation insignifi- by trauma from the distal end of the metaphysis when the epi-
cant. For younger children with more temaining growth, the physis is displaced anteriorly with a hyperextension injury (41,
potential for angular and length deformity is significant. 45). The current incidence of vascular injury is approximately
The outlook for newborns with separations sustained at the 1 %. A single vascular deficit occurred in each of twO reviews
time of delivety in general is good. Remodeling occurs rapidly. (51,76). In another four reviews, there were no vascular injuries
If part of the physis is damaged, however, tne consequence is (2,45,64).
major deformity (a rare event). In some patienrs, nearly normal NeeI' (51) found vascular insufficiency in 1 of 21 patients
growth continues for a decade until the adolescent growth spurt with displaced separations of the lower femoral epiphysis; this
makes a growth disturbance obvious (25). was promptly relieved by reduction of the separation. Bassett
and Goldner (4) reported on a patient with arterial spasm associ-
ated with displacement in the sagittal plane. At the time of initial
Complications
examination, shortly after injury, the foot was pale and cold.
Early complications of separations of the distal femoral epiphysis Pulses were not palpable. After reduction, the color improved
may include injury to the popliteal artery, neurapraxia of the and tne pulses returned. There were no sequelae to the temporary
peroneal nerve, associated ligamentous injUJy, and recurrent dis- vascula.r occlusion.
placement of the epiphysis (Table 23-4). Complications tnat If vascular impingement occurs but is relieved by prompt
occur later include angular deformity, leg-length discrepancy, reduction of rhe displaced epiphysis, the patient must be
observed for 48 to 72 hours to rule alit an intimal tear with
tllt'ombosis. Vascular impairment may develop slowly from
increasing compartmental pressure. If the patient has inordi-
nate persistent pain, with a cool and pale foot, a femoral
TABLE 23-4. DISTAL FEMORAL PHYSEAl
arteriogram and compartment pressure measurement should
FRACTURES: PITFALLS AND
PREVENTION be considered, even if peripheral pulses are present. An arterio-
gram is nOt indicated for routine, closed hyperextension epi-
Pilfall Preventive Strategy physeal displacements, as long as the clinical examination is
Consider undisplaced physeal injury in negative after reduction (38,81). In a patient with an acute
Missed diagnosis
athletes with tenderness at physis fracture with vascular injury, in whom the foot is pale, cool,
or laxity on stress and nonviable, popliteal artelY exploration is indicated after
Careful physical examination of fracture reduction and stabilization. Arteriography is not man-
polytrauma patients for tenderness, darory for an isolated vascular injury because the site of
or consider bone scan if
unresponsive the lesion is known and can be addressed at the time of re-
Vascular.impairment Check pulses, temperature, muscle duction. If there is an associated fracture of the pelvis or
function; angiogram if abnormal femoral shaft, arteriography may be necessary to localize the
Peroneal nerve Avoid excessive stretch through vascular injUlY.
injury traction or excessive varus stress at
reduction
Redisplacement Apply spica cast if needed; internally Peroneal Nerve Injury
fix if displaced or unstable; early
follow-up to allow correction The peroneal nerve is the only nerve injured with any appreciable
(within 1 week after injury) frequency in this rype of fracture. It may be stretched by anterior
Knee joint instability Check ligaments when fracture
or medial displacement of the epiphysis.
stabilized or healed; tailor
treatment to age and activity Lombardo and Harvey (45) reported a patient with an associ-
Progressive' Minimize trauma at reduction; ated peroneal nerve palsy that resolved spontaneously over 6
angulation magnetic resonance imaging may months. Stephens et al. (76) reported twO parients with peroneal
help to make earliest diagnosis; nerve palsies who recovered completely. Both were adolescems
follow-up at 6 months after trauma
to detect growth disturbances witn Salter-Harris rype II separations. Roberts (64) found one
patient with neurapraxia of the peroneal nerve associated with
medial displacement of a Salter-Harris type II separation. Tne
 'hnptl'l' 23: Frrtftures rind Dislocations About the Knee 1005

TABLE 23-5. INCIDENCE OF COMPLICATIONS AFTER SEPARATION OF THE DISTAL FEMORAL EPIPHYSIS IN
CLINICAL REVIEWS

Number Popliteal Peroneal Angular Leg-Length Knee

Reference Patients Artery Injury Nerve Injury Deformity Discrepancy Stiffness

Aitken" 15 1 1 4
Lombardo b 34 1 11 13 11
Stephens c 20 2 4 8 4
Roberts d 50 1 9 11 4
Neer" -l.l _1_ 1 3
Totals 140 2 (1%) 4 (3%) 26 (19%) 36 (24%) 23 (16%)

a Aitken AP, Magill HK. Fractures involving the distal femoral epiphyseal cartilage. J Botie Joint Surg Am 1952;34:96-108.
b Lombardo 5 Jr, Harvey JP Jr. Fractures of the distal femoral epiphyses. Factors influencing prognosis: a review of 34 cases. Jr Bone Joint Surg Am
1977;59;742-751. .
C Stephens DC, LouisDS, Louis E. Traumatic separation of the distal femoral epiphyseal cartilage plate. J Bone Joint Surg Am 1974;56:1383-1390.

d Roberts JM. Fracture separation of the distal femoral epiphysis. J Bone Joint Surg Am 1973;55:1324.
< Neer CS II. Separation of the lower femoral epiphysis. Am J Surg 1960;99:756-761. .

separation was satisfacrorily reduced by closed means, and the instability of the knee. Lombardo and Harvey (45) found knee
nerve injury spontaneously resolved in several months. laxiry in 8 of 34 patients. Brone and Wroble (15) found three
Peroneal nel'Ve injury is reporred ro occur in approximately ACL tears associated with Salter-Harris rype III fractures of the
3% of separations of the distal femotal epiphysis. It rarely re- medial femoral condyle.
quires rreatment other than reduction of the separation. The Bertin and Goble (7) found that 6 of 16 patients seen in
exception ro this is a transected nerve in association with an open follow-up fot distal femoral physeal fractures had positive ante-
injury, which may be treated with repair or grafting. Persistent rior drawer and Lachman tests; 1 patient had laxity to valgus
neurologic deficit after 3 to 6 months warrants electromyo- stress. They surmised that during injury, knee ligaments stretch
graphic examination. If the conduction time is prolonged and in series just before fracture-separation of the adjacent cartilagi-
fibrillation or denervation is present in distal muscles, explora- nous physis. They emphasized the importance of early diagnosis
tion and microneural reanasromosis or resection of any neuroma of associated ligament injury. If there is no meniscal injury, a
may be indicated. rehabilitation program is indicared initially. If there is a reparable
meniscal tear, cruciate reconstruction at the time of meniscal
repair after physeal healing may be indicated, depending on the
Recurrent Displacement patient's age and activity level.
Separation of the distal femoral epiphysis may be quite unstable
after reduction. Bassetr and Goldner (4) found that 10 of 25
patients had loss of reduction after tile initial manipulation. Progressive Angulation
Thomson (78) found that 6 of 30 had either an unacceptable Progressive angulation aftet separation of the distal femoral epi-
reducrion or loss of reduction. After reduction of anterior dis- physis usually is caused by asymmetric growth (1,8,60) from
placemem, the epiphysis may tilt forward again as swelling sub- either trauma to the physis at the initial injury (Salter-Harris
sides. On the other hand, immobilization in extension stabilizes rype I or II) or physeaJ offset with bony bar formation after
reduction of posterior or mediolateral displacement. Aitken and healing (28) (Salter-Harris rype III or IV; Fig. 23-17). Occasion-
Magill (2) pointed out that the gastrocnemius acts as a strap ally, progressive angulation follows nonphyseal fractures (Fig.
against the posterior aspect of the distal femoral epiphysis when 23-18), in which an associated Salter-Harris rype V physeal in-
the knee is extended. If reduction is lost so that a second manipu- jUly presumably was not noted (34). The risk of angular disturb-
lation is required, imernal fixation should be used. ance is highest in juveniles. If the growth defect is secondary to
a persistently displaced Salter-Harris rype IV injury, evidence of
bony union is prcsem be[\'Veen the displaced epiphysis and the
Knee Joint Instability
metaphysis across the fracture line.
Symptomatic knee joint instabiliry may persist after the epiphy- If the separation is a Salter-Harris rype II injury, the physis
seal separation has healed. This finding at follow-up implies distal to the triangular metaphyseal fragment usually is spared.
concomitant injury ro knee ligaments, often unappreciated at The localized area of growth inhibition occurs in that portion
the time of initial management of the epiphyseal separation. of the physis not protected by the metaphyseal fragment. If
Aitken and Magill (2) found that four of nine patients had "some progressive angulation occurs after a Salter-Harris rype II separa-
evidence of relaxation of the anterior cruciate ligament." In the tion with lateral displacement, the subsequent deformity usually
20 patiems reviewed by Stephens et al. (76), 5 had persistent is varus. Conversely, if a Salter-Harris type II separation occurs
1006 Lower Extremity

epiphysis and the meraphysis is carefully removed wirh a curet

and power bur. The defecr is fiJled with autogenous far (42,43)
or cranioplasric methacrylate.
Hemiepiphysiodesis may be considered in maturing adoles-
cems wirh progressive varus or valgus angularion associated wirh
a central bony bridge wirh some remaining growth medially or
laterally. Enough growrh may remain in rhe segment of physis
between rhe bony bridge and rhe perimeter on rhe same side
to correct rhe deformity. Eirher stapling (85) or percutaneous
epiphysiodesis (65) can be done ar rhe edge of rhe physis opposire
rhe bony bridge, often wirh sarisfactory resulrs. Bowen er al.
(l 0) devised a chart based on skeleral age rhat is useful in estimat-
ing the amount of correction of angular deformity thar hemiepi-
physiodesis will effecr. Neverrheless, because of rhe physeal bar,
rhis procedure has an element of un predicrabi Iity thar coumer-
A balances irs simplicity. If hemiepiphysiodesis is used to correcr
angular deformity, rim ely epiphysiodesis of rhe opposite limb
may be required to prevent signiftcant limb-Iengrh discrepancy
(Fig. 23-19).
If the patient is wirhin 2 years of skeletal marurity, correcrion
of significant angular deformity by epiphysiolysis wirh an exter-
nal ftxaror may be considered (23,25,48,58,59). The pins can
be held by one of the many types of adjustable lengrhening
ftxators (24,25,37,55). Gradual distraction and realignment are
done with careful attention to the possibility of neurologic com-
promise. These techniques are demanding and are best done by
rhose wirh experience.
If the patient is approaching skeletal maturity, corrective oste-
otomy is the preferred treatment. For associated shonening, an
opening-wedge osteotomy is preferable. The technique for cor-
recting deformity has been described and illustra[ed by Abbort
and Gill (1) and by Scheffer and Peterson (69). An osteoromy
B is made at rhe supracondylar level, parallel to rhe articular surface
FIGURE 23-17. Mechanism of physeal bar formation after Salter-Harris
of rhe condyles. The hinge of rhe osteoromy should be in me-
type III and IV fractures. Physeal vessels that normally are distal (A) may taphyseal bone, which is bener able to deform plastically than
anastomose with metaphyseal vessels because of vertical translation is corrical bone. Usually no more than 15 degrees of correerion
after Salter-Harris type IV fracture (B). (From Gomes LsM, Volpon JB.
Experimental physeal fracture separations treated with rigid internal can be obtained withour cracking the hinge. The distal fragment
fixation. J Bone Joint Surg Am 1993;75: 1756-1764; with permission.) is rhen tiJred to place rhe arricular surface in horizontal align-
ment. A triangular fragment of aurogenous iliac bone is inserted
in the opening. If the hinge is srrong and the parienr is slender,
immobilizarion in a cast may be all that is needed. Orherwise,
ftxation with crossed pins or plate and screws may be necessary.
with initial medial displacement, the subsequent deformity often
An alrernative method of fixarion for an opening-wedge oste-
is valgus.
otomy or for lengrhening and angular correcrion of the distal
If a localized area of premature arrest consrirutes less than
femur is exrernal fixation. The DeBastiani device or an Ilizarov
25% to 30% of the total area of the physis and if ar leasr 2
construcr (33,55) is useful because the amount of lengthening
years of growrh remain, excision of the bony bridge should be
or angulation can be adjusred posroperatively, and significant
considered (65). The bridge can be accurarely defined by MRl,
angulation and length deformities can be correcred.
bur the study must be ordered with attenrion called to the physis,
Abborr and Gill (1) noted rhar a compensarory deformity
rarher than to the knee irself. The characrerisrics of partially
may occur in [he proximal tibia, and if angularion of the femur
bound wan:r in physeal cartilage are disriner from those of free
is corrected, subsequent osreotomy for correcrion of rhe ribial
synovial fluid, and excellenr conuasr can be obtained with proper
deformity may be indicated. Although no long-rerm dara exist,
planning. The surgeon should reguesr proton-densiry sequences
any coexisring tibial deformiry of more than 10 degrees probably
wirh far suppression or T2-weighred gradient-echo images (fast-
should be corrected ro maintain a horizontal knee joint.
field echo) (19). AJternatively, helical CT scans may used to
creare a map of the injured physis (20,44). The technique of
Leg-Length Discrepancy
excision is well described by Peterson (60). A peripheral bridge
can De approached directly. A centtal bridge is approached Progressive leg-length discrepancy may follow a separarion of
through a metaphyseal window. The area of union between the rhe disral femoral epiphysis if premature arresr of rhe physis
 Chapter 23: Fractures" find Dislocations Aholtt the Knee 1007

A B

c D
FIGURE 23-18. A: Genu valgum deformity of the right knee in a 14-year-old boy who sustained a right
femoral shaft fracture at 10 years of age. Band C: Anteroposterior and lateral tomograms demonstrate
bony bar formation in the posterior and lateral aspects of the distal femoral epiphysis. D: After distal
femoral supracondylar osteotomy and bony bar resection of the distal femur.
1008 Lower Extremity

A B
FIGURE 23-19. A and B: Comminuted, open, T-condylar fracture of the distal femoral metaphysis and
epiphysis in a 1O-year-old girl. (Figure continues.)

occurs (22). If the patient is within 2 years of skeletal maturiry physiodesis or shortening of the opposite limb. Epiphysiodesis
at the time of injury, the shortening probably will be insignifi- should be timed by either the Moseley method (49) or Green-
cant. If there are more than 2 years from the time of injury w Anderson method (31).
skeletal maturity, the leg-length discrepancy may progress at a
rate of I cm (% in.) per year.
Sometimes the growth disturbance is not a discrete bar but Stiffness
a partial physeal slowing. The progression of leg-length discrep-
ancy is best followed by serial examinations. Every 6 months, a Limitation of knee motion after separation of the distal femoral
scanogram and bone age are obtained and the clinical discrep- epiphysis may be caused by intraarticular adhesions, capsular
ancy is measured. The leg lengths can be planed on the Moseley contracture, or muscular contracture. Regaining k11ee motion
straight-line graph (49). After three sequcmial scanograms over is difficult after immobilization in flexion for reduction of an
a period of 12 to 18 months, discrepancy at skeletal maturity anteriorly displaced epiphysis. As soon as possible, the knee
can be estimated by extrapolation according w the rate of grow til should be graclually extendecl. Limitation of knee extension usu-
of each limb. ally is caused by contracrure of the posterior capsule and a weak,
If the estimated discrepancy at skeletal maturiry is less than stretched-out quadriceps muscle. This should be treated with
2.5 cm (1 in.), no definitive trcatment is indicated. If the esti- active and active-assistive range-of-motion exercises, with em-
mated discrepancy is 2.5 w 5 cm, surgical closure of the contra- phasis on quadriceps strengthening. Internal fIxation with early
lateral femoral or tibial physes in the opposite extremiry at the motion may be considered. For patients with stiffknees in whom
appropriate time should be considered (47). In older patients conservative treatment has failed, surgical release of contractures
close to skelctal mamriry, shortening of the contralateral femur and adJlesions, Followed by continuous passive motion, may re-
at the subtrocl1anteric or mid-diaphyseal level is an option. gain significant motion (21).
If the estimated discrepancy at maturity exceeds 5 cm, length- Intraarricular adhesions may form in the k11ee with hemar-
ening of the short femur by corricowmy and slow distraction throsis. An irregular articular surface from a Salter-Harris rype
witl1 an external fixaror should be considered (Fig. 23-20). Large II! or IV injury may contribute w early degenerative changes.
discrepancies after injury early in life can be equalized by re- The incidence of permanent persistent stiffness is relatively low
peated lengthenings, combined if needed with appropriate epi- [23 of 140 patients (16%) (2,45,51,65,76); see Table 23-5].
 Chllpter 23: Fractures and DiJ-IOCfUions About the Knee '009

c D

FIGURE 23-19. (continued) C and D: After irrigation and de-

bridement and cannulated screw fixation of the metaphyseal
and epiphyseal fractures. E: One year after injury, the articular
E surface is restored but the distal femoral physis is closed.
1010 Lower Extremity

FIGURE 23-20. A: Salter-Harris type II fracture of the distal femur with medial
metaphyseal fragment in an 8-year-old boy. B: After being lost to follow-up
for 4 years, he presented with 6 cm of shortening and a mild varus deformity.
C: Magnetic resonance image with gradient-echo sequence shows physeal bar
formation involving approximately 40% ofthe physis. D: Distal femoral osteot-
omy and proximal femoral lengthening of 9 cm to match the existing and
A anticipated future discrepancy produced satisfactory results.

B,C D
 ClJltPII'r 23: fractures ami Dislocations Aboftt the Knee 1011

FRACTURE OF THE PROXIMAL TIBIAL

EPIPHYSI
Historical Review
The physis of the proximal tibia is well protected, in contrast
ro the distal femoral physis. On the lateral aspect, the proximal
tibial epiphysis is bumessed by the upper end of the fibula.
Anteriorly, the tubercle projects down from the epiphysis ro
overhang the adjacent metaphysis. The supetficial ponion of the
medial collatetal ligamenr (MCl) extends beyond the physis to
inserr into the uppet metaphysis. In the posteromedial corner,
the insenion of the semimembranosus muscle spans the physis.
Thus, there is nearly circumferenrial reinforcement to the peri-
chondrium.
Because of this protection, separation of the proximal tibial
epiphysis is relatively rare (see Table 23-1). Neer and Horwitz
(52) reported an incidence of 0.8% in 2,500 consecutive physeal
fractures. Mann and Rajmaira (46) reviewed 2,650 long bone
ftactures in childten; 15 (0.6%) were physeal separations of the
proximal tibia, mosrly in adolescent boys.
The mOSt setious complication of injury ro the proximal tibia
is vascular compromise. The popliteal artery is tethered by its
major branches near rhe posterior surface of the proximal ribial
epiphysis. The posterior tibial branch passes under the arching
fibers of the soleus. The anterior tibial artery passes forward FIGURE 23-21. Medial view of fracture-separation of the proximal
rhrough an aperture above the proximal border of rhe interos- tibial epiphysis resulting from hyperextension of the right knee. Poste-
riorly displaced proximal tibial metaphysis impinges on the adjacent
seous membrane. A hyperexrension injury that tesults in poste-
popliteal artery.
rior displacement of the upper end of the metaphysis may sttetch
and tear the bound popliteal artery (Fig. 23-21).
Similar to separations of the distal femoral epiphysis, injuries
ro the proximal tibial epiphysis may cause shortening or angula- quent growrh disturbance was required in a third of rhe parienrs.
rion from subsequent growth inhibition. This inhibition can Two patienrs presented late with associated arterial insufficiency.
occur after Salter-Harris type I and II injuries (76,82,89). Pre- Shelton and Canale (93) reponed 39 injuries ro the proximal
sumably, a concurrent longitudinal compression force damages tibial epiphysis. Posterior displacement of the shaft with disrup-
the deeper proliferative zone of the physis. tion of the popliteal artery was found in two patients. Unsarisfac-
Some authors (87,93) include complete avulsions of the tibial tolY resulrs because of chronic vascular insufficiency, growth
tubetcle in reviews of fracture-separations of the proximal tibial disturbance, or traumatic arthritis occurred in four patients.
epiphysis. However, avulsion fractures of the tibial tubercle con- In 1983, Bertin and Goble (7) reported a rerrospecrive study
stitute a specific subgroup considered in a separate section of of physeal fractures abollt the knee in which 8 of 13 patienrs
th is chapter. wirh separations of the proximal tibial epiphysis had ligamel1[olls
Poland (61) reported 24 children with fracture-separations laxity manifested by positive anterior drawer and Lachman tests.
of the proximal tibial epiphysis, most of them younger than 9 These authors described a subset of three parients with almost
years of age. He srared that the usual mechanism of injulY was identical Sal ter- Harris type III fractu re-separarions wi rh associ-
a direct crushing fotce, such as a wagon wheel rolling over a ated MCL tears.
child's leg. In Poland's day, such an injury was often open, and In 1989, Poulsen et al. (91) reviewed 15 patients with proxi-
infection frequently Jed ro amputation, if not death. Poland mal tibial epiphyseal fractures. Concomitant avulsion fractures
found that experimental separation of the upper tibial epiphysis of the tibial insertion of the ACL occurred in five patients. One
could be produced most easily on cadavers between the ages of patient had primary repair of the ribial collateral ligament. Ar
8 and 15 years, and most injuries ro the proximal tibial epiphysis follow-up, twO patients had combined anterior and medial lax-
occur in rhis age group. ity, and another twO patients had isolated anterior hxity.
Nicholson (90) reponed four separations of the proximal In 1991, Wozasek et al. (%) teported 31 injuries of the
tibial epiphysis, all in children struck by auromobiles. ]n three proximal tibial epiphysis. Four patients had signs of distal is-
of the four patients, the displacement was posterior. Burkharr chemia before reduction that resolved after reduction. One pa-
and Peterson's (87) clinical review of 28 fracture-separations tient had a delayed diagnosis of ischemia that required amputa-
included four avulsion fractures of the tibial tubercle and five tion, and one had peroneal palsy.
open injuries ro small children from rotary lawn mowets. Of In 1998, Gautier et al. (89) performed a meta-analysis of the
the 19 remaining injuries, half occurred during athletics and literature including their own cases, and found a 25% incidence
half in moror vehicle accidents. Corrective surgery for subse- of signiJ1canr growth disturbance.
1012 l.ower E'Ktremil)!

llrgical Anatomy 8M
Bony Anatomy
The ossific nucleus of rhe proximal tibial epiphysis appears by
2 monrhs of age. Ir lies in the cencer of rhe cartilaginous anlage,
somewhat closer ro rhe metaphysis rhan ro rhe articular surface.
Occasionally, the ossification cencer is double. The secondalY
cencer in rhe rubercle appears berween rhe 9rh and 14th years.
MG lG
By the 15th year, the upper epiphysis unites with the tubercle
and is almost completely ossified.
The distal surface of the epiphysis is concave ro match rhe
convex upper surface of rhe metaphysis. There is a slighr central
norch in the surface of the metaphysis. The epiphysis is higher MCl
on rne lateral surface rhan on the medial surface. The physis
slopes down somewhar farther on rhe lateraJ side than on rhe
lCL
medial sidc. In the posrerolateral corner, the physeal surface is
immediately inferior ro rhe upper tibiofLbular joinr. From rhis MIGA
poinr, the perimeter of the physis exrends across rhe posrerior
aspecr of rhe LIpper tibia proximal to rhe origin of the poplireus
muscle. On rhe medial side, the physis is proximal ro the inser-
rion of rhe superficial MCL. On rhe anreromedial and ancerolar-
eral surfaces of rhe upper tibia, rhe physis creares a circumferen- L1GA
rial ridge berween rhe vertical surface of the epiphysis and the
sloping of the meraphysis. This ridge is palpable through rhe
overlying skin and subcuraneous rissue. In rhe midline anceri-
orly, the physis dips down underneath rhe tibial rubercle.
The larct·a1 edge of rhe physis is separated from the proximal
tibiofibular joinr by a rhin layer of joinc capsule. Hemorrhage
from a separarion may extend into the adjacent joint cavity and
FIGURE 23-22. Posterior anatomy of the right popliteal region. Note
through it inco rhe knee joinc irself (92). The physis closes that the popliteal vessels are protected from bone (especially the tibia)
slighrly earlier posreriorly rhan anteriorly (86). only by the popliteus muscle. The vessels are tethered by the geniculate
branches and by the trifurcation. MG and lG, medial and lateral gas-
trocnemius heads; SM, semimembranosus; MCl, medial collateralliga-
Soft Tissue Anatomy ment; lCl. lateral collateral ligament; MIGA, medial inferior geniculate
artery; L1GA, lateral inferior geniculate artery; AlA, anterior tibial ar-
The synovium and the capsule of the knee joinc insert into the tery.

ptoximal ribial epiphysis well above rhe physis. There is a defecr

in the capsule where the popliteus rendon runs over the postero-
larer:tI corner of rhe ribia. The arcuate ligamenc arches over the
popliteus tendon from the proximal tibia ro rhe posrerior aspect vessel against rhe knee capsule. The poplireus musclc intervenes
of rhe epiphysis. The capsular ligament anchors rhe menisci to berween rhe aaety a.nd bone. The I:lteral inferior geniculare ar-
rhe ribial epiphysis medially and larerally. The lareral collareral tery runs across the surface of the poplitcus muscle, anterior to
ligamenr (lCU of the knee inserts inco rhe fibula (Fig. 23-22). the lateral head of rhe gastrocnemius, and rums forward under-
The MCl inserrs beyond rhe physis into rhe upper metaphysis neath the lCL. The medial inferior geniculate artery passes along
of rhe ribia. The parellaI' ligament inserts, for rhe most part, into the proximal border of rhe poplitcus muscle, anterior to the
rhe secondary ossificarion center of rhe tLIbercle, alrhough some medial head of the gastrocnemius, and extends forward along
fibers exrend beyond rhe physis into rhe anterior aspecr of rhe the medial aspeCt of the upper ribia. Beneath the soleal arch,
upper ribial diaphysis. The semimembranosus muscle inserrs the popliteal artery divides into the anterior tibiaJ and posrcrior
above and below rhe physis in rhe posteromedial corner. As ti biaJ branches.
rhis tendon approaches the proximal tibia, it divides inco four The proximal ribial epiphysis derives much of its blood sup-
inscrtions: the posrerior capsule of the knee joint, the posrerior ply from an anasromosis berween the geniculate arteries posrerior
surface of the ribial epiphysis, the medial surface of rhe ribial ro the patellar ligament. Multiple sma! I vessels pass backward
epiphysis, and rhe medial surface of rhe ribial meraphysis. and downward into the anterior aspect of the epiphysis. Other
small vessels enrer the epiphysis on the posterior surface, adjacent
ro rhe attachment of the posterior cruciate ligament (PCl). More
Vascular Anatomy
vessels enter rhe medial and lateral surface of the epiphysis. The
The disral portion ofrhe popliteal artery lies close ro the postcrior diffuse exrraarticular blood supply to this epiphysis makes it less
aspccr of the upper tibia. Firm connecrive tissue septa hold the vulnerable to ischemia from injUlY.
 Chapter 2.3: Fractures and DiJlocatwm About the Knee 1013

Mechanism of Injury
TABLE 23-6. CLASSIFICATIONS AND
Fracture-separation of the proximal tibial epiphysis can be IMPLICATIONS OF PROXIMAL
caused by a direcr or indirect Force. A direct Force may be im- TIBIAL PHYSEAL FRACTURES
posed when a child's leg is run over by the wheels of a vehicle Classification Implications
or when it is caught berween bumpers of twO auwmobiJes (Fig.
23-23). More oftl'Jl, separation of the proximal tibial epiphysis Mechanism of injury
I. Hyperextension Risk of vascular disturbance
is caused by an indirect mechanism. The lower leg is Forced inro
II. Varus/valgus Usually results from jumping; very near
abduction or hyperexrension against the fixed knee. An apex of maturity
deFormity on the medial side implies a panial tear of the superfi- III. Flexion Pes anserinus or periosteum may be
cial ponion of the MeL. Indirect injuries to adolescents occur entrapped
during spons, mowr vehicle accidents, or falls. Less Frequently, Salter-Harris pattern
flexion injuries of the proximal tibial physis have been described, I Fifty percent nondisplaced
II Thirty percent nondisplaced
all in boys 15 or 16 years of age as tlley starred or landed from III Associated collateral ligament injury
a jump (95). Many Ilad closure of the physis posteriorly, result- possible
ing in genu recurvawm deformity. Vascular injUly has not been IV Rare
reponed with this injury (96). These fractures represent a transi- V Has been reported; diagnosis usually
tion berween tibial wbet'cle fractures and ribial epiphyseal sepa- late
rations, in comparing the mechanism of injury and Frac[UI'e
anatomy.
Injury to dle proximaJ tibial epiphysis can occur From passive
extension of rhe legs of a newborn ar the time of a difficult
breech delivery (74). Separations of tnis epiphysis have occurred
CI assifica tio n
during passive manipulation of the lower limbs in infants with
arthrogryposis (26), and attempts at closed manipulation of val- Most separations of the proximal tibial epiphysis are Salter-Har-
gus deformities have produced this lesion. Parll010gic separations ris lype I and J[ injuries (Tables 23-6 and 23-7). The frequency
have been reponed in association with osteomyelitis of the proxi- oFSaltel--Harris rype III injuries may be skewed by the inclusion
mal tibia or meningomyelocele (27,84). of displaced avulsion fractures of the tibial tubercle, and the

FIGURE 23-23. A: Comminuted Salter-Harris type II fracture

of the proximal tibial epiphysis in a 9-year-old boy_ Additional
injuries included peroneal nerve injury, popliteal artery lacera-
tion, and compartment syndrome of the tibia. B: At follow-up,
note valgus deformity ofthe proximal tibia with delayed union
of the proximal tibial metaphysis_ B
1014 LOlVer E'xrremity

TABLE 23-7. FREQUENCY OF TYPES OF FRACTURE-SEPARATION OF THE

PROXIMAL TIBIAL EPIPHYSIS

Sa Iter-Harris
Classification Aitkena Burkhart!' Shelton C Total

I 3 9 12 (15%)
II 9 9 17 35 (43%)
III 2 6d 10d 18 (22%)
IV 3 8e 3 14 (27%)
V 2 2 (3%)
81,

• Aitken AP. Fractures of the proximal tibial epiphyseal cartilage. Clin Orthop 1965;41:92-97.
b Burkhart SS, Peterson HA. Fractures of the proximal tibial epiphysis. J Bone Joint Surg Am 1979;61:
996-1002.
C Shelton WR, Canale ST. Fractures of the tibia through the proximal tibial epiphyseal cartilage. J Bone

Joint Surg Am 1979;61:167-173.

d Includes avulsion fractures of the tubercle extending up into the proximal tibial epiphysis.
C Includes five open injuries from rotary lawn mowers.

incidence of Salter-Harris type IV injuries depends on wherher Signs and Symptoms

open injuries to the knee (i.e., lawn mower) are included, as in
A patient with a separation of the proximal tibial epiphysis usu-
rhe series by Burkhart and Peterson (87).
ally has a knee joint tense with hemarthrosis. Extension is limited
Fifty percent of Salter-Harris type I separations of the proxi-
because ofhamsrring spasm. Typically, tenderness is present over
mal ribia are nondisplaced. Suess radiographs may reveal widen-
the proximal tibial physis 1 to 1.5 cm distal ro the joint line.
ing on the medial or posterior aspecL If displaced, the meraphysis If the proximal end of the metaphysis is displaced posteriorly,
is medial or posrerior relative to the epiphysis. Presumably, the a concavity is seen and felt anteriorly at the level of the tibial
overhanging wbercle prevents anterior displacement and the fi- tubercle. If the metaphysis is displaced medially, a valgus defor-
bula prevenrs lareral displacement of the metaphysis. There may mity is present. Thete may be tenderness or angubtion of the
be an associated fracture of the proximal diaphysis of the FJbula proximal fibula as well. If the proximal end of the metaphysis
or a separation of the proximal fibular epiphysis. protrudes under the subcutaneous tissues on the medial aspect
Two thirds of Saln;r-Harris rype IT fractllre-separations of of the knee, a tear of the distal end of the Mel should be
the proximal tibial epiphysis :Ire displaced. Displacement of the suspected.
tibial metaphysis usually is medial (fig. 23-24), and the associ- Vascular status must be carefully documented. Routine angi-
ated metaphyseal fracture usually is lateral, resulting in valgus ography is not mandarory because ischemia usually resolves with
deformity. The proximal fibula also may be fractllred. reduction, but moror function, pulses, warmth, and color should
Saker-Harris type III separations have a vertical fractllre line be checked frequently during the initial 48 to 72 hours. Welch
through rhe proximal epiphysis from the anicular surface to the and Wynne (94) described a nondisplaced separation of the
physis. Most commonly, the lateral epiphysis is fractured, and proximal tibial epiphysis that was initially misdiagnosed as an
the MCl frequently is torn. This lateral fragment may require isolated tear of the MCl because tenderness over the medial
internal fixation, and the MCl may require surgical repair. aspect of the proximal tibia was interpreted as evidence of an
Salter-Harris lype: IV injuries can involve the medial or lateral avulsed ligament. Operative exploration showed the distal at-
ribi:ll plare:lu. Saher-Harris type V injuries are rare bur have tachment of the ligament was intact below the level of the physis.
been reponed in the proximal tibia. UsualJy, rhe diagnosis is Stress radiographs revealed an epiphyseal separation.
made in rcrrosp..:cr when progressive :lngulation or leg-length Fracture-separations of the ipsilateral distal femoral and
discrepancy is noted. A rype V injury localized ro the anterior proximal tibial epiphyses may occur simultaneously (Fig. 23-
portion of the physis may cause genu recurvarum. A triplane 26). This injury in children is analogous to the floating knee
fractllre-separation may rarely involve the proximal tibial epi- injury in adults. Internal derangemene of the knee joint may
physis. occur with separarion of the proximal tibial epiphysis. Concomi-
tane avulsion of the tibial eminence also has been reponed.
Proximal tibial fractures also can be classifIed by the direction
of deformity (Fig. 23-25). The classic hyperextension type has
an apex-posterior angulation and results from forced hyperexten-
sion. The flexion type results from inrernally generated forces Radiographic Findings
of jumping or landing and has a anterior apex. Varus and valgus Nonclisplaced separations may nor be visible radiographically.
rypes result from abduction or adduCtion forces. Swelling about rhe proximal tibia may obscure soft rissue shad-
 Chapter 23: Fractures and Dislocatio1lS About the Kllee 1015

A
FIGURE 23-24. A: Salter-Harris type II separation of the proxi-
mal tibial metaphysis, with medial displacement of the proxi-
mal tibial metaphysis and complete fracture of the upper third
of the fibula with complex soft tissue injury. B: After reduction
and percutaneous fixation with a 4.5-mm cannulated screw. B

A,B c
FIGURE 23-25. Classification of proximal tibial physeal fractures by direction of displacement. A: Type
I: hyperextension type, usually caused by direct force. Risk of vascular damage exists. B: Type II: varus
or valgus type. Less risk of vascular injury. Reduction may be inhibited by interposition of pes anserinus
or periosteum. C: Type III: flexion type (rare), usually caused by internal forces as in jumping. Carries
least risk of vascular injury; occurs near end of growth.
 1016 Lower Ex·tremity

FIGURE 23-26. A: Salter-Harris type IV fracture of the proximal tibia and Salter-Harris
type III fracture of the distal femur treated with open reduction and internal fixation.
A B: Four years later, growth is restored.

ows. An associated hemarrhrosis is manifesred by an increased Bohler (9) advised placing a calcaneal pin. The leg is rhen
space becween the patella and disraJ femur. Sttess radiographs flexed over rl1e surgeon's forearm, which is placed in the popliteal
in both coronal and sagirraJ planes should be obrained, bur hy- fossa. Longitudinal tracrion is applied ro rhe pin while the sur-
perextension of the knee should be avoided because of rhe possi- geon's arm lifts up. Upward tracrion on the proximal tibial me-
biliry of injury to the popliteal vessels. taphysis may be accomplished with a second pin inserted under
The radiographs are scanned For evidence of fracture lines the tibial tubercle. A long leg cast is applied after reducrion is
extending proximally rhrough the epiphysis or distally through obtained.
the metaphysis. A small bony fragmenr at the periphery of rhe An abduction fracture with valgus angulation usually can be
metaphysis may be rhe only clue ro the diagnosis. Fracrure lines reduced by adducring the leg on the exrended knee. This should
may be visible onJy on oblique views. be a gentle manipulation to decrease the risk of injury ro rhe
Mosr patients with separations of the proximal tibial epi- peroneal nerve. Afrer reduction, a long leg cast wirh varus mold-
physis are adolescents in whom the secondary ossification of the ing is applied wirh rhe knee in slighr flexion.
ribial tubercle has appeared. A smooth, horizontal radiolucent
line through the base of rhe tubercle should nor be confused with
an epiphyseal fracture. It may represenr an incomplete fusion of Indications for Operative Treatment
the cwo secondary ossiflcarion cemers: the tubercle ossicle and
Separarions of the proximal tibial epiphysis may be surprisingly
rhe main ponion of rhe proximal tibial epiphysis.
unstable. Smooth pins can be inserted percutaneously, crossing
Compured romographic scans may be helpful in determining
distal fO the physis ro mainrain reduction. The proximal ends
the trearmenr of Salter-Harris eype III and lV fracture-separ-
should not protrude inco the knee joinr. An image inrensiJier
ations. MRl may identify soft tissue interposition in displaced
makes percutaneous flxa tion easier.
proximal tibial epiphyses, which are difflculr to reduce by closed
Open reduction is indicated for displaced Salter-Harris type
methods. Wood et at. (95) reported a patient in whom the pes
1lI injuries. An anrerior incision is used co allow inspection of
anserinus was folded inro the fraCture site.
the articular surface. A pin. is inserted in the displaced fragmenr
and is used co guide it coward reducrion. Other pins or screws are
Treatment rhen inserted hori/.ontally 'lCl'OSS the epiphysis. Small cannulared
screws often are helpful in this type of fracture.
Nonoperative Treatment
A similar technique is used for displaced Salter-Harris rype
Hyperextension fractures are reduced with a longitudinal force lV injuries. Fix,ltion can be obrained by placing screws across
on the tibia combined with a genrle, anterior translating force the larger metaphyseal, as well as the epiphyseal, fragmenrs (Fig.
on the proxima] metaphysis. Counterrracrion on the femol'al 23-26). If there is a lineal' peripheraJ rear of the meniscus overly-
shaft is applied by an assiStant. ing the injured condyle, repair is performed. Primary repair of
Nicholson (90) reponed reducrion of posrerior displacement concomitanr complere Iigamencous injury also should be consid-
of the metaphysis by pulling the proximal ribia forward and erec!'
flexing rhe knee to 90 degrees wirh mild inrernal rorarion of rhe Operarive flxarion of a hyperextension injury may be indi-
tibia. cared for stabiJizarion if an associated poplireaJ artery injury is
 C/;tfpter 23: Fractures and DisLoraliom AbOttt the Kilti' 1017

repaired. Immediate exploration is not indicated For symptOms be insened from a disral-tO-proximal direction to avoid passing
of peroneal nerve injury. Peroneal neuropathy associated with through [he join t capsule. Smoorh ~~- or Y32-in. Kirschner wires
a separation of the proximal tibial epiphysis usually recovers can be used and temoved 6 to 8 weeks after insenion.
spomaneously wirh rime. For nondisplaced Salter-Harris rype III separarions, a long
leg casr is worn for 6 to 8 weeks. If displacement exceeds 2
mm, we perform closed or open reducrion and flxarion wirh
• AUTHORS' PREFERRED METHOD percutaneous pins or cannulared screws. AIter the patient has
V OF TREATMENT been anesrherized, a Steinmann pin is insened into the fragmenr
and used to guide the fragment into position wirh rhe help of
If a proximal tibial epiphysis is nondisplaced, we place the pa- an image intensifier. AIrer reducrion, one or rwo smooth pins
tient in a long leg cast with the knee flexed 30 degrees. The cast or small cannulared screws are insened rransversely across rhe
and underlying padding are initially bivalved From top to bot- epiphysis, taking care not ro cross the physis in a young child.
tom. Anteroposterior and lateral radiographs are repeated 1 week AIrer inrernal fixarion has been obrained, rhe Jmee is again care-
after injury to conFlrm acceptable position. The cast is removed fully messed into valgus to see if the MCL is intact. Similarly,
6 to 8 weeks after injury. If subperiosteal new bone formation a lateral view with stress in the sagirral plane is obrained ro rule
has appeared and if the leg is nomender, active range-oF-motion our associared cruciare injury. If a rear of rhe MCL is derecred,
and muscle-srrengthening exercises are begun. We do not allow we may proceed wirh primary ligamenrous repair, eSl)ecially in
the patiem to return to vigorous activities until the region is ao adolescen t.
nontender and knee range of motion and quadriceps srrength A similar rechnique is used for reduction and fixarion of
are near normal. SaJrer-Harris rype IV separarions. IF reducrion is not anaromic,
Before reducing a Salter-Harris rype I hyperextension injury, we perform an open reducrion under direct vision. Fixation pins
we check for signs of neurologic or circulatOry impairment. If the may be removed under brief general anesrhesia when rhe cast is
displacement is significant, we prefer to use general anesthesia for removed, 6 ro 8 weeks afrer injury. If the fracrure is open and
reduction. With the patient supine, the fracture is reduced by the fragment is deviralized (j.e., lawn mower injury), rhe avascu-
flexing the hip and knee to 45 degrees while applying longitudi- lar piece is removed. Non-weighr bearing is advised for 2 months
nal rraction. The upper leg is grasped behind the calf. The distal afrer Salter-Harris rype III and IV injuries, but active range-of-
tibia is stabilized, usually by holding it between the surgeon's motion exercises should be sraned immediately afrer removal of
knees or between his or her elbow and chest. The proximal the cast.
metaphysis is pulled gently forward. Ar this point, flexion of the The parient is followed for 2 years to warch for Slgns of
knee is increased to 90 degrees, rhe peripheral pulses are checked angular deform iry or persisten t instabi liry.
again, and a lateral radiograph is obtained. If reducrion is satis-
factOry, a long leg cast wirh the knee flexed ar 60 degrees is
Prognosis
applied, and the cast is bivalved from tOp to bottOm. Direct
pressure over the proximal posterior ribia should be minimal. The overall prognosis for separarions of rhe proximal ribial epi-
Radiographs are obrained rhe nexr day and 1 week later. The physis is fairly good. Shelton and Canale (93) found thar 24
cast is changed to extend rhe knee to 30 degrees at 3 to 4 weeks. of 28 parients (86%) followed unril afrer skeleral maruriry had
Ar 6 to 8 weeks after injury, the casr is convened to a posterior satisfactory resulrs. If a small group of lawn mower injuries is
splim, and acrive range-of-motion exercises are begun. separared from rhe series of Burkhart and Pererson (87), 76%
For an abduction injury wirh valgus angularion, we sedare of rhe remaining 21 patjems did well afrer initial reduccion.
the patienr, aspirate any significant knee effusion under srerile Most of the fractures in borh series occutred in adolescents, and
precaurions, and rest carefully for a concomitanr tear of the MCL mosr injuries were closed.
or cruciare ligament. Valgus angulation is corrected by putting Open injuries of rhe proximal ribia have a much worse prog-
manual longitudinal tracrion on the leg. The knee is heJd in nosis. All rhe lawn mower injuries reponed by Burkhart and
almosr full exrension. With an assistant srabilizing the distal Pererson (87) had adverse sequelae. Four parienrs had significant
thigh and knee, the valgus angularion is correCted by guiding angularion (Fig. 23-27), fWO pacients had major leg-Iengrh dis-
the leg imo adduction. Tracrion is nor released until reducrion ([epancies, one conrracred osreomyelitis, and one had a severed
is accomplished. If rhe radiogLlphs confirm reducrion, the ex- peroneal nerve. Direcr crushing injuries to rhe knee wirh exren-
tremiry is immobilized in a long leg casr, molded into varus, sive bruising or laceration of overlying soft rissue also have a
wirh the knee flexed 15 to 20 degrees. Neurovascular srarus is poor ptognosls.
checked before and Jfrer reduction. The casr is removed in 6 to Benin and Goble (7) warned rhac nearly half rhe parienrs
8 weeks, and a knee immobilizet may be used for supporr for wich proximal ribial physeal fractures can be expecred to have
an addirional 2 ro 4 weeks. Jigamenrous instabiliry 5 years aFter injury. They noted thar per-
For flexion injuries, reducrion usually is obrained by applying sistent MCl insufficiency, genu valgum, and early degenerative
longirudinal rraction wirh rhe knee in full exrension. An exten- changes in rhe knee could follow Salrer-Harris rype III injuries.
sion cast is worn For 4 to 6 weeks, after which musc!e-srrengrhen- Poulsen er aJ. (91) found rhat 6 of 11 parients complained of
ing and range-of-motion exercises are begun. If a Salter-Harris pain or discomforT ar an average follow-up of 7 years. Four
rype I or II fracrure is unsrable aFrer reducrion, percuraneous patients had persisrenr ligamentous laxiry, and three parients had
crossed Kirschner wires should be used for flxarion. These can degenerative changes on radiographs.
1018 Lower E-r:tremity

TABLE 23-8. COMPLICATIONS OF PROXIMAL

TIBIAL FRACTURES

Complication Incidence

Vascular impairment 10%

Peroneal palsy 3%
Knee instability/degenerative joint disease 33%
Growth disturbance 10%-25%

Data from references 53, 87, 89, 90, 93, and 96.

loss of periosteal stability or ineffeceive splinting from surround-

ing soft tissues. The face that the collateral ligaments do not
attach co the proximal tibial epiphysis also may be a faceor in
instability. Ie is wise co obtain radiographs I week after injuJY
to check reduction. At that poine, it still is nOt roo late co remani-
FIGURE 23-27. Despite anatomic reduction, growth disturbance (so/id pulate the exuemity if necessary. If reduction cannot be main-
arrow) and valgus deformity occurred after metaphyseal fracture ofthe tained initia.lly, percuraneous pin fixarion or open reduction with
proximal tibia caused by a lawn mower accident. The fracture proved to inrernal fixation may be indicated, especially with displaced frac-
be a Salter-Harris type IV injury because of fracture extension through
the unossified epiphysis. cures. In unstable fractures with vascular injury, reduction and
pin fixation should precede exploration of rhe popliteal artery.
If rhe knee is swollen, sufflcienr flexion co maintain reduccion
of an anteriorly displaced sepal·arion may compromise circula-
The Salter-Harris classification is nOt always useful in predict- tion of the lower leg. Internal fix:Hion allows flexibility in posi-
ing risk of growrh disturbance afrer separarion of the proximal rioning the knee in a cast afret injury.
ribial epiphysis. Complete or partial growth arrest can occur
after Salter-Harris rype I, II, and III injuries, as we]] as after rype
IV and V injLll·,ies. Burkhart and Peruson (87) reponed two Vascular Injury
p:lCicnts with significant leg-length disCl"epancies and angular Nicholson's repon (90) of a patient with associared arterial in-
deformities after Salter-Harris type I and JI injuries. Sileiton and jUly is notable. The patient was seen less than an hour after an
Canale (93) reponed that all seven patients in their series with injury susrained while playing football. The knee was tense with
growth disturbances had fractures classified as Salter-H:uris rype effusion and extremely tender. There was a deep depre.ssion in
lor II. No significant growtl1 disturbances were associated with the area of the ribial rubercle, indicati ng posterior di.~placement
13 Salter-Harris type III or IV injuries. Subsequent osteoarthritic of the metaphysis relative to the epiphysis. The foot was warm,
cl1anges in the knee were related to fracrure patterns with inuaar- but the patient could not move his toes actively. Both pulses in
ticular extcnsion. the foot were absent and did not return aftl'r reduce ion of [he
The direction and degree of displacement are factOrs in the fractul·c. Exploration of the popliteal fossa revealed that bOth the
frequency of associated neurovascular or ligamentous injuries. popliteal artery and vein were completely severed. An attempr at
Posterior displacement of the metaphysis relative to the epi physis anastomosis failed and ampuration was performed.
is more likely to cause neurovascular or ligamentous injury than Burkhart and Peterson (87) reponed a patienr witl1 vascular
is displacement in the mcdial or anterior direction. Hyperexten- occlusion. A 12-year-old hurdler sustained a closed Salrer-Harris
sion injuries often cause neurovascular deficits because of im- type III injury that was treated wirh closed reduction and a long
pingement and stretch on structures running tlHough the popli- leg cast. Increased pressure in borh the anterior and postl'rior
teal fossa. muscle compartments caused narrowing of the terminal
branches of the popliteal artery, although artcriography showed
Complications that the poplireal artery itself remained patclH. fascioromies ;lI1d
Complicarions of proximal tibial fractures may be early or late. a s)'m pathectomy failed co save the leg.
Table 23-8 shows the incidences of the most common complica- Arterial insufficiency may result from either a rear in rhe
tions from major series. popliteal arrery at the time of epiphyseal separation (Fig. 23-28)
or from a compartmellt syndrome. Delay in recognition results
in delay of treatment, which is potencially catasrrophic. Arteriog-
Instability
raphy is nor mandatOry for isolated injuries but may be helpful
Separations of the proximal tibial epipl1ysis al·e surprisingly un- if rhe vascular supply is questionable. FracCLll·e fixation should
stable, regardless of the Salter-Harris rype. This is because of be followed by arterial exploration (posterior or posteromedial
 Chilpter 23: FraNure.; and Dislocation" About the Knee 1019

geons familiar with this technique, is an option in patients close

to skeleral maturity who have severe angular deformity and a
large leg-length discrepancy.

Leg-Length Discrepancy
The proximal tibial physis grows approximately y" in. per year.
If complete growrh arrest follows an epiphyseal separation at
this level and the patient is within 3 years of the end of growth,
an equalization procedure is unnecessary. If more years of growth
remain, epiphysiodesis of the opposite extremity may be consid-
ered. If arrest occurs before age 6 to 8 years, leg lengthening at
a later stage may be indicated. If rhe growth arrest is partial, it
is helpful to measure with sequenrial scanograms the relative
growrh rates of the two extremities so that the discrepancy at
skeletal maturity can be predicted. rf rhe predicted discrepancy
is less than 2.5 cm, no equalization procedure is planned. If the
expected discrepancy is 2.5 to 5 cm, epiphysiodesis of rhe oppo-
sire lower extremity is appropriate. If rhe expected discrepancy
exceeds 5 cm, limb lengthening should be considered.

AVULSION OF THE TIBIAL TUBERCLE

Considering the force wirh which the contracting quadriceps
muscle pulJs on its insertion, especialJy during jumping (concen-
trica.lly) or landing (eccentrically), it is surprising that rhe tibial
tubercle is not avulsed more frequently. The incidence relative
to injuries of other apophyses remains ill defined for two reasons.
First, the severe type of avulsion of rhe ribial rubercle that extends
proximally through rhe upper epiphysis of rhe ribia inro rhe knee
FIGURE 23-28. Anteroposterior radiograph at the time of arteriogram joim is sometimes reponed as a Salter-Harris type II[ separarion
shows a Salter-Harris type III fracture-separation of the proximal tibial of the proximal tibial epiphysis. Second, an acure localized avul-
epiphysis. The arterial flow through the popliteal vessels is blocked.
sion fracture of the ribial tubercle is sometimes thoughr ro be a
varianr of the Osgood-Schlaner (OS) lesion. For example, Shel-
ton and Canale (93) and Burkhart and Peterson (87) included
extraarticuJar tubercle avulsions in their reviews of proximal tib-
approach) and repair or vein grafting. Companmenr syndrome
ial physeal separations, whereas Ogden (53) included in his series
is n'eated by fasciotomy and delayed wound closure or skin
of ribial tubercle avulsions some cases that overlap wirh OS le-
grafting.
sIon.
The incidence of avulsion fracrures of rhe tibial tubercle,
compared wirh all epiphyseal injuries, is probably between rhe
Premature Growth Arrest
0.4% reponed by Burkhart and Peterson (87) and the 2.7%
Angulation from a localized area of growth inhibition may occur reported by Ogden et al. (117). The difficulty in separating
after any type of proximal tibial separation. The degree of pro- avulsion fracrures of rhe ribial tubercle from OS lesions stems
gressive angulation depends on the proximity of the area of largely from the lack of precise definition of eitller entiry. Some
growth arrest to the periphery of the physis. The amounr of differences are listed in Table 23-9, but some clinical fearures
angulation also depends on the years left for growth after injUlY. are similar. Some patiel1[s with OS lesions have a histoly of
If the area of growth arrest is localized to less than a third specific trauma. Avulsion fracrures of the tibial rubercle local ized
of the total area of the physis and ar least 2 years of growrh co rhe disral fragmenr of the rubercle (rype I) occasionally calise
remain, resection of the bony bridge may be attempted. Alterna- little more than poinr tenderness.
tively, epiphysiodesis or stapling of the side of the physis opposite An OS lesion may precede an acute avulsion of tne tibial
a peripheral bar may srop progression of the deformity (88). rubercle. Deliyannis (l06) reported a complere avulsion 'of the
Existing deformity at the time of surgeq may require proximal tibial ruberosiry in a 16-year-old boy who had been seen previ-
tibial osteotomy. If there is significanr valgus deformiry, an open- ously for an OS lesion. Levi and Coleman (lIS) scated thar 4
ing-wedge osteotomy to correct valgus deformity and gain length of 15 patienrs with fracrures of the ribial rubercle had hiswries
may injure the peroneal nerve. Slow correction after corrico- of OS lesions. Ogden et al. (117) reponed that 9 of their 14
tomy, wirh guided lengthening using an exrernal fixator by sur- patients wirh fracrures of rhe ribial ruberosity had preexisting
1020 [ow(';" Extremity

treated by open reduction, with various forms of fixation. The

TABLE 23-9. COMPARISON OF THE CLINICAL
FEATURES OF OSGOOD- authors warned that the size of the avulsed fragment often is
SCHLATTER LESION AND ACUTE underesrjmated because the tibial rubercle is incompletely ossi-
TRAUMATIC AVULSION OF THE fied at the time of injury.
TIBIAL TUBERCLE In an in-depth study of 14 fractures of the tibial rubercll' by
Osgood- Acute Traumatic Avulsion Ogden et al. (117), the sequence of events in the morphologi~
Schlatter Lesion of the Tibial Tubercle development of the ribial tuberosiry was related to the narrow
age range in which these fracrures occur. An analogy was drawn
Onset often insidious Acute injury (often in athletics) ro the fracture ofTiliaux because both injuries occur ar an age
Intermittent mild Immediate marked pain and
when physiologic epiphysiodesis has begun. Two pathologic
symptoms swelling
Partial disability Often unable to stand or walk fracrures were included in this report.
Symptomatic and Often open reduction and internal In 1981, Chrisrie and Dvonch (103) reported eighr avulsion
supportive fixation fractures of the tibial tubercle in seven patients. PJI the injuries
treatment occurred in boys 13 to 17 years of age who were playing basket-
Prognosis fairly good Rapid healing and return to full
(occasionally long- activities
ball. The degree of dispbcemenr varied. The aurhors recom-
term symptoms mended an attempt at closed teduction, even in severely dis-
with ununited placed fractures, before resorring to open reduction and inrernal
ossicle) fixation. They pointed out that rhe healing of this injury occurs
by epiphysiodesis, bur genu recurvarum rarely resulrs because
the patients are close to skeletal maruriry.

Surgical Anatomy
OS lesions, 7 in the contralateral knee and 2 in the ipsil<lteral Bony Anatomy
knee. Ogden (53) defi ned an OS lesion as an avulsion of rhe
anterior surface of rhe apophysis. He scared that there is no In its final adult form, the tibial tubercle is a bony prominence
separation between the ossific nucleus of the apophysis and the on the anrerior aspect of rhe proximal tibia. It lies approximately
adjacent tibial metaphysis. If there is a separation through tne one 1'0 two fingerbreadths distal 1'0 the proximal articular sutface
physis deep to the ossific nucleus of the tubercle, an avulsion of the tibia and forward of the anterior rim of the proximal
fracture of the tubercle has occurred. This distinction ofren is articular surface. The tubercle is at a point where the broad, Rar
difficult ro recognize on radiographs of an incompletely ossified anrerior surface of the tibial condyles narrows sharply to become
tibial rubercle. the anrerior border of the diaphysis. Helfet (110) showed thar
In an adolcscenr, the parellaI' ligament inserts not only into the tibial tubercle is in line with the medial half of rhe patella
the developing tibial tubercle, but beyond into the adjacent peri- when the knee is Rexed and with the lareral half when the knee
chondrium of the physis and the periosteum of the adjacent is extended. Thus, the position of the tibial rubercle in the coro-
metaphysis (107,117). With an OS lesion, the central fibers of nal plane relative 1'0 the parella is a function of rhe position of
the patellar ligament avulse a localized fragment of surfaCe carri- the knee joint. This is because the proximal end of the tibia
lage and bone from the secondary ossification center. The dis- rorares relative to the distal end of the femur with flexion and
placement of this fragment is not severe because the remaining extension movements of the knee.
fibers of the patellar ligament that fan our medially and laterally Ehrenborg (l07) divided the posrnaral dcvelopmenr of the
remain intact. With a limited, minimally displaced avulsion frac- rjbial rubercle inro four stages (hg. 23-29). The cartilaginous
rure of tne tibial tubercle, a cleavage plane is present through stage occurs before rhe secondary ossificarion center appears and
part of the physis between the secondary ossification center of persisrs in girls until 9 yeal-s and in boy, until J a years of age.
the tubercle and the adjacent metaphysis of the proximal tibia. The apophyseal stage, in which the ossificltion center appears
The perichondrium is torn adjacent to the separared portion of in the rongue of cartilage, occurs bet\veen 8 and 12 years in girls
rhe physis. A severely displaced avulsion fracture of the ribial and berween 9 and 14 years of age in boys. The epiphyseal stage,
tubercle implies a more extensive tear of the fibrous expansion in which the secondary ossificltion centers coalesce 1'0 form a
of the insertion of the patellar ligament. tongue of bone conrinuous with the proximal tibial epiphysis,
In 1971, Hand et al. (09) reported seven avulsion fracrures occurs in girls between LO and 15 years and in buys berwcen
of the tibial tubercle, all in boys 14 ro 16 years uf age and all I 1 and 17 years of age. In the final bony srage, the epiphyseal
resulting from sports or play activities. Six of the seven parienrs line is closed between the fully ossified tuberosity and the tibial
were (I'eated successfully by open reduction and internal fixation. metaphysis.
These authors noted that a large periosteal Rap could become
folded into the gap undernearh the avulsed tubercle.
Soft Tissue Anatomy
Levi and Coleman (115) reported uniformly good resultS in
14 parients with avulsions of the tibial tubercle. All but one of The p:lIdlar ligament, which lies bCt\veen the distal pole of the
the parients were boys, with an average age of 14 years, and all patella and the tibial rubercle, is the terminal portion of rhe
injuries were sustained during sports or play activities. All were illSerring rendon of the pOlVerful quadriceps muscle. During the
 Chapter 23: Fmctttre;' tlnct Distocfltiom A bout the KllU 1021

Secondary Coalescence Physis

ossification of ossification closed
center center

FIGURE 23-29. Development of the tibial tubercle. A: In the cartilaginous stage, there is no ossification
center in the cartilaginous anlage of the tibial tubercle. B: In the apophyseal stage, the secondary
ossification center or centers forms in the cartilaginous anlage of the tibial tubercle. C: In the epiphyseal
stage, the primary and secondary ossification centers of the proximal tibial epiphysis have coalesced. 0:
In the bony stage, the proximal tibial physis has closed.

apophyseal stage of developmenr of the tubercle, the patellar determine the amounr of patellofemoral reaction force devel-
ligamenr insens inro an area approximately 10 mm long, cotre- oped by extending the knee against resistance (116).
sponding [Q the flbrous canilage proximal and anrerior ro the
secondary ossification center. The main attachment is in the
Vascular Anatomy
proximal area of this insertion zone, at the level of the cartilage
lying between the secondalY ossification cenrers of the tubercle The tibial tubercle receives its main blood supply from an anasto-
and the main ponion of the proximal tibial epiphysis. The fibro- mosis behind the quadriceps tendon. In panicular, a pl'Ominent
cartilaginous tissue lying anrerior to the secondary ossification leash of vessels bilarerally arises from the anterior tibial recurrent
cenrer receives only the distal part of the insertion. During rhe artery and may be wrn with this fractllre (118,122). Several small
epiphyseal stage, the pateHar ligament inserts through fibrocarti- branches extend down imo the secondalY ossiflcation center. A
lage on the anrerior aspect of the downward-projecting rongue smaller pan of the blood supply emers the superficial surface of
of the proximal tibial epiphysis. The inserting fibers merge dis- the tlIbercie from adjacent periosteal vessels. T rueta (I 21)
tally inro deep fascia after spanning the physis. With traumatic showed in injection studies rhat a few of the longitlldinal vessels
avulsion of the tibial tubercle in this stage of development, a in the patellar ligament itself extend illW the rubercle. Ogden
broad flap of adjacent periosteum is arrached ro the displaced et al. (I 17) showed blood vessels entering the medial and lateral
fragmenc. In the fin:ll bony stage, the tendon fibers insert directly aspects of the tLlbercie. They demonstrated cartilage canals in
inro bone. After physiologic epiphysiodesis has occurred, the the physis carrying these branches of the meraphyseal vessels in
tibial tubercle rarely is avulsed if the patient has normal bone. children up ro 10 to 12 years of age.
Although the patellar ligament represents the main insertion
of the quadriceps muscle OntO the leg beyond the knee joint, it
is reinfotced by retinacular fibers radiating from the medial and
Mechanism of Injury
lateral margins of the patella obliquely down ro the respective Acure traumatic avulsions of the tibial tubercle occur most ofren
tibial condyles. Also, longitlldinaHy oriented retinacular fibers during spons or play activities (97,104,108,112,119). Bohler
extend from the distal margin of the vastlls lateral is down to the (9) stated that most avulsions originated from "a leap over a
anterior aspect of the lateraJ tibial condyle, partly merging with wooden horse" in physical training. Of the seven avulsions re-
the inserting fibers of the ilioribial band (120). Similarly, longi- ported by Hand et al. (109), four occurred while playing football
tudinal fibers extend from the distaJ margin of the vascus medialis and rhree while jumping during play. Of the 15 injuries reponed
down ro the anterior aspect of the medial tibial condyle. Frazer by Levi and Coleman (115), 5 occurred while playing basketbaJl,
(l00) showed that the insertion of the medial retinaculum ex- 2 while diving from a springboard, 2 during competitive run-
tends beyond rhe proximal tibial physis inro the metaphysis. ning, and 1 during a high jump. AJI eighr injuries reponed by
After traumatic avulsion of the tibial tuberosi ry, a limited Christie and Dvonch (103) occurred while playing baskerball.
amount of active extension of the knee still is possible through Avulsion of the tibial tlIbercie occurs when the patellar liga-
the rerinacular extensions of the extensor mechanism. However, menr traction exceeds the combined Strength of the physis un-
parella alta and an extensor lag are present. derlying the tlIbercle, the surrounding perichondrium, and the
The anatomic position of the tibial tubercle is biomechani- adjacenr periosteum. This can occur in rwo ways. The first mech-
cally importanr (102,105,114). It is one facror that determines anism is violem comraction of the quadriceps muscle against a
the length of the momenr arm from the parellar ligament ro the fixed tibia. This can happen when an athlete jumps or lands, as
center of roration of the knee (113). This moment arm helps in basketball or tracle The second mechanism is acute passive
1022 Lower Extremity

ing part of the tubercle, is avulsed and displaced upward. In the

second type, the sccondalY center of ossification in the tubercle
has already coalesced with the rest of the proximal tibial epi-
physis, and the entire lip formed by the front of the upper tibial
epiphysis is hinged upward. In the third type, the line offracture
passes proximally across the proximal physis of the tibia.
Ogden and associates (117) refined the c1assiflcation and de-
scribed three types, depending on the distance of the fracture
from the distal tip of the tubercle (Fig. 23-31). Each type is
divided into two subtypes, depending on the severity of displace-
ment and comminution:

Type I-The separation through the diStal portion of the

physis under the tubercle breaks up proximally through the sec-
ondary ossification center of the tubercle.
Type II-The separation extends anteriorly through the area
bridging the ossification centers of the tibial tubercle and the
proximal tibial epiphysis.
Type III-The separation beneath the tubercle propagates
through the proximally proximal tibial epiphysis into the knee
joint under the antetior attachments of the menisci.

Ogden noted that the degree of displacement depends on the

severity of injury to adjacent soft tissue attachments.

Signs and Symptoms

Swelling and tenderness are centered over the anterior aspect of
FIGURE 23-30. Contracting quadriceps mechanism exerts extension
torque on the knee joint. whereas contracting hamstring muscles exert the proximal tibia. Joint effusion and tense hemarthrosis may
flexion torque on the knee joint. Asterisks indicate points of possible be present. A freely movable triangular fragment of bone may be
failure when the knee is jammed by opposing torques. palpated subcutaneously berween the proximal tibia and the fem-
oral condyles. This fragment may have rotated so that the distal
end projects forward, tenting tne overlying skin. [f the avulsed
fragment is held and moved passively, crepitus may be felt be-
flexion of the knee against the conn·acted quadticeps. This can t\.yeen the fragment and the proximal tibia. A palpable defect on
hap[xn when a person makes a bad landing at the end of a jump the anterior aspect of the tibia at the upper end of the anterior
or fall. In other words, avulsion of the tubercle can result from border of the diaphysis represents the bed from which the frag-
sudden acceleration or deceleration of the knee extensor mecha- ment was avulsed. In a markedly displaced Watson-Jones type III
nism. avulsion, the palpable defeer can be as much as 3 cm long.
Some predisposing factors to avulsion of the tibial tubercle The injured knee is held in 20 to 40 degrees of flexion by
have been identified. Patella infeta, with a relatively short patellar hamstring spasm. The amount of patella alta is proportional to
ligament, can impose incteased tension on the distal insertion the severity of displacement of the tibial tubercle. The patella
of the quadriceps mechanism. Tight hamstrings can increase may be displaced proximally as much as 10 cm. With associated
flexion torque, opposing active extension of the knee (Fig. 23- joint effusion, the patella may seem to float off the anterior
30). As mentioned earlier, the weak link in the extensor mecha- aspect of the distal femur. With a type r avulsion, the patient
nism in adolescents is the changing physis beneath the tibial usually can actively extend the knee, although not completely.
tubercle. Acute disruptions are more common in knees with With type II and III lesions, full extension is impossible.
preexisting OS disease, which indicates a mechanical vulnerabil-
ity from either overdevelopment of the quadriceps mechanism,
lack of flexibility of the knee flexors, or impaired coordination Radiographic Findings
between opposing torques about the knee. In addition, Ogden Because the tubercle lies just lateral to the midline of the tibia,
et al. (117) reported two patients with what were probably
the best profile can be obtained by a lateral projection, with the
pathologic fractures. One injury occurred in a child with myelo-
tibia rotated slightly internally. Soft tissue technique helps define
me~ingocele, and the other patient had metaphyseal dysplasia
the margins of the patellar ligament and smaller fragments of
with preexisting varus deformity of the injured knee.
bone. In children and adolescents 9 to 17 years of age, the normal
tubercle is ossified to valying degrees. One or more secondalY
Classification ossification centers form at the distal end of the tubercle during
Watson-Jones (82) described three types of avulsion fractures of the apophyseal stage of development. The presence of several
the ribial tubercle. In the first type, a small fragment, represent- centers does not represent an abnormality. Multiple ossification
 Chapter 2): Fractures and DisLoctlliol1J About the Kllee 1023

FIGURE 23-31. Classification of avulsion fractures of the tibial tubercle. A: Type I fracture across the
secondary ossification center level with the posterior border of the inserting patellar ligament. B: Type
II fracture at the junction of the primary and secondary ossification centers of the proximal tibial epi-
physis. C: Type III fracture propagates upward across the primary ossification center of the proximal
tibial epiphysis into the knee joint. This fracture is a variant of the Salter-Harris type III separation and
is analogous to a Tillaux fracture of the ankle because the posterior portion of the proximal tibial physis
is closing. (From Ogden JA, Tr05s RB. Murphy MJ. Fractures of the tibial tuberosity in adolescents. J Bone
Joint Surg Am 1980;62: 205-215; with permission.)

cencers coalesce and join wi[h [he proximal [ibial epiphysis dur- extent as the patella, the ratio berween the overall leng[h of the
ing the epiphyseaJ stage of development. At [his time, a horizon- patella and the distance between the patella and tibial rubercle
[al radiolucem band becomes apparenc on [he anceropos[erior would nOt change. The best method for estimating patella aha
radiograph a[ [he dis[al end of the tubercle. The band represents after avulsion of the tibial ClIbercie is that described by Black-
a groove filled with cartilage berween the tip of the tibial tubercle bume and Peel (98): the position of the patella is compared
and [he upper end of the ancerior border of the diaphysis. During with a line extrapolated forward from a tangent across the upper
the epiphyseal stage of development, the borders of the tubercle surface of the tibia. Even this method gives varying degrees of
~rc sharply defined. patellar displacement, depending on contraction or spasm in the
After an avulsion of the tibial tubercle, the siz.e and degree quadriceps muscle.
of displacemem of the fragment are best seen on the lateral
radiograph (Fig. 23-32). In a type I injury, the distal end of the
Treatment
tubercle is displaced upward and forward to varying degrees.
The avulsed fragment corresponds to that parr of the tubercle Minimally displaced, small avulsion fragments have been treared
between the proximal border of the inserting patellar ligament successfully by closed methods. The leg is positioned with the
and the distal end of the secondary ossification cencer. In the knee extended and the hip slightly flexed. Reduction can be held
second rype of avulsion of the tubercle, the fragment is larger, by a long leg cast that is well molded above the proximal pole
hinging or separating at the level of the horizontal portion of of the patella. Most authors advise open reduction and internal
the proximal tibial physis. In type J[[, the fracture line extends fixation of type II and IJJ fractures. A midline vertical incision
proximally from beneath the tubercle through the proximal tibial is recommended co facilitate any possible knee surgery in the
epiphysis and exits the upper surface of the epiphysis (Fig. 23- future. The fracture bed is carefully cleared of debris. If a perios-
33). The fracwre line emerges anterior to the tibial spine. If this teal flap is folded under the avulsed fragment, it is extracted and
rype of injury is comminuted, fragmenration occurs at the level held spread out while the fragment is reduced with the knee
of the horizontal component of the proximal tibial physis. In a extended. Depending on the siz.e of the avulsion fragment and
type III lesion, [he central ponion of the physis beneath the the patient's age, fixation is obtained with transfixing pins or
proximal tibial epiphysis may have already closed. Bruijn et al. screws and is rei nforced by repair of the torn periosteum.
(J 0 1) reported a "sleeve" fracture of the tibial tubercle in a
14-yeat-old gymnast; his radiographs appeared normal, but G
Operative Treatment
months latn a 4-cm, ossified, proximally displaced sleeve repre-
senting the base of the patellar tendon was seen. We recommend open reduction and internal rlxation of all but
Closure of the gap between the avulsed fragment and its bed the smallest undisplaced fragments. Closed methods can be used
indicates satisfactory reduction. Persisrence of even a small gap in minimally displaced fractures if the knee can be actively ex-
between the distal end of the tubercle and the adjacent metaphy- tended to 0 degrees. For open reduction, we prefer a vertical
sis may indicate an interposed flap of periosteum. incision centered over the tibial tubercle, along either its medial
Before reduction of an avulsed tibial tubercle, the degree of or lateral border. We are careful co clear the gap between the
patella alta and, therefore, the sevel-ity of displacement can be displaced fragment and its bed of any soft tissue interposition.
determined by one of sevnal radiographic methods (98,99, III). With type III fractures, the menisci should be inspected for tears.
Because the tibial tubercle is displaced proximally to the same If rhe reduced fragment is large enough, we prefer co use one
1024 Lower b:tremity

A B

FIGURE 23-32. Three variations of avulsions of the tibial tubercle. A: Anterior injury
with avulsion of the tubercle and anterior aspect of the epiphysis. B: Classic Salter-
Harris type III fracture, beginning in the physis and extending into the articular sur-
face of the epiphysis. C: Comminuted epiphyseal-metaphyseal fracture of the proxi-
c mal tibia.

or twO cancelJous screws, exrending rhrough rhe rubercle, parallel Jocking) suture may add srrength co the repair; sutures also may
ro the joint inro rhe meraphysis. If rhe parienr is more rban 3 be used in rhe periosreum and lateral rendon expansion. Aftcr
years from skeleral maruriry, smooth pins are llsed (Fig. 23- wound closure, a well-flrting long leg or cylinder casr is applied.
34). If rhe fracture is comminured, we prefer mulriple screws The casr is carefully molded on eirher side of the reduced ribial
or tbreaded Steinmann pins reinforced by periosreal sutures. A rubercJe and proximal to rhe parella so that rhe la[[er is held
srrong, rension-holding surure such as rbe Krackow (running downward.
 Chapte,. 2.3: Fractures and DisLocations About the Knee 1025

A B
FIGURE 23-33. A: A 15-year-old boy with a comminuted, displaced tibial tuberosity avulsion sustained
while jumping in a basketball game. B: After open reduction and internal fixation with multiple cancel-
lous screws.

Postreduction Care
The cylinder or long leg cast applied after reduction of the
avulsed tubercle is worn for 4 to 6 weeks and rhen is bivalved.
For the nexr 2 weeks, the posrerior half of rhe cylinder casr is
worn as a spline berween exercise periods. Gende acrive range-of-
motion and quadriceps-snengrhening exercises are begun three
times a day. At 6 weeks afrer injuly, exercise of rhe quadriceps
against some resistance can be sraned if rhere is no renderness
over the ribial rubercle. The parienr is permined ro rerum to
arhlerics and vigorous play only afrer me quadriceps srrengrh
equals thar of rhe opposire side and range of morion has been
regained.

Prognosis
The omcome of a well-reduced avulsion fracture of [he ribiaJ
rubercle is consisrenrly good. Mosr parienrs rerum to normal
funcrion, including sporrs. AJI 15 parienrs reporred by Levi and
Coleman (115) had rerurned to normal acriviry withour defor-
miry or resrricrion I to 18 years afrer injury. AJI bur one of
A B
rhe pariems reponed by Ogden er al. (117) were complerely
asymptomaric, wirh no disabiliry. All seven patienrs reponed by
FIGURE 23-34. Open reduction and internal fixation of type II tibial
tuberGle fracture (A). After anatomic reduction (B), a large fragment is Chrisrie and Dvonch (103) had rerurned to normal funcrion ar
stabilized with two screws. an average of 3 years after injury.
1026 Lower Extremil.y

rum is rare after avulsion fracture of the tibial tubercle, despite

TABLE 23-10. COMPLICATIONS OF TIBIAL
the fact that healing actually occurs by epiphysiodesis. The expla-
TUBERCLE AVULSION
nation of this apparent paradox is that avulsions of the tubercle
Early almost always occur in patients vcry close to skeletal maturity.
Compartment syndrome Compartment syndrome has been reported in seven patients
Meniscal tears
with type III fractures, presumably because of tearing of anteriol'
Infection
Late tibial recurrent vessels, which fan out at the tubercle Out retract
Genu recurvatum intO the anterior compartment when tOrn (118,122) (Fig. 23-
Loss of flexion 35). Close monitOring is necessary for patients treated Ilonopera-
Refracture tively and careful in.spectjon, possibly with prophylactic anterior
fasciotOmy, is recommended for patients trC'ated operatively
(J 18,122).
Minor complications also have been reported. Christie and
Dvonch (03) reported a patient with persistent loss of 25 de-
grees of knee flexion 19 months after a rype III injury. Hand
Complications et al. (09) reported a patiem with persistent quadriceps atrophy,
The early and late complications of avulsion of the tibial cubercle and Levi and Coleman (115) repomd a patiel1t with a persistent
are listed in Table 23-10. prominence 7 years after open tedunion and internal fixation.
Blount (R) noted that genu recurvatum caused by premature To this short list could be added the expected complication of
closure of the anterior portion of the physis is likely to OCCUl' pateJla alta if a displaced tibial tubercle is not reduced adequately.
after avulsion of the tibial tubercle in skeletally immature chil-
dren, usually those younger than 11 years of" age. Genu recurva-
OSGOOD-SCHLATTER LESION
Osgood-Sch latter (OS) lesions are considered separately from
acute traumatic avulsions of the tibial tubercle because the
pathophysiologic process, treatmel1t, and outcome differ some-
what (121,129). Although acute avulsion of the tubercle is al-
most always related to a specific injury, the patient with an OS
lesion often can give only a vague histolY about tht· onset of
symptoms. Whereas an adolescent with a displaced acute avul-
sion of the tibial tubercle is immediately unable to stand or walk,
an adolescent wjth OS disease often tries to continue sports and
play activities despite discomfort. Treatment of acute avulsion
of the tubercle depends on the size of the avulsed fragment
and tbe degree of displacement, but usually open reduction and
internal fixation are indicated. Trearment of OS lesions usually
is symptOmatic and supportive. The prognosis for a reduced and
healed avulsed tubercle is excellent. The patient makes a rapid
return to full activities within sevetal months. On the Other
hand, jt llsually takes up to 2 years For resolutjon of the symp-
toms of an OS lesion, and occasionally disability persists into
adulthood.
Despite these differences, there is convincing evidence tbat
the OS lesion and acute traction of the tibial tlIbercle represellt
a spectrum of avulsion phenomena. The contrasting clinical pic-
tl!re probably is due to the fact [har a limited amount of tissue
is displaced to a limited degree in the OS lesion (see Table 2)-
9).
In 1891, Paget (62) described the clinical syndrome that latu
became known as OS disease. In [903, Osgood (132) and
Schlatter (136) published separate papers on the subject. Begin-
ning with Osgood's article, three timely papers on the subject
have in common the conviction that the etiology is trauma.
Osgood (J 32) reported 10 patientS in whom he observed that
funCtion was not completely lost, although recurrell[ soreness
FIGURE 23-35. Probable mechanism of development of compartment
syndrome after tibial tubercle avulsion. The anterior tibial recurrent and weakness caused some disability in athletic participation. In
artery is torn and retracts into the anterior compartment musculature. a dissected specimen, Osgood observed that aftet" simulating the
 ChfljJ/I'i' 23: .Fmcmres fllld Dislocations About tbe Knee 1027

the tibial tubercle is in the apophyseal stage and rhe secondary

ossification center has appeared. The cartilage overlying the ossi-
fication center anteriorly and underlying it posteriorly is fibro-
carti laginous and can resist tension forces better than the bone
in the secondary ossification center itself, which may give way
during contraction of the extensor mechanism. During the epi-
physeal stage of tibial tubercle development, rhe ossiflcarion cen-
ter has become stronger by enlargement and coalescence with
the main ossification center of the proximal ribial epiphysis.
During rhis stage of development, violent conrractioll of the
quadriceps mechanism produces the acure fracture-separation
through the tubercle physis that was discussed in the preceding
seCtion.

Mechanism of Injury
Usually no specific injury or event can be directly related to the
onset of symptOms; however, repeated normal stresses Ot overuse
can produce a limited Ot localized disruption (117,130,131).
Bilateral lesions are found in approximately one fourth of pa-
B (len ts.
FIGURE 23-36. Development of Osgood-Schlatter lesion. A: Avulsion Other anatOmic variants may predispose to the development
of osteochondral fragment that includes surface cartilage and a portion of OS lesions. Lancourt and Cristini (114) found patella infera
of the secondary ossification center of the tibial tubercle. B: New bone
fills in the gap between the avulsed osteochondral fragment and the
in a small series of adolescents with OS lesions before pl1yseal
tibial tubercle. closure. The low-lying patella, with shortening of the patellar
ligament, may explain the increased stress on the tibial rubercle.
Jakob et aJ. (128) found patella alta in 185 knees in 125 patients
with OS disease. In most, the lesion had healed. These findings
lesion with localized osteotOmy of the tibial tubercle at the inser- also were reported by Aparicio (123). They believed that parella
rion of rhe central ligament, repeated rraction on rhe quadriceps alta after OS disease had run its course implied a preexisting
muscle produced upward displacement of the detached fragment quadriceps COntl'aCture, especially of the rectus femoris. They
of no more than ~ in. The knee sri II could be extended with the repeatedly observed rhar children with OS disease had a well-
ribial rubercle derached if the retinaculum was intacr. Osgood developed, even hypertrophic quadriceps muscle with decreased
concluded that the clinical lesion represented a localized rupture elasticity. Willner (39) found genu valgum, pronated feet, and
of the centtal insertion of the quadriceps mechanism. internal rotation of the knee in all of his 78 patients with OS
In 1962, Ehrenborg (125) published a comprehensive study lesions. Turner and Smillie (138) found that patients with the
of OS disease that included 218 affected knees in 170 patienrs. OS lesion had a substantial increase in lateral tibial [Drsion. Also,
No patient was older than 15 years of age at the time of initial as in acute avulsion of the tibial wbercle, tight hamstrings may
examination, and the age of onset of the clinical syndrome coin- increase the resistance of the knee to extension by quadriceps
cided wirh the apophyseaJ srage of development of the tubercle. action, thereby increasing the tension force on the patellar liga-
He explained the telatively painless onset of the clinical course ment. Patients with cerebral spastic diplegia, characterized by
by noring that the avulsed cartilaginous tissue contained velT hamstring contracture, are vulnerable to OS lesions in the appro-
few pain £bers. priate age group. Rosenthal and Levine (134) showed a relatively
1n 1976, Ogden and Sourhwick (131) reported 53 patients high incidence of the OS lesion in patients with cerebral palsy.
with OS lesions; 41 were in the apophyseal stage of tibial tubercle
development at the onset of symptOms. They observed new bone
formation anterior to the secondary ossification center and con- Signs and Symptoms
cluded that the weak link that failed under tension was the devel- The patient with an OS lesion usually is berween 11 and 15
oping ossification center with overlying hyaline cartilage rather years of age. Boys are more frequently affected than girls. Ap-
than the cartilage at the base of the tubercle apopl1ysis (Fig. 23- proximately half the patients give a histDly of precipitating
36). trauma. The pain usually has been present intermittently over
a period of several months before the patient is Seen by the
physician. The pain is aggravated by running, jumping, kneel-
Surgical Anatomy
ing, squatting, and climbing or descending stairs. Rest or reStric-
The age tange in which each of the two principal rypes of avul- tion of strenuous activities usually brings relief.
sion injuries occurs is related to the specific stage of development Physical findings are localized swelling and tenderness at the
of the tuberosiry at that time (110). The OS lesion occurs when insertion of the patellar ligament. There is no effusion of the
1028 Lower Extremity

knee joinL Pain is reproduced by extension against forced resis- srages. Occasionally jr is helpful ro compare lareraJ radiographs
tance. There may be some quadriceps arrophy. of rhe affecred knee wirh those of the normal side.
A prospecrive srudy (133) of OS lesions done wirh serial
MRI, CT, and bone scans showed rhat rhe mosr striking fearure
Radiographic Findings was sort tissue inflammarion, nor bony avulsion. Tendon rhick-
ening was seen in all parienrs and a disrended deep infrapatcllar
Radiographs are not indicated in all parienrs wirh OS lesions.
bursa ,vas presenr in rwo rhirlk An ossicle was seen in only one
The diagnosis is clinical, bur plain films may be helpful if orher
rhird of rhe parienrs, wirh both early and lare disease. Scimi-
bony enriries must be ruled out, if sympwms arc prolonged, 01'
graphic uptake rarely exceeded normal.
if rhe parienr is older. The OS lesion is besr seen 011 a lateraJ
projecrion taken with rhe knee in slighr inrernal roration. A film
taken with soft tissue technique may confirm the diagnosis by Treatment
showing that rhe edges of the parellaI' ligamenr are blurred.
The most impotranr thing a physician can do is ro explain rhe
Small, fbkelike fragmems of rhe secondary ossification cenrer
narural hisrory of the disease ro the famity, because OS disease
of the tubercle may be displaced slighdy anreriorly and superi-
is relared to activiry and resolves wirh rest and marurarion. Many
orly, but these are difficult ro disringuish from normal multicen-
are relieved to know rhat it is nor relared to any innaarricular
tric ossificarion of rhe rubercle. Latet in rhe course of the disease,
derangemenr or risk of arrhriris. Treatmenr measures 1110sr orren
rhe ossicles may enlarge, presumably because of further ossifica-
recommended for OS lesions are sympromatic and supportivc
tion of the canilaginous componem of the avulsed fragmenL
(79,124-126). The goal of such neatmenr is ro ease pain and
Also, the gap between the avulsed fragmenrs and rhe tibial tuber-
sweJling. A remporary restricrion of athletics or vigorous activi-
osity may fill in with bone. The displaced fragments sometimes
ties may be sufficient. In the acure stages of OS disease, activirics
fail ro unite and remain as separare ossicles dClached from the
should be restricred co mild forms of athleric parricipation, such
anterior border of rhe maruring rubercle (Fig. 23-37). An undue
as walking or swimming. As symptoms improve, moderare ac-
prominence of rhe rubercle irself may be presenr in rhe residual
riviries such as tennis, baseball, swimming, and roller skating
can be allowed. JaJ<ob er al. (128) proposed scretching exercises
for rhe quadriceps co relieve rension on the ribial tubercle.
Strerching exercises also are indicared for the hamsrrings, which
commonly are righr.
If severe symptoms inrerfere with normal acrivities, a knee
immobilizer or a cylinder cast may be used for 6 weeks. Turner
and Smillie (138) suggested mulriple drilling in parienrs with
enlargement and irregularity of rhe tubercle, and the)' advised
excision of ununired fragments or ossicles after marurity.
Some investigators (135,139) recolTlmend against nearing
OS lesions with local injecrions of steroids because this may
impair healing and result in scarring of rhe overlying skin, with
sign ificam cosmeric deform iry.

~ AUTHORS' PREFERRED METHOD

\...~ OF TREATMENT

When we see an adolescenr early in rhe course of symptoms

from an OS lesion, we discuss rhe natural hisrory wirh the parienr
and parenrs. We rell rhem that symptoms may wax and wanc
with acriviries for several years, bur rl1is is nor a sign of serious
imernal derangement of the joinr. If symptoms are markedly
severe, we advise a knee immobilizer or cylinder casr for weighr-
bearing acriviries. When rhere is no acme tenderness, quadriceps-
snengrhening exercises and hamsrring-srretching exercises are
begun. Resrricrion of arhleric acrivities is advised according co
rhe severity of symprorns. The parienr often can tell which acrivi-
ries cause recurrenr discomforr-usually those rhat involve
jumping, such as baskerball or hurdling, and rhose that require
reperirive knee flexion and extension, such as bicycling. Nonsre-
roidal anriinflammaroty medic;lrions and icing afrer spons may
FIGURE 23-37. Extreme example of Osgood-Schlatter lesion. Lateral
radiograph shows enlargement of the tibial tubercle, ununited ossicles. relieve symptoms.
and patella alta. Operativc rrearrn,:nr is reserved for ununired ossicles wirh
 Chapter 23: Fractures alit! Dislocations A bout the Knee 1029

persisrent symproms afrer rhe physes have closed. Excision is patella and usually is described as a bipartite parella (149,150,
performed rhrough a shon incision by longitudinally splitting 161) or dorsal defect of the patella.
rhe discal fibers of rhe parellar ligament. The ossicle can be The greatest difficulty with fractures of the parella in children
shelled our wirhom extensive dissecrion. Posroperarive casring is diagnosis. Developmental anomalies may be confused with
for 6 weeks may be necessary if mOre dissecrion is performed. fractures (141,155,158), and the size of fracture fragmen ts, espe-
cially in sleeve fracrures, may be underestimared in a growing
child hecause the parella is pardy cartilaginous (I ')3). Belman
Prognosis
and Neviaser (143) pointed out [hat it is not uncommon for
The overall prognosis for OS lesions is excellent. Afrer rhe symp- the diagnosis of patellar fracture in a child to be missed or sub-
roms run rheir course, rhe parient usually rerurns ro full activity, stantially delayed.
including participarion in athletics. Some prominence of the
tibial tubercle may persist, and rarely kneeling may be difficult Anatomy
(140).
Symproms persisting beyond the normal course of the lesion Bony Anatomy
usually are associated with an ununited ossicle (127,137). Mital The anlage for the patella develops in the ni nth embryonic week.
et a1. (130) found ununited ossicles in 14 of 118 patients with It lies deep to the tendon, not embedded in it. At birrh, the shape
OS lesions. Painful ossicles in adults are successfully treated with is well defined in cartilage form. Ossification of the cartilaginous
simple excision. anlage begins between 3 and 6 years of age. Often there is more
An OS lesion occasionally predisposes ro an avulsion fracture than one central ossicle-thelT may be as many as six irregular
of the tibial tubercle. Patients and their parents should be in- cemers. Cradually, the ossicles coalesce, and ossification pro-
formed about this if they choose to continue recreational or ceeds peripherally until all but the articular surface is replaced
sporrs activities despite persistent discomfort. by bone. Umil ossification is complete, the edges of the enlarging
ossific nucleus may appear irregular on a radiograph (18). The
pattern of bony development is similar in this respect to the
FRACTURES OF THE PATELLA growing epiphysis of the distal femur (Fig. 23-38). Ossification
of the patella usually is complete by the beginni ng of rhe second
Patellar fracrures are much less common in children than in decade.
adults (J43,152,153). Bostrom (145), in his discussion of the
incidence of patcllar fractures in children, cited threc large series:
Diebold (48), who reported that 16 of 1,200 patients were
younger than 16 years of age; Schoenbauer (163), who reponed
5 of 578 parients ro be younger than 16 years of age; and Ray
and Hendrix (59), who reported 12 of 185 patients younger
than 16 years of age. In rhese rhree seties, less than 2% of patellar
fractures occurred in skeletally immatul'e patients.
The low incidence of fracrures of the parella in childl'en may
be due ro the fact that the osseous portion of the patella is less
subject to both impact and tensile forces in children than in
adults. It is surrounded by a thick layer of cartilage that acrs as
a cushion against a direct blow (46). The l'elative magnitude
of forces generated in the extensor mechanism of a child's knee
is no doubt less than an adult's knee because of rhe smaller
muscle mass and shorter moment arm in children. A child's
patella also has greater mobility in the coronal plane.
Although the patella may escape fracture from direct injUlY
in children, it is more vulnerable to osteochondral fracrure or
avulsion of the medial margin associated wirl1 lateral patellar
dislocation (160).
Avulsion fractmes of the patella are classified according ro
location. A superior avulsion involves the superior pole of rhe
patella and appears ro be rhe least common parrern. An inferior
avulsion involves the lower pole of the patella and usually is
caused by an acute injury (142), however, it should be distin-
guished from a Sinding-Larsen-Johansson lesion (164), an in-
complete avulsion caused by repetitive cyclic stress. A medial
avulsion involves IllOSt of the medial margin of the parella and
accompanies acute lateeal dislocarion of rhe parella. Lateral avul- FIGURE 23-38. Normal knee in a 6-year-old child. Note irregular ossifi-
sion fracture usually involves [he superolarcral margin of rhe cation of the patella and the distal femoral condyle.
1030 Lower .baremity

Congenital absence (144) and congenital hypoplasia (163)

of the patella are uncommon. Although these variations in devel-
opment have been reported as isolated findings, [hey also occur
as parr of the hereditary symptOm complex onychoosteodysplasia
or nail-patella syndrome (144).
An unossified patella may be bipartite or multipartite. Parti-
tion of the patella into almost equal anterior and posterior por-
tions has been reported, often in patients with multiple epiphy-
seal dysplasia (149). The overall incidence of bipartite patella in
adolescenrs is reponed to range from 0.2% to 6%. It is more
common in boys than in girls. AJthough Kohler and Zimmer
(155) stated that unilateral bipartite patella is rare, Green (150)
found that 57% of his patients had unilateral bipartite patella.

Vascular Anatomy
Scapinelli (J 62) studied the blood supply to the human patella
in specimens ranging from birth to old age. Because neither he
nor Crock (146) noted differences between immature and ma-
ture specimens, it is presumed that the pattern of blood supply
in children is similar to that in adults. An anastOmoric circle
surrounds the patella. Contributions to the anastOmosis derive
from the paired superior and inferior geniculate arteries, as well
as from the supreme geniculate artery above and the anterior
tibial recurrent artery below. From the anastOmotic ring,
branches converge centripetally toward the anterior surface of
rhe patella and enter through foramina in the middle third of
this surface. Additional blood supply to the patella enters the
disul pole behind the patellar ligament. Thus, virtually the entire FIGURE 23-39. A 15-year-old male renal transplant recipient felt a
"pop" in the knee after a fall down stairs. Lateral radiograph demon-
blood supply to the patella comes from the anterior surface or strates avulsion of the patellar tendon from the interior pole of the
distal pole, with essentially no penetration of vessels from the patella with proximal migration of the patella and quadriceps muscle.
medial, proximal, or lateral margins of the patella. Scapinelli
(J 62) noted that these findings correlate with rhe facr that mar-
ginal fractures of rhe patella rarely unite. AJso, injury to blood
vessels entering the anterior aspece of the patella may lead to
osteonecrosis of the proximal pole. lieved rhar the fragmentation represented stress fractures caused
by excessive rension in the muscle associated wirh a flexed-knee
gaiL Three of the fragmented patellae healed afrer hamstring
Mechanism of Injury lengthening. Kaye and Freiberger (154) found either elongation
As in adults, fractures of the patella in children result from a Ot fragmentation of the patella in nearly a third of parients with
direct blow (most common), sudden contraction of the extensor cerebral palsy and fragmentation of rhe patella in a patient with
mechanism, or a combination of both. Direct impact may cause anh rogryposis.
a linear or comminured fracture pattern.
Avulsion of the distal pole of the patella can occur from
tensile loading. HoughtOn and Ackroyd (153) reponed three Classification
displaced avulsion ftaceures sustained in tllis way. Two patients
were jumping, and the third was propelling a skateboard. Each Fracrures of the patella usually are classified according to loca-
injury was witnessed by a parenr or teacher, and in none was tion, patrern, and displacement of the fracture. To the anatOmic
there direct trauma to the knee. classification should be added the sleeve fracture, which occurs
Preexisting abnormaliries in the extensor mechanism may in YOLlIlger children (Fig. 23-40). A sleeve fracture is an avulsion
predispose to avulsion fractures (Fig. 23-39). Blount (8) reported of a small bony fragment from the distal pole of the patella,
a displaced transverse ftacture of the patella in a 6-year-old boy together with a sleeve of articular cartilage, periosteum, and rerj-
who had sustained a previous laceration of the quadriceps mech- nacuJum pulled off the remaining main body of the patella.
anism [hat resulred in limited knee flexion. The acute patellar The exrent of injury is not appreciated on initial radiographs.
fracrure was produced by sudden forceful flexion against the If allowed to heal withom reducrion and fixarion, this gap may
scarred quadriceps. Rosenthal and Levine (134) found fragmen- fill in completely or p:lITially with bone and fIbrous rissue, wirh
tarion of the disral pole of the patella in seven patients with enlargemenr of the patella. This injury has been reporred in
spastic cerebral palsy involving the lower extremities. They be- children 8 to 12 years of age (53).
 I.npter 23: hnetlll"l's Ilnd DisLoca6ons Abollt the KI1et' 1031

FIGURE 23-40. Sleeve fracture of the patella. A: A small segment of the distal pole of
the patella is avulsed with a relatively large portion of the articular surface. B: On lateral
view, the small osseous portion of the displaced fragment is visible, but the cartilaginous
A portion is not seen. C: Healed sleeve fracture after open reduction and internal fixation.

B c
1032 LouJer Extremity

Sign and Symptoms Longitudinally oriented marginal ftactures arc best seen on
axial or skyline views. lt is important w differentiate a medial
The injured knee is swollen and tender, often with tense hemar-
marginal fracture that traverses the entire thickness of the bone
rhrosis. Fuli knee extension is difficult, and weight bearing often
from a medial tangential osteochondral fracture. The laner may
is impossible. Palpation may reveal a high-riding patella or a
be difficult to appreciate on an overpenetrated radiograph. An
palpable defect in the extensor mechanism. If the distal pole is
osteochondral fracture may include a substanriaJ amount of car-
avulsed, voluntary contraction of the quadriceps muscle draws
tilage not visible on plain radiographs. Lateral marginal fractures
the patella upward, but the patellar ligament remains lax.
usually are velTically oriented and include the entire thickness
With marginal fractures, there may be little more than tender-
of the patella. If a marginal fracture is old, the edges of the
ness and localized swelling over the lateral or medial margin of
fragment are sclerotic. Lateral tilt, lateral subluxation, and lateral
the patella, and straight-leg raising may be possible (147). An
overhang of the patella relative to the femoral condyles also are
avulsion fragment adjacent to the medial margin of the patella
best evaluated on the axial or skyline view.
may indicate that an acute latera] dislocarion of rhe patella has
Sma.!1 flecks of bone adjacent w the distal pole may be note-
occurred. The patella may have reduced spontaneously afrer rhe
worthy (142). If the fragment is scalelike and closely approxi-
injury. If dislocarion has occurred, the apprehension test is posi-
tive. The patient either resists passive manipulation by contract- mated to the anterior surface of the patella, it may represent
ing the quadriceps or may even grasp the examiner's hand to an accessory ossification center. A sympromatic, small, visible
prevent further passive displacement. radiodensiry after specific injury or overuse may represent a Sind-
ing-Larsen-Johansson lesion (J64). Small and similarly benign-
looking ossicles may signify a sleeve fracrure if a good hiswry
Radiographic Findings of acute avulsion injury is given and associated clinical signs are
Transverse fractures are best seen on lateral radiographs. The present. Fragmentation or elongation of the distal pole associared
amount of displacement varies. Jn a child, the major fragments wirh patella alta in a child wirh cerebral palsy indicates long-
may tilt away from one another, with the maximal gap anteriorly standing extensor mechanism stress.
and minimal gap posteriorly (143). This may signify that the A bipartire parella is best seen on the anteroposterior radio-
articular cartilage remains intact, even with a complete fracture graph, which shows a crescem-shaped radiolucent line in the
through the bony portion of the patella (Fig. 23-41). The extent superolateral quadrant of the patella and rounded margins of
of displacement may not be fully appreciated unless the knee is the accessory ossicle. If symptoms are confusing, comparison
flexed w 30 degrees when the radiograph is made. radiographs of the opposire knee are helpful. A similar radio-

A B
FIGURE 23·41. A: Incomplete transverse fracture of the patella. The articular cartilage of the patella
remains intact, but the fracture gaps anteriorly. B: Lateral radiograph shows incomplete transverse
fracture of the patella.
 Chapter 2.3: Frl/crurfJ and Dislocations About the Knee 1033

graphic appearance of rhe contralareral parella SllppOrrs rhe diag- adults. A diasrasis of 3 mm or more 011 radiogr;lflhs or a srep-
nosis of biparrire parella. off on rhe anicular surface of 3 mm or more is an indicarion
for open reducrion and inrernal flxarion. Ir may be more diftlculr
ro esrimare rhe amounr of gap or rhe degree of srep-off in a
Treatment
younger child because of rhe partial ossificarion of (he patella.
Closed rreatmenr is recommended for nondisplaced fracrures. An inabiliry volunrarily [0 exrend rhe knee fully indicares an
Aspirarion of hemanhrosis relieves pain. A well-molded cylinder associated rear of rhe retinaculum rhar should be repaired. An
casr in exrension is applied, and progressive weighr bearing is open fracrure requires appropriare debridemenr and irrigation,
permirred. Immobilizarion may be conrinued for 4 ro 6 weeks. as well as inrernal fixarion when indicared.

Operative Treatment
Operarive rrearmenr is reserved for displaced fracrures rhar ex- ~ AUTHORS' PREFERRED METHOD
hibir 3 mm or more of anicular displacemenr or fracrures that ,~ OF TREATMENT
disrupr rhe exrensor mechanism. Reducrion and inrernal fixarion
are preferable ro parellecromy. Fixation rechniques include a We advise closed rrearmenr if rhe fracrure is nor displaced. A
circumferenrial wire loop, nonabsorbable surures rhrough Jongi- well-molded cylinder or long leg casr is applied ro hold rhe
rudinally drjJJed holes, rhe AO rension-band rechnique, or screws knee in exrension. Parrial weighr bearing is allowed as soon as
or rhreaded pins. Ogden (53) believes rhar ro avoid growrh Jis- symproms permir, usually wirhin rhe flrsr several days. Srraighr-
rurbance, circumferential wiring rhrough adjacenr sofr rissue leg raising should be possibJe by 1 week afrer injury.
around rhe patella is preferable ro wiring rhrough rhe parella. For displaced rransverse fracrures, we perform open reducrion
Blounr (8) also advised a circular rum of wire abour rhe parella. wirh inrernal fixarion using rhe modified rension-band rechnique
Orhers have poinred our rhar circular wire fixarion may rhrearen wirh a wire loop over parallel Kirschner wires. A longirudinal
rhe blood supply ro rhe parella. However, Maguire and Canale midline incision is preferred ro facilirare possible furure surgery
reponed no growrh disrurbance afrer rhe use of cerclage wi res. abour rhe knee. The rerinaculum on both rhe medial and lareral
Weber er al. (83) advised rension-band wiring rhrough a rrans- sides is repaired mericulously from ourward in roward rhe mar-
verse incision, and Rang (62) advised rension-band wiring for gins of the patella.
displaced rransverse fracrures in older children. An experimenral We advise excising displaced marginal fracrures, wherher they
srudy by Weber er al. (165) supporred fixarion by eirher modi- are on rhe medial or lareral margin. The exceprion is a marginal
fied rension-band wiring or by rhe Magnusson wiring merhod. fracrure rhar includes a significanr pan of rhe anicular surface.
The former consists of a wire loop passed beyond rhe rips of This lesion is more properly considered an osreochondral frac-
rwo longirudinal fixarion wires and over rhe anrerior surface of rure, and a fragmenr larger [han 1 cm should be replaced and
rhe parella (Fig. 23-42). The Magnusson rechnique consisrs of fixed by Herberr screws.
a wire loop passed rhrough longirudinal drill holes in the rwo
apposed fragments. All aurhors agree rhar mericulous repair of
any adjacenr rerinacular rear is as imporranr as accurare approxi- Postoperative and Postfracture Care
marion and srable fixarion of bony fragmenrs (9,145,151).
Immobilizarion in a cylinder casr is conrinued for 4 ro 6 weeks
Sleeve fracrures require careful approximarion of rhe disraJ
afrer eirher closed rrearmenr or open reducrion and inrernal fixa-
pole ro prevenr persisrenr deformiry and exrensor lag. Houghron
rion. Quadriceps-srrengthening exercises are begun as soon as
and Ackroyd (153) and Wu er aJ. (166) advised careful reducrion
possible. The casr may have ro be changed as swelling diminishes.
of rhe disral pole wirh rhe arrached sleeve of canilage ro rhe
Afrer removal of rhe casr, quadriceps-srrengrhening exercises are
main body of rhe pareJJa. Modified rension-band wiring around
conrinued and range-of-morion exercises are begun. I r is helpful
rwo 10ngirudinaJ Kirschner wires helps centralize flxarion in rhe
ro begin flexion exercises wirh rhe parienr prone. Rerum ro vigor-
small fragmenr. The exrensor rerinaculum should be repaired.
ous acriviries or arhlerics is nor permirred unril muscle mass and
For medial marginal fracrures, Rorabeck and Bobechko (160)
range of morion are equal ro rhose in rhe opposire extremiry.
advised excising rhe osreochondral fragmenr and repairing rhe
exrensor appararus in acure dislocarion of rhe parella. Griswold
(15 I) suggesred rhar marginal fracrmes of rhe pareJJa do besr
Prognosis
wirh surgery. He advised excision because fibrous union can
cause persisrenr pain. Pererson and Sn:ncr (158) described rrcar- The prognosis is good for nondisplaced fracrures in which accu-
mem of concurrent avulsions of rhe medial and lareral margins rate apposirion of fragmenrs, wirh healing, has been achieved.
of rhe parella in a 12-year-old boy; a good result was obrained Comminuted, displaced parellaI' fracrures are uncommon in
wirh opera rive repair. growing children. Those rreared wirhour reducrion may heal
wirh e1ongarion of rhe parella and diminution of funcrion of
rhe exrensor mechanisll). Comminured fracrures in adolescenrs
Operative Versus Conservative Treatment
approaching skeleral maruriry are besr rreared by parellecromy.
lndicarions for open rrearmenr of fracrures of rhe parella in chil- Symptoms dut persisr afrer marginal fracrures usually can be
dren are essenrially rhe same as for fracrures of the parella in rreared by simple excision of rhe fragmenr.
1034 Lower EXfremi(y

A B

FIGURE 23-42. A: Displaced transverse fracture of the patella;

note open distal femoral and proximal tibial physes. Band C:
After reduction and internal fixation with tension-band tech-
nique using figure-af-eight wire over parallel longitudinal
pins. c
 Cbflpter 23: Fractures llnd Dislocations About tbe Knee 1035

Complications Surgical Anatomy

Complications of unreduced displaced ftacwres include patella The parella tracks in the intercondylar notch berween the medial
alta, extensor lag, and quadriceps atrophy. Houghton and Ack- and lateral femoral condyles during flexion and extension of the
royd (153) reponed these findings at shon-term follow-up of a knee (175,178). With increasing knee flexion, the contact area
displaced sleeve fracture in a 9-year-old girl treated by aspiration on the articular surface of the patella moves [Q the proximal
and immobilization aJone. The fragments had remained sepa- patella. Between 90 and 135 degrees of flexion, rhe patella glides
rated and the bone had filled rhe defecr. Two years larer, moder- into the intercondylar notch berween the femoral condyles. The
are quadriceps atrophy and an exrensor lag persisred, along wirh two primary areas of contact are the medial patellar facet with
a subchondral defeer in the cel1[ral area of rhe anicular surface. the medial femoral condyle and the superolateral quadrant of
Failure to restore lengrh after injury precludes return ro oprimal the lateral patellar facet with the lateral femoral condyle. Soft
funcrion (156,157). tissue suppon for the patellofemoral joint includes the quadri-
ceps muscle, the patellar ligament, and the vasws medialis and
lateralis muscles.
Dislocation of the patella may tear the medial rerinaculum,
PART II: INTRAARTICULAR AND but rhe rest of the quadriceps muscle-patellar ligament complex
LIGAMENTOUS INJURIES ABOUT THE continues to apply significant compression forces as the parella
KNEE dislocares laterally. These forces are believed to cause fracrure of
the medial patellar facet, the lateral femoral condyle articular
rim, or both (180,184,186) (Fig. 23-43). Osteochol1dral frac-
rures are uncommon wirh chronic recurrent subluxation or dislo-
OSTEOCHONDRAL FRACTURES cation of the patella because of laxiry of the medial rerinaculum
and lesser compressive forces on the patella and rhe lareral femo-
Osteochondral fractures of rhe knee usually involve the medial ral condyle. In adults, compressive or rotalY forces at the knee
or lateral femoral condyle or the patella. The diagnosis often is are dissipated between caJcified and uncalcifled carrilage without
difficult because even a large osteochondral fragment may con- involvement of rhe subchondral bone. In adolescents, osteo-
tain only a small ossified ponion that is visible on plain radio- chondral fracrure extends into the subchondral bone.
graphs. Differential diagnoses include meniscal injury and osteo-
chondriris dissecans (169,174,176).
Coleman (173) reponed five osteochondral fracwres of the Mechanism of Injury
patella in children and recommended removal of loose bodies,
repair of articular defects, and repair of rhe medial retinaculum Kennedy (180) described the rwo mechanisms of osteochondral
to prevent recurrent patellar dislocation. Rosenberg (J 86) re- Fracrures: exogenous, a direer blow and a shearing force to either
poned 15 osteodlOndral fractures of rhe lateral femoral condyle the medial or lareral condyle, and endogenous, a flexion-rota-
caused by flexion-rotation forces [Q the knee rather than by rion injury of the knee in which conraer berween the ribia and
direct blows. He concluded that osteochondral fractures of the femoral condyle causes the fracture. The endogenous mechanism
lateral femoral condyle are caused by direct force from the pa- is also the cause of osteochondral fracrure with parellar disloca-
relJa, although not all patients had patellar dislocations. He aJso tion secondary [Q rhe shearing force of the patella againsr rhe
recommended removal of the loose osteochondral fragments. lateral femoral condyle (172,182). Ahstrom (168) reponed 18
Rorabeck and Bobechko (185) reponed 18 children with acme osteochondral fractures; 14 occurred cluri ng spons-related acrivi-
patellar dislocations and osteochondral fractures of rhe parella ties. Mosr patients give a history of a rwisting injury consistenr
or lareral femoral condyle. They recommended repair of the wirh acute parellar dislocation, bur a few report a direct blow
medial rerinaculum in addition to removal of rhe osteochondraJ to rhe lateraJ or medial femoraJ condyle, accounting for a shear
fr'agmen r. injury. Nietosvaara et aJ. (183) reponed that of 69 acure patellar

A B
FIGURE 23-43. Osteochondral fractures associated with dislocation of the right patella. A: Medial facet.
B: Lateral femoral condyle.
1036 Lower E-aremi~y

Physical findings may include knee effusion and renderness

TABLE 23-11. MECHANISM OF
over rhe medial or lareral femoral condyle or rhe medial parella.
OSTEOCHONDRAL FRACTURES
The knee usually is held in 15 to 20 degrees of Hexion, and
Site Mechanism movemem in any direcrion is resisred. Arremprs ar flexion or
exrension of rhe knee and manipularion of rhe parella elicir pain.
Medial femoral Direct blow (fall)
condyle Compression and rotation (tibiofemoral) Srerile aspirarion of rhe knee using local anesrhesia usually ob-
Lateral condyle Direct blow (kick) rains a bloody aspirare, occasionally wirh fat globules suggesrive
Compression and rotation (tibiofemoral) of an inrraarrlcular fracture. Lare physical findings are idenrical
Acute patellar dislocation to rhose of a loose body: inrermirrenr locking and carching of
Patella (medial Acute patellar dislocation
rhe knee jojnr or a palpable fragmenr beneath rhe skin.
margin)

Radiographic Findings
Because rhe osreochondral fragmenr may be difficulr to see on
plain radiographs, anreroposrerior and lareral views musr be care-
dislocarions in children and adolescems, 62 (90%) occurred in fully assessed for even rhe smallesr ossified fragmem (Fig. 23-
falls; 39% also had osreochondral fracrures. 44). A runnel view may help locare a fragmeur in rhe region of
rhe inrercondylar notch. Osreochondral fragmenrs also may be
locared ar rhe exrreme periphery of rhe joim in rhe suprapatellar
Classification pouch or beneath the MCL or LCL (Fig. 23-45). The ribial
The classificarion of osreochondral fracrures of rhe knee is based ruberosiry should nor be confused wirh an osreochondral frag-
on rhe sire, rhe rype, and rhe mechanism of injury. The classifica- menr, as noted by Ogden (I 84). OccasiorlaHy, a large osreochon-
tion outlined in Table 23-11 is based on rhe descriprions of dral fragmenr wirh a small ossified ponion can be seen more
osrL:ochondral fracrures by Kennedy (180) and Smillie (188). clearly wirh arrhrography, CT anhmgraphy, or MRI.

Signs and Symptoms Methods of Treatment

Mosr children and adolescenrs wirh osreochondral fracrures of Mosr aurhors recommend opera rive rrearmem of acure osteo-
rhe knee give a hisrory of a flexion-rolarion injury consisrenr chondral fracrures of rhe knee, eirher excision of rhe fragmenr
wirh parellar dislocarion. Rarely, parienrs wirh mulriple rrauma or fixation ro irs anaromic locarion. Kenrlcdy (180) and Smillie
have an osreochondral fracrure from a severe direcr blow or open (188) recommend replacemenc in acure injuries if rhe fragmem
injury of rhe knee. Severe pain, swelling, and difflculry in weighr is large, easily accessible, and in a weighr-bearing area of rhe
bearing are immediare afrer osteochondral fracrure. knee. If arrhrowmy is delayed for 10 days or more, fixation is

A B
FIGURE 23-44. Osteochondral fracture of lateral femoral condyle after patellar dislocation. A: Fragment
seen in lateral joint space. B: Lateral view.
 C'/;flpter 23: Fractllres find Dislocatiom About ,he Knee 1037

FIGURE 23-45. Osteochondral fractures associated with disloca-

tion of the patella. A: Medial facet of patella. B: lateral femoral
condyle. B

contl'aindicared because the articular surface defect has already Operative Treatment
begun EO fill in with fibrocartilage. Other authors recommend The first srep in uearmenr is to obrain adequate radiographic
excision of small fragments from the medial or lateral condyle studies EO assess the size and origin of rhe fragmenr accurarely.
or the patella (167,177,179,187). Excision or fIxation of rhe If rhe fragment is small «2 cm) and from a non-weight-bearing
fragmenr may be done with arthroscopy or arthrotomy, and area, we prefer arrhroscopy for inspection of the joint and re-
fixatioll devices vary from small, smoorh or threaded Steinmann moval of the fragmenr. Arthroscopic examination also may be
pins to counrersunk screws (171,190). Lewis and Foster (181) done if imaging stlldies do nor clearl), reveal the size and origin
reported good resulrs in eight osteochondraJ fractures afrer fixa- of the ft'agmene. If the fragment is lal"ger than 2 cm and from
rion wirh Herbert bone screws. They cite as advantages of rhis a weighr-bearingsurface, either medial or lareral arrhroromy may
technique: be necessalY, as indicated by rhe location of the fragment, ro
rerurn rhe fragmenr to irs bed and fix ir with smal!, rhreaded
1. Litde cartilage damage is dOlle durillg insertion.
Steinmann pins placed in a retrograde or transverse direction
2. Because the screw is enrirely buried, it does not inrerfere with
through the femoral condyle into the subcutaneous tissue medi-
soft rissues.
all)' or laterally. The pins should nor be left prorruding inro rhe
3. Fixation is rigid enough to allow the use oFconrinuous passive
joim, bm should be buried beneath the articular cartilage and
monon.
cut off in the subcutaneous tissue for easy removal after fracrure
4. Reoperation For screw removal is unnecessary.
healing. For velY large fragmems, especially in adolescen rs near-
ing skeletal mawrit)', we use countersunk minifragmenr screws
or Herberr screws. These screws may require later remov::tl even
• AUTHORS' PR FERRED METHOD
,~ OF TREATMENT if buried benearh articular cartilage. Regardless of the fixation
device chosen, care should be taken ro avoid penetration of the
Trearmenc of the osteochondral fragmem depends on five fac- distal femoral physis, especially in younger children.
tors: size, site, stabiliry, surface, and subchondral srarus of the
lesion (189,191). lfrhe fragment is from a non-weight-bearing
Postoperative Care
area, arthroscopic excision is recommended with debridemenr
of the Fragmenr's crater to stable edges and perforarion of the After fixation of a large osreochondral fragment with pins or
underlying subchondral bone co encourage cell ingrowth. Wirh screws, a long leg, bene-knee cast is applied wirh the knee flexed
unstable or loose lesions larger than 3 mm in weighr-bearing ro 30 degrees. Non-weight-bearing ambulation is allowed on
conract areas, fragmenr salvage is :mempred if the fragmenr can crutches, and quadriceps muscle-strengthening exercises al'e
be reduced, irs articular surface is prisrine and nor cl'l':llcllared, begun. The casr is removeJ ::tr 6 weeks after surgery, quadriceps
and its subchondral segmenr is adequate for fixation, llsually 3 exercises are continued, and weight bearing gradually progresses.
mm in deprh. Bioabsorbable fixation devices can be used but Full weight bearing is allowed after swelling has subsided ::tnd
cany a risk of srerile synovitis with recurrent efFusions. Mosr radiographs show he::tling of the fractLlre fragmenr. Rerurn ro
osteochondral fracrures associated wirh patellar dislocation, arhleric activities is permirted when knee range of morion has
either from rhe parella or lareral femoral condyle, can be removed recovered and quadriceps strength is equal ro that of the unin-
arthroscopically. Rarely, after a severe direct blow, a large osteo- volved extremiry.
chondraJ fracture of rhe femoral condyle requires open reduction Afrer arthroscopic excision of a small fragment, a knee immo-
and imernaJ fixarion. bilizer splint is fitted, quadl'iceps-strengthening exercises are
1038 Lower Extremity

FIGURE 23-46. Comminuted osteochondral fracture of the patella after acute lateral dislocation of the
patella at the time of a karate kick. (Courtesy of John Roberts, MD, Bangor, Maine.)

begun, and weight bearing is allowed as ro!et·ated. The immobi- 100,000 children each year. The most common causes of these
lizer is discominued 2 weeks after anhroscopy. fractures are bicycle accidenrs and athletic activities (210,211).
A stable, pajnle~s knee can be obtained in many patienrs with
Prognosis closed rreatmem (190), but displaced fractures irreducible by
closed means require open reduction.
Osteochondral fractures with smaJi fragments not involving the
Garcia and Neer (199) reported 42 fractures 01 the tibial
weight-bearing portion of the joint usually have a good prog- spine in patients ranging in age from 7 ro 60 years, 6 of whom
nosis. The prognosis is more uncertain, however, if the fracrure had positive anterior drawer signs indicating associated collateral
fragment involves a large ponion of the weight-bearing surface. ligament injuries. They reported successful closed management
When :lcute p:ltellar dislocation requires arthroromy for fixation in half their patiems. Meyers and McKeever (209), however,
or removal of a latge osteochondral ftagmenr, Rorabeck and recommended arthroromy and open teducrion for all displaced
Bobechko (185) and Bassett (170) recommend operative repair fractures, followed by cast immobilization with the knee in 20
of the medial retinaculum. Ahstrom (168) noted poor tesults degrees of ~exion rather than hypetextension, believing that hy-
after osteochondral fracture associated with recurrem patellar perextension aggravated the injury in one of their parienrs.
dislocation, but believed these were related more ro the chronic Gronkvisr er al. (201) reponed late instability in 16 of 32 chil-
dislocation or subluxation th:ln ro the articular injury. Even after dren wi th tibial spine fractures, and recommended surgery for
surgical fixation, large osteochondral fractures with incongruous all displaced tibial spine fractures, especially in children older
anicular surfaces may cause loss of motion and late osteoarthritic rhan 10 years because "tile older the patient the more the de-
changes (Fig. 23-46). mand on rhe amerior cruciate ligament-ribial spine complex."
Because of elongarion of rhe anrerior cruciate ligamem (ACL),
Complications which conrribures to insrability, they recommended coumer-
sinking rhe tibial spine-proximal tibial epiphyseal fragmenr dur-
Complications of surgical rreatmem, especially with large frag-
ing open reducrion. Baxter and Wiley (193) nored mild to mod-
ments, include adhesions in rhe supraparellar pouch, quadriceps
narc knee laxiry at follow-up ill 45 patienrs, even after anatomic
insufficiency, and malalignment of the quadriceps-patellar liga-
reducrion of the ribial spine.
ment complex. Threaded Steinmann pins or coumersunk screws
McLennan (208) reponed 10 patienrs with type III intercon-
that prorrude inro tne joint may cause synovitis and loss of knee
dylar eminence fractures rreared with closed reduction and with
joim motion.
arthroscopic reduction wirh or without inrernal fixation. At sec-
ond-Jook arthroscopy 6 years afrer the initial injUlY, those treared
FRACTURE OF THE TIBIAL SPINE wirh closed reducrion had more knee laxity than those treated
(INTERCONDYLAR EMIN NCE) anhroscopicaJly. Jn a long-rerm (average 16 years) follow-up
srudy of G1 children with anterior tibial spine fractures, Janarv
Avulsion fracture of tne tibial spine is a relatively rare injulY in er al. (203) found pathologic knee laxity from 3 to 9 mm in 18
children: Skak et al. (219) reported that it occurred in 3 per (38%) of rhe 47 patienrs clinically rested.
 C/;ilpter 23: Fmcflm:s ((lid Dislocations Ahout the Kltee 1039

A B
FIGURE 23-47. Posterior tibial spine fracture. A: Lateral radiograph of the left knee of a 10-year-old
girl with an avulsion of the posterior tibial spine. B: Magnetic resonance image shows that the posterior
cruciate ligament (solid arrow) is attached to the posterior tibial spine fragment (open arrow). (Courtesy
of Claiborne A. Christian, MD, Memphis, Tennessee.)

Falstie-Jensen and S0ndergard-Perersen (J 97) reported four the anterior poles of the menisci forward co the ancerior tibial
parienrs with moderare or complere displacement of rhe fracrure spine. It is triangular, with its base at the ancerior border of rhe
and incarcnarion of rhe medial meniscus benearh rhe ribial proximal tibia. In rhe immarure skeleton, the proximal surface
spine. They recommended arrhroscopic release of rhe incarcn- of rhe eminence is covered encirely with cartilage. Marz er aJ.
ared meniscus and open reduction and Flxation of the ribial (266) found the medial meniscus to be ((apped under rhe frag-
spine fracture if necessary (206,207). Hayes and Masear (202) ment in 8 of 10 rype III lesions.
reporred one parient wirh an anterior cibial spine fracture associ- In a cadaver study by Roberts and Lovell (215,216), fracrure
ared wirh injury of rhe MCL. For parients wich a positive ancerior of the ancerior intercondylar eminence was simulated by oblique
drawer sign or orher evidence of ligamentous insrability, they osreotomy benearh rhe eminence and traction on rhe ACL. In
recommended sCI'ess radiographs and, if necessary, examinarion each specimen, rhe displaced fragment could be ['educed inco irs
under anesthesia, followed by repair of any injury co rhe ACL bed by extension of rhe knee. In adults, the same s((ess mighr
or collateral ligament. Robinson and Driscoll (217) reponed one cause an isolated tear of rhe ACL, but in children rhe incom-
patienr wich avulsions of the femoral and ribial inserrions of rhe pletely ossified tibial spine is weaker co tensile stress rhan the
ACl and associared MCl injury. ligament, so failure occurs rhrough the cancellous bone benearh
The posterior inrercondylar eminence is even more rarely the subchondral bone of the ribial spine.
injured in children chan rhe anterior eminence (222) (Fig. 23-
Roberts and Lovell (216) found che anterior ribial spine to Mechanism of Injury
be injured 10 rimes more frequenrly rhan che posrerior tibial A fall from a bicycle was rhe most common mechanism of injury
spine. Goodrich and Ballard (200) and Ross and Chesrerman in the series of Meyers and McKeever (210) and Roberrs and
(218) ceported isolared avulsion of rhe posterior tibial spine at Lovell (216), but ancerior tibial spine fractures also have been
rhe insertion of rhe PCL. reponed ill children p,uriciparing in arhlcric activities or with
mulriple trauma (213,214). The injury probably occurs as the
cibia is rotated relarive to the femur and forced into hyperexten-
Surgical Anatomy sion.
The ACl arraches disrally co the anrerior ribial spine and the
ancerior horn of tl1e medial meniscus, wirh separate slips anterior
Classification
and lareral as wei!. The ligament rests againsr rhe lareral roof of Meyers and McKeever (210) proposed a c1assificarion of tibial
the inrercondylar notch of the femur. The intercondylar emin- Spl ne fracrures based on the degree of displacemenc (Fig. 23-
C'IlCt: is chac parr of rhe proximal surface of the ribia lying berween 48):
1040 Lower Ext'rernit)1

1. Type I-minimal displacemenr of rhe fragmenr from rhe

resr of rhe proximal ribial epiphysis
2. Type IJ-displacemenr of rhe anrerior rhird to half of rhe
avulsed fragmenr, which is lifred upward bur remains hinged
on irs posrerior border in conract wirh the proximal tibial
epiphysis
3. Type III -complere separation of the avulsed fragmenr from
the proximal ribial epiphysis, with upward displacemem and
roration

Signs and Symptoms

A,B C Physical findings in acure injury include pain, effusion from
FIGURE 23-48. Classification of tibial spine fractures. A: Type I-mini- associated hemarthrosis, and reluctance ro bear weight. Extremes
mal displacement. B: Type II-hinged posteriorly. C: Type III-complete of morion are resisred because of increasing pain. Genrle srress
separation. (Modified from Meyers MH, McKeever FM. Fracture of the
intercondylar eminence of the tibia. J Bone Joint Surg Am 1959;
testing should be performed to derect any tear of rhe MCl or
41.209-222; with permission.) LCL or physeal fracture of the disral femur or proximal tibia.
Patieurs with late malunion of a displaced tibial spine fracrure
may lack ful] extension because of a mechanical bony block.

A B

FIGURE 23-49. Stages of displacement of tibial spine fractures. A: Type I

fracture, minimal displacement (open arrow). B: Type II fracture, posterior
hinge intact. C: Type III fracture, complete displacement and proximal migra-
C tion.
 Chapter 23: Fractures and Dislocations About the Knee 1041

Radiographic Findings
Adequate anteroposterior and lateral radiographs are essential to
evaluate the degree of displacement of the anterior tibial spine,
although rhe fracture is best seen on rhe lateral view. Both views
should be carefully scrutinized: the avulsed fragment may be
mostly nonossifled cartilage with only a small, thin ossified por-
tion visible on the lateral view. Obtaining rhe anreroposrerior
radiograph more parallel to the normal posterior rilt of the proxi-
mal tibial articuJar surface may better reveal rhe fragment (Fig.
23-49).
If rhe fragment appears narrow and confined to the central
portion of rhe intercondylar eminence, closed reducrion may be
successful. If rhe fragment is wider and extends medially or lat-
erally beneath the articular surface of the tibial epiphysis, the
anrerior horn of a meniscus may be interposed benearh rhe frac-
rure fragment.
Stress views should be obrained if collateralligamem injury
or physeal fracrure is suggested by physical examinarion. These
can be done wirh rhe patient sedated or, if necessary, under
general anesthesia. Abnormal widening of the joint space con-
firms an associated tear of the collateral ligament or may indicate
occulr fracrure of the distal femoral or proximal tibial physis.
A malunited displaced fragment appears on the lateral view
as a large intraarricular extension imo rhe intercondylar norch.
A lareral view raken with the knee in hyperexrension may reveal FIGURE 23·50. Reduction of type II tibial fracture with knee in 10 to
impingement of rhe proximal porrion of the malunired fragmem 20 degrees of flexion.
on rhe arricular surface of the distal fem UL

Methods of Treatment flexion (Fig. 23-50). Anteroposterior and lateral radiographs are
obtained to confirm satisfactOty reduction of the tibial spine
For nondisplaced or minimalJy displaced (types I and II) frac-
fragments and are repeated in 1 to 2 weeks to ensure that rhe
tures of rhe anterior ribial spine, most invesrigawrs recommend
fragment has not become displaced. The cast is removed in 6
closed rreatment. The position of immobilizarion, however, is weeks and physical therapy is continued to strengthen the quad-
controversial; some recommend hyperextension, orhers 10 to 20 riceps and hamstring muscles and to increase range of motion.
degrees of flexion. For type III displaced fracrures, most au thori-
ties recommend open reduction and internal fixation (194,209,
Operative Treatment
222,223,226). Bakalim and WilpuJla (192) reported successful
Alrhough closed reduction of type III fractures can be attempted
closed reduction in 10 patients, none of whom had evidence of
by placing the knee in neutral ro slight flexion, we usually have
laxiry of the ACL at follow-up, although some complained of
not found this successful. We prefer open reduction through an
anteroposterior instability. Smillie (186) suggested that closed
anteromediaJ arthroromy or arthroscopic treatment. This ap-
reduction by hyperextension can be accomplished only with a proach allows inspection of the anterior horns of both menisci
large fragment. Meyers and McKeever (209) recommended casr and distracrion of the meniscus if its interposition beneath the
immobilizarion with the knee in 20 degrees of flexion for all anterior tibial spine fragment prevents anatomic reduction. The
type I and II fractures and open reduction or arthroscopic treat- fragment is reduced with the knee in neutral or 10 to 20 degrees
ment of all type III fractures. of flexion.
If open surgelY is used, numerous flxarion techniques are
available (206-208) (Fig. 23-51). In a young child in whom
the fragment often is large and mostly cartilaginous, the frag-
• AUTHORS' PREFERRED METHOD ment can be reduced in the tibial epiphyseal crarer and secured
\..~ OF TREATMENT with peripheral absorbable sutures. In an adolescent with a small
fragment, a nonabsorbable suture can be woven through the
We prefer closed treatment of mOSt type I and II fractures. If ACL and out the distal end of rhe tibial spine fragment. From
hemarthrosis causes severe pain, aspiration can be done under an anreromedial starring point on the tibial metaphysis, drill
sterile condirions, after which rhe child is placed in a long leg holes are placed obliquely into the crater in the tibial epiphysis,
cast with rhe knee in a position of neutral to 10 degrees of carefully avoiding the remainder of the tibial physis. The frag-
1042 Lower Extremity

2 mm -++------"'+\
drill
guide

A B C

l l l
,,\\\
,,\~

~
.,11\

~ ~
------ --------- --------- .

Threaded
II Drill
Kwire \\ holes
Threaded
K wire
\\ I)
D E F
FIGURE 23-51. Techniques of fixation of tibial spine fractures. A: Peripheral sutures for large cartilagi-
nous fragment in young child. B: Transepiphyseal pull-out suture for smaller fragment in an adolescent.
C through F: An arthroscopic technique using suture to pull down on the tibial spine fragment through
two drill holes. tied anteriorly. C: A threaded Kirschner wire passed into the reduced fracture. D: Non-
threaded Kirschner wire passed parallel to the threaded Kirschner wire. E: A Hewson passed through
the medial drill hole retrieving a polyglactin (Vicryl) suture passed through the medial porthole. F: The
suture knotted down with the fracture reduced. (C through F redrawn from Mah JY, Otsuka NY, McLean
J. an arthroscopic technique for the reduction and fixation of tibial-eminence fractures. J Pediatr Orthop
1996;16: 119-121; with permission.)
 Chapter 23: Fractures and Dislocations About the Knee 1043

FIGURE 23-53. Type III displaced tibial spine fracture in 17-year-old

boy fixed with small fragment screw.

to expose the fracture fragmenrs and the defect in the proximal

tibia. After the medial meniscus is examined, retraction is used
to allow examination of the anterior horn of the lareral meniscus
ro ensure the menisci are not impeding rhe reducrion. The knee
is placed in extension, and the fragment is reduced arrer any
clots and cancellous bone have been removed from rhe defect.
Two holes are drilled from disral to proximal through the ribial
B
metaphysis and epiphysis, with care raken to driJl rhe holes into
FIGURE 23-52. A: Displaced type III tibial spine fracture. B: Three the central area of the crater in the tibial epiphysis. A 1-0 no nab-
months after open reduction and internal fixation with pull-out suture
technique. sorbable suture is passed through the distalmost portion of the
ACL jusr proximal to tile fracture fragment. With surure carriers,
the ends of the suture are passed through the drill holes and
tied on themselves after the reduction is satisfactory. The knee
is flexed and extended to ensure the reduction is srable. The
ment is rhen reduced in irs bed, and surures are broughr our
wound is irrigared and closed.
rhrough rhe drill holes anteromedially and ried securely (Fig.
After reduction anJ fixation, a long leg cast is applied wirh
23-52). Tn skelerally mature parients, in whom rhe integriry of
rhe knee in neutral or slight (10 to 20 degrees) flexion. The casr
rhe ribial physis is nor a concern, rhe anterior tibial spine can
is removed 6 weeks after surgery, and strengthening exercises
be fixed with a mini fragment screw direcred obliquely into the
of the quadriceps and hamstrings and active range-oF-motion
proximal ribial metaphysis (Fig. 23-53).
exercises are begun. Weight bearing progresses From rouch-down
ro full weight bearing.
Open Reduction and Internal Fixation of Fractures of the
Tibial Spine Arthroscopic Technique
The knee is exposed through the distal portion of an anreromed- After removal of any obstructions to reducrion, rhe fracture is
ial parapatellar incision (196). The capsule is opened medially reduced by probe manipulation. Reducrion is maintained by use
1044 LouJer Extremity

of an ACL reconsrruction guide. For fixation of noncomminuted tion of an ACL avulsion in an I I-year-old gi 1'1. They recom-
fragments larger rhan 1 em, a 20-mm cannulated screw is in- mended early removaJ of transepiphyseaJ metalwork or the usc
serted through a proximal medial paraparellar portal (194,223). of anhroscopically inserred intr-aepiphyscal fixation to avoid rl1is
The screw should be placed so rhe proximal. ribial physis is nor complicarion. This technique probably should be reserved for
violared. The screw head should be wirhin rhe ACL substance skt'letally marure patients or the screw should be angled to avoid
to prevem impingemem in exrension. Countersinking rhe screw the physis. Mah et a1. (206,207) found that both of their surgi-
in an arrempr to restore isomerty is counterproducrive because caJly treated type III patients had negative l.achman, anterior
the ligamenr already is atrenuated from the inirial injury. drawer, and pivot-shift tesrs at follow-up, wirh a mean anterior
translation of 2.5 mm measured arthrometrically. They sug-
gested thaI' the anaromic reconstruction prevented laxity, find-
Prognosis and Complications ings nor shown by orher reports that acknowledged that rhe
laxity after injury or surgelY was due to the interstitial elongation
Prognosis of ribiaJ spine injuries in children is good, wirh Illosr
of rhe ACL accompanying the avulsion fracrure.
patients regaining an excellent range of morion. Wiley and Bax-
reI' (224) found a measurable loss of exrension in 45 pariencs
wirh ribial spine fractures, 60% of whom had losses of more than
10 degrees; no patienr, however, complained of any subjective
LIGAMENT INJURIES
feelings of knee insrabiJity. Willis er a1. (225) found clinical signs
The increasing number of reporrs of acute disruprion of the knee
of anterior insrability in 64% of 50 patients ar an average follow-
ligamen rs in children and adolescents (218,229,234,24 ],242,
up of 4 years and objective evidence of laxity in 74%, but again
257,262,263,266,268,277,278,280) refures the long-held belief
no pariem complained of instabiliry.
that complete disruption of knee ligaments can occur only afrer
Poor resulrs may occur afrer rype III fracrures of the ribial
the physes have stopped growing (188). This increased frequency
spine associared wirh unrecognized injuries of rhe coJlater'alliga-
of knee ligament injuries in children probably is related co rhe
ments or complications from associared physeal fracture (211,
more frequent panicipation of children in vigorous sporrs, the
220,221). Malunion of type III fracrures may cause mechanical
increasing incidence of multiple trauma, and a heightened
impingement of the knee during full extension (206-208) (Fig.
aw;:neness among physicians concerning the frequent association
23-54). For sympromatic adolescents, rhis can be corrected by
of ligamenrous injury wirh fracrutes about the knee.
excision of the' malunired fragment and anaromic reinsenion of
Fracrures of the epiphyses or physes about the knee are more
the ACL. Lombardo (205) reponed avulsion of a fibrous union
common rhan ligamentous injuries aJone. Isolated knee ligamclH
of the tibial spine 3 years after original injury.
injury is rare in chiJdren younger than 14 years of age because
Mylle er al. (212) reported anterior epipllysiodtsis with hy-
rhe ligaments are stronger than rhe physes (237,243,261,267,
perexlension of the knee 2 years afrer rransepiphyseal screw fixa-
288). The inherenr ligamentous laxiry in children :llso may offer
some protection against ligament injUly, but rhis decreases as
the adolescent approaches skeleral maturity. Bertin and Goble
(232), after reviewing 29 fractures, concluded that physeal frac-
tures about the knee are associated with a higher incidence of
ligamentous injury.
Befol"e the 1990s, reporrs of ligamentous injmie's in child ren
were isolated case rcpons, and most recommendations were for
conservative rrearment. More recent repons have indicated an
increased awareness of ligamenr injury in associarion with phy-
SGll fractures (238), as well as isolated ligament injuries, and a
more aggressive approach, especially in adolescents approaching
skeletal marurity (231,242,244,246,272,279,287).
Stanirski et al. (285) reporred 70 children and adolescenrs
with acute rraumaric knee hemarthroses; arthroscopic examina-
rion revealed ACL injuries in 47% of rhose 7 to 12 years of age
and in 65% of rhose 13 [0 ] 8 years of age. They delermined
that boys 16 to 18 years of age engaged in organized SpOrts and
girls 13 to ]5 years of age engaged in unorganized SpOrts had
the highest risk For complete ACL tears; 60% of rhese patienrs
had isolated ACL rears.

Surgical Anatomy
The MCL and LCL of rhe knee originate from d1e distal femoral
FIGURE 23-54. Lateral radiograph of a malunited displaced fracture epiphysis and insert into the proximal ribial and fibular epiphy-
of the intercondylar eminence of the tibia with an extension block. ses, except for the superficial portion of rhe Jv[CL, which inserts
 Chapter 23: Fractures and Dislocations About the Knee 1045

Older adolescents may describe the knee as buclJing or "jump-

ing out of place" and can usua.lly relate rhe location and severiry
of their pain as well as the rime berween injUlY and onser of
pain and swelling. Rapid inuaarricular effusion within 2 hours
of injury suggests hemarthrosis, usually from injury ro rhe ACL.
Palmer (274) described four mechanisms capable of produc-
ing disruprion of rhe ligamenrous srrucrures abom rhe knee:
abduction, flexion, and incernal rorarion of rhe femur on rhe
ribia; adduction, flexion, and exrernal roration of rhe femur on
rhe tibia; hyperextension; and anrerior-posrerior displacemen [.
The mosr common mechanism in adolescenrs is abduerion, flex-
ion, and internal rotarion of the femur on rhe ribia occurring
during arhletic competition when the weighr-bearing exrremiry
is srJ'uck from the [areral side. The classic abduction, flexion,
and internal rorarion injury in rhe adolescent may cause rhe
"unhappy rriad" of O'Donoghue: rears of the MCl and ACL
and injury to rhe medial meniscus.
Isolated injury of rhe LCL is rare in children, bur a direcr
blow ro rhe medial aspecr of rhe knee may rear rhe LCL, usually
wirh avulsion from rhe fibula or a physeal injury rhrough rhe
diml femur (258). Isolared injuries of rhe ACL and PCL have
been reported (256,267,278). Disruprion of the ACL wirh mini-
A B
mal injury ro other supporring srrucrures may be caused by hy-
FIGURE 23-55. Anatomy of medial and collateral ligaments of the perextension, marked imernal roration of rhe ribia on rbe femur,
knee in the adolescent. A: Superficial origins and insertions. B: Capsular
and meniscal attachments. and pure deceleration. In contrasr, isolared injury of rhe PCL
most ofren is caused by a direct blow ro the from of rhe ribia
wi th rhe knee inflexion.

imo rhe proximal [ibial meraphysis disral [Q rhe physis (Fig. 23- Classification
55). In children, rhese ligamenrs are srronger rhan rhe physes,
Classiflcarion of knee ligamenr injuries is based on three consid-
and signiflcanr rensile srresses usually produce epiphyseal or phy-
erations: the severity of rhe injuly, rhe specific anaromic locarion
seal fracrures radler rhan ligamenrous injury. The ACL originares
of the injury, and rhe direcrjon of rhe subscquenr insrabiliry
from rhe posrerolareral inrercondylar norch and inserrs inro rhe
caused by an isolated Jigamenr injury or combinarion ofligamenr
ribia slighdy anrerior ro [he inrercondylar eminence. The PCL
In)Unes.
originares from rhe posreromedial aspect of the intercondylar
A first-degree ligament sprain is a rear of a minimal number
norch and arraches on the posterior aspect of rhe proximal ribial
of fibers of the ligamenr wi rh localized tenderness bur no insra-
epiphysis. The ACL in children has collagen fibers conrinuous
biliry. A second-degree sprain is disruprion of more ligamenrous
wjrh rhe perichondrium of rhe tibial epiphyseal canilage; in
flbers, causing loss of funerion and more joint reaction bur no
adulrs, rhe ligamenr inserrs direcdy imo rhe proximal ribia by
signiflcam insrabiliry. A rhird-degree sprain is complere disrup-
way of Sharpey's fibers. This anaromic difference probably ac-
tion of rhe ligament, resulring in insrabiliry. Although difflculr
coums for rhe facr rhar fracruJe of rhe anrerior ribial spine occurs
ro assess clinically, rhe degree of sprain also is derermined during
more frequendy in children rhan does ACL injury.
stress testing by rhe amount of separation of rhe joi nr surfaces:
flrsr-degree sprain, 5 mm or less; second-degree sprain, 5 ro 10
mm; and rhird-degree sprain, more than 10 mm.
Mechanism of Injury
The anaromic classification of ligamenr injuries describes the
The mechanism of ligamenrous injury varies wirh rhe child's exacr location of rhe disruprion (250):
~gc. In younger children, ligamenrous injury rypically is associ- A. MCL insufficiency (Fig. 23-56)
ated wirh signiflcanr polyrrauma. Clanron er al. (237) reponed 1. Superficial
that five of nine children wirh acure knee ligamenr injuries were a. Femoral origin
s[t'uck by auromobiles. In conrrast, adolescenrs are more likely b. Middle porrion
ro susrain Jigamenrous injury during conr~cr sports or spons c. Tibial inserrion
rh~r require "cuning" maneuvers while running (219,268). As 2. Deep
cxacr a dcscriprion as possible of the mechanism of injury should a. Men iscofemoral
be obtained, including rhe position of rhe knee ar rhe rime of b. Middle porrion
injury, rhe weighr-supponing srarus of rhe injured knee, wherher c. Meniscoribial
rhe force applied was direcr or indirecr (genera red by rhe parienr's B. ACL insufficiency
own momenrum), and rhe position of rhe exuemiry afrer injury. J. Femoral origin
1046 Lower Extremity

A,S c
FIGURE 23-56. Medial collateral ligament injury. A: Femoral origin. B: Middle portion. C: Tibial inser-
tion.

A,S c
FIGURE 23-57. Lateral collateral ligament injury. A: Femoral origin. B: Middle portion. C: Fibular inser-
tion.
 ClJt1plfr 23: Fmel1lreJ and Dis/oeatiom About the Knee 1047

2. Inrerstjtial is impossible after aspiration, rhe diagnosis of an entrapped me-

3. Tibial instltion niscus should be considered.
a. Withom avulsion of the imercondylar eminence Palpation of rhe collateral ligamenrs and their bony origins
b. With avulsion of rhe imercondylar eminence and insenions should locare renderness at rhe site of the ligament
C. LCl insufficiency (Fig. 23-57) injury. A defect in rhe collareral ligaments ofren can be felr if
1. Femoral origi n rhe MCl is avulsed from its insertion on rhe ribia or if rhe lCl
2. Middle ponion is avulsed from the fibular head. If the neurovascular srarus is
3. Fibular insenion normal, stabiliry should be evaluated by suess tesring.
D. PCl insufficiency Suess testing for ligament injury in children (248,249), with
1. Femoral origin or wirhour concomiranr fracture, is velY subjective, and its use-
2. Imersti rial fulness depends on the knowledge and experience of the exam-
3. Tibial insmion iner. Stress tesring may be done immediarely after injUlY in co-
a. \X!irhour avulsion of rhe imercondylar eminence operative adolescents who do nor have orher significant injuries,
b. Wirh avulsion of the imercondylar eminence but sedation or general anesthesia may be required for accurate
diagnosis. In nonemergent siruarions, beginning the examina-
Finally, rhe instabiliry of rhe knee joinr caused by rhe liga- tion by tesring the uninjured knee often calms patients and
menr disruption is classified as follows (255,281): makes rhem more cooperarive; it also establishes a baseline for
A. One-plane instabiliry (simple or srraight) assessing rhe ligamenrous stability of the injured knee. In rhe
1. One-plane medial standard srrcss resrs of specific collateral and crucjate ligamenrs
2. One-plane lateral of the knee described in rhe following sections, rhe uninjured
3. One-plane posterior knee should be examined flrsc
4. One-plane anrerior
B. Rotary instabiliry
1. Anteromedial Valgus Stress Test of Medial Collateral Ligament
2. Anterolateral The valgus or abducrion srress resr is done wjth rhe child supine
a. In flexion on rhe examining rable and rhe knee to be examined on rhe side
b. Approaching extension of the rable closest ro rhe examiner. The exrremiry is abducted
3. Posterolareral off rhe side of rhe rable and the knee is flexed approximarely 20
4. Posteromedial degrees (Fig. 23-58). Wirh one hand about rhe lareraJ aspecr of
C. Combined instabiliry rhe knee and rhe orher supporting the ankle, the examiner ap-
1. AnterolateraJ-posterolateraJ plies gende abduction or valgus stress ro rhe knee while rhe hand
2. Anrerolateral-anreromedial ar rhe ankle gently externally rotates the leg. Stabiliry of the knee
3. Anteromedial-posteromedial is nored at 20 degrees of flexion and again ar neuual.
Using this classification, one-plane medial instabiliry, for ex-
ample, means that the tibia moves abnormally away from the
femur on the medial side. In ameromedial rotary instabiliry, the Varus or Adduction Stress Test of Lateral Collateral
tibia rorates anreriorly and externally and moves away from the Ligament
femur on the medial side. The classification becomes more com-
The varus or adduction srress resr is done in a manner similar
plex as more significant ligamentous injuries involving more ana-
to the valgus stress resc It should be done wirh the knee in full
tomic locations are included, bur determining the type of insta-
extension and in 20 degrees of flexion. The lCL may be palpable
bility resulring from the injUlY is helpful in planning treatment.
as a taur strucrure on rhe lareral aspect of rhe knee.
The stabili ry of rhe collateral ligaments may be differenr when
resred in exrension and in flexion. If a colJateralligamenr is rom
Signs and Symptoms but the cruciate ligaments and posterior capsule are intaCt, lirtle
Both lower cxnemities are examined for comparison. Largc areas instabiliry can be derecred with the knee exrended. Flexion of
of ecchymosis and cxrensive effusion are easily identified, but t he knee relaxes rhe capsule and more insrabiliry is evident wirh

smaller areas may require careful palpation. In general, acute the same degree of ligamenrous injury. Significant insrabiliry
hemarthrosis suggests ruprure of a cruciate ligamem, an osreo- with varus or valgus srress resring wirh rhe knee in full exrension
chondral fracrure, a peripheral rear in rhe vascular porrion of a usually indicates a cruciare as well as a collateralligamenr disrup-
meniscus, or a rear in rhe deep porrion of the joinr capsule non.
(239,240,245). The absence ofhemarrhrosis is nor, however, an
indicarion of a less severe ligamem injury, because wirh complere
Stress Testing of Anterior Cruciate Ligament
disruption rhe blood in rhe knee joinr may escape inro rhe sofr
rissues rarher rhan disrend rhe joint. The range of morion of the The anterior drawer tesr, as described by Slocum, is rhe classic
injured knee, especially exrension, is compared wirh that of the maneuver for resting the srability of the ACL (Fig. 23-59). The
uninjured knee. IF significant effusion prevenrs full exrension, Lachman and pivot-shift rests, howcver, are considered more
srerile aspirarion can be performed. If complete knee extcnsion sensirive for evaluating ACl injury when the examinarion can
1048 Lower Extremity

A B
FIGURE 23-58. Valgus stress test of medial collateral ligament. Extremity is abducted off table, knee
is flexed to 20 degrees, and valgus stress is applied. A: Frontal view. 8: Lateral view.

be done in a relaxed, cooperarive adolescenr (Fig. 23-60). To and fingers causes anrerior rranslarion of rhe ribia in relarion ro
perform rhe Lachman resr, the examiner firm Iy stabilizes the rhe femur thar can be palpated by the thumb; a soft or mushy
femur with one hand while using the other hand to grip the end poinr indicares a positive test. When the ACL is disrupted,
proximal tibia, with rhe thumb placed on rhe ameromedial joinr the normal patellar ligamenr slope is obliterated.
margin. An anteriorly directed lifting force applied by rhe palm

Stress Testing of Posterior Cruciate Ligament

The posterior drawer rest for evaluation of the PCL is done wirh
the pariem supine. With rhe pacienr's foor secured ro the rable
and the hip flexed 90 degrees, a posterior force is applied ro rhe
proximal tibia. Posterior movement of rhe tibia on the femur
grearer than in the uninjured extremiry indicates posrerior insra-
biJiry (Fig. 23-61).

Active Quadriceps Contraction Test of Posterior

Cruciate Ligament

A With rhe patienr supine, the relaxed limb is supporred with the
knee flexed to 90 degrees. It is imporranr ro supporr rhe thigh
adequarely so thar the child's muscles are complcrely relaxed.

B
FIGURE 23-59. Anterior drawer test of anterior cruciate ligament.
Foot is positioned in internal, external, and neutral rotation during
examination. With anterior cruciate insufficiency, an anterior force (Al
displaces the tibia forward (8). FIGURE 23-60. Lateral pivot-shift test of anterior cruciate ligament.
 Chapter 23: Fractures and Dislocatiom About the Kllee 1049

FIGURE 23-61. Posterior cruciate ligament injury. Note posterior sagging of the tibia with posterior
cruciate injury.

The examiner's other hand stabilizes the foor and rhe parienr Radiographic Findings
genrJy slides the foot down the table ro conrracr me quadriceps
Anreroposterior and lateral radiographs are obrained when any
muscle. Tibial displacemenr resulring from rhe quadriceps con-
ligamenr injury of the knee is suspected in children. The radio-
rraC[ion is noted (Fig. 23-62). When rhe PCl is ruprured, con-
graphs are carefully inspeered for evidence of occulr epiphyseal
tracrion of the quadriceps muscle resulrs in an anrerior shifr of
or physeal fractures or bony avulsions. The inrercondylar norch,
the ribia.
especially, is inspecred ro deteer a tibial spine fracture, which is
confirmed by anrerior or posterior instability on physical exami-
nation. Occasionally, a small fragmenr of bone avulsed from the
medial femur or proximal tibia indicates injury to rhe MCL.
Similarly, avulsion of a small fragmenr of bone from rhe proxi-
mal fibul"r epiphysis or the lateral aspect of the disral femur
may indicate lCl injuty.
In children with open physes, stress radiographs are especially
helpful ro evaluate medial and lateral instability associated with
physeaJ fractures (Fig. 23-63). GenrJe stress views may be ob-
rained with sedation, but general anesthesia may be required
if rhe diagnosis is unclear. There are no accepred guidelines
correlating joinr space widening medially or laterally with knee
A joinr inscability in children, and stress views of the opposite knee
may be required for comparison. If plain radiographs show a
fracrure of rhe disral femoral or proximal tibial physis, srress
views may be obtained only ro evaluate suspected ligamenrous
insrability. Conversely, if rhe initial radiographs appear normal
bur rhere is significanr effusion abour rhe knee, srress views
should be obtained to rule out a fr:lcrure of the physis of the
disral femur or proximal tibia.
Other radiographic findings include avulsion of the anrerior
or posterior ribial spine indicative of injUlY to the ACl or PCl,
widening of the joinr space, and posterior subluxation of the
B
tibia on rhe femur. C1anron er al. (237) consider a joinr space
FIGURE 23-62. Active quadriceps contraction test of posterior cruciate of8 mm or wider ro be a definitive indication of ligament injury.
ligament. A: Patient gently slides foot down the table to contract the
quadriceps muscle. B: The tibia shifts anteriorly with quadriceps con- Sanders et al. (278) reported 1.8 cm of posterior subluxation of
traction when the posterior cruciate is torn. rhe tibia on the anreroposterior srress view in a 6-year-old child
1050 Lower Extremit)'

A B
FIGURE 23-63. Stress radiographs of suspected ligamentous injury. A: Valgus stress radiograph of 14-
year-old boy with medial collateral ligament injury and tibial spine fracture. B: Varus stress radiograph
of 10-year-old boy with lateral collateral ligament injury. (A courtesy of John Roberts, MD, Bangor,
Maine.)

with complete PCL disruption. MRI should be used to evalu<tte 7 returned to sports activities; all experienced recurring episodes
ligamentous <tnd meniscal lesions in confusing c<tses (284). of giving way, effusion, and pain. Of the 24 treated surgically,
torn menisci were found arthroscopically in 18 and 22 had satis-
factory results.
Methods of Treatment Lipscomb and Anderson (263) reported treatment of24 ACL
Clanton et al. (237) and others have noted dut the best treat- injuries in adolescents (12 to 15 years of age) with intraarticular
menr for knee ligamenr injuries in children has not been cle<trly augmentation using the semitendinosus or gracilis tcndon. They
defined. Poor results have been reported after conservative creat- used boles drilled in the appropriate position through the tibial
ment and after primary repair (236,238,270). Most authorities physis and an over-the-top technique for placcment of the aug-
recommend conservative rreatment of aCllCe ligament injuries in mentation over the femoral condyle. One patient had significant
young childl-cn, but give no clear indications for surgery. The growth disturbance. Wester et al. (289) developed graphs to
numerous reconstructive techniques devised for the ACL are help predict the amount of shortening and angular deformity
basically either extraarcicular (avoiding the physes) or intraarticu- to expect after ACL repair in skeletally immature patients. Ac-
lat (228,254,260,265,286). The intraarticular procedures more cording to theil' calculations, when done within I year of matu-
accurately replace the ACL with an anatomic or biomechanical rity, reconstruction should result in a maximum of 5 degrees of
substitute that allows the isometric placement of the graft critical valgus angulation and 1 cm of shortening.
to prevent subsequent loosening. DeLee and Curtis (242) and Engebretsen et al. (247) reponed
McCarroll et al. (268) compared 16 adolescents with ACL moderate [0 severe instability in adolescenrs wirh ACL ruprures
injuries treated conservatively with a similar group of 24 adoles- after primary surure with inrraarricular or exrraarricular augmell-
cents who had arthl'Oscopic examination and extraarticular or tarion. Kannus and Jarvinen (262) reponed successful closed
intraarticular reconstruction of the ACL. Of the 16 treated non- rreatmenr of grade II (moderate) ligamenr injuries in adolescenrs,
operatively, 6 required later surgery for meniscal injury and only bur unacceprable results in grade III (complere) ligamenroLis
 Chapter 23: Fractures and DisLocations Abo/It the Klier 1051

rears; rhey recommended surgical repair of all grade IlIligamenr rive choice for a parienr willing to accept rhe functional limita-
injuries in adolescenrs. Parker er aJ. (275) reponed good resulrs tions. We use a three-phase approach. Phase one begins shortly
afrer ligament reconsrrucrion using hamsrring rendons in six after injury and lasts 7 to 10 days. Brief immobilization (3 ro
children wirh open physes 00 ro 14 years of age). They placed 5 days) with a knee immobilizer for comfon is followed by daily
a groove over the front of the tibia and another over the rop of out-of-brace exercises with acrive knee flexion and passive knee
rhe femur withour violating the physes, alrhough this is not an extension. Ambulation is wirh crutch-protecred partial wcighr
isomerric posirion of rhe ACL. bearing. During this time, we reinforce patient education on the
consequences of imprudenr return to high-level SpOrts. Phase
two focuses on rehabilitation of the lower extremiry and lasts
• AUTHORS' PREFERRED METHOD approximately 6 weeks. Emphasis is placed on restoration offull
,~ OF TREATMENT knee motion, fl.exibiliry, strengrh, and endurance with panicular
arrenrion to regaining rhe normal quadriceps/hamstring strength
Before derermining rrearmenr, we analyze each knee ligamenr ratio. As the ratio is normalized, crutch use is decreased and
injury, considering the child's skeletal age, rhe family's arhleric then eliminated. The role of funcrional bracing has nor been
expectarions for the child, the presence of associated fracrures, defined in children and issues of fit, size, and cost need to be
wherher rhe injury is ro an isolared ligament or ro mulriple considered. Phase three conrinues the rehabilirarion, incorpo-
ligamenrs, and wherher the resulring insrabiliry is single-plane rates the use of a functional brace for sporrs, and allows rerurn
or multiplane. ro low- and moderate-demand SPOrtS when quadriceps and ham-
srring srrength and endurance are equal to those of the opposite,
Medial Collateral Ligament noninjured side as determined by isokinetic resring at funcrional
Isolated grade I or II sprains of rhe MCl are rreared wirh speeds (>260 degrees/second). In the hnal parr of this phase,
crurches or a hinged knee brace for 1 ro 3 weeks, depending on sports readiness tasks are done at less than full speed. Monthly
resolurion of symproms. Rerurn to arhleric activities is allowed follow-up evaluates program compliance and rules our any fur-
when a full, painless range of morion is achieved and the parienr ther knee changes in funcrion. Compliance wirh a nonoperarive
can run and cut wirhour pain. Isolared complete (grade III) program designed ro be a temporizing measure ofren is quire
disruption of rhe MCl can be treated wirh 6 weeks of immobili- difficult for an emerging athlere who is surrounded by peer,
zarion in a hinged knee brace followed by rehabilitation of rhe coaching, and, often, parenral pressures to rerum to high-de-
quadriceps muscles and knee motion provided rhis is an isolated mand spons.
injury. The physician must ensure that there is no associared Surgical management of ACl tears in skelerally immature
injury ro the ACl before using nonoperative trearmenr for a parienrs is highly conrroversial. In parienrs wirh whar we rerm an
grade III MCl injury. ACL pLus knee (one with combined ACl and meniscal injul'ies),
Grade III disruptions of rhe MCl in adolescenrs often are surgical reconstruction usually is recommended because of rhe
associared with ACl injury or ribiaJ spine fracrure, as well as
poor prognosis of meniscal repair alone wirh compromised ACl
severe injury ro the posreromedial knee capsule. If suess resring
function (227,229,233,252,264,269,272,275,282,283). How-
demonstrares gross instabiliry, surgical repair is indicared. Mid-
ever, physeal injury and resroratioll of ligamenrous isometry are
substance rears of rhe MCl and reatS of rhe capsule can be
concerns in the maruring femur and ribia. The safe percenrage
sutured. An MCl avulsed from irs distal insertion can be reat-
of physeal invasion, even in the cenrral ponion, thar will be
rached wirh a sraple if ir can be placed well distal ro rhe physis;
tolerated, is unlmown. Experimenral work in rodents by Garces
if not, the ligamenr is repaired to the surrouncl.ing soft tissue.
et al. (251), lapin models by Guzzanti et al. (253) and Janarv
et al. (259), and in canines by Sradelmeyer et al. (282) suggests
Anterior Crueiate Ligament
rhar cenrral femoral physeal invasion by driJling rhat involves
A rom ACl does nor constitute a surgical emergency, despite
less than 7% ro 9% of the toral physeal area does nor produce
rhe image projecred by celebriry arhletes and rheir urgent care.
significanr length or angular deformities in rhese experimeIHal
A frank discussion musr be held wirh rhe parenrs and rhe parienr
models. In animal studies rhat used tendon or fascial autografts,
concerning furure vocarion, sporr demands, rrearmenr options,
either free or in conrinuity, ro fill the defects created in femoral
outcomes, and risks involved wirh rerum ro currenr sporr activ-
and proximal tibial physes and epiphyses, J anarv et al. (259)
iry. The orthopaedic surgeon must assume rhe role of a "knee
found thar rhin bone cylinders developed around the tunnels
counselor," particularly wirh patienrs with a hisroly of chronic
knee abuse. AJI uearmenr algorithms are based on an accurate filled with tendon grafts and questioned wherher large tunnels
and complete diagnosis, which is achieved by clinical, imaging, would create enough cylinder bone to cause physeal bridges of
and, if necessary, anhroscopic means. The rrearmenr goal is a consequenrial size, even when centrally placed. Whether rhe ef-
funcrional lmee wirhour progressive inrraarticular damage or fects seen in these various quadruped models can be translated to
predisposi rion ro premature osteoanhrosis. the unique demands of human bipedal gait remains unanswered.
Nonsurgical treatment does nor indicare nontrearmenr (229, Also in question are the effects of exposure time afrer physeal
252,271). The goal of rhis program is defined from rhe ourset: invasion because the animal models had shorr exposure times
it is a remporizing measure unril rhe parienr becomes mature in conrrast to the 2 to 4 years of growrh remaining in adolescenc
enough for an adult-rype ACl reconsrrucrion, or ir is rhe dehni- humans, especiaJly boys. An addirional concern is rhe olltcome
1052 Lower Extremity

of the grafted tissue that provides the biologic scaffold for neolig- maining at the distal femur and proximal tibia is limited (Fig.
ament formation in terms of the tissue's size, strength, isometry, 23-66).
and growth. None of the animal series used any type of rransphy- The major limitation of the physeal-sparing procedure de-
seal fixation. scribed by Parker et al. (275) is the lack of anatomic isometry
No data specifically address the timing ofACL teconstruction of the neoligament. Each of their six patients who were 10 to
in skeletally immature patients after acute injury. We wait 14 14 years of age had an associated meniscal tear that required
to 21 days to allow abatement of the initial inflammatory phase, treatment. At 2-year follow-up, outcomes were favorable. Al-
in keeping with the data that suggest in adults a reduced fre- though not optimal, this technique provides a reasonable option
quency of fibroarthrotic complications if surgery is delayed. Dur- in very young patients with symptomatic functional instability,
ing this time, crutch-protected gait is used and restoration of usually due to noncompliance in a nonoperative program and
full passive extension is sought. We also use this time to reem- often associated with a subsequent meniscal tear.
phasize the 6-month time frame expected for recovery before Partial transphyseal techniques use 6- to 8-mm patellar or
return to sports. Even with contemporary accelerated rehabilita- hamstring autografts in continuity that are passed through 6-
tion programs, return to sport is a function of biology and not to 8-mm tibial proximal tunnels more vertically oriented in an
arthroscopic technology. The rare patient who presents with a attempt to improve graft isometry. The over- the-top graft is
locked knee from a concomitant displaced meniscal tear requires attached to the femoral metaphysis, with care taken to not violate
mote urgent surgery for both injured structures. the lateral femoral physis. Lo et al. (264) reported 29 truly skele-
Reconsrruerion ofthe ACL requires consideration of the three tally immature patients who had reconstruction of their torn
"Ts": tissues, runnels, and technique. Autograft tissues include ACL using this method, the largest series to date. All patients
patellar and hamstring tendons, most commonly the semitendi- had excellent functional outcomes and objective test results at
nosus alone or with gracilis augmentation. Allograft ACL substi- an average follow-up of 3 years. No clinical or radiographic
tution has been reported in eight children (227). Concerns of evidence of limb deformity was seen.
potential viral transmission and graft strength alterations second- Complete transphyseal ACL reconstruction methods are the
same as adult techniques and are done in patients who are T an-
ary to sterilization effects remain (273). Synthetic ACL use as a
ner stage 3 or higher.
backup to autograft or allograft causes concerns about longevity,
Graft choice depends on the surgeon's preference and may
foreign body synovitis from wear particles, and fixation tech-
be a multistrand hamstring configuration or a patellar bone-pa-
niques. Direct ACL repair is destined to failure unless a suffi-
tellar tendon-tibial tubercle construct. Graft fixation may be
cient-sized bone fragment is avulsed to allow direct bone union.
intraarticular or extraarticular. McCarrol et al. (269) reported
Exrraarticular ACL reconstruction using fascia lata slings in
good results from such reconstructions in mature adolescents
a variety of configurations has had limited success in adults, and
with arthroscopically documented ACL complete tears that com-
similar outcomes are predicted in skeletally immature patients
monly were associated with meniscal tears that required repair.
who wish to return to high-demand sports. An additional con-
Even with the excellent results achieved by this experienced
cern is the potential tethering effect on the lateral knee produced
group of knee surgeons, they advocated delaying reconstruction
by this method with secondary femoral or tibial physeal asym-
in skeletally immature patients until sufficient maturity is
metric growth.
reached to allow a complete transphyseal procedure.
Tunnels for ACL reconstruction are technique dependent
Postoperative rehabilitation is based on physiologic principles
and include grooves in the proximal tibial epiphysis, over-the- that reduce deleterious effeers of immobilization, protect the
top femoral placement, and more vertical proximal tibial physeal healing rissues, avoid negative misuse effects, and encourage graft
and epiphyseal tunnel orientation to provide improved graft maturation by providing physiologically tolerable stresses to it.
isometry. When selecting tunnels, we considet three types: phy- Advancement to the next rehabilitative phase is predicated on
seal sparing, partial rransphyseal, and complete rransphyseal the patient achieving previously determined functional criteria.
(283). Physeal-sparing methods avoid any physeal invasion with The program is divided into four phases: phase1, weight bearing
intraarticular passage of the graft. Partial transphyseal techniques and motion restoration; phase 2, muscle strength gains; phase
use a central transphyseal and epiphyseal proximal tibial tunnel 3, progressive improvement in speed, power, endurance, and
with intraarticular passage of a hamstring or patellar tendon graft agility; and phase 4, sport readiness and return to sport. Phase
to an over-the-top femoral position with femoral metaphyseal 1 begins immediately after surgery and continues for 6 weeks.
fixation. Complete transphyseal procedures involve central, iso- The patient uses crutches for protected weighr bearing and is
metrically oriented tibial and femoral tunnels and intraarticular encouraged to progress to full weight bearing without crutch
graft passage and femoral and tibial epiphyseal or metaphyseal support by 4 ro 5 weeks. The postoperative knee immobilizer
graft fixation sites. Physeal-sparing techniques are used with is replaced with a postoperative brace that limits extension to
quite skeletally immature, Tanner stage 0 to 1 patients, usually - 30 degrees and flexion to 90 degrees. Active flexion is encour-
with an associated meniscal injury that requires treatment (Fig. aged and passive full extension out of the brace is done a mini-
23-64). In patients who are somewhat more mature (Tanner mum of four times daily. At the end of this phase, full weight
stage 2), partial rransphyseal methods are suggested (Fig. 23- bearing and passive extension are expected, as is knee flexion
65). In patients who ate Tanner stage 3 (boys with curly axillary to 110 degrees. Resistive closed-chain hip flexor, quadriceps,
hair and girls who are postmenarchal) and above, complete rrans- hamstring, and gastrocnemius and anterior tibial and peroneal
physeal, adult-type reconstructions are done because growth re- exercises are done three times daily. If concomitant meniscal
 'hapter 23: Fractures (/nd Dislocations About the Knee 1053

Medial view Anteroposterior view Medial view Anteroposterior view

A B

c D

E F
FIGURE 23-64. Physeal-sparing anterior cruciate ligament reconstruction technique (A and B). Intraop-
erative arthroscopic views oftibial tunnel preparation of the epiphysis (e) and notchplasty (D). Epiphyseal
"tunnel" groove under the anterior transverse meniscalligament (E) with semitendinosus graft in place
(F). (Courtesy of Scott Cameron, MD, Marshfield, Wisconsin.)
1054 Lower Extremity

Medial view Anteroposterior view

.\

FIGURE 23-65. A and B: Schematic views of a partial transphyseal ante-

Gracilis/semi- rior cruciate ligament (ACL) reconstruction with medial hamstring
tendinosus graft. C, D, and E: Radiographs of a 16-year-old girlS years after partial
transphyseal ACL reconstruction done at Tanner stage 2. Note the
A,B notchplasty effect. There is no evidence of femoral or tibial deformity.

C-E

repair was done, prorecred weighr bearing and knee flexion limi- brace use is cominued for 3 ro 6 monrhs afrer rerum ro sporr,
tation ro 90 degrees are conrinued (or 8 weeks. Phase 2 encom- usually ar rhe parienr's requesr.
passes rhe nexr 6 weeks, during which rime closed-chain resisrive
exercises are cominued wirh quadriceps suengrh expecred ro be Prognosis and Complications. Limired dara exisr abour posr-
rwo rhirds o( rhe opposire normaJ side by isokineric resting at operarive complicarions afrer ACL reconsuuction in skelerally
120 degrees per second wirh rhe knee prorecred ar - 30 degrees immarure parienrs, bur rhe same rype of complicarions seen in
o( exrension. Gail' should be normal and passive knee motion adulrs also mighr be expecred in younger parienrs: loss of morion,
full. Phase 3 lasrs 6 weeks, wirh progressive emphasis on resrora- donor and inserrion site problems, and reflex symparheric dys-
tion of rhe quadriceps-hamstring srrengrh rario, which should uophy. A1rhough limired clinical and experimeIHal dara in skele-
be 75% ro 80% of normal by isokinetic resring. A funcrional raJly immature models suggesr rhar deformiry and growrh com-
brace is fined dnring rhis rime and a running program is insri- plicarions are uncommon afrer ACL reconsrruction, rhese
rUfed. Phase 4 lasrs for 6 weeks and involves normalizarion of complicarions are possible, especially when judgmenral or surgi-
lower ex.rremiry muscle srrength, power, and endurance. Agiliry cal rech nical errors occur.
drills are advanced and sporr-speciflc readiness rasks are done ar
progressively higher rares of speed. AI' rhe end of rhis phase, Authors' Prefen'ed Treatment. In immarure parienrs wirh iso-
knee range of morion should be full and wirhout pain, there lared ACL rears, we recommend nonoperarive managemenr wirh
should be no signs of funcrional insrabiliry, and rhe knee sagirral suong emphasis on parienr counseling abour che porenriaJ for
srabiliry should be wirhin 3 mm of rhe opposire normaJ side addirional inrraarricular damage wirh rerum to high-demand
wirh normal muscle srrengrh, power, and endurance. Funcrional spons. [n parienrs wirh a concomiram meniscal injury char fe-
 Chapter 23: Fraeturn and DisLocations About the Kfler: 1055

Medial view Anteroposterior view

Bone
plug

Screw

A B

FIGURE 23-66. A and B: Schematic views of one type of complete

transphyseal anterior cruciate ligament reconstruction using a patel-
lar tendon-bone construct. Inset shows an alternative intraarticular
fixation method. C An arthroscopic view of such fixation using a
bioabsorbable screw. D and E: An alternative fixation technique
using a multistranded hamstring graft with "button" femoral fixa-
c tion.

D E
1056 Lower Extremity

quires repair, the so-called "ACl plus" knee, we recommend Isolated grade III injulY of rhe PCl in children and adoles-
ACL reconsrruction, even in those who are relatively immarure, cenrs can be treated with 6 weeks of immobilization in a cast-
because of the high potential for repeated intraarticular damage brace or hinged Imee brace. If significant functional symptoms
leading [0 premarure degenerative arrhrosis. Three types of ACL persist in an adolescenr, the PCL can be reconstrucred at or near
reconstruction are possible: physeal sparing, partial transphyseal, skeletal maturity. In a young child with grade III MCl or leL
and complete transphyseal. The choice must be tailored [0 the injury in addition to PCl injLlly, the collateral ligament can he
patient's physiologic and anatomic assets and liabilities. surgically repaired to convert the multi plane instabiliry to a sin-
gle-plane instability. PCL injUly may be associated wirh ACT.
injllly, primarily in knee dislocations, and surgical intervention
Grade III Sprains of Both Medial Collateral and Anterior
usually is appropriate for this combination of injuries, especially
Cruciate Ligaments
in patients nearing skeletal maturiry (235).
The combination of grade III injuries of both the MCL and
ACL is, unforrunately, fairly common, especially in older adoles-
cents. In addition [0 complete disruption of the ACL, the MCl Postoperative Care and Rehabilitation
is torn either from its femoral origin, in its midsubsrance, or
from irs tibial insertion. This combination of injuries results in After casr-brace or hinged brace immobilization, aggressive reha-
mulriplane instability. Treatment is based on the child's age and bilitation is recommended, including strengrhening of the quad-
the specific injuries. In children wirh more than 2 years of skele- riceps and hamstrings, progressive range-of-motion exercises,
ral growth remaining who have an avulsion of the MCL from and progressive weight bearing. A vigorous physical therapy pro-
its femoral origin, we recommend 6 weeks of immobilization in gram is more difflculr for younger children, but rehabilitation
a hinged knee brace, followed by vigorous rehabilitation. If the becomes progressively more imponant as the child becomes
MCL is [Orn in its midsubstance or avulsed from its tibial inser- older, and it is critical in adolescents returning to high-demand
rion wirh gross laxiry, we recommend sutgical repair with sutures competitive spons. Bracing is recommended during SpOrts ac-
in the midsubstance tear or a staple in the proximal tibia distal tivities for adolescents with previous ACL injuly.
[0 the physis with no repair of the ACL, thus converting the

multiplane instability [0 single-plane instability. If anterior or

Prognosis
anterolateral instability persists during growth in a very young
child, an extraarticll!at tenodesis can be done to protect the Isolated injuries of the collateral ligaments, wirh or without phy-
menisci until skeleral maturity. If symp[Oms warrant, intraarticu- seal fractures, have a generally good prognosis. With grade III
lar reconstrucrion of rhe ACl can be done as the adolescen r nears isolated injuries of the ACL, however, long-rerm results are ex-
skeletal maturity. For an adolescent within 12 [0 24 months of tremely variable, depending on the amount of late instability
skeletal maturity with grade UI injuries of the MCL and ACl and the demands placed on the knee during athletic activiries
resulting in multiplane instability, we recommend surgical rreat- during adolescence or young adulthood. The worst prognosis is
ment of both ligaments. Careful repair of rhe posteromedial knee for combined grade III injuries of the cruciate and collateral
joint capsule ofren is required. ligaments that are treated conservatively.

Lateral Collateral Ligament Complications

Grade III injuries of the LCL are rare in children. Occasionally,
the lateral capsular sign is seen on radiographs obtained for evalu- The three most serious potential complications of knee ligament
ation of knee injury. Most ofren, the lCL is avulsed from the injlllY are neurovascular complications, meniscal injuries, and
proximal fibular epiphysis; proximal and midsubstance tears are late instability.
uncommon. This injury is n'eated in the same manner as injury Careful assessment of the neurovascular status is mandarory
to rhe MCL. For isolated gtade III injuries, a 6-week period of at the initial examination. Any indication of neurovascular injury
immobilization in a hinged knee brace is recommended. If ACl associated with severe knee ligament injury shouJd prompt im-
injury is associated with lCL injulY, rreatment is as described mediate investigation, including arteriography of rhe popliteal
for combined injuries of the MCL and ACL. In young children, artery.
There is a high incidence of meniscaJ injury associated wirh
the LCl is repaired and the ACl is left untreated. If instability
ACl disruption, especially in adolescents. Even if surgical recon-
persists ,IS the adolescent nears skeletal maturity, inrraarticular
strucrion of an isolated ACl rupture is nor planned, arthroscopy
reconstruction can be done at that time. In adolescents near
may be done to identify any associared meniscal injulY and to
skeletal maturity at the time of injury, we prefer [0 repair both
determine if primary repair or partial meniscectomy is appro-
the ACL and lCL.
pnate.
Rarely, children wirh combined grade III injuries of the col-
Posterior Cruciate Ligament lateraJ and cruciate ligaments rhat have been treated conserva-
In general, PCL injuries in children are associated with a bony tively acquire late instability. For young children with functional
avulsioJl. If nondisplaced, they should be n'eated with immobili- instability, reconstruction of the collateral ligament should be
zation; if displaced, they should be treated wirh open reduction done ro convert the multiplane instabiliry ro a single-plane insta-
and internal fixation. biliry. Then, as the child nears skeletal maturity, the cruciate
 Chapter 23: Fractures and Dislocations Abollt the Knee 1057

ligament can be reconstructed if necessaly. In an adolescent ap- Classification

proaching skeletal maturiry who has multiplane insmbiliry, both
There is no specific classification of knee dislocations in children,
the cfuciate and coJlateralligaments should be reconstructed as
bur the dislocation may occur anteriorly, posteriorly, medially,
in adults.
or laterally. The most common single-plane dislocation is ame-
nor.

KNEE DISLOCATIONS
Signs and Symptoms
Acme dislocations of the knee are uncommon in children be-
cause me forces required ro produce dislocation are more likely Because of the potential for associated vascular II1j ury , acute
ro fracture the disral femoral or proximal tibial epiphysis (300). lUlee dislocations in children may be emergent situations. The
Acute knee dislocation usually involves major injuries of associ- dislocation causes obvious deformiry about the knee. With ante-
ated soft tissues and ligaments and often neurovascular injuries. rior dislocation, the tibia is prominent in an abnormal anterior
Adequate follow-up srudies of acute knee dislocations in chil- position. With posterior dislocation, the femoral condyles are
dren younger than 10 years of age are few (296), and mOSt abnormally prominent anteriorly.
in formation has been obtained from reportS of knee dislocations After the dislocation is reduced, the stabiliry of the knee
in adults. Kennedy (305), in a classic 1963 study, analyzed 22 should be evaluated with gentle stress testing. For isolated ante-
dislocations in young adulrs and recommended early ligament riot or posterior dislocations, the integrity of the collateral liga-
repair if the knee was unstable after reduction. Sisk and King ments should be carefuJly evaluated.
(313) reviewed 62 patients treated for acme knee dislocations The neurovascular status of the extremity should be carefully
and recommended surgical treatment for patients younger than evaluated both before and after reduction, especiaJly the dorsalis
40 years of age. pedis and posterior tibial pulses and peroneal nerve function.
Any abnormal vascular findings, either before or after teduction,
require arteriography and, if necessary, arterial exploration. Ab-
Surgical Anatomy normalities in the sensory or motor function of the foor and
distribution of the peroneal nerve function should be noted.
Soft Tissue Anatomy
The pertinent surgical anatOmy in acute dislocation of the knee
involves the soft tissues and the vascular and ligamenrous struc- Radiographic Findings
tures about the knee. Knee dislocation usually occurs with dis-
ruption of both cruciate ligaments. With direct anterior or poste- Anteroposterior and lateral radiographs at the initial evaluation
rior dislocation, the collateral ligaments and the soft tissues may confirm the clinically suggested direction of the dislocation,
be retained because the femoral condyles are stripped out of most commonly anterior (Fig. 23-67). Radiographs in both
their capsular and coJJateral ligament attachments, and when views after reduction detect any occult fractures of the tibial
reduced slip back inside them. Knee dislocations in adolescents spine, distal femoral physis, or proximal tibial physis. If colJateral
have been associated with tibial spine fractures, osteochondral ligament injUlY is suspected, stress views also are obtained.
fractures of the femur or tibia, meniscal injuries, and peroneal Femoral arteriograms are obtained at the initial evaluation if
nerve injuries (295). dorsalis pedis or posterior tibial pulses are absent or diminished.
The knee dislocation is reduced as quicldy as possible and the
vascular stams reevaluated. AJthough distal pulses often are ab-
Vascular Injury sem immediately after injUly and return after reduction, an arte-
riogram can be done even after satisfactory pulses are resrored
The anaromic structure of particular clinical significance is the
to detect an intimal tear that may cause late thrombosis and
popliteal artery. The collateral circulation about the knee is rela-
occlusion. Arteriography is unnecessary when pulses are normaJ
tively poor, and if the popliteal artery is damaged, collateral
before and after reduction; however, the vascular status should
circulation usuaIly is insufficient ro maintain viability of the
be carefully monitored for 48 to 72 hours after reduction.
extremity distal ro the knee (295,302). The popliteal arrery basi-
caIly is fixed to the femur at the adductor hiatus and to the tibia
by a fibrous arch. During anterior dislocation of the knee, clle
artery often is stretched enough to cause inrimal disruption and Methods of Treatment
possibly subsequent vascular occlusion.
When treating a knee dislocation in a child, the physician must
consider not only the acute knee injulY with associated soft tissue
and ligament injulY and underlying fractures, but the possibility
Mechanism of Injury of neurovascular injury. No large series are available for compari-
Most knee dislocations in children occur with mulriple trauma, son of the methods of treatment. In reports of knee dislocations
especially in car, bicycle, or motorcycle accidents or pedes- in adults, most surgeons recommend repair of ligamentous inju-
trian-vehicle accidents. ries, especially in young patients. Closed reduction and splinting
1058 Lower E\·tremit)'

A B
FIGURE 23-67. Dislocation of the knee. A and B: Anteromedial dislocation of the knee in a 14-year-
old girl. C: Intimal tear andocclusion of popliteal artery after anterior knee dislocation in a male 19-
year-old. (Courtesy of Richard E. King, MD, Atlanta, Georgia.)

followed by 6 weeks of immobilization in a long leg cast usually mandatOry. If pulses are absenr before reducrion, even if rhey
is appropriate for children with acute knee dislocations wirhout are satisfacrory afrer reduction, we frequently obtain an arterio-
arterial injury. (n adolescents approaching skeJetal maturity, gram ro deteer any intimal rears that we believe should be re-
grade III injuries of rhe cruciate or collareral ligamenrs may be paired surgically. Obviously, the absence of the pulses after re-
surgically repaired. duction is an emergem siwation. If vascular injury has occurred,
surgical correction must be done within 6 ro 8 hours of injulY
to prevent subsequent ischemia and possible limh loss. In rhis
AUTHORS' PREFERRED METHOD critical siruation, we obtain the arteriogram in the operating
OF TREATMENT room, if at all. Arteriography is not mandatOry in an isolated
injury but is necessary to pinpoint the site of vascular injury if
Our choice of treatment of knee dislocations in children is based ipsilateral proximal injuries are present.
on three factOrs: the child's age, associared ligamenrous injury, If primary arterial repair or grafting of the popliteal artery is
and associated vascular injury. requirecl, we recommend fasciotomy of all four compartments
In a child without vascular injury, the dislocation is reduced of the leg at the same time to prevent the development of a
and the stability is rested by clinical examination and, if neces- compartment syndrome. Repair or reconstruction of ligaments
sary, srress radiographs. Isolated eruciate ligament injury is should not be a([empred at this time because this is too extensive
rreated nonoperarively, as described earlier. a procedure to be underraken during emergent arterial repair.
If there are no postoperative complications after vascular re-
Operative Treatment pair, children may be immobilized in a cast for an additional 4
Injuries ro borh rhe cruciate and collateralljgaments are n·eared to 6 weeks and then started on a rehabilitation program. For
as outlined earlier. In an adolescent approaching skeletal maw- adolescenrs near skeletal maturity who require vascular repair,
riry with cruciare and colLHerailigament injuries bm no vascular cwo options are available for rreatment of the ligamenrous inju-
inju,y, we recommend repair or reconsrruction of rhe ligaments ries. The Jigamenrs can be repaired approximarely 2 weeks after
as previously described. vascular repair; under ideal circumstances, with good wound
In any child with a suspeered arrerial injulY, arteriography is healing and no postoperative complications, an experienced sur-
 Chapter 23: Fractures lind Dislocations Abollt the Knee 1059

geon can undenake delayed primary repair of rhe ligamem inju- size. The medial facet of the patella comes in conraer wirh the
ries. The orher oprion is ro wair and perform lare reconsrrucrion femoral groove only when flexion reaches 90 ro 130 degrees.
if required for cruciare or collareral ligamenr insrability. The average adult trochlear femoral groove heighr is 5.2 mm
and lareraJ femoral condyle height is 3.4 mm. The pareJlar arricu-
lar carrilage is 6 ro 7 mm deep, the thickest articular carriJage
Postoperative Care in rhe body and a reflection of the joint's inherent incongruity.
For mosr knee dislocarjons rreared wirh closed reducrion, 3 ro The usual normal lam·al alignment of the parella is checked by
the medial quadriceps expansion and focaJ thickening of rhe
6 weeks of casr immobilization is followed by quadriceps and
capsule in rhe areas of the medial parellofemoral and medial
hamstring strengrhening, range-of-morion exercises, and pro-
meniscopatellar ligamenrs (297). Dynamic stabiliry depends on
gressive ambulation wirh crurches. If surgical repair is required,
muscle forces, primarily the quadriceps and hamstrings ;l(ring
posroperarive rehabilitarion is rhe same as rhar described earlier
for ligamem injuries. through an eleganr lower exrremity articulated lever sysrem rhat
creares and modulares forces during gaiL The quadriceps blends
with rhe joinr capsule ro provide a combinarion of dynamic and
Prognosis sraric balance. Tighrness or laxity of any of rhe facrors involved
wirh mainrenance of the balance leads ro varying levels of insra-
The prognosis for acute knee dislocarions in children is identical bility. Acure parellar dislocarion almost always is in a lareral
ro d1.ar for isola red or combined ligamenrous injuries. The worsr direction unless it is due ro a medially orienred direcr blow or
prognosis is in children in whom late vascular repair results in follows overvigorous lareral rerinacular release. SaJlay et al. (312)
ischemic changes in the exuemity and in adolescents who require demonstrared avulsions of rhe medial parellofemoral ligamenr
lare ligamenr reconsrrucrion because of knee instabiliry. from the femur in 94% (15 of 16) of parienrs during surgical
explorarion aher acute parellar dislocation. Desio et a1. (297),
using a cadaveric serial curring model, found rhar rhe medial
Complications pareJlofemoralligament provided 60% of the resistance ro lareral
The most serious complications result from unrecognized and parellar translarion at 20 degrees of knee flexion. The medial
unrreared vascular injury or a lare jmimal rear thar causes rhrom- parellomeniscal ligamenr accounred for an addirionaJ 13% of
bosis of rhe poplireal anery wirhin 24 ro 72 hours of injury. the medial quadranr rem·aining force. If rhe deficir produced by
Careful evaluarion and consranr monitoring of the vascular sra- arrenuarion of the medial vectors afrer acute dislocarion is nor
tus of the injured limb are mandarory, and aggressive use of eliminated, patellofemoral balance is lost, resulring in feelings
arreriography is recommended, with immediare surgical explora- of knee insrabiliry and recurrenr dislocarion.
rion and repair or vein grafring when indicared. The patella is under significant biomechanical compressive
load during activity. Ir has been esrimared thar at 60 degrees of
knee flexion, rhe forces across the pareUofemoral articularion are
three rimes the body weighr and increase to over seven rimes
PATELLAR DISLOCATIONS the body weighr during full knee flexion.
The quadriceps mechanism is aligned in a slightly valgus posi-
Parellar dislocation is relatively common in children if all sublux-
tion in relarion ro rhe patellar tendon. This aJignmenr can be
arions and dislocations from varying causes are considered, but
approximared by a line drawn from rhe anrerosuperior iliac spine
acure rraumatic parellar dislocarion caused by a direcr blow is
ro the cemer of rhe parella. The force of rhe pare liar tendon is
rare in children. McManus er al. (309) reviewed 55 acute patellar
indicated by a line drawn from the center of rhe parella to rhe
dislocarions in children and concluded rhar aCllre dislocation
ribial rubercJe. The angle formed by these twO lines is called rhe
occurs only in children wirh underlying patellofemoral dysplasia.
quadriceps angle or Q angle (Fig. 23-68). As rhis angle increases,
Mosr acute parellar disJocati.ons occur in parienrs berween 16
the pull of rhe exrensor mechanism rends to subluxare rhe patella
and 20 )'L:lrs of age and are more common in female than in
larerally. Recurrenr parellar dislocarion is mosr likely associated
male patienrs.
wirh some congeniral or developmental deficiency of rhe exren-
sor mechanism, such as pateUofemoral dysplasia, deficiency of
rhe vasrus medialis obliquus, or an increased Q angle wirh malal-
Surgical Anatomy
ignmenr of rhe quadriceps-pareJiar rendon complex.
The patella is a sesamoid bone in rhe quadriceps mechanism.
As rhe inscrrion site of all muscle componenrs of the quadriceps
complex, it serves biomechanically ro provide an extension mo-
Mechanism of Injury
mem during range of morion of rhe knee joint. The rrochlear Larsen and Lauridsen (306) found rhar a direcr blow to rhe
shape of rhe disral femur stabilizes rhe parella as ir tracks through medial aspect of rhe parella accoullted for only 10% of rhe acure
a range of motion. The hyaJ ine carrilage of the pareJia is the knee dislocarions in rheir series. Parellar disJocarions are more
thickest in the body. likely ro be caused by falls, gymnastics, dancing, cheerleading,
Ar 20 degrees of knee flexion, the inferior pole of rhe parella and a wide variery of other activiries. Acute parellar dislocarion
comacts a relarively small area of rhe femoral groove. Wirh fur- also should be considered in the evaluJrion of all arhletic injuries
rher flexion, the contaer area moves superiorly and increases in in adolescenrs and young adulrs.
1060 Lower Ex/remit)'

FIGURE 23-69. Acute dislocation of the left patella in a 6-year-old boy.

FIGURE 23-68. The Q angle. Normal valgus alignment of the quadri- associated osteochondral fractures. These fractures included 15
ceps mechanism: line drawn from the anterosuperior iliac spine to cen- capsular avulsions of the medial patellar margin and 15 loose
ter of the patella, line drawn from center of the patella to tibial spine.
intraarricular fragments detached from the patella, the lated
femoral condyle, or both. All knee ligaments sl10uld be carefully
evaluated because the mechanism of patellar dislocation may
cause associated ligamentous injuries.
Classification
Although there is no specific classification of patellar dislocations
in children, acute dislocation should be distinguished clinically Radiographic Findings
from chronic patellar subluxarion or dislocation. Approximately
Radiogr:1phs after acute dislocarion are obtained primarily to
15% of children with acute patellar dislocations expnience re-
derect any associated osreochondral fracrure. Occasionally, an
current dislocations. Cash and Hughston (293) reponed a 60%
osteochondral fragment from the medial aspect of the patella or
incidence of redislocation in patients 11 to 14 years of age, 30%
the lateral femoral condyle is visible on the anteroposterior or
in patients 19 to 28 years of age, and in only one patient older
lateral view. The classic "sunrise" view is difficult ro obtain in
than 28 years of age. Intraarticular dislocation of the patella also
a child after acute dislocarion because the required positioning
should be recognized (292,298,299.301). This injury is uncom-
of the k.nee causes pain. Rarely, stress radiographs may be ob-
mon in children but occurs frequently in adults with chronic
tained fot evaluation of suspected physeal fracwre or ligamen-
soFt tissue laxity or severe degeneration of the quadriceps tendon.
touS injury. CT or MRJ is valuable to checl< for an osteuchondral
fractu reo
Signs and Symptoms
The orthopaedist rarely sees a child with an acute patellar disloca-
Methods of Treatment
tion in whom the patella remains in a dislocated position (Fig.
23-69). Usually, the patella has reduced spontaneously with ac- Most acute patellar dislocations in children reduce sponta-
tive or passive exrensiol1 of the knee. Sympt:oms include difFuse neously; if not, reduction usually can he easily obrained. AFrer
parapatellar tenderness and pain with any attempt passively to approlHiare sedation, reduction is done by flexing d1C hip to
displace the patella. A defect may be palpable in the medial relax (he quadratus femoris, gradually extending the knee, and
attachment of the vastlls medialis obliquus to the patella if the gently pushing the patella medially back into its normal position.
medial retinaculum is completely avulsed. Tenderness on the Smgery rarcly is indicared for acute parellar dislocations in
Jater::tl aspect of the knee usually is not as severe as on the medial children (170,294,306). Surgical repair may be indicared if rhe
side. Hemorrhage into the joint may cause hemarthrosis, and vaStliS medialis obliquus is completely torn from the medial as-
severe hemanhrosis should suggest the possibility of an osteo- pect of the patella, leaving a large, palpable soft tissue gap. If
chondral fracture (311). Nierosvaara et al. (183) reponed that osreochondraJ fracwre has occurred, arthroscopy may be indi-
of 72 patients with acute patellar dislocations, 28 (39%) had cated For removal or repair of an osteochondral loose body. Even
 Chapter 23: Fractures find Dislocations About the Knee 1061

more rarely, open reduction and fixation of a large fragment

and repair of the medial retinaculum may be necessary.
Avulsion of the quadriceps tendon from the patella most
often causes inrraarricular dislocation. Closed treatmenr is un-
successful, so open reduction is necessary to reduce the parella
and repair the tear of the quadriceps tendon. Even more uncom-
mon is the inrraanicular dislocation, in which the patellar liga-
menr is rom from the tibial tuberosiry. Associated injLllY of tne
cruciare ligamenrs should be carefully evaluated at the rime of
surgery and surgically repaired as indicated .

• AUTHORS' PREFERRED METHOD

,~ OF TREATMENT

Most acme patellar dislocarions in children are easily rreared by

closed merhods with satisfacrory resulrs. A cylinder cast is used FIGURE 23·70. Chronic lateral patellar subluxation in 13-year-old girl.
for 2 to 4 weeks or, in children with compliant parenrs, a knee
immobilizer is worn for the same durarion. Surgical inrervention
is appropriate in rhe circumsrances ourlined previously, most
commonly for an inrraarticular osteochondral fracture. We gen- in children likely ro have chronic subluxation or dislocation,
erally prefer arrhroscopic examinarion and removal of the frag- including age younger than 16 years, radiographic evidence of
ment if possible, and perform arrhroromy only if necessary for dysplasia of the patella or lateral femoral condyle, significant
removal or fixation of a large osteochondral fracture. Acute surgi- atrophy of the vasrus medialis obliquus, hypermobility of the
cal repair of the vastus medialis obliquus rarely is indicated. patella, and multiple previous dislocations (Fig. 23-70).
Initial rreatment of chronic patellar subluxation or disloca-
Postoperative Care and Rehabilitation tion in adolescenrs is immobilization followed by aggressive
physical therapy for rehabilitation of the vastus medialis obliquus
After the 2- to 4-week immobilization period, a physical therapy
and quadriceps muscles. Surgical inrervenrion is warranred in
program is begun for progressive strengthening of the quadriceps
children with several risk facrors who do not respond to this
muscles and genrle range-of-motion knee exercises. After arthro-
treatmenr regimen and conrinue ro have subluxation or disloca-
scopic debridement and removal of an OSteochondral fragmenr,
tion (29\ ,304,307,308). Micheli and Stanitski (310) reviewed
immobilization is conrinued an additional 3 weeks, followed by
33 skeletally immature patienrs with lateral retinacular releases
the same rehabilitation program. Rarely, if surgical repair of the
and found that the procedure did not interfere with permanent
vastuS medialis obliquLlS is required, cylinder cast immobilization
alignmenr of the exrensot mechanism. They recommended the
is conrinued for 4 ro 6 weeks during the posroperative period.
technique for children who do not respond ro an aggressive
physical therapy program.
Prognosis
The prognosis of patellar dislocations in children is generally Operative Treatment
good. Approximately one in six children with acme patellar dis- Ifsubluxation or dislocation persists after adequate lateral release,
locations experiences recurrenr dislocations. Cash and Hughston correction of the medial deficiency is indicated, usually by ad-
(293) noted 75% satisfacrolY results after nonoperative treat- vancement of the medial retinaculum and muscle and plication
menr in carefully selected patienrs. of the vastus medialis muscle (Fig. 23-71A). If deficiency of the
vasrus medialis obliquus is severe, this procedure can be done
Complications at the time of lateral retinacular release. Transfer of the semiten-
dinosus through the inferior pole of the patella also has been
Complications frequently occur because of an unrecognized os-
reported in skeletally immature patients (303) (Fig. 23-71 B).
reochondraJ fracture, which is diagnosed later by rhe presence
This may be indicated in adolescenrs with continued instability
of a loose body. Radiographs obtained aftet injury should be
after lateral release and medial realignment, or in children with
carefully scrutinized for any osteochondral injUlY. Occasionally,
associated conll\:erive tissue disorders. In skelerally mature pa-
complications occur because of associated ligamenrous injury,
particularly of the medial collateral or cruciare ligamenrs, and rienrs with a signiflcanrly abnormal Qangle, the Elmslie-Trillat
procedure reporredly achieves good results in approximately
especially in adolescenr male athletes.
80%. This technique displaces the anterior tibial rubercle medi-
ally to decrease the Q angle (Fig. 23-71 C). The Elmslie-Trillat
Chronic Patellar Subluxation
procedure is conrraindicated in patients with open physes be-
Chronic patellar subluxation or dislocation is common in adoles- cause of the possibiliry of growth disturbance of the anterior
cents, especially girls. Several risk facrors have been idenrified tibial tubercle, with resuJting genu recurvarum.
1062 Lower Extremity

A,S c
FIGURE 23-71. Surgical technique for treatment of chronic patellar subluxation or dislocation. A: Lat-
eral retinacular release and medial imbrication. B: Semitendinosus tenodesis. C: Elmslie-Trillat procedure.

MENISCAL INJURIES of the knee joint capsule, except where the popl iteus is interposed
laterally, and are artached loosely to the borders of the tibial
Although less common in children than in adults, meniscal inju- plateaus by the coronalY ligaments. The inner edges are concave,
ries are becoming more frequenr in children and adolescenrs, thin, and unattached. The menisci are largely avascular, except
especially those involved in competitive athletics (314,319,343, near their peripheral attachment to the coronalY ligaments.
364,377). DeHaven and Linrner (330), in a study of 3,431 Although the lateral meniscus shows more developmental
athletes, found inrernal derangemenr of the knee to be one of variation, as demonstrated by Clark and Ogden (325), it is never
the [WO most common injuries in young athletes, particularly discoid in shape during normal development. The predominant
boys. Most meniscal injuries occur in adolescenrs older than 12 collagen is type I arranged circumferentialJy with oblique, verti-
years of age, but they have been reported in very young children cal, and radial fibers present to diminish hoop stresses with
(290,339,363,374). King (348) reported 52 patients younger weight bearing. The menisci show constanr ratios of meniscal
than 15 years of age who had undergone arthrotomy because to articular tibial plateau surface areas during development and
of suspected meniscal injuries, and Fowler (334) reponed 117 demonstrate intimate concordant maturation of the menisci
meniscectomies in patients 12 to ]6 years of age. with the tibia (325). In addition to lesser roles of synovial fluid
distribution and contribution ro knee stability, rhe major role
of the menisci is ro share weight-bearing loads by increasing
Surgical Anatomy
articular contact area and reducing the load per unit area on
The menisci develop early in fetal life from the intermediate articular cartilage, with 70% of the lateral compartment load
zone of mesenchyme between the distal femur and the proximal borne by the lateral meniscus and 50% of the medial load by
tibia and assume their adult semilunar form by the 10th fetal the medial meniscus. Recent in vivo MRl documentation of
week (325,347). During the remainder of growth, the menisci normal meniscal motion under load was reported by Vedi et aJ.
change in size but not in shape. Growth of the meniscus occurs (373). \X1i th weight bearing, the anterior medial meniscus moved
in the petipheral part, where the avascular fibrocartilage becomes an average of 7.\ mm and the posrerior medial horn showed
100se-textuI'ed vascular fibrous tissue. The peripheral edges of an average excursion of 3.9 mm along with 3.6 mm average
the menisci are convex, fixed, and artached ro the inner surface mediolareral radial displacemenr. The lateral anrerior meniscus
 Chapter 23: Fractures and Dis/ocatiotlS A bout the Knee 1063

and the lateral posrerior horn moved an average of 9.5 and 5.6 rhc knee parcially Hexed changes che relacion of che femoral
mm, respecrively, wi rh a radial mediolateral average displace- condyles to che menisci, and forces che menisci coward che cenrer
menr of 3.7 mm. These findings of dramaric dynamic changes of the joinr, where they are likely co be injured. These rwiscing
of meniscal posirion reaffirm rhe preliminalY work reporred by mechanisms occur primarily in spoces and may cause associaced
Thompson et al. (371). ligamentous injuries. Meniscal injuries also may be associaced
Biomechanically, rhe menisci acr as a joinr filler to compen- with degenerative changes, cystic formacion, or congenital
sare for rhe incongruiry berween che arricularing surfaces of rhe anomalies (334).
femur and cibia and prevenr capsular and synovial impingemenr
during flexion and exrension of the knee. The menisci are pushed
Classification
ourward by the compression forces of the tibia and femur, bur
che strong anrerior and posrerior artachmenrs of rhe menisci The mosr commonly used classification is based on the rype of
generate circumferenrial rension forces (hoop forces) chac coun- meniscaJ cear found at surgery, either peripheral, buckcr-handle,
ceraer chis ourward or radial force (366). The menisci cransmic horizonraJ cleavage, transverse, or complex. Although previous
and discribure loads berween the arcicular surfaces, serving as scudies reponed thac lateral lesions were more common in chil-
shock absorbers to spare che articular caniJage from compressive dren, King (348) found more medial lesions in his patiencs, most
loads and to prorecr che joinr from osreoarrhriric changes. commonly peripheral decachmenc of rhe posrerior portion (fig.
The menisci aiso are believed to nourish rhe arcicular carcilage 23-72). He also noced rhac rhe younger rhe pacienr, rhe more
and lubricare rhe joinr by che distribution of synovial fluid. They peripheral rhe rear; conversely, bucker-handle rears occurred
contribute co srabiliry in all planes but are especially imponanr mosr ofren in older chi Idren and adolescents.
!'Oraly stabilizers and are essential for tl1e smoorh gliding or rora-
cion motion as the knee moves from flexion into extension.
Signs and Symptoms
The mosr difficulr aspecr of trearmenr may be making che con'eer
Mechanism of Injury
diagnosis. Bergsrrom ec al. (231) and ]uhl and Boe (345) re-
Meniscal rears are mosr commonly produced by rocacion as rhe pOl-red diagnosric accuracy in approximacely 20% of children
flexed knee moves coward exrension. This rocacionaJ force wich believed co have meniscal injury. An accurare hiscory may be

A,B c

D E
FIGURE 23-72. Meniscal tears in adolescents. A: Peripheral. B: Bucket-handle. C: Horizontal cleavage.
D: Transverse. E: Complex,
1064 Lower EXlremit)'

difflculr W obwin in a very young child. The older rhe parienr, of false-positive and false-negarive findings reponed on MRl
rhe more likely a hiswry of specific injury. The parienr usually interpretation by radiologisrs: 37.5% accuracy, 50% positive and
rehaes feeling or hearing a "pop" ar rhe rime of injury, wirh 50% negative predictive indexes, 50% sensitivity, and 45% spec-
frequenr popping and giving way after injury. Pain is reported by ificity. Current MRl techniques usually provide limited infor-
approximately 85% of patienrs, with renderness over rhe affected mation about tear size and srability or predictability of healing
joint line. More rhan half report giving way and effusion of rhe after repair. As with any tesr, clinical correlation is mandatory
knee joint. McMurray's and Apley's rem may be helpful in rhe before trearment decisions are made.
diagnosis of a chronic lesion, but wirh acute injury the knee
usualh' is wo p3inful to allow these maneuvers (329).
Methods of Treatment
In Vahvanen and Aalto's series of patients with documented
meniscal rears (372), almost one rhird of the parients had no The rraditional treatment of a tOrn meniscus has been meniscec-
significanr findings on physical examination. We und the classic tomy, but numerous repons (317,322,333,342,350,355,369,
McMurray test of little value in this age group whose rears are 372) indicating the poor long-rerm results of meniscecwmy in
peripheral and nor degenerarive posterior horn lesions. The most children have made rhis less common. Up to 60% to 75% of
accurare physical findings are joint line tenderness (especially patients have degenerative changes after meniscectomy. Manzi-
middle to posrerior) and exacerbation of the pain with varus one et at. (52) reported 60% poor results in 20 children and
(medial) and valgus (lateral) and rotation stress (imernal, medial; adolescenrs after meniscectomy. In cadaver studies, Baratz et
external, lateral) at 30 w 40 degrees of knee flexion. These signs al. (320) showed that the conraer stresses on the tibiofemoral
have v3lue: 92.3% negative predictive value, 93.3% sensitivity, articularion increase in proporrion to the amount of the menis-
and 92.3% specificity (284). cus removed and the degree of disruption of the meniscal struc-
rut·e. Clearly, as much of rhe meniscus should be preserved as
possible.
Radiographic Findings As King (348) pointed our, removal of a damaged meniscus
Routine radiographs are obtained primarily to eliminate other to minimize irreversible damage to rhe joinr is advisable, bur
sources of knee pain. Arthrography (326) may help delineate every effort should be made to spare the meniscus. The exact
meniscal tears, but has been used less frequently since the advent meniscal injury and potenrial for repair can be determined ar-
of arthroscopy and MRl (357,359). MRl's accuracy rates report- throscopically to help formulare treatmenr plans. Zaman and
edly range from 45% to 90% in the diagnosis of meniscal tears Leonard (378) recommended observation of small peripheral
(324,343,361,365), and it is the preferred imaging merhod for rears, repair of larger peripheral rears, and, when necessary, par-
evaluating meniscal injuries in children. MRl should not be used rial meniscectomy, leaving as much of the meniscus as possible;
as a scn.:ening procedure because of significanr Jimirarions of rhe rhey concluded that total meniscectomy is conrraindicared in
rechnique in this age group (284,323,351,361,368). Takeda et young pariems (Fig. 23-73). In general, peripheral tears, which
al. (370) reviewed the MRl signal inrensity and paHern in the are most common in children, and longitudinal rears are good
menisci of 108 knees in 80 normal children 8 to 15 (average candidates for repair, with success rates of up to 90% reported
12.2) years of age using rhe classification of Zobal et al. (379), (328,338,341,353,357). Sisk (366) recommended that repair be
which allows for equivocation for type III signals. Using tibial limited to the most peripheral 25% of the meniscus.
tubercle maturity as a definirion of skeleral maturity, Takeda et
a1. (370) found signal inrensity to be proportional to age, wirh
high signal (grades III and III) evident in 80% of pariems 10
years of age or younger, 65% by 13 years of age, and 33% ar
15 years of age, simiJar to the faJse-positive rare of 29% reported
in asymptomatic adults (336,351). Overall, two thirds of rhe
patients had posirive findings (grades II or Ill), often grade Ill-A,
which is equivocal extension through the surface of the meniscus.
Takeda er at. suggesred rhar the decrease in signal intensity was
proporrional to diminution of peripheral vascularity, especially
in the posrerior horn of the meniscus. Schwartzberg et al. (368)
used unilareral MRl ro srudy 55 asymptomatic 9- to 15-year-
olds wirh negative knee examinations and found that 51 % had
grade fII and 27% grade II signal changes in their medial me-
nisci. Grade J[] signals were found in 7% and grade II changes
were seen in 7% of lateral menisci. All children with grade III
changes in the lateral meniscus also had grade III signals in rhe
medial side. These investigators cautioned against misinrerpreta-
rion of pediarric knee MRls and emphasized rhe necessiry for
correlation of rhe clinical findings wirh any imaging study re-
sulrs. In another series (284), poor correlation was seen between FIGURE 23-73. Arthroscopic partial medial meniscectomy for bucket-
MIU repons and arthroscopic findings, with significalH numbers handle tear in an adolescent.
 Chapter 23: Fractures and DisLocations Abolll the Knee 1065

long and cannot be displaced more than 3 mm, we immobilize

the knee in a cylinder cast for 3 weeks in the acute setting. For
similar chronic injuly (>3 months), we arthroscopically rasp
the interface berween the meniscal edges and immobilize the
knee in a cylinder cast for 4 weeks. If tne tear is in zones I or
2, and is longitudinal with a noncomminured inner segment
that can be reduced anatomically, repair is done (Figs. 23-75
and 23-76). If a chronic situation exists, rasping of the fragment
edges and use of a fibrin clot are techniques that have been
reponed to enhance healing. Mintzer et al. (356) had a 100%
success rate in meniscal repairs in 26 adolescent athletes (29
repairs) with an average follow-up of 5 years. Four patients had
open physes at time of the meniscal repair. Most (78.5%) were
zone 0 to 1 tears with an average length of 2.3 cm. Thirteen
patients had associated ACL tears rhar were reconsrructed. All
FIGURE 23-74. Arthroscopic repair of a peripheral tear of the posterior but two of the parients rerurned to rheir preinjUlY spon level.
horn of the medial meniscus. If the central fragment is macerated with multi planar rears or
ones that cannot be reduced, repair is not done (Fig. 23-77).
The fragment is excised to the stable remaining meniscal rim.
Resulrs of repairs of tears that are unstable and located in the
Open and anhroscopic techniques For meniscal repair share cenrrcd third (zone 2 to 3) have not been reponed to any extenr
several important Factors: in skeletally immature patients. Rubman et al. (362) reponed
good results in adults with central zone meniscal repairs, with
1. Anatomic reduction of the meniscus 80% being asymptOmatic at an average foJlow-up of under 4
2. Multiple, closely placed sutures that are not readily absorb- years. Most (72%) had associated ACL injuries that were recon-
able
structed. These investigators suggested that the repairs would
3. Careful avoidance of neurovascular structures
seem to be more indicated in patients in their second and third
4. Fixation of the meniscus directly on the knee capsule (Fig.
decades than in older patients. Unstable tears in the central third,
23-74)
white-white zone are excised, taking care to preserve as much
Although King (349) suggested over six decades ago that, stable meniscal rim as possible. The rare radial tear or horizontal
based on experimental evidence in dogs, longitudinal meniscal
tears could heal if communication with peripheral blood supply
existed, it was not until the work ofArnoczky and Warren (318)
in the 1980s that meniscal repairs were begun based on docu-
mentation of the meniscal blood supply. They believed that tears
within 3 mm of the meniscosynovial junction were vascularized,
and ones more than 5 mm away were avascular unless bleeding
was seen at surgery. Tears in the 3- to 5-mm range had inconsis-
tent vascularity. The zones of meniscal injUlY are 0 to 3: 0 repre-
sents the synovial-perimeniscal vascular plexus, 1 corresponds
to the red-red junction of vascularity (0 to 3 mm), 2 is the
red-white transitional area from vascular to avascular (3 to 5
mm), and 3 is the white-white avascular region (5 mm to the
central border).
Some questions still remain about tile ability of the repaired
meniscus to transmit load because of the altered fiber arrange-
ment.

• AUTHORS' PREFERRED METHOD

\...~ OF TREATMENT

Treatment is based on a classification scheme we cal I SAKS, an

acronym that represents size, site, shape and stability of the tear
(5); acuity of the lesion (A); and knee stability (KS) or ACL and
FIGURE 23-75. Arthroscopic view of a red-white junction tear in a 15-
MCL integrity. In a stable knee with an acute, arrhroscopically year-old girl. Arrowheads denote the vascular edge of the peripheral
documented ourer third peripheral tear that is less than 1 cm meniscus.
1066 Lower Extremity

A B
FIGURE 23-76. A: Arthroscopic view of a displaced 'fragment (large arrow) of a large peripherallongitu-
dinal tear of the lateral meniscus. The small arrows indicate the stable peripheral meniscal margin. B:
Full-thickness articular damage (arrow) of the lateral tibial compartment from the trauma that caused
the meniscal injury.

rear is debrided, leaving as much intacr meniscus as is srable. of 10% ro 15 % are seen in peripheral rears of less rhan 2 cm
Wirh horizontal rears, rhe smaller of rhe two leaves is resecred. and in 60 % if rhe rears exceed 4 cm. In rears that have been
In an adolescent patient with an unsrable knee from an MCL pl'esell[ for less rhan 8 weeks, the results are good in approxi-
injury and a periplleral meniscal rear, repair of rhe meniscus and marely 85 %, compared wirh 65 % in morl' chronic rears (>8
ligament is indicated. If rhe meniscal rear is in a zone not amena- weeks) (325). These dara probably are applicable to parients
ble ro repair, rhe fragment is debrided and the collareralligamenr older rhan 11 or 12 years of age because rhe perimeniscal blood
injury is managed nonoperarivcly. supply panern at rhar age is idenricaJ ro rhe flow in adulrs.
Oureomes afrer meniscal repair in adulrs are negarively relared In parients with whar we call the "ACL plus" knee, one wirh
to rhl' Iengrh and chroniciry of rhe meniscaJ injury. Failure rares
concomitant meniscal and ACL tears, meniscal salvage, by repair
if possible, and ACL reconstrucrion are indicated. To aJlow knee
instabiliry ro persist invi res repeat meniscal injury and addiriorLll
arricular compromise.
Multiple rechniques exisr for repair (309,316,32:'3,325,356).
Four main rypes of repair are used: outside-in, inside-our, all
inside, and open, depending on rhe meniscaJ rear characrerisrics.
Open repair usually is reserved for injuries associared wirh com-
plete rears of the MCL or meniscal damage thar cannot be ap-
proached anhroscopicaJly. Inside-our repairs use various zone-
specific cannulae that allow precise surure placemem, usually a
vertical matrress stirch, which has been shown ro have surure
strength twice rhar of a horizontal stirch. Outside-in repairs use
spinal needles placed across rhe capsule and meniscus. A sutute
is passed through the needle and brought outside rhe knee, a
knot is fashioned, the suture is reintroduced intraarricularly, and
the knor is used ro maintain meniscal reduction and fixation.
The outsides of rhe sutures are then tied to the outer capsule.
This technique is helpful in areas where more blind suture pas-
sage could cause neural and vascular compromise. The all-inside
sutLIre technique is technically demanding and currently an
emerging method. A variery of bioabsorbable meniscal anchors
are in use rhat obviare the need for capsular cxpo,ure and exrernal
FIGURE 23·77. Arthroscopic view of a comminuted, macerated white-
zone free edge tear of the medial meniscus. This pattern of injury is sutures. These devices somcrimes are roo long or bulky to use
best treated by tear debridement and not by repair. in a child's knee.
 Chapter 23: Fractures and DisLocations About the Knee 1067

Preparation of the edges of the meniscal tear is a matter of signal intensity and flattening on MRI correspond to inuasub-
the tear's acui ty and pattern. A meniscal rasp can be used to stance tears or degeneration of lateral discoid menisci not detect-
stimulate a vascular response at the perimeniscal vascular leash. able by arthroscopy. Based on rheir findings, MRI seems to be
Improved results in patients with chronic tears have been re- mOIe sensitive rhan arthroscopy in the detection of intrasub-
poned with use of a fibrin clot, which provides a collagen frame- stance lesions of lateral discoid menisci (Fig. 23-78).
work for vascular invasion and repair. The reader is referred to
standard arthroscopic texts for details of meniscal repair (325).
Classification
Postoperative Care and Rehabilitation Watanabe et al. (375) described three major types of discoid
Because meniscal healing is slow, careful rehabilitation after sur- meniscus: type 1, completely disk-shaped semilunar type with
gical repair is especially important. Knee motion should be re- a thinner center; type 2, incomplete semilunar type with a con-
stricted by a cast or brace for 4 to 6 weeks, with limited weight cave or convex free edge; and type 3, hypermobile or Wrisberg
bearing. Full weight bearing is then allowed and a strengrhening type without posterior tibial capsular attachment. The most
program is begun. Rerum to vigorous sports activities is not common is the complete type. Neither Be/lier et al. (321) nor
allowed for at least 6 months. Hayashi et al. (340) found any Wrisberg type 3 lesions in their
combined total of 72 discoid menisci, and they believed it to
be a rare lesion. The most common sites of meniscal tear are at
Complications the posterior segment and inside the middle segment.
Complications after either arthroscopic or open repair may in-
clude hemorrhage, infection, persisrent effusion, stiffness, and
neuropathy. Both the popliteal artery and inferior geniculate Methods of Treatment
branches are close to the posterior capsule and are easily lacer-
When chronic locking of the knee, joint effusion, or pain war-
ated. Postoperative infection should be suspected if swelling or
rants surgical rreatment, arthroscopic subtotal or partial menis-
pain persists with an elevated temperature. Swelling is best
cectOmy is preferred whenever possible (335,354). Hayashi et
rreated with external compression dressings, and stiffness is best
al. (340) advised reducing the thickness of complete-type discoid
prevented by appropriate postoperative rehabilitation. Neuroma
menisci to prevent new tears; they recommended leaving a rim
formarion rarely causes significant symptoms, but occasiona.lly
of 6 mm in complete and 8 mm in incomplete lesions. Because
persistent localized renderness may warrant excision.
the arrangement of collagen fibers of the discoid meniscus differs
from that in the normal meniscus, and because the tear is most
commonly close to the least vascular and mOSt mobile area,
DISCOID MENISCUS partial meniscectomy may not be helpful for many tears in dis-
coid menisci.
Discoid meniscus (327,331,332,344.358) is a common cause of In a study of 47 knees with symptomatic discoid lateral me-
knee symptoms in children and adolescents. As noted by Woods nisci, Pellacci et al. (360) found that the results of partial menis-
and Whelan (376), discoid meniscus probably is a congeniral cectomy were better than those of total meniscectomy. Aichroth
deviarion that usually occurs laterally. According to Hayashi et
et al. (315), however, recommended arthroscopic partial menis-
aJ. (340), the thickness of a discoid meniscus, its poor vasculari-
cectomy only when the posterior attachment of the discoid me-
zation, and a flimsy artachment of the posterior area to the
niscus is stable; total meniscectomy is recommended for Wrisb-
capsule make it more susceptible to mechanical suess than a
erg-type (type 3) discoid menisci with posterior instability.
normal meniscus. In their study of 53 sympromatic discoid lar-
Sugawara et al. (367) evaluated 139 partial or complete ar-
eral menisci, mosr of the patients were berween 10 and ] 5 years
throscopic meniscectomies and found that 9 knees (6.5%) re-
of age.
quired 2 or more operations. Of this group, seven knees had
The most frequent symptom is pain during ordinary activi-
partial meniscectomies oflatera! discoid menisci. Because of their
ties, followed by giving way, locking, and snapping of the knee
joint (346). Knee extension usually is limited and the quadriceps findings, they suggested that the most appropriate initial treat-
muscles often are atrophied. Occasionally, effusion, hemarthro- ment for latetal discoid menisci without tears is observation of
sis, and instability also are present. Radiographs often are nega- the clinical coutse, with minimal treatment using diagnostic ar-
tive, but they may show widening of the lateral compartment, throscopy. If clinical symptoms are serious or if an apparent
squaring of the femoral condyle, hypoplasia of the lateral tibial meniscal tear is identified, they recommended subtotal or total
spine, tilting of the tibial articular surface, and apparent elevation meniscectomy rather than partial meniscectomy.
of the fibular head. Arthrography or MRI may be helpful in The need for total meniscectomy usually is dicrated by the
establishing the diagnosis (330,333,337), but a hotizontal tear thickness of the discoid meniscus, the location of the tear, and
in the midsubstance or a uansverse cleavage in the middle seg- the duration of symptoms preoperatively. Despite the generally
ment may not be visible. Even with arthroscopy, identification poor prognosis after total meniscectomy, several investigators
of tears in the midsubstance of the meniscus may be difficult. (321,331,340) report excellent results in children after total
Hamada et al (337) reported that intrameniscal regions of high meniscectomy of discoid lateral menisci.
 1068 Lower Extremity

A B

FIGURE 23-78. A: Magnetic resonance image of a 3-year-old girl

who had symptoms of popping and catching in the knee demon-
strates large discoid lateral meniscus. B: Arthroscopic view of dis-
coid lateral meniscus. C: Arthroscopic subtotal meniscectomy.
(Courtesy of Robert H. Miller III, MD, Memphis, Tennessee.) c

• AUTHORS' PREFERRED METHOD appreciated; the injury is estimated ro go unrecognized initially

,~~ OF TREATMENT in approximately one third of patients (378,381,382,386-388,
390,395). Most of these dislocations occur during athletic activi-
For types 1 and 2 discoid menisci, we recommend arthroscopic ries, especially with a severe t"visting movement. The dislocation
partial mcniscecromy and shavil)g ro a stable meniscus with an or subluxation may be associated with orher skeletal injuries,
inract peripheraJ rim. For the rare eype 3 discoid meniscus with especially proximaJ tibiaJ fractures (392). Disruption of the prox-
no posterior capsular anachmenr, the options are rotaJ menisccc- imal tibiofibular joint is classified as subluxation, anterolateral
rom)' or posterior repair combined with panial meniscectomy. dislocation, posteromedial dislocation, or superior dislocation
(Fig. 23-79). The most common eype is anterolateral dislocation.
Pain along the lateral side of the knee and leg is the mosr com-
TIBIOFIBULAR DISLOCATIONS mon symptom of subluxation. Isolated anterolateral dislocation
may be idenrified by a palpable mass lateral ro the tibia and
Dislocations of the proximal tibiofibular joint are infrequent usually is visible on radiographic examination.
in children and adolescenrs, bur may be more common rhan Symproms caused by subluxation usually subside with n:st,
 Chapter 23: Fractltres and Dis!oCflriolJj" About the Kllet' 1069

I
I
I
I
\
\
\
\
\
\
I
I
1
I
I
I

,,
I
I

A B

./(
\
\
\
\
I
I
I
I
I
I
I
I
FIGURE 23-79. Tibiofibular subluxation-dislocation I
(Ogden). A: Anterolateral. B: Posteromedial. C: Supe-
rior. c

bur cylindet· casr immobilizarion rna)' be required. Mosr disloca- problems ar rhe knee and ankle joines. Resecrion of rhe fibular
rions, especially acure dislocarions, can be reduced closed by head alrers rhe normal conrour of rhe lmet:: and may cause pero-
rushing rhe head of rhe fibula bacbNard. Posreromedial disloca- neal nerve palsy, chronic ankle pain, and larcral knee insrabiliry.
rions ofren are associared wirh severe disruprion of the joint These procedures should be reserved for patienrs wirh failed
capsule and ruprure of rhe LCL, and these may require open ligamenr reconsrruction or rhose who are nor candidares for
reducrion, capsulorL'haphy, and. repair of rhe ligamenr. Superior reconsrrUCClon.
dislocarions are rare and usually are associared wirh fracrures of
rhe ribia, which may require open reduction and. internal fixa-
tion. Recurrene subluxation or dislocation may cause progressive
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Joint Surg /1m 1969;5\ :517-')26 SmJle! 1978;49:621 -626.
370. Takeda Y, lkara T, Yoshida 5, er al. MRI high signal intCl1siry in 394. WeinerT CR, Raczka R. Recurrenr dislocation of the superior ribiofib-
the menisci of asymptomaric children. j BOII~ Joint Surg Br 1998;80: ular joinr. .1 Bone Joim SUig Am 1986;68: 126-128.
463-467. 395. \'(fong K, Weiner OS. Proximal tibioftbular synosrosis. Gin Orlhnp
371. Thompson WO, Thaere Flo Fu FH, et al. Tibial meniscal dynamics ]978; 135:45-47.
 FRACTURES OF THE SHAFT OF
THE TIBIA AND FIBULA
STEPHEN D. HEINRICH

EPI DE IOLOGY COMPLICATlO ASSOCIATED WITH

Surgical Anatomy DIAPHYSEAL TIB1A/FIB LA FRACTURES
Compartmenr Syndrome
C A SIFICATION
Fracwres of the Proximal Tibial Metaphysis Vascular Inj uries
Angular DeFormi ry
DIAPHYSEAL l~RACTURES OF THE TIBIA A '0 Malrotation
FIBULA Leg Length Discrepancy
Signs and Symptoms Upper Tibial Physeal Closure
Radiographic Evaluation Delayed Union and Nonunion
Treatment
Open Fracrures SPECIAL fRACTURES
Diaphyseal Fractures Toddler's Fracrure
POSTFRACTURE IMMOBILIZATIO Bicycle Spoke Injuries
Floating Knee
rOSTFRACTURE REHABILITATION
Tibial Fracrure in Paraplegic Children
FRACTURE F THE DISTAL TIBIAL METAPHYSI Stress Fracrures of rhe Tibia and Fibula

EPIDEMIOLOGY mon among children 1 to 4 years of age, whereas most tibial

fractures in children 4 to 14 years of age occur in sporring or
Tibial and Rbular fractures are the third most common pediarric traffic accidents (2,4,6,7,10,11). Over 50% of combined tibial
long bone injuries 05%) after femoral and radial/ulnar fractures and fibular fraCtures result from vehicular trauma. In contrast
(l ],12). The overall prevalence of tibial (racwl'es in both boys ro the rotational etiology of most tibial fractures, most isolated
and girls has increased since 1950 (Table 24-1) (7). The average fibular fractures result from a direct blow (6, 11).
age of occurrence is 8 years, and the frequency of occurrence The tibia is the second mosr commonly fractured bone in
does not change significantly with age (6). Sevency percenc of abused children. ApproximareJy 26% of all abused children with
pediatric tibial fractllres are isolated injuries; ipsilareral fibular a fracrure have an injured tibia (9).
fractures occur wirh 30% (4,12,13). Fifry percell[ [Q 70% of Approximately 9% of pediatric ribial fracrures are open. Con-
tibial fractures occur in the distal third, and 19% ro 39% in the comitanr fracwres of the ankle and foot are the most common
middle third. The least commonly affected porrion of the tibia injuries associated with fractures of the ribia and fibula, followed
is the proximal third, yet these may be most problemaric. Thirty- by humeral, femoral, and radial/ulnar franures (3). The average
five percent of pediatric tibial frac[llres are oblique, 32% commi- index severity score of a child with a tibial fractUre is 10 (range
nuted, 20% transverse, and] 3% spiral (11). Tibial fracrures in 0-45). The average hospital stay is 6~ days (range ]-50). The
children under 4 years of age usually are isolated spiral, sharply avnage hospital COSt For a pcJiatric tibial fracture is $7,156.00
oblique fractures of rhe disLlI and middle thirds. Most tibial (range $4SS.00 to $88,706.00) (3), The COSt vatiation depends
fractures in older children and adolcscl'ncs are at rhe ankle. Rota- on (a) associated injuries, (b) open fracture, and (c) need For
rional forces produce an oblique or a spiral fraCture and are surgical managemenr.
responsible for approximately 81 % of all tibial fracrures without
Rbular fracrures (2,4,5,] 0,] 1). Bicycle spoke injuries are com-
Surgical Anatomy
Bony Structure
n
. Stepl.en D. Heinrich: Scerioll of Pediarrie Orrhopaedies, Dcparllllcnr of The tibia ("f1ute ) is the second largest bone in the body. At
Onhopaedic Surgery, Louisiana Stare lvlc:Jical Cellter, Nt:w OrlC:IIlS. Louisiana. the proximal aspeCt of rhe tibia are twO concave condyles: the
1078 Lower Extremi~y

TABLE 24·1. CHANGE IN THE PREVALENCE OF TABLE 24-2. MUSCLE ORIGINS AND
PEDIATRIC TIBIAL FRACTURES" INSERTIONS ON THE TIBIA

Years Semimembranosus Inserts on inner tuberosity

of the proximal tibia
1950-1955 1980-1983 Tibialis anterior, extensor Attaches to the lateral
digitorum longus, biceps condyle of the tibia
Female femoris
0-9 years old 6.6 7.2 Sartorius, gracilis, Inserts on the proximal
10-19 years old 3.8 4.9 semitendinosus medial surface of the
Male tibial metaphysis
0-9 years old 10.1 14.3 Tibialis anterior Arises on the lateral surface
10-19 years old 7.1 10.7 of the tibial diaphysis
Popliteus, sol ice, flexor Attach to the posterior
a Per 10,000 population. digitorum longus, tibialis diaphysis of the tibia
Reprinted from Bengner V, Ekhom T, Johnell 0, et al. Incidence of posterior
femoral' and tibial shaft fractures. Acta Orthop Scand 1990;61<251; Patellar tendon Inserts into the tibial
with permission tubercle
Secondary slip of fascia Occasionally inserts into the
lata tibial tubercle
Tensor fascia lata Attaches to Gerdy's
tubercle the lateral
aspect of the proximal
tibial metaphysis
medial condyle is larger, deeper, and narrower than the lateral
conJylc. An elevated process, the tibial rubercule, located be- Reprinted from Gray H. Anatomy: descriptive and surgical. In: Pick
tween the tWO condyles is the site of attachment of the patellar TP, Howden R, eds, Anatomy: descriptive and surgical. New York:
Bounty Books, 1977:182; with permission.
tendon. The shaft of the tibia is prismoid, with a broad proximal
extent that decreases in size until the distal third, where it gradu-
ally increases in size. The tibial crest is prominent medially from
the tibial tubercle ro the tibial plafond and is subcutaneous wirh-
out any overlying muscles (5).
The tibia develops from three ossification centers: one ill the posterior tibial artery divides several centimeters distal to this
shaft and one in each epiphysis. The tibial diaphysis ossifies at point, leading to the peroneal artery (Fig. 24-]) (5).
7 weeks of gestation and expands both proximally and distally.
The proximal epiphyseal center appears shortly after birth and
unitcs with the shaft at approximately 16 years of age. The distal
Nerves
epiphyseal ossil'lcation cenrer appears in the second year of life, The posterior tibial nerve runs adjacent and posterior ro the
and the distal tibial physis closes at approximately 15 years of popliteal artery through rhe popliteal fossa. The common pero-
age, Two other centers may occur occasionally: in the medial
malleolus and in the ribial tubercle (5),
The tibia articulates with the condyles of the femur proxi-
mally, with the fibula at the knee and the ankle, and with the
talus disralJy (5). Twelve muscles have either their origin or TABLE 24-3. MUSCLE ORIGINS AND
INSERTIONS ON THE FIBULA
insertion on the ribia (Table 24-2).
The fibu!J articulares with rhe ribia and the talus. The fibular Soleus, flexor hallucis Arise from the posterior
diaphysis ossifies at abour 8 weeks of gesration. The distal epi- longus aspect of the diaphysis
physis is visible at 2 years of age, and rhe proximal secondary Peroneus longus, peroneus Arise from the lateral aspect
brevis of the fibular diaphysis
ossification center at 4 years. The distal fibular physis closes at Biceps femoris, soleus Attach to the head of the
about 16 years; the proximal physis closes later, at age 16 ro 18 peroneus longus fibula
years (5). Nine muscles have either their origin or insertion on Extensor digitorum longus, Attach to the anterior
the fibula (Table 24-3) (5). peroneus tertius surface of the f,ibular
extensor hallucis longus shaft
Tibialis posterior Arises from the medial
aspect of the fibular
Vascular Anatomy diaphysis
The popliteal artery descends vertically between the condyles of
Reprinted from Buckley Sl, Gotschall C, Robertson W, et al. The
the femur and passes berween the rwo heads of rhe gastrocnemius relationship of skeletal injuries with trauma score, injury severity
muscle, It ends at the distal border of rhe popliteus muscle, score, length of hospital stay, hospital charges and mortality in
where ir divides inro the anrerior and posterior ribial arteries. children admitted to a regional pediatric trauma center. J Pediatr
Orthop 1994;14:449; with permission.
The anter,jor tibial artery passes berween the tibia and the fibula
over the proximal aspect of the inrraosseous membrane. The
 Chapter 24: Fractures of the Shaft of the 7'ibia and FibuLa 1019

neal nerve passes around the proximal neck of the fibula. 1t

divides into the deep and superficial branches, passing into the
anterior and the lateral compartments of the lower leg (5), re-
spectively. Each branch inervates the muscles within its compart-
ment. Th.e deep peroneal nerve provides sensation to the fI tst
web space, whereas the superficial branch has a sensor repre enta-
tion across tbe dorsal surface of the foot.
anterior
tibial artery
Fascial Compartments
The lower leg has four fascial compartments (Fig. 24-2). The
amerior compartment contains the extensor digitol'um longus,
the extensor hallucis longus, and the tibiaJis anterior muscles;
the anterior tibial artery and deep peroneal nerve run in this
\.'\ I posterior compartment. The latera.! compartmem contains the peroneus
tibial artery
longus and brevis muscles. The superficial peroneal nerve runs
\ 'I through this compartment. The superficial posterior com pan-
menr contains the soleus and gastrocnemius muscles. Tbe deep
peroneal artery posterior compartment comains the flexor digitorum longus, the
flexor hallucis longus, and the tibialis postcrior muscles. The
posterior tibial artery, peroneal artery, and tibial nerve run in
this compartment (5).
FIGURE 24·1. Vascular anatomy of the proximal tibia.

CLASSIFICATION
Nonphyseal injuries of the tibia and the fibula can be classitll'd
into three major categories based on the combination of bones
fractured and the location of the injuries (Table 24-4).
Posterior Tibial
A. & V.
Deep
Posterior
Fractures of the Proximal Tibial
Anterior Tibial Metaphysis
A. & V.
The peak incidence for proximal tibial metaphyseal fractures is
Deep Peroneal N.
berween the ages of 3 and 6 years. The most common mecha-
Anterior nism of injury is a force applied to the Luera I aspect of the

TABLE 24-4. CLASSIFICATION: NONPHYSEAL

FRACTURES OF THE PEDIATRIC
TIBIA/FIBULA

Proximal tibia metaphysis

Distal tibia metaphysis
Diaphyseal injuries
Isolated tibial fractures
Traumatic
Stress
Isolated fibular fractures
Traumatic
Stress
Fractures of both the tibia and fibula
Special fractures
Toddler's fracture
Bicycle spoke injuries
FIGURE 24·2. Fibroosseous compartments of the leg. (Reprinted from Floating knee
Sharps CH, Cardea JA. Fractures in the shaft of the tibia and fibula. In: Fractures in paraplegic children
MacEwen GO, Kasser JR, Heinrich SO, eds. Pediatric fractures: a practical Stress fractures of the tibia and the fibula
approach to assessment and treatment. Baltimore: Williams & Wilkins,
1993.318; with permission.)
1080 Lower Extremity

B c
FIGURE 24-3. A: Anteroposterior and lateral radiographs of the proximal tibia metaphyseal fracture
with an intact fibula in a 3-year-old child. B: Anteroposterior and lateral radiographs in the initial long
leg cast demonstrate an acceptable alignment. C: Posttraumatic tibia valga is present 1 year after fracture
union. (Reprinted from Sharps CH, Cardea JA. Fractures in the shaft of the tibia and fibula. In: MacEwen
GD, Kasser JR, Heinrich SD, eds. Pediatric fractures: a practical approach to assessment and treatment.
Baltimore: Williams & Wilkins, 1993: 321; with permission.)
 Chapter 24: Fracture; of the Shaft of the Tibia and Fibula 1081

extended knee. The conex of the medial tibial metaphysis Fails develops aFter a proximal tibial fracture in a child relates the
in tension, often resulting in an incomplete Fraceure. The fibula deformity ro a concomitanr injury ro the pes anserinus rendon
ordinarily escapes injury, alrhough plastic deformation may plate. The pes anserin us tethers the medial aspect of the physis
occur (14-17,21-24,27,32-38). just as the Fibula tethers the lateral aspect of the proximal tibial
Children with proximal tibial metaphyseal fractures presenr physis. The proximal tibial fracture disrupts the pes anserinus
with pain, swelling, and tenderness in the region of the Fraceure. tendon plate, producing a loss of the tethering affect and leading
Motion of the knee causes moderate pain, and the child will not ro medial physeal overgrowth and a hemichondrodiasrasis (15,
walle Crepitance is seldom idenriFied on physical examination, 18, 19,36,3R). Removal from the fracture and repair of the folded
especially if the fracture is incomplete (14-17,21-24,27,32,33, periosteum that forms the foundation of the plate has been sug-
35-38). gested ro decrease the risk of recurrence of the varus deformity.
Radiographs usually show a complete or incomplete fracrure Another theolY postulates that the progressive valgus defor-
of the proximal tibial metaphysis. The medial aspect of the frac- mity occurs because vascular flow ro the proximal tibial physis
ture often is open, producing a valgus deformity (14- [7,21-23, increases after fracture, producing an asymmetric physeal re-
32,33,35-38). sponse that causes increased medial growth (23). SuPPOrt for
this theory includes quanritative bone scans performed monrhs
after proximal tibial metJphyseal fractures that have shown in-
creased tracer uptake in the medial aspece of the physis compared
Valgus Deformity
with the lateral aspect (37). Developmental tibia valga has been
The most common sequelae resulting of proximal tibial meta- reported to occur after simple excision of a bone graft from the
physeal fracrures is valgus deformity (Fig. 24-3).1n 1953, Cozen proximal tibial metaphysis (35), tibial osteotOmy (14,22), and
(17) reponed four patients with valgus deformities after fractures osteomyelitis of the proximal tibial metaphysis (14,35). Ogden
of the proximal tibial merapl1ysis. Since that time, many other idenrifted an increase in the collateral geniculate vascularity to
investigarors (12,15,16,21-25,27,35,36) have reported tibia the medial proximal tibia in a cadaver angiography study of
valga after proximal tibial metaphyseal fractures. a 5-year-old child. This also supports the theory that medial
Many theories have been proposed ro explain the develop- overgrowth occurs secondary to an increase in the blood flow
menr of a valgus deformity after a proximal metaphyseal fraceure supplying the medial aspece of the proximal ribia following in-
(Table 24-5). Proximal tibia valga can be caused by a poor reduc- jury (26). The overgrowth of the ribia that occurs in many chil-
tion, particularly if the knee is immobilized in flexion, because dren with tibial valgus deformity after fi'acture is funher evidence
the flexed position of the knee makes it difficult ro determine of an abnormaliry in the response of rhe proximal tibial physis
the meclunical axis of the leg on radiographs (33,37). Lehner to fracture (22,35). Tibia valga deformity can occur after nondis-
and Dabas suggested that an expandi ng medial callus produced placed fracture and can recur after correcrive tibial osteotomy
a valgus deformity (25), whereas Goff (20) and Keret et al. (24) (Fig. 24-4), further supponing the premise thar asymmetric phy-
believed that the lateral aspect of the proximal tibial physis was seal growrh is the cause of most posttraumatic tibia valga deform-
injured (Salter Harris type V fracture), resulting in asymmetric ities (37). Robert et al. (30), in an analysis of 25 patients with
proximal tibial fracrures, identified three groups of patienrs.
growth of the proximal tibial physis. Taylor (23) believed that
Twelve children with greenstick or complete fractmes developed
the valgus deformi ty was secondary ro postfraceure stimulation
valgus deformities, which were progressive in II. No child wirh
of the tibiaJ physis without a corresponding stimulation of rhe
a torus fracture developed a valgus deformity. In 3 childrcn,
fibular physis. Pellen (28) suggested that premature weight bear-
alrered growth at the distal tibial physis compensared for rhe
ing produced an angular deformiry of the fracture before union.
compromised tibia valga; in 4 children, corrective osteotomies
Rooker and Salter (31) believed that the periosteum was trapped
were performed. The valgus deformity recurred in 2 of these 4
in the medial aspect of the fracture, producing an increase in
children, and two had iatrogenic compartmenr syndromes. This
medial physeal growth and a developmenral valgus deformity.
study suppons the recommendation that developmental tibia
A recently suggested etiology for the valgus deformity that
valga should nor be correcred unril the child reaches puberty.
At that point, a proximal ribial medial epi physiodesis can be
performed to allow the tibia to correct slowly (2,27,30,34,35).
Support for a "wait and see" attitude also was provided by
Zionrs and MacEwen (38), who followed for an average of 39
TABLE 24-5. PROPOSED ETIOLOGIES OF
months seven children with progressive valgus deformities of the
TRAUMA INDUCED TIBIA VALGUS
tibia after metaphyseal fracrures. Most of rhe deformity occurred
Asymmetric activity of medial portion ot proximal tibial physis during the First year afrel' injury. The tibia conrinued to deform
(overgrowth) (14,21,23,25,27,30,35,37) at a slower rate for up to 17 months after injUlY. Six of their
Tethering effect, fibula (8,22,35) seven patients had spontaneous clinical corrections. At follow-
Inadequate reduction (29)
up, all children had less than a 10 degree deformity.
Interposed soft tissue (pes anserinus) (36); medial collateralliga-
ment (16)
Loss of tethering effect of the pes anserinus (23) Treatment
Early weight bearing producing developmental, valgus (28)
Physeal arrest of the lateral aspect of the proximal tibial physis Nondisplaced proximal tibial metaphyseal fractures are stabilized
with a long leg cast with rhe knee in nearly full extension and
a varus mold.
1082 L/JUJer Extremity

A B

FIGURE 24-4_ Developmental valgus

after a proximal tibial metaphyseal frac-
ture and a subsequent corrective osteot-
omy. A: Radiograph taken 6 months
after a fracture of the proximal and dis-
tal tibia in a 5-year-old girl. The proximal
tibial injury was nondisplaced. The scar
from the initial proximal metaphyseal
fracture is still seen (arrow). This child de-
veloped a moderate valgus deformity of
the tibia within 6 months of fracture. B:
A proximal tibial corrective osteotomy
was performed. C: Two months postop-
eratively the osteotomy was healed and
the deformity corrected. D: Five months
later there was a recurrent valgus defor-
mity of 13 degrees. (Courtesy of John J.J.
CD Gugenheim, MD.).
 Chapter 24: FractureJ of the Shaft of the Tibia and Fibula 1083

Orrhotic devices do not alter rhe natural hisroly of posrrraumatic

tibia valga and are not recommended. However, because the
valgus deformiry usua.lly is associated with overgrowth, a contra-
lateral shoe lift of appropriate size may make the deformity less
apparenr.

DIAPHYSEAL FRACTURES OF THE

TIBIA AND FIB ULA

Sevenry percenr of pediatric tibial Fracrures are isolated injuries

(11,13,101). The Fractures can be incomplete (torus, greenstick)
or com plete. Most tibial Fractures in children under 11 years of
age are caused by a rorsional Force and are located in the distal
third of the ribia. These oblique or spiral Fractures occur when
the body rotates with the foot in a fixed position on the ground.
The fracture line starts in the distal anreromedial aspect of the
bone and propagates proximally in a posterolateral direction.
Although the intacr fibula prevenrs signiflcanr shortening of the
tibia, varus angulation develops in approximately 60% of iso-
lated tibial fractures wirhin the flrsr 2 weeks after injUlY (l01)
(Fig. 24-6) because rhe force of contracrion of rhe long flexor
muscles of the lower leg are convened inro an angular momenr
by the inract fibula (Fig. 24-7). Isolated transverse and commi-
nured fractutes of the tibia are caused by direct trauma. Trans-
verse fractures of the tibia with an intact fibula seldom displace
(8,46). Comminuted fractures drift into varus alignment like
oblique and spiral fractures (8,46,101).
Approximately 30% of pediarric ribiaJ diaphyseal fractures
have associated fibular fractures (11,13,101). Plastic deforma-
tion of the fibula may produce valgus malalignmenr of the tibia.
FIGURE 24-5. Proximal tibial metaphyseal fracture with interposition The fibular injury must be identified to prevenr recurrence of the
of both the pes anserinus fibers and the periosteum into the fracture malal ignmenr after reduction. An associated complere Fracture of
medially.
the fibula usually results in valgus malalignmem because of the
acrion of rhe muscles in rhe anterolateral aspect of the leg (Fig.
24-8).
Displaced proximal tibial fractures require closed reduction An isolated fracrure of the fibular shaft is rare in children
with general anesthesia in the operating room, with fluoroscopy and normally results from a direct blow to the lareral aspect of
ra verify an anaromic reducrion. If closed reduction ro an ana- the leg (Fig. 24-9). Most isolated fractures of the fibular shaFr
ramic position or slight varus callOot be obtained, an open reduc- are nondisplaced and heal quickly with sympramatic care. Com-
tion is indicated. Interposed soft tissue is removed from the partment syndrome may accompany this in jUlY, and observation
Fracture (Fig. 24-5), and the pes anserinus plate is repaired iF for this associated problem is mandatoly.
ruptured. The child is placed inro a long leg, straight knee cast
after reducrion, and the fracture is checked once again. Frequent
foJlow-up visits are required ro verify maintenance of the reduc- Signs and Symptoms
tion. The cast is removed approximately 6 weeks aFter injury.
The child may return to normal activities after recovery of nor- The signs and symptoms associated with tibial and fibular dia-
mal knee and ankle range of motion. Long-term follow up with physeal Fracrurcs vary with tbe severiry of the injury and rhe
a warning to the Family of possible growrh abnormaliry is manda- mechanism by which it was produced. Pain is rhe most common
toty. symptom. An isolated fibular fracture normally produces mild
A child with a posmaumatic valgus deformity is followed pain, whereas tibial fractures produce more severe pain. Children
unril sponraneous correction occurs or until the child is old with suess fracrures of the tibia or fibula complain of pain on
enough For surgical imervenrion. Tibial osteotomies rarely are weight bearing, bur no pain ar rest.
indicared and generally should be delayed unril adolescence. A Children with fracrures of the ribia or fibula have edema at
well-timed proximal tibial medial epiphysiodesis can provide rhe Fracture site, and the area is tender to palpation. Young
comparable results wirhour many of rhe risks of osteoromy (34). children with nondisplaced fractures may refuse to walle IF rhere
1084 Lower E'(tremiry

A,B c
FIGURE 24-6. Anteroposterior radiograph of a distal one-third tibia fracture without a concomitant
fibula fracture in a 10-year-old child. A: The alignment in the coronal plane is acceptable (note that the
proximal and distal tibial growth plates are parallel). B: A varus angulation developed within the first
2 weeks after injury. C: At radiographic union, a 10 degree varus angulation is present.

FIGURE 24·7. A: Fracture of the proximal third of the tibia without a concomitant fibular fracture.
Note the valgus angulation of the tibia fracture. B: The valgus malalignment spontaneously corrected
into neutral alignment. C: The fracture united with a mild posterior and medial translation without an
angular deformity.
 Chapter 24: Fractures of the Shaft of the Tibia and Fibula 1085

c
1086 Lower Extremity

Ant. TIbialis
Muscle

Ext. Dlgltorum -----!fIH.

Longus Muscle

Ext. HaHuds -------:lI~tt.'I'%fI.

Longus Muscle

FIGURE 24-8. The muscles in the anterior and the

lateral compartments of the lower leg produce a
valgus deformity in complete ipsilateral tibia and
fibula fractures.

FIGURE 24-9. A: Plastic deformation of fi-

bula secondary to a direct blow to the lateral
aspect of the leg (closed arrows). Note medial
nondisplaced fracture of the tibia. (Figure
A continues.)
 Chapler 24: Fractures of the Shaft oftht' Tibia and Fibula 1087

B
FIGURE 24-9. (continued) B: The tibia fracture displaced in the cast a
week later from the force exerted by the plastically deformed fibula. A B
FIGURE 24-10. A: Spiral fracture of the distal tibia. The fracture is
difficult to identify on the anteroposterior radiograph. B: The fracture
is easily identified on the lateral radiograph.

is significalH injlllY to the periosteum, a bony defeer may be

present w palpation in patienrs with a complete fraerure. Neuro-
logic impairmel1( secondary w the force that created the fracture
Treatment
is !"are except with fibular neck fracrures caused by direer trauma.
AJthough arterial disruption is uncommon in pediatric tibial Cast Immobilization
and fibular diaphyseal fractures, both the dorsalis pedis and the
Pediatric tibial and fibular shaft fractures usually are uncompli-
posterior tibial pulses should be chcckcd, and a Doppler exami-
cated and can be treated by a simple manipulation and cast
nation should be performed if they are not palpable. CapiJlary
application (67). Isolated fractures of the tibial shaft often de-
filling, sensation, and pain response patterns also should be mon-
velop a varus malalignment. Valgus angulation and shortening
iwred.
can present a significant problem in children who have complere
Concomitant soft tissue injuries must be evaluated carefully.
fractures ofborh rhe tibia and rhe fibula (Fig. 24-11). A recurva-
Open fractures must be treated aggressively to reduce the risk
tum deformity also can develop.
of late complications.
Displaced fractures are reduced in the operaring room to
allow painless manipulation with muscle relaxation and the use
of Auoroscopy w guide the reduction. The child's ankle initially
Radiographic Evaluation may be left in some plantar Aexion (20 degr·ees for fraerures of
Anreroposterior and lateral radiographs that include the knee the middle and distal thirds, 10 degrees for fractures of rhe proxi-
and ankle joints (Fig. 24-10) should be taken whenever a tibial mal third) to prevent posterior angulation at the fracrure.
or fibular shaft ftacture is suspected. Comparison views of the The fracture is evaluated under AUOtoscopy before cast appl i-
uninvolvcd Jeg normally are not neccssalY. Children with sus- carion to determine the mosr appropriate way ro manipulate rhe
pected fi·acrures not apparent on the initial radiographs may need bone (Q achieve an acceptable reduction. A shon leg cast is ap-
to be treated with supportive casting to control the symptOms plied with the foot in appropriate position and wirh either a
associated with the injuries. Technetium radionuclide scans ob- varus or valgus mold. The cast material is taken w the inferior
tained at least 3 days after injlllY are useful to idenrify fractures aspect of the patella anteriorly and to a point 2 cm distal to rhe
that are unapparent radiographically. popliteal flexion crease posteriorly. Plaster is lIsed for the inirial
1088 Lower Extremity

A,B c

FIGURE 24-". A: Complete fracture of the tibia and the fibula with
a valgus deformity and shortening. B: The fracture was closed re-
duced. C: The valgus deformity increased after 2 weeks. 0: The cast
was wedged. E: Radiograph 6 weeks after injury shows a good align-
D,E ment and callus formation.
 Chapter 24: Fractures of the Shaft of the Tibia and Fibula 1089

cast because of its abiliry [Q mold [Q the comour of the leg and cast open. A plastic block (Fig. 24-12) of the appropriate size
the ease with which it can be manipulated while se[[ing. The is placed into the open segment and the cast is wrapped with
alignmenr of the fracture is rechecked aftet the shorr leg cast new casting material after the alignment has been checked radio-
has been applied. The cast is then extended [Q the mld-thigh graphically. This wedging technique lengthens the tibia while
with the knee flexed. Most children with complete unstable dia- correcting the malalignmenr (Fig. 24-13).
physeal tibial fractures are placed into a bent knee (45 degrees)
long leg caSt [Q control rotation at the fracture site and assist in Combination Technique
keeping the child non-weight bearing during the initial healing Approximately 45% of the cast opposite the apex of rhe mal-
phase. aligned fracture is cut perpendicular to the shaft of the tibia.
The alignment of the fracture must be checked closely during Two vertical curs separated by approximately 0.5 cm are made
the first 3 weeks after the cast has been applied, when muscle 90 degrees from the first cut in both directions directly over the
atrophy and a reduction in tissue edema may lead to a loss of fraerure. A wedge of casting material is temoved from the apex
fracture alignment. Some children require a second cast applica- side of the malaligned fraerure, and the cast opposite the apex
tion with remanipulation of the fracture under general anesthesia of the fracrure is opened. This closes the defect in the casr over
several weeks after injury. Acceptable position is somewhat con- the apex of the fracture and produces a change in the angular
troversial. Remodeling of angular deformiry is limited. No abso- alignment of the bone without a signiflcanr change in the length
lute number can be given, but the following general principles of the bone.
may be beneflciaJ in decision making.

1. Varus and valgus deformiry in the upper and mid-shaft tibia Operative Treatment
remodel slowly if at all. Up [Q 5 degrees of deformiry can be
Unstable fractures of the tibia and flbula may require operative
accepted, but not more than 10 degrees.
reduction and surgical stabilization. Common methods of fixa-
2. Translation of the entire shaft of the tibia in a young child
tion include percutaneous pins, bioabsorbable pins (42), external
is satisfactory, whereas in an adolescent, 50% apposition
fixation, and plates with screws. ImramedulialY nails are seldom
should be obtained.
indicated.
3. Up to 10 degrees of posterior angulation may be tolerated,
Operative treatment is rarely needed for tibial fractures in
although remodeling is slow
children. Weber et al. (13) reponed that only 29 (4.5%) of
4. No more than 1 cm is acceptable, because overgrowth is
638 pediar.ric tibial fraerures required surgical inrervenrion. The
minimal.
indications for operative treatment include open fractures, frac-
tures in children with spasticiry (head injury or cetebral palsy),
Wedging of a Cast and fractures in which open treatment facilitates nursing care
Occasionally, loss of fracture reduction requires the cast [Q be (floating knee, multiple long bone fractures, multiple system
"wedged." The fracture alignment in the cast can be changed injuries) (40,44,52,54,57,60,64,70,72,77,80,81,87,92,100).
by crearing a closing wedge, an opening wedge, or a combination Children with stable fractures or minimally displaced frac-
of wedges. The location for the wedge manipulation is deter- tures should be treated conservatively whenever possible. Com-
mined by evaluating the child's leg under fluoroscopy and mark- minuted tibiaJ fractures, unreducible fractures, fractures that
ing the mid-point of the tibial fractLIre on the outside of rhe cannot be maintained in a reduced position, fractures associated
cast. If fluoroscopy is not available, a series of paper clips are with a compartmenr syndrome, grade II or III open injuries
placed at 2-cm intervals on the cast. Al1teroposterior and lateral (Fig. 24-13), or fractures associated with multiple system injuries
radiographs are then taken. The paper clips deflne rhe location should be treated with operative stabilization (40,44,52,54,57,
of the fracture and the location of the casr manipulation. 60,64,70,72,77,80,81,87,92,100).

Closing Wedge Technique Open Fractures

A wedge of cast material encompassing 90% of the circumfer-
ence of the leg with its base over the apex of the fracture is Open tibial fractures in children are [[-eated in the same manner
removed. The cast is left intacr opposite the apex of the fracture. as comparable injuries in adults, and they are classified by the
The edges of the cast are brought together to correct the angula- Gustillo and Anderson System (61) (Table 24-6 and Fig. 24-
tion at the fracture. This wedging technique produces mild frac- 14). Mosr open fractures of the tibia result from high-velociry
ture shortening and may pinch the skin at the location the wedge InJuries.
is removed. It also may increase compartment pressures because
the volume of the cast is reduced. Treatment Principles
Edwards outlined management principles for high-grade open
Opening Wedge Technique
fracwres in 1983 (56):
The side of the cast opposite the apex of the fracture is cut
perpendicular to the long axis of the bone. A small segment of • Rapid debridement, irrigation, and antibiotic therapy
the cast is left intact directly over the apex of the malaligned • Fracture reduerion followed by application a rigid flxation
tibia (approximately 25%). A casr spreader is used to "jack" the device
1090 Lower t.:lClremity

A B
FIGURE 24-12. A and B: Blocks used to hold casts open after wedge corrections of malaligned fractures.
The wings on the blocks prevent the blocks from migrating toward the skin.

• Jnrraoperative angiography and compartment pressure stud ies • 50Ft rissue injuries heal better in children than in adults.
when suFficiency of the vascular proFusion is unclear or com- • Devitalized unconraminated bone that can be covered with
partments tight soFt tissue will incOl'porate intO the fracture callus.
• Open wound treatment with loose gauze packing • Exrernal fixation can be maintained, when necessary, until
• PostOperative suspension of the leg fracture consolidation.
• Staged debridement of necrotic soFt tissue and bone in rhe • Periosteum GIn reForm bone even with segmenral bone loss
opcrating room every 24 to 72 hours until a good granularion in youngel' children.
base develops • Some unconraminated grade I open wounds can be primarily
• Debyed closure or application of a split-thickness skin graFt closed.
when necessary; delayed myocutaneous flap as needed
Buckley et al. (47) reponed 011 41 children with 42 open
• Closed cancellous bone graFting For bone defecrs or delayed
Fracrures of rhe tibia (J 8 grade II, G grade lILA, 4 grade HlB,
union
and 2 grade IIIC). Twenty-rwo (52%) of the fractures were
• Rcmoval of external fixation device followed by application
comminured. All wounds were irrigated and debrided, and anri-
of a weight-bearing cast in compressible Fracrures aFter success-
biotics were administered For at least 48 hours. Twenty-two frac-
ful soft tissuc coveragc
tures were treated with reduction and cast application, and 20
• Continued exrernal fixation and graFring For noncompressible
wjth external fixation. Three children had early inFections, and
fracrures
one of them developed lare osteomyelitis. All infections had re-
The principles of trearmenr for open tibial fracrul'es in adults solyed at last follow-up. The average time ro union was 5 monrhs
have been modified by the unique characteristics of the pediatric (range 2-21monrhs). The time ro union was directly propor-
skeleton. These differences include the following (40,52,60,95): tional to rhe severity of the soft tissue injury. Fracrure parrern
 Chapter 24: Fractures of the Shaft of the Tibia and Fibula 1091

A B

C D
FIGURE 24-13. A: Anteroposterior and lateral tibial radiographs of an 11-year-old boy who was struck
by an automobile sustaining a markedly comminuted tibia fracture without a concomitant fibula frac-
ture. B: Despite the comminution, length and alignment were maintained in a cast. C: The patient's
fracture shifted into a varus malalignment that measured 10 degrees (right). The cast was wedged,
resulting in the reestablishment of an acceptable coronal alignment (left). D: The patient's fracture
healed without malunion.
1092 Lower Ex:trernity

A B c

FIGURE 24·14. Gustillo and Anderson clas-

sification of open fractures. A: Grade I The
skin wound measures less than 1 cm long,
usually from within, with little or no skin
contusion. B: Grade II. The skin wound mea-
sures more than 1 cm long, with skin and
soft tissue contusion but no loss of muscle
or bone. C: Grade lilA. There is a large se-
vere skin wound with extensive soft tissue
contusion, muscle crushing or loss, and se-
vere periosteal stripping. D: Grade IIIB. Like
grade IliA but with bone loss and nerve or
tendon injury. E: Grade IIIC. Like grade lilA
or B with associated vascular injury. (Re-
printed from Alonso JE. The initial manage-
ment of the injured child: musculoskeletal
injuries. In: MacEwen GO, Kasser J, Heinrich
SD, eds. Pediatric fractures a practical ap-
proach to assessment and treatment. Ba Iti-
more: Williams & Wilkins, 1993:32; with
D E permission.)
 Chllpter 24: Fmc! ures of the 'hllft of the Tibia and Fibula 1093

TABLE 24-6. CLASSIFICATION OF OPEN TABLE 24-7. EARLY COMPLICATIONS

FRACTURES ASSOCIATED WITH OPEN
PEDIATRIC TIBIAL FRACTURES
Grade I
Low-energy wound, < 1 cm long Grade
Bone piercing skin from inside/out
Minimal muscle damage Complication II III Combined
Grade II
Wound >1 cm in length Delayed union 18% 12% 26% 16%
Moderate soft tissue injury Nonunion 5% 6% 16% 7.5%
Grade III Malunion 9% 4% 11% 6.5%
High-energy wound Infection 12% 21% 11%
Usually >10 cm Compartment 9% 2% 5% 4%
Extensive muscle devitalization syndrome
Bone widely displaced or comminuted Physeal arrest 2% 5%
Special cases Weeks to union 13 12 17 13.5
Shotgun wound
High-velocity gunshot (>2,000 ft/s) Reprinted from Hope PG, Cole WG. Open fractures of the tibia in
Segmental fracture children. J Bone Joint Surg [Br) 1992;74:546; with permission.
Segmental diaphyseal loss
Farmyard environment
Associated vascular injury

Reprinted from Gustillo RB, Anderson JT. Prevention of infection

in the treatment of one-thousand and twenty-five fractures of
long bones. J Bone Joint Surg [Am} 1976;58:453; with permission. 50% of the patienrs complained or pain at rhe fracture sire;
23% reponed decreased abilities ro panicipate in sportS, joint
stirfness, and cosmetic defects; and 64% had leg lengrh inequali-
ties (Table 24-8). Levy et al. (8 J) found comparable late sequelae
after open tibial fracrures in children, including a 25% preva-
lence of nightmares surrounding rhe events of the accident. Bla-
also had an effecr on rime ro union. Segmenral bone loss, infec- sicr and Barnes (43) and Song et at. (95) found thar mosr lare
rion, and rhe use of an exrernal fixarion device were associaled complications associared with pediatric open tibial fracrures oc-
with delayed union. Four angular malunions of more rhan 10 curred in children over rhe age 12 and 11, respectively.
degrees occurred, three of which spontaneously correcred. Four
children had more than 1 cm of overgrowTh (47).
In a series of 40 open lower extremity diaphyseal fractures Soft- Tissue Closure
in 35 children, Kramer er al. (76) reponed 22 ribial fracrures The riming of soft rissue closure afrer an open tibial fracrure
(1 grade 1, 10 grade II, and 11 grade III). EXlernal fixarion was that cannor be primai'ily closed is important in decreasing the
used for 15 fractures, casting for 5, and internal flxarion for 2. morbidity associared wirh this injury (73,83). In a series of 168
Two children required early amputation, 4 required soFr rissue
8aps, and 13 children had skin grafrs. Two additional children
required Fascioromy for companment syndrome and were in-
cluded in rhe group of open tibial Fracrures. Ten of the 24 inju-
ries healed within 24 weeks. hve children required bone grafring TABLE 24-8. LATE COMPLICATIONS
beFore healing. ASSOCIATED WITH OPEN
PEDIATRIC TIBIA FRACTURES
Hope and Cole (69) reported rhe resulrs of open ribial fra.c-
rures in 92 children (22 grade I, 51 grade 11, and 19 grade Grade
TIl). Debridement and irrigation were performed on admission,
Complication II III Combined
antibiorics were given for 48 hours, and teranus prophylaxis was
adm inisrered as needed. Primary closure was perFormed in 51 Pain 38% 48% 65%
children, and 41 Fracrures were left open. Eighteen soft tissue Decreased athletic 19% 15% 47%
injuries healed secondarily, and 23 required either a splir-rhick- activity
ness skin grafr or a rissue flap. Sixty-five (71%) of rhe 92 fractures Decreased mobility 19% 20% 35%
(Stiffness)
were srable and were reduced and immobilized in an above- Cosmetic complaints 6% 17% 53%
the-knee plasrer cast. External fixation was used for unstable Leg length
fracrures, injuries with significant sofr tissue loss, and fractures 5hort (0.5-2 cm) 22% 23% 40% 27%
in patiems with multiple system injuries.Early complicarions of Equal 14% 46% 33% 36%
open rjbial fraccures in rhese children were comparable with Long (5.0-2 cm) 64% 31% 27% 37%
those in adults (Table 24-7) (44,47,49,51,53,62,66,69.78,84,
86,89). Primary closure did nor increase the risk of infection iF
Reprinted from Hope PG, Cole WG. Open fractures of the tibia in
children. J Bone Joint Surg fBr] 1992;74:546; with permission.
rhe wound was small and unconraminated (40,52,69). At reeval-
uarion 1.5 ro 9.8 years after injury, Hope and Cole found (har
1094 Lower Extremity

open tibial fractures with late secondaty wound closure, Small be elevated enough to produce an ischemic injury but not high
and Mollan (93) found increased complications with early fasci- enough to occlude arterial inflow, rhe pressure of peripheral
ocutaneous flaps and late free flaps and no complications with pulses is an unreliable sign of elevated tissue pressures.
fasciocutaneous flaps created more than 1 month after injuty. Compartment pressure measuremenrs are mandatory in any
Complications associated with free flaps were decreased if the patient suspected of having a compartment syndrome. This can
procedure was performed within 7 days of injury. be performed by needle manometty, saline infusion, or a wick
Ostermann, HenlY, and Seligson (85) reported 115 grade II catheter. A fasciotomy is indicated for any patient with a signifi-
and 239 grade III tibial fractures in a series of 1,085 open frac- cant elevation of compartment pressures or, more importantly,
tures. AJI patients "vere treated with early broad-spectrum antibi- symptoms suggestive of a compartment syndrome. When mea-
otics, serial debridements, and the application of an external suring compartment pressure in the leg after a tibial fracture,
fixation device. Tobramycin-impregnated polymethylmethacry- placement of the needle is a problem. Buchholz showed tlut
late was placed into the wounds, and dressings were changed there was a pressure gradient vertically through a comparrment.
every 48 to 72 hours until the wounds spontaneously closed, or
had delayed primary closure or a flap. No infections occurred
in grade I fractures; approximately 3% of grade II fractures and ~ AUTHOR'S PREFERRED METHOD
8% of grade III fractures became infected. No infections oc- \....~ OF TREATMENT
curred in patients who had the wound closed by 8 days after
injuty. On the basis of this and other analyses, it now is recom- Diaphyseal Fractures
mended that wounds associated with open tibial fractures be Simple pediatric diaphyseal tibial fractures unite quickly, and
closed within 7 days of injury (7,48,49,50,75,85,88,98). A de- cast immobilization can be used without affecting the long-term
layed primaty closure can be performed if the wound is clean range of motion in the knee and the ankle. A bent knee, long
and does not involve significant muscle loss. Tension at the leg cast provides maximal comfort to the patient and controls
suture line must be avoided. rotation of the fractured fragments. Children with nonclisplaced
fracrures generally do not need to be admitted to the hospital.
Vascular Injuries Children with more extensive injuries should be admitted for
observation and teaching of wheelchair, crutch, or walker use.
VasCLJar injuries have been reported in approximately 5% of Displaced fractures may significantly disrupt the surrounding
children with open tibial fractures. Arterial injuries associated soft tissues and produce a large hematoma in the fascial compart-
wirh open tibial fractures include those to the popliteal artery, ments of the lower leg. Circulation, sensation, and movemem
the posterior tibial arrery, the anterior tibial artety, and the pero- of the toes should be monitored carefully after injuty. The child
neal arrcry. Complications are common in patients with open should be admitted to the hospital, and reduction should be
tibial fj'actures and associated vascular injuries. Amputation rates performed with general anesthesia and fluoroscopy. Stable frac-
as high as 21 % have been reported with grade IllS fracrures tures are casted after reduction. The fj'acrure must be checked
and as high as 79% with grade IllC fracrures. Isolated anterior within a week of manipularion to verifY maintenance of the
tibial and peroneal artery injuries have a good prognosis, whereas reduction. The cast can be wedged to correct minor alignment
injuries of the posterior tibial and popliteal arteries have a poor problems. Significant loss of reduction requires repeat reduction
prognosis (39,63,68). Patients with open tibial ftactures and with general anesthesia (Table 24-9). The long leg cast is
vascular disruption may benefit from an arterial and possibly changed to a short leg cast at 4 to 6 weeks after injuty. Children
venous shunt before the bony reconstruction is performed. This over 11 years of age are placed into a patellar tendon-bearing
allows a meticulous repair offracrure and keeps the limb perfused cast after removal of the long leg cast (89).
until the primary vascular repair is performed (58).

Compartment Syndrome
The prevalence of compartment syndromes in adults with open TABLE 24-9. ACCEPTABLE ALIGNMENT OF A
tibial fractures ranges from 6°;') to 9% (44,53,78). Compartment PEDIATRIC DIAPHYSEAL TIBIAL
FRACTURE
syndromes OCCLIr in approximately 5% of children with open
tibial fractures. Normal compartment tissue pressure in. the lower Patient Age
leg is approximately 0 mm Hg. Compartment blood inflow is
decreased at 20 mm Hg, and prolonged pressures of 30 to 40 <8 Years 2::8 Years
mm Hg or within 30 mm Hg of diastolic blood pressure may Valgus 5' 5°
cause severe nonteversible injury to the muscles within a fascial Varus 10' 5'
compartment. Anterior angulation 10' 5°
Symptoms and signs associated with compartment syndrome Posterior angulation 5' 0°
Shortening 10 mm 5 mm
in.c1ude pain out of proportion to the injury, burning, throbbing, Rotation 5' 5°
pain increased by passive strerch, and nerve dysfunction. The
comparrment is tense to palpation. Because tissue pressures can
 Chapter 24: Fmctltres of (hI' Shaft of the Tibia and FibuLa 1095

Fracwres in pariems wirh spasriciry, a Hoaring k.nee, mulriple wirh uncomplicared grade] fracrmes can be placed in a casr.
long bone fracrures, exrensive sofr rissue damage, or mulripJe Smoorh pin fixation will prevenr displacemenr of unsrablc frac-
sysrem injuries are srabilized wirh an exrc-mal Fixarion device, tures. Most children with grade II and all children with grade
percutaneous Kirschner wires, or flexible imramedullalY nails. III wounds require more rigid fracrure srabilization, usually wirh
external fixarion.
The most versarile exrernal fixation device for grade II or III
Open Fracture Treatment
open pediarric ribial fracwres is a unilareral frame (Fig. 24-16).
Grade J open fracrures can be pinned afrer irrigarion and de- The unilateral frame is easy ro apply and allows minor correc-
bridemene of rhe wound (Fig. 24-15). A long leg spline is applied rions in angular alignmenr and lengrh. Secondary pins can be
and is changed (Q a long leg casr afrer wound closure. Exrernal used for added support (Fig. 24-17). These are connected to the
f1xarion generally is used for grade If or 1II open ribial fraccures. standard pins or the body of rhe external fixation device. This
Open ribial fracrures of any grade should have rhorough irri- aJlows control of segmental fragmencs. Fracrure reducrion
gation and debridemenc of rhe wound as soon as possible. The clamps can be applied ro rhe pin clamps ro assisr in manipularing
patienr's tetanus srams is dercrmined, and prophylaxis is admin- rhe fracrme. A small-pin circular frame can be used for compli-
istered as needed. The sofr rissue wounds can be exrended (Q be cared fracrmes adjacenr to rhe joint (Fig. 24-18).
certain that the area is cleansed and debrided of all foreign mate- External fixation pins are applied no closer rhan 1 cm ro rhe
rial. DeviraJized bone can be left in place if it is clean. The physis. The exrernal fixarion device is applied, and a reducrion
operarive wound extension can be closed with the open segment maneuver is performed. All of the connections in rhe exrernal
in clean grade J injuries. The wound is allowed (Q heal by second- fixarion device are righrened after reducrion has been obrained.
ary imemion if ir has moderate conraminarion ar rhe rime of Secondary pins ro improve fracture srabiliry are placed ar rhis
the irrigation and debridemenr. Grade II and III wounds also time. Limired imernal fixation of the fracture can be used to
are debrided of deviralized rissue and foreign material. Pariems aid in conrroHing fracture alignmenr (Fig. 24-19). A posrerior

A,B c
FIGURE 24-15. A: Anteroposterior radiograph of a grade I open distal one-third tibia fracture in a
7-year-old child. B: Two percutaneous pins were used to stabilized this fracture after irrigation and
debridement. C: Good fracture callus was present and the pins were removed 4 weeks after injury.
1096 Lower Extremity

A B

FIGURE 24-16. A and B: Type II open fracture of the tibia in a 5-year-

old boy treated with debridement, unilateral external fixation. and
split-thickness skin graft. C: Four months after removal of the external
c fixation.
 Chapter 24: Fractures of the Shaft of the Tibia and FibuLa 1097

FIGURE 24-17. A: Anteroposterior and lateral raciiographs of

a grade IIIB open fracture of the distal tibia and fibula. B: An-
teroposterior and lateral radiographs after fracture reduction
and stabilization with an lIizarov circular fixation frame. (Re-
printed from Sharps CH, Cardea JA. Fractures in the shaft of
the tibia and fibula. In: MacEwen GD, Kasser J, Heinrich SD,
eds. Pediatric fractures: a practical approach to assessment and
treatment. Baltimore: William & Wilkins, 1993 325; with per-
B mission.)
1098 Lower Extremity

A B

c D
FIGURE 24-18. A: Anteroposterior and lateral radiograph of the tibia of a 12-year-old boy who was
struck by a car. This child sustained a grade IIIB open middle one-third tibia fracture, a Salter-Harris type
II fracture of the distal tibial physis with associated distal fibular fracture (closed arrows), and a tibial
eminence fracture (open arrow). B: Irrigation and debridement, and application of an external fixation
device, were performed. C: The fracture of the distal tibial physis was stabilized with a supplemental
pin attached to the external fixation device. Open reduction and internal fixation of the fibula were
performed to enhance the stability of the external fixator in the distal tibia. D: Anteroposterior and
lateral radiographs of the tibia approximately 9 months after injury demonstrate healing of the tibial
eminence fracture, the comminuted middle one-third tibia fracture, and the distal tibial physeal fracture.
The distal tibial physis remains open at this time.
 Chapter 24: Fractures of the Shaft of the Tibia and Fibula 1099

Safe Drilling Zone malalignment of the fracture. As the muscle atrophy and weak·
ness resolve, so does the limp.
Active physical therapy may be beneficial in treating children
with a tibial fracture. In an older child progressing from a bent
knee cast ro weight bearing on a shorr leg cast, knee range of
motion exercises and quadriceps strengthening are useful. Pro-
gressive weight bearing on a shorr leg cast requires the patient
ro wean off crutches or a walker. In some children, this requires
supervision. After removal of the cast, roe rises for strength
should be performed. The child may return ro sportS with a
healed fracture and the ability to hop equal to the uninjured
side.

FIGURE 24·19. Safe drilling zone. A: The area occupied by the growth
plate is approximately 1 cm in height because of its undulations. B: The
safe drilling zone is at least 1 cm from the physis. (Reprinted from FRACTURES OF THE DISTAL TIBIAL
Alonso JE. The initial management of the injured child: musculoskeletal
injuries. In: MacEwen GD, Kassel' J, Heinrich SDH, eds. Pediatric frac- METAPHYSIS
tures: a practical approach to assessment and treatment. Baltimore:
Williams & Wilkins, 1993: 36; with permission.) Fractures of the distal tibial metaphysis often are greenstick inju-
ries. The anterior cortex is impacted while the posterior correx is
displaced, with a tea.r of the overlying periosreum. A recurvatum
deformity often occurs (Fig. 24-20). Reduction of these injuries
splint can be applied ro prevent the foot from dropping into should be performed with general anesthesia and maintained
plantar Aexion. This splint is easy ro remove during subsequent with a long leg cast. The foot should be in plantar Aexion to
pin care and dressing changes of the open injury.
prevent recurvatum at [he fracture site. The foot is broughr up
after 3 to 4 weeks, and a shorr leg walking cast is applied. U n-
stable injuries can be treated with percutaneous pins (Fig. 24-
POSTFRACTURE IMM 0 BILIZATI0 N 21) or with open reducrion and internal fixation (Fig. 24-22).

The lengrh of immobilization varies with the child's age and the
type of fracture. The duration of immobilization was 8 ro 10
weeks in the Steinerr and Bennek series (96). Hanson et al. (6)
found that healing time ranged from 5 to 8 weeks for "fissures
and infractions" and from 5 to 13 weeks for oblique, transverse,
and comminuted fracwres. Hoaglund and States (66) reporred
rhat in 43 closed fractures in children, the average time in a
caSt was 2.5 months (range 1.5-5.5 months), whereas the five
children with open fractures were immobilized fat 3 months.
Kreder and Armstrong (77) found an average time to union
of 5.4 months (range 1.5-24.8 months) in a series of 56 open
tibial fractures in 55 children. The factor with the most effect
on union time was the age of the patient. Grimard et al. (60)
reporred that rhe age of the patient and the grade of the fracture
were significantly associated with union time. Blasier and Barnes
(43) found that children under 12 years of age required less
aggressive surgical rrearmem and healed faster than older chilo
dren. They also found that younger children were more resistam
to infection and had fewer complications than older children.

POSTFRACTUR REHABILITATION
Most children with a tibial fracture do not require extensive
rehabilitation. Children's normal walking and running activities
serve as rherapy. Most children limp with an out-toeing rotation A
gait on the involved extremity for several weeks after the cast is FIGURE 24-20. A: The lateral radiographs demonstrate a mild recurva-
removed. This usually is due ro muscle weakness rather than a tum deformity. (Figure continues.)
1100 Lower Extremity

B c
FIGURE 24·20. (continued) B: The ankle was initially immobilized in an ankle neutral position, produc-
ing an increased recurvatum deformity. The cast was removed and the ankle remanipulated into plantar
flexion to reduce the deformity. C: The ankle was then immobilized in plantar flexion, which is the
proper position for this type of fracture.

A,B c
FIGURE 24·21. A and B: Unstable distal metadiaphyseal fracture of the tibia and fibula in a 15-year-
old girl. C: This fracture was stabilized with percutaneous pins because of marked swelling and fracture
instability.
 'hapter 24: r"aetures of t:he Shaft of the Tibia and FibuLa 1101

A B
FIGURE 24-22. A: Anteroposterior radiograph of a distal one-third tibialfibula fracture in a 9-year-old
girl with a closed head injury and severe spasticity. The initial reduction in a cast could not be maintained.
B: An open reduction and internal fixation with a medial buttress plate was performed to achieve and
maintain the alignment.

COMPLICATIONS ASSOCIATED WITH effLciem in delivering blood as venous outflow becomes oc-
DIAPHYSEAL TIBIA/FIBULA cluded. The arterioles and capillaries close when the pressure in
FRACTURES the compartment exceeds [he pressure in the vessels. Ischemia
soon follows.
Compartment Syndrome
Patienrs with a compartment syndrome complain of pain
The amerior compartment of the leg includes the extensor hal- out of proportion to the severiry of [he injury. The compan-
lucis, the extensor digitorum longus, and the [ibialis anterior menr is firm ro palpation. The patient may have a sensory
muscles. It is surtounded by [he tibia, the fibula, the interosseous defect in the distribution of the nerves that run through the
membrane, and the anrerior fascia. A comparnnem syndrome compartment. Weakness of the muscles within the involved
may occur after either a minor closed fracture or a severe injury companment and pain on passive motion of the toes also are
in which [he interosseus membrane is disrup[cu (79). Schrock common. Paralysis of [he muscles in the involved compartmem
(90) also described comparrmem syndromes aftcr derotational is a late fi nding.
ostcotomies of [he tibia in children. Paticms with a compartment syndrome of the deep posterior
Compartment syndromes also have been reported in the comparnnenr have severe pain that increases with passive exten-
other three compartments of rhe lower leg aErer uauma. Hemor- sion of [he roes, plamar hyperesthesias, weakness of roe flexion,
rhage and soft tissue edema produce an elevation in [he pressure and [enseness of the fascia berween the [ibia and [he triceps area
wi[hin the myofascial compartmenr thar impairs venous oudlow. in the distal medial part of [he leg (82). Lare complica[ions
The small arterioles leading inw the comparTmenr become less include clawed [Des and limited subtalar motion secondary (Q a
1102 Lower Extremity

300

100

~ mercury
manometer

~ 20cc cyringe
alf

air
.l.

IV extension tube
3 way stopcock open
to syringe and both
extension tubes
FIGURE 24-23. Whitesides' technique for measuring intercompartmental pressure. (Reprinted from
Whitesides TE, Hanley TC, Morinotok K, et al. Tissue pressure measurement as a deterinant for the need
of fasciotomy. Clin Orthop 1975;113 :43; with permission.)

fibrous contracture of the muscles in the deep posrerior compart-

ment (71).

Diagnosis
Direct intracomparrmenral pressure measuremenrs ar the level
of the fracture provide an accurare assessment of comparrment
condirions and al10w early fascioromy to reduce rhe pressure.
Whiresides et al. (99) designed an inexpensive appararus thar
perm irs accurare measurement of compartment rissue pressure
(Fig. 24-23). Orher commercial devices also are available to mea- CJOo'V
~ ~ "a~""
surc comparrment pressures. Normal tissue pressures are about .r9C;:o'?O" A
o mm Hg. Vascular flow ceases in the microcirculation of an
extremity by the time tissue pressures wirhin a closed com parr- o;j:iP~~~'O
mel1t reach rhe diastolic pressure. Comparrmcl1t release should
be performcd when rhe pressures are within 20 ro 30 mm Hg of
rhe diastolic pressure. This is especially crirical in a hypotensive
polyrrauma patient.

Treatment
First rhe cast should be bivalved and the padding divided. If afrer
removal of circular wraps there is no relief, fasciotomy should
be considered. Any child who has evidence of a compartment
syndrome should undergo an emergent fasciocomy. The rwo-
incision rechnique is preferred (Fig. 24-24). One incision is an-
terolateral and the second posteromedial. The fascia surrounding
each of the four comparrments should be opened from proximal
to distal. If rhe wound can be closed primarily, it should be, but
usually the wound is left open with retenrion sutures and a FIGURE 24-24. Preferred decompression technique for the lower leg,
using medial and Ilateral incisions. A: Anterior compartment. B: Lateral
delayed closure is performed. Fibulectomy should nor be per- compartment. C: Tibialis poster'ior. 0: Posterior compartment. E: Super-
formed ror decompression of a compartment syndrome in a ficial posterior compartment. (Reprinted from Alonso JE. The initial of
skeletally immarure patient because subsequenr fibular shorten- evaluation of the injured child: musculoskeletal injuries. In: MacEwen
G, Kasser J, Heinrich 5D, eds. Pediatric fracture: the practical approach
ing can produce a valgus deformity at the ankle and may result to assessment and treatment. Baltimore: Williams & Wilkins, 1993; with
in external tibial torsion and a severe gait impairment (l7,55). permission.)
 Chapter 24: F,.aet/lrt'S of till' Shaft of the Tibia and Fibula 1103

Ineversible injury co muscles and nerves begins after approxi-

mnely 5 hours of ischemia (91). Ninety percell( of muscle fibers
show evidence of injury after 8 hours ofiscbemia (65). Hyperes-
thesia, moror defects, and decreased pulses are late changes and
denore signiflcanr rissue injury. They occur only afrer rbe is-
chemia has been well escablished and [he injury is permanenr
(71 ,99).

Vascular Injuries
Vascular injuries associated with ribial fractures are uncommon
in children; however, when [hey do occur, rhe sequelae can be
devastaring. [n an evaJuarion of14 parienrswith lower extremiry
fractures and concomiranr vascular injuries, Allen er al. (39)
nored that only 3 children returned ro normal funcrion. One
facror lead ing ro a poor ourcome was a delay in diagnosis. EvaJua-
tion for vascular compromise is imperative (during the primalY
and secondary trauma surveys) in all children with tibiaJ frac-
rures.
The ribial fl·acrure mosr frequently associated wirh vascular
injUlY is in rhe proximal metaphysis. The aneerior tibial arrery
is in close proximiry ro the proximal ribia as ir passes over rhe
ineerosseous membrane inro rhe anterior comparrment (63,68).
Distal ribiaJ fractures aJso are associated wirh injuries to rbe
anterior ribial arrelY. The vessels are injured when rhe distal
fragmenr is translared posreriorly. Posterior ribial arrelY injury
IS rare.

Angular Deformity
Spontaneous correcrion of axial malalignment afrer a diaphyseal A B
fracrure of a child's forearm or femUl" is common. Remodeling FIGURE 24-25. Four-year, two-month old child with a middle one-
of a maJaligned ribial fracture, however, ofren is incomplete (Fig. third transverse tibia fracture and a plastically deformed fibula fracture.
A: Lateral view shows 20 degrees posterior angulation. B: The deformity
24-25) (45). is still 15 degrees 4 years after the injury.
Swaan and Oppers (97) evaluared 86 children creared for
fractures of the ribia. The original angularion of the fracture was
measured on radiographs in the sagirtal and fronral projections.
Girls I ro 8 yearsofgeand boys 1 to 10 years of age demonscrated shaft fractures ([·eared in above-the-knee casts. Deformities in
moderare spontaneous corr·ection of residual angularion afrer rwo planes did nor remodel as completely as those in one plane.
union. 1n gids 9 ro 12 years of age and boys 11 ro 12 years of The smallest correcrion occurred in posreriorly angulared frac-
age, approximately 50% of the angularion was corrected. No [LIres, followed by fractures with a valgus malalignmenr (Fig.
more than 25% of rhe deformity was corrected in children over 24-26). Sponraneous remodeling of malunited tibial fractures
13 years of age. Bennek and Sreinen (41) found that a recurva- in children has been reponed ro srop 18 months after fracrure
rum malunion of morc rhan 10 degrees did not complerely cor- (6)
reno T weney-six of 28 children with varus or vaJgus deformities
at union had significant residual angular deformities at follow-
Malrotation
up. Valgus deformities had a worse outcome because the tibiora-
lar joint was lefr in a deflcienr position. Because rotarional malalignmenr of the tibia does not sponta-
Weber et al. (13) demonsrrated that a fractUl"e with varus neously correct wirh remodeling (6), all malroration should be
m;llalignmenr of 5 ro 13 degrees complerely carre red ar rhe avoided. A rorarional computerized tomographic evaluarion can
level of the physis. Most children wirh va[gus deformities of 5 be performed if rhere is any quesrion abour rhe rotational align-
ro 7 degrees did nor have a full correcrion. ment of the fracture.
Hanson er al. (6) reporred 102 pediatric ribial fractures, 25 Rorarional malalignment of more rhan 10 degrees may pro-
of which had mal un ions of 4 to 19 degrees. Angular malunions duce signiflcanr funcrional impairment and necessirare a derora-
ranged from 3 ro 19 degrees ar follow-up, wirhout a single pa- tional osteoromy of the tibia. The derorarionaJ osteoromy should
tienr having a complere correction. The spontaneous correcrion be performed in rhe supramalleolar aspect of rhe distal ribia.
was approximarely 13.5% of rhe rota! defonniry. Shannak (11) The tibia is osteoromized and internally fixed. The fibula is left
reviewed rhe results of rrearment of 117 children wirh ribial 1I1lacr.
1104 Lower Extremi~y

B
FIGURE 24-26. A: Anteroposterior and lateral radiographs 2 months after injury in a 6-year-old boy
reveal a valgus and an anterior malunion at the fra ure. B: One year later, the child still has a moderate
valgus and anterior malalignment of the distal fractured segment. This malalignment produced painful
hyperextension of the knee at heel strike during ambulation.
 Chapter 24: Frr[cwres of the Shaft of the Tibia alld Fibula 1105

Leg Length Discrepancy ture complicated by a second fracture involving the supracondy-
lar aspect of the femur. This patient also developed a recurvatum
Hyperemia associated wirh fracrure repair stimulates the physes
deformity secondary co closure of the anterior proximal tibial
in the involved leg, producing growth acceleration. Tibial
physis. At present, no universally acceptable explanation can be
growth acceleration after fracture is less than that seen after fem-
given for this phenomenon. Some patients have iatrogenic clo-
oral fractures in childten of comparable ages. Shannak (10)
sure after placement of a proximal tibial traction pin, the applica-
showed that the average growth acceleration of a child's tibia
after fracture is approximately 4.5 mm. Comminuted ftactures tjon of pins and plaster, or the application of an external fixation
have the greatest risk of accelerated growth and overgrowth. device. Other children have an undiagnosed injUly of the tibial
Swaan and Oppers (97) reporred that young children have physis at the time of the ipsilateral tibial diaphyseal fracture
a greater chance for overgrowth than older children. Accelerated (74). Regardless of etiology, closure of the physis produces a
growtll <tfter tibial fracture occurs in children under 10 years of progressive recurvatum deformiry as the child grows.
age, whereas older children may have a mild growth inhibition
associated with the fracture (6). The amoune of fracture shorten-
ing also has an effect on growth stimulation. Fractures with Delayed Union and Nonunion
significant shortening have more physeal growth than fractures
Delayed union and nonunion are uncommon after tibial frac-
without shortening at union (l0). The presence of angulation
tures in children. The use of an external fixation device or infec-
at union does not affect the amount of overgrowth (59).
tion after operative intervention may lengthen the time to union
in some p<ttients. Inadequate immobilization that allows p<tt-
Upper Tibial Physeal Closure terned motion also can slow the rate of healing. A f1bulectomy
Morron and St<trr (83) reported closure of the upper tibial physis approximately 4 cm from a tibial nonunion allows compression
after fracture in two children. Both patients sust<tined a commi- at the nonunion site and induces healing (Fig. 24-27). A postero-
nuted fracture of the tibial diaphysis without a concomitant lateral bone graft also is an excellent technique co produce union
injury of the knee. Both fractures were reduced and stabilized in younger children (Fig. 24-28). Adolescents near skeletal matu-
with Kirschner wires pl<tced distal co the tibial tubercle. A genu riry can be treated with a reamed inrramedullaty nail, with a
recurvatum deformicy developed after the anterior physis closed. concomitant fibular osteotomy and correction of angulation at
Smillie (94) reported one child who had an open tibial frac- the nonunion site performed as necessary (Fig. 24-29).

A B
FIGURE 24-27. A: Anteroposterior radiograph of the distal tibia and fibula in a 5-year-old boy with an
open fracture. B: Early callus formation is seen 1 month after injury. (Figure continues.)
1106 Lower Extremity

FIGURE 24-27. (continued) C: The tibia has failed to unite 10

months after injury. D: The patient underwent a fibulectomy 4
cm proximal to the tibial nonunion. The tibial fracture united 8
CD weeks after surgery.

FIGURE 24-28. A and B: Posterolateral

tibial bone graft for a nonunion of an open
A,S tibia fracture.
 Chapter 24: FmclIJres oj the Shaft of the Tibia and Fibula 1107

A B

c o
FIGURE 24-29. A: Anteroposterior and lateral radiographs of a 14-year-old adolescent who was struck
by a car, sustaining a grade 1118 open fracture of the tibia. B: Anteroposterior and lateral radiographs
of the tibia after irrigation and debridement, and application of an external fixation device. C: The
patient developed a nonunion at the tibia, which progressively deformed into an unacceptable varus
alignment. D: The nonunion was treated with a fibular osteotomy followed by a closed angular correc-
tion of the deformity and internal fixation with a reamed intramedullary nail.
1108 Lower Extremity

SPECIAL FRACTURES The examination of a child with an acute limp SLurS on the
uninvolved side. This serves as a concrol for the sympromatic
Toddler's Fractures
extremiry. The examination begins at the hip and proceeds ro
External rotation of the foot with the knee fixed in an infanr the thigh, knee, lower leg, ankle, and foor. It is imporrant ro
or roddler can produce a spiral fracture of the tibia without a note the areas of poinr tenderness, an increase in local tempera-
concomitam fibular fracrure (fig. 24-30). This fracture parrern ture, and any swelling or bruising of the leg (140).
was first reported by Dunbar et a1. (108) in 1964. The traumatic Radiographs of the tibia and fibula should be obrained in
Cf)isode often is unwirnessed by the adult caretaker. Most chil- borh anteroposterior and lateral projections. An internal oblique
dren with rhis injury are under 6 years of age. Sixry-three of76 view can be helpful in identifying a nondisplaced roddler's frac-
such fractures reporred by Dunbar et al. were in children under
ture. Fluoroscopy also may assist in the identificuion of subrle
2l-1 years of age. Spiral tibial fracrures occm in boys more often
fractures. Occasionally, a fracture line cannot be identified, and
than in girls and in rhe right leg more often than in the lefr.
the firsr evidence of fracrure becomes apparent radiographicaJ Iy
The average age at injury in one study was 27 months. Most
when periosteal new bone forms I week ro 10 days afrer rhe
children report tripping or twisting their ankles. OccasionaJJy,
injuly (Fig. 24-31). Technetium radionuclide imaging can assist
a child susrains a toddJer's fracrure in a fall from a height 004,
140). in the diagnosis of radiographically unapparenr fractures. A pa-
Oujhane er al. (129) analyzed the radiographs of 500 acutely rient with a spiral fracture of rhe tibia has diffuse increased up-
limping roddlers and identified 100 in whom a fracture was the take of tracer throughout the affected bone (black tibia). This
etiology of the gait disrurbance. The most common site of frac- can be differentiated from infection because infecrion tends to
ture was the distal metaphysis of the tibia. The fibula was [tac- produce a local area of incteased tracer uprake (108).
[llrecl with the tibia in 12 of the 56 tibial fracrures. Only one A child with a roddler's fracture should be immobilized in a
physcal injury was nored. bent knee, long leg cast for approximately 3 weeks. Mosr chil-

A B
FIGURE 24-30. A: Anteroposterior and lateral radiographs of an 18-month-old child who presented
with refusal to bear weight on her leg. Note the spiral middle one-third "toddler's" fracture (arrows).
B: This fracture healed uneventfully after 4 weeks of immobilization in a cast.
 Chapter 24: Fractures of the Shaft of the Tibia and Fibula 1109

A B
FIGURE 24-31. A: An anterior posterior radiograph of the tibia is in a 3-year-old child who refused to
bear weight on the right leg 3 weeks before presentation. The history of obvious trauma was absent.
His parents brought him into the hospital also when he refused to weight bear on his left leg. The
radiographs revealed periosteal new bone formation in the mid-shaft of the right tibia. There was also
tenderness to palpation in the mid-left tibia as well despite normal radiographs. B: A bone scan was
obtained which showed increased uptake in both the left and right tibia. There was significantly less
uptake on the left side, the more recent injury.

dren require an addirional2 weeks ofimmobilizarion in a below- injured passenger riding on rhe handlebars or rhe rear fender
rhe-knee walking casr once the above-rhe-knee casr is removed. (J 11,126).
hant er '11. (120) reviewed 60 bicycle spoke injuries in chil-
dren under 14 years of age. The mosr common age range of
Bicycle Spoke Injuries injury was 2 to 8 years.
Bicycle spoke injuries normaJly occur when a bicycle overturns The initial appearance of the extremity in a child wirh a
and the child's foot is thrusr forcibly between rhe spokes of rhe bicycle spoke injuly may be deceiving. The foor ofren appears
rurning wheel (Fig. 24-32). This produces a severe compression normal or may show only minor skin abrasions. The parient
or crushing injury ro rhe soft rissues of rhe foot and anlde. An ofren presents 24 to 48 hours afrer rhe accident complaining of a
oblique or spiral fracrure of the tibia also can occur (Fig. 24- painful swollen foor and leg. This injury is similar to a "wringer"
33). The injLllY to rhe foor, ankle, and lower leg can be com- injury of rhe arm because rhe inirial examinarion may nor reveal
pounded when the child's foot is exrracred forcibly from rhe the true extenr of the injury. ham et a1. (120) idemified rhree
spokes of rhe bicycle. This scenario occurs mosr commonly when componems to rhis trauma: (a) a laceration of the rissue from
twO children are riding a bicycle designed for one, with rhe rhe knifelike action of the spoke, (b) a crushing from rhe im-
1110 Lower Extremity

FIGURE 24-32. The mechanism of a bicycle spoke injury. The foot is

FIGURE 24·33. Oblique radiograph of a 4-year-old child who sustained
impinged between the spokes of the wheel and the frame of the bike.
an oblique fracture of the distal tibia and transverse fracture of the
fibula when his foot was caught in the spokes of a bicycle. Note the
proximal fibular fracture (arrow).

pingement between the wheel and the Frame of the bicycle, and
(c) a shearing injury from the coefficient of these twO forces.
non-weight-bearing cast at the completion of care for the foot
The laceration created by this injury oFten involves the malleoli,
injury (111). The tibial fracture may need to be stabilized with
the Achilles tendon area of the heel, and the dorsum of the
an external fixation device if the soft tissue loss on the foot and
Foor. A child with a bicycle spoke injUly may require multiple
ankle is severe.
debridements, and definitive treatment mlLSt await delineation
of the necrotic area.
A child with a bicycle spoke injury should be admitted to the
Floating Knee
hospit;J because the extent of the damage may not be identified
initially. Initial therapy consists of a mild compression dressing Significant trauma can cause fractures involving both the femur
with a multilayered cotton bandage. The extremity is elevated and the tibia. In the past, these injuries oFten were treated with
and the child is kept at bedrest during the first 24 hours. A long tracrion and casting (Fig. 24-34). The extent of rhe injuries
leg splint is applied if a tibial fracture is present. The child may often left permanent functional deficits when not aggressively
ambulate with crutches non-weight bearing after that. Frequent managed (45,80).
inspection of the extremity must be made during the subsequent Most children over 2 yeats of age with ipsilateral femoral
48 hours. Debridement of deviralized tissue is perFormed as ne- and tibial fractures are treated with operative stabilization of the
crosis becomes apparent. Large areas of hematoma Formation Femur and cast immobilization of the tibia after reduction. In
are [l'eated with aspiration to prevent further elevation of the children under 6 years of age, the femoral fracture can be stabi-
overlying skin. Wound closure with a split-thickness skin graft lized with a unilateral external fixatot or a plate with screws; in
is performed if full-thickness skin loss occurs. Occasionally, a children 6 years of age and older, flexible intramedullary nails
Free flap may be required, but this is rare. Most patients regain can be used. Open reduction and plate fixation are used for
normal Function of the foot and ankle. The average time for fractures in the subtrochanteric or supracondylar area of the
complete healing may be 5 to 6 weeks (111,120,126). A child femur in adolescents. The tibial fracture is reduced closed and
with a concomitant tibial Fracture is placed in an above-the-knee stabilized with a long leg cast after the femoral fracture has been
 Chapter 24: Fmctures of the Shaft of the Tibia find FibuLa 1111

A B

FIGURE 24-34. A: Ipsilateral fracture of the distal

femur and tibia without an ipsilateral fibula fracture in
a 5-year-old. B: The child was treated with tibial pin
traction for the femoral injury (pin applied below the
tibial tubercle) and a short leg splint for the tibia frac-
ture initially. C: The child was placed into a spica cast
after 2 weeks of traction. The tibial traction pin was
c used to help stabilize both fractures.
1112 Lower Extremity

A,B c
FIGURE 24-35. A: Anteroposterior radiograph of a grade lilA segmental tibia fracture with an ipsilateral
fibula and femur fracture in a 10-year-old boy with aplastic anemia. B: The tibia fracture was irrigated,
debrided, reduced, and stabilized with an external fixation device. The femur fracture was stabilized
with antegrade Ender nail fixation. C: Lateral radiograph of the tibia demonstrates the segmental nature
of this fracture (arrows) and the excellent alignment achieved with the external fixation device.

reduced and stabilized. Open tibial fractures and those in which dren with myelomeningocele who sustained pathologic fractures
a reduction cannot be maintained after casting are reduced (open of rhe proximal tibia. These two children had tense hyperemic
if necessary) and stabilized with a uniJareral external fixaror (Fig. skin and radiographic evidence of exuberant new bone forma-
24-35). If closed reduction is not possible, open reduction with tion, suggesring a malignanr rumor (Fig. 24-36). Borh children
pin fixation or external fixation is indicated. had a biopsy because of this radiographic fInding.
Fractures around the knee are common in children with para-
plegia because of rhe length of the lower extremiry and the associ-
Tibial Fracture in Paraplegic Children
ation with joint contraerures (116). These fractures are more
Moror paralysis from poliomyelitis was once the most common common in children with flaccid paralysis than those with spastic
cause of lower exrremiry weakness in children. Because these paralysis (121,133)
patients have sensation, fractures are identified early. Disease Solltter (98) stressed that clinical findings such as swelling,
trends have changed, however. As late as 1958, 90% ro 95% of warmth, and erythema are common in paraplegic children with
children with myelomeningocele died in the first year of life, a fracture. He stared that "fractures ro the growth plate in para-
usually from a neurosurgical complication. Recent advances in plegic children ofren resemble osteomyelitis."
neurosurgelY and urology have significantly increased the life James (l2l) reported 44 fractures in 22 children in a popula-
span of children with myelomeningocele. The mortality rate for tion of 122 children with myelomeningocele. The mOSt com-
these children is now 3% ro 5%. Orthopaedic surgeons, there- mon age range at fracture was 3 ro 6 years. These fractures were
fore, are seeing an increasing number of paraplegic children who more common in a flail limb. Only 6.6% of the patients with
havc scnsOlY deficits (J 07,112,113). quadriceps activiry had fractures, whereas 19% of those with no
Tibial fracrures in children without sensation require special active muscle contraction (flail limb) had fractures. This inci-
:mcntion. Gillies and Hartung (I J 3) are the first to report chil- dence decreased to 12.5% in a group of children with spastic
 Chapter 24: Fractures of the Shaft of the Tibia and FibuLa 1113

bilateral distal tibial and fibular physeal injuries in a child with

myelomeningocele.
Trauma probably is the primary factOr producing the com-
plex radiographic findings associated with a tibial fracture in
a paralytic child (16). Repeated microtrauma can lead to a
metaphyseal infraction, subperiosteal hemorrhage, and, perhaps,
physeal hemorrhage. Subsequent healing produces endosteal and
periosteal callus formation and some generalized osteopenia sec-
ondary to the immobilization (Fig. 24-36). The widening of the
physis most likely is secondary to a disturbance of the normal
reabsorption mechanism during bone development at the me-
taphysis. This results from frequent subclinical metaphyseal in-
fractions. It also could be produced by hemorrhage into the
physis itself.
Fracture of the tibia in a paralytic child can occur with minor
trauma. Many fractures are nondisplaced, and nonoperative
therapy is indicated. Displaced fractures are reduced closed and
immobilized for 3 ro 4 weeks in a bulky dressing or a posterior,
molded, well-padded splint. The child should be fitted with an
orthosis or placed back inro a reciprocal gait orthosis (if the child
already had one) after the immobilization is discontinued.
Lower extremity fractures are common after a child has been
immobilized in a cast, especially after hip surgery. This finding
has led to the term fracture disease, which describes multiple
fractures secondalY to osteopenia after immobilization. Because
of this, a child predisposed to fractures after immobilization may
benefit from a shon course of in-hospital split Russell's traction
with frequent general physical therapy for range of motion. The
child should not be allowed to walk or crawl for approximately
FIGURE 24-36. An undisplaced fracture of the proximal tibial metaph- 7 days after the traction is discontinued. This allows the stiffness
ysis in a child with myelodysplasia. Note the exuberant new bone for-
mation. that accompanies the immobilization to improve.
Physeal injuries may require prolonged periods of immobili-
zation. Healing is determined by the absence of local warmth
and swelling and the reconstitution of the width of the physis
radiographically (24).
paralysis. The tibia and femur were the most common bones
affected. The most common locations for tibial fractures were
the distal diaphysis and distal metaphysis.
Stress Fractures of the Tibia and Fibula
Parsch and Rossak (30) reponed 31 fractures in 120 patients
with myelomeningocele. They emphasized treatment with a Roberts and Vogt (32) reponed an "unusual rype of lesion"
wrap and splint until early fracture consolidation. To prevent in the tibia of 12 children in 1939. All of these were determined
"fracture disease," they stressed early standing and walking to to be stress fractures involving the upper third of the tibial shaft.
help reduce the degree of osteopenia these children develop. Since then, numerous reports of stress fractures involving the
Drummon and Freehafer (07) reported 58 fractures in 25 tibia and the fibula have been published (Fig. 24-34) (56, I 02,
patients among 84 children with myelomeningocele. Ten frac- 106,110,117,119,123,125,127,128,131,134,135,139).
tures were in the tibia. Eleven of the 58 fractures occurred after The pattern of stress fractures in children differs from that
the removal of a spica cast, suggesting that immobilization wors- in adults 005,106,136). In adults, the fibula is involved in stress
ened osteopenia and increased the risk of subsequent fracture. fractures twice as often as the tibia; in children the tibia is affected
Complications in patients with paralysis and a ribial fracture more often than the fibula. The prevalence of stress fractures in
are rare and usually are related to pressure sores produced by boys and girls is equal.
ill-padded casts. Early physeal arrest can occur, producing a leg A child with a stress fracture usually has an insidious onset
length discrepancy, and physeal involvement is common in para- of symptoms 005,106). There is evidence of local tenderness
lytic children with fractures (37). Golding (14) reported one that worsens with activity. The child may have a painful limp.
physeaJ injury to the distal tibia in a child with myelomeningo- A toddler with a stress fracture will not bear weight on the
cele. Gyepes et al. (16) reported seven metaphyseal and physeal involved extremity. The pain tends to be worse in the day and
injuries in patients with myelomeningocele. Radiographs were to improve at night and with rest. The knee and the ankle have
characterized by an irregular, dense, widened physis and adjacent fuJi ranges of motion. Usually, there is no swelling at the fracture
subperiosteal new bone formation. Stern et al. (38) reported site (75,103,105,106,110,118).
1114 Lower Extremiiy

FIGURE 24-37. Bilateral mid-tibial stress fractures in an adolescent with genu varus.

Radiographs reveal changes consistenr with a S[I'ess fracture accelerates. New bone is produced ro splint the weakened cortex.
approximately 2 weeks after the onset of symproms (l06). Ra- This bone is immature, however, and does not have the strength
diugr:lphic evidence of ftKmre rcpJir can maniFest in one of of the bone it replaces. A fracture occurs when bone reJbsorption
three ways: 10caliLed periosteal new bone formation, endosteal outstrips bone production. When the ofFending force is reduced
rhickening, or, rarely, a radiolucenr conical fracmre line (Fig. or eliminated, bone production exceeds bone reabsorption. This
24-:m (75,105,106,117,135). produces corrical and endosteal widening with dense repair bone
Technetium radionuclide bone imaging reveals a local area that later remodels ro mature bone (109,122,129).
of increased [["acer uptake at tne site of the Fracmre (Fig. 24-
.-)8). Computerized tomography rarely demonstrates the Fracture
line, but delineates increased marl"OW density and endostcal and Tibia
periosteal new bone formation. It also may show soFt tissue
edema. Magnetic resonance imaging (75, I J 8) shows a localized The most common location for a tibial stre s fracture is in the
band of very low signal inrensiry conrinuous with the Cortex. upper third. The child normally has a painFul limp of gradual
MR signaling can be diagnostic of stress fracmre and differentiate onser with no hisrory of a specific injury. The peak incidence
it Ilicely from malignan~y obviating the need for biopsy (Fig. of tibial stress fractures in children is between 10 and 15 years
24-39). of Jge. I)Jin is relieved with rest. The pain is described as dull,
Stress Fractures occur when the Force applied ro a bone is occurring in rhe calf near the upper end of the tibia on its medial
cxceeded by the bone's capacity ro withstand ir. Initially, osteo- aspect, and occasiona.lly is bilateral. Physical frndings include
clJsric tunnel fotmation increases. These tunnels normally fill local tenderness on one or both sides of the ribial cresc wirh a
with mawre bone. With continued Force, cortical reabsorption varyrng degree of swelling.
 Chapter 24: Fractures of the Shaft of the Tibia and Fibula 1115

A B

FIGURE 24-38. A: Lateral radiograph of the proximal tibia in a 9-

year-old who complained of pain in the right leg. There was no history
of trauma, and the radiographs were unremarkable. B: A bone scan
2 days after the onset of symptoms demonstrates increased tracer
uptake in the proximal one third of the tibia in both the anteroposter-
ior and the lateral projections (arrows). C: Increased bone density and
subtle periosteal new bone formation was identified in the proximal
c tibia 3 weeks later (arrows). (Courtesy of James Conway, M.D.)

The treatment of a child with a stress fracture of the tibia Tenderness is localized to the distal half of the fibular shaft.
(or fibula) begins with aerivity modification. An active child can Swelling normally is not present. The obvious bony mass com-
reSt in a long leg walking cast for 4 to 6 weeks followed by monly seen in a stress fracture of the fibula in an adult is normally
gradual increase in activity. Nonunions of suess fractures of the not seen in a comparable fracture in a child.
tibia have been described. Green (I 14) reponed six nonunions, No radiographic abnormalities are identified in the first 10
three of which were in children. Two required excision of the days to 2 weeks after the symptoms begin. The earliest sign of
nonunion sire wirh iliac cresr bone grafring. The rhird was a suess fracrure of the fibula is the ptesence of "eggshell" callus
n'eared by electromagnetic stimularion. In all rhree, rhe srress along the shaft of the fibula (Fig. 24-37) (103). Fracture itself
fracrures occurred in rhe middle rhird of rhe ribia. cannot always be seen because the periosteal callus may obscure
rhe changes in the narrow canal. Radionuclide bone imaging
can help to idenrify stress fractures before the presence of radio-
Fibula
graphic changes.
Pediatric fibular srress fractures normally occur between the ages The differential diagnosis includes sarcoma of bone, osreo-
of 2 and 8 years (l15). The fracrures are normally localized to myelitis, and a sofr rissue injury without accompanying bony
rhe distal rhird of rhe fibula. injury. Treatment consists of rest or, in a very acrive child, a
Tl1e child presents wirh a limp and may complain of pain. shorr leg walking cast for 4 to 6 weeks.
1116 Lower Extremity

A B

FIGURE 24-39. A: Stress fracture of the dyplasia of the fibula in

a 14-year-old girl with mild genu varus. B: Bone scan of stress
fracture showing marked increased tracer uptake. C: Magnetic
resonance image demonstrates new central bone formation and
an inflammatory zone around the fibular cortex. (Reprinted from
Sharps CA, Cardea JA. Fractures of the shaft of the tibia and fi-
bula. In: MacEwen GD, Kassar JR, Heinrich SD, eds. Pediatric frac-
tures: a practical approach to assessment and treatment.
c 1993: 324; with permission.)

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 DISTAL TIBIAL AND FIB ULAR
FRACTURES
R. JAY CUMMINCS

D[AG OSJS Triplane Fracrures

Open Fracrures and Lawn Mower Injuries
MECHA ISM OF [ JURY A 0 CLASSIFI 'ATIO LJreral Ank.le Sprains
C1assiflcarion of Ankle Fracrure in Children (Dias-Tachdjian)
AnlJe Dislocations
A ATOMY REHABIUTAT[ N

TREATME T PROG OSI5 A 0 COMPLlCATIO S

DiSEaI Tibial Physeal Fracrures Delayed Union and Nonunion
Fractures Involving rhe Distal Fibula Deformity Secondary ro Malunion
Juvenile Tillaux and Triplane Fracrures Growth Arrest
Juvenile Tilbux Fracrures Arrhritis
Fracrures of rhe Incisura Avascular Necrosis of rhe Distal Tibial Epiphysis

Injuries ro the disral ribial and fibular physes are generally re- anlde injuries in adulrs and rhose in children. Bishop (8) in
poned ro account for 25% ro 38% of ali physeal fracrures (57), 1932 classified 300 ankle fracrures according ro Ashhursr and
second in frequency only ro distal radial physeal fracrures (93); Bromer's sysrem; 33 fracrures were physeal injuries, and rhe
however, Pererson er al. (94) reporred rhar phalangeal physeal grouping of rhese injuries according ro mechanism of injury
fractures were mosr common, followed by physeal injuries of represents one of the firsc anemprs to classify physeal ankle inju-
rhe radius and ankle. In skeletally immarure individuals, physeal ries.
anlde fracrures are slighdy more common than fracrures of rhe Airken's (2) srudy of21 physeal anlde injuries in 1936 is one
ribia] or fibular diaphysis (80). Up ro 58% of physeal ankle of rhe firsr ro attempt ro derermine rhe resulrs of rrearmenr of
fracrures occur during sporrs activiries (45,127) and accoum for rhese injuries; he also oudined an anaromic classification. Only
10% to 40% of all injuries ro skeletally immature athletes (87, one of his parienrs (5%) had a deformiry after fraoure, in con-
91,1 15). Physeal anlde fracrures are more common in males than rrasr ro McFarland (82), who in 1932 reponed deformiries in
in females (I 12). Tibial physeal fracrures mosr commonly occur 40% of a larger series of parienrs. [n 1955, Caruthers and Crens-
becween the ages of 8 and 15 years, and fibular fracrures berween haw (21) reported 54 physeaJ ankJe fracrures, which were classi-
rhe ages of 8 and 14 years (112). fied according ro rheir mocLficarion of Ashhursr and Bromer's
Although Foucher (39) reponed rhe ftrSr parhologic srudy of sysrem. They confirmed that growth-related deformiries were
these injuries in 1863, Poland's 1898 monograph (97) is gener- frequent afrer adduction (Salter-Harris rype III and IV injuries)
ally recognized as rile mosr exrC[lsive early srudy of physeal frac- fracrures and infrequenr afcer fracrures caused by exrernal rora-
tures. He poimed our thar in children ligamems are srronger rioll, abduction, and plantarflexion (Salter-Harris rype II inju-
rhan physeal cartilage; forces rhat result in ligamenr damage in ries). Spiegel and colleagues (112), in a 1978 review of 237
adulrs cause fracrures of rhe physes in children. In 1922, Ash- physcal ankle fracwres, reponed a high incidence of growrh
hursr and Bramer (4) published a thorough review of [he litera-
abnormalicies afrer Salter-Harris rype III and IV injuries bur also
run: and rhe resulrs of their own exrensive invesrigarions and
found complicarions in 11 (16.7%) of 66 patientS with Saher-
described a classificarion of ankle injuries based on rhe mecha-
Harris rype II fractures. Mosr of rhese parienrs had only mild
nism of injllly. This classificarion did nor differemiare becween
shortening, but 6 had angular deformiries thar did nor correct
with growrh. Based on rhe resulrs of 65 physeal ankle fracrures,
Kling and co-workers (69) concluded chat rhe frequency of
R. Jay Cummings: Department of Orthupdcdics, Nemours Children's growrn-relared deformiries could be reduced by open reducrion
Clinic, Jacksollville, Florida. and imernal fixarion of Salrer-H:uris III and IV fracrures.
1122 Lower Exrremiry

A separate group of fracrures, occurring in adolescenrs and pain near a malleolus with eirher inabiliry ro bear weighr or
known as transitional fractures, has been idenrified. Such frac- tenderness to palpation at rhe malleolus. Chande prospectively
rures, which include juvenile Tillaux and rriplane fracrures with srudied 71 children wirh acure ankle injuries ro determine if
rwo ro four fracrure fragmenrs, have been described by Kleiger rhese guidelines could be applied to pediarric patienrs wirh ankJe
and Mankin (67), Marmor (81), Cooperman and co-workers injuries (25). It was derermined that if radiographs were obrained
(27), Karrholm (61), and Denton and Fischer (31). only in children who had tenderness over rhe malleoli and an
inabiliry to bear weighr, a 25% reducrion in radiographic exami-
nations could be achieved withour missing any fracrures. There-
DIAGNOSIS fore, a sysremaric search for localized tenderness, keeping in
mind the physeal anatOmy of rhe ankle, is helpful in derermining
Parienrs with significanrly displaced fracrures have severe pain when to order radiographs as well as how to inrerpret them.
and obvious ddormiry. The position of the foot relarive ro rhe For parienrs wirh obvious deformiries, anreroposrerior and
leg may provide imporranr informarion about the mechanism lareral radiographs cenrered over the ankle may provide sufficienr
of injury (Fig. 25-1) and should be considered in planning reduc- information to plan treatment. Although obraining views of the
rion. The stams of the skin, pulses, and sensory and motor func- joint above and below is recommended for most fractures, ob-
tion should be derermined and recorded. Tenderness, swelling, raining a film cenrered over rhe mid-ribia ro include rhe knl'C'
and dcformiry in the ipsilateral leg and foor should be nored. In and ankle joinrs on rhe radiograph significantly decreases the
patienrs with ribial shaft fractures, the ankle should be carefully qualiry of ankle views and is nor recommended.
evaluared c1inicaJ Iy and radiographically. For parients withour obvious deformiries, a high-quality 11101'-
Patienrs wirh nondisplaced or minimally displaced ankle frac- rise view of the ankJe is essenrial in addition ro anrcroposterior
tures ohen have no deformity, minimal swelling, and moderare and lareral views. On a srandard anteroposrerior view, rhe latcr;t1
pain. Because of rheir benign clinical appearance, such fracrures portion of the distal tibial physis is usually parrially obscured by
may be easily missed if radiogl'aphs are nor obrained. The facr rhe disral fibula. The venical component of a rriplane or Tillaux
rhar all physicians have an obligarion to tly to minimize unneces- fracrure can be hidden behind the overlying fibular cortical
sary radiographs, borh ro avoid unnecessary irradiarion of pa- shadow (73). A study by Vangsness and co-workers (121) found
rients and for cost containmenr, creares a dilemma for physicians rhar diagnosric accuracy was essenrially equal when using anterO-
evaluating pediarric ankle injuries. Guidelines known as the Ot- posrerior, lareral, and monise views compared with using only
rawa Ankle Rules have been established for adulrs to try ro derer- mortise and lateral views. Therefore, if only rwo views are to be
mine which injuries require radiographs (J 14). The indications
obrained. the anreroposterior view may be omitted and lareral
for radiography according to rhe guidelines are complaints of
and morrise views obtained.
Haraguchi et al. described two special views designed to de-
rect avulsion fracrures from the lareral malleolus rhar are nor
visible on roucine views and to disringuish wherher rhey repre-
sent avulsions of the anrerior ribiofibular ligament or rhe calca-
neofibular ligamenr arrachmenrs (49). The anrerior tibiofibular
ligamenr view is made by posirioning the fool' in 45 degrees of
plantar flexion and e1evaril1g rhe medial border of the foor 15
degrees. The calcaneoflbular ligament view is obrained by rorar-
ing rhe leg 45 degrees inward.
Srress views may occasionally be l1eeded ro rule our ligamen-
rous insrability (Fig. 25-2), aJrhough ligamenrous injulY ar rhe
ankle is infrequenr in skelerally immature parienrs. Srress views
may be considered ro document a Salrer-Han·is rype I fracrure,
but a parienr wirh clinical signs of rhis fracrure should be n·eared
appropriarely, regardless ofsrress view findings. Srress views may
help document laclc of motion ar the fracrure in an apparent
nonunion (Fig. 25-3).
Bozic er al. srudied the age at which rhe radiographic appear-
ance of rhe incisura fibularis, ribiofibular c1eal· space, and tibio-
fibular overlap develop in children (15). The purpose of their
srudy was ro facilitate rhe diagnosis of disral ribiorlbular syndes-
moric injury in children. They found rhar rhe incisura became
derecrable ar a meal1 age of 8.2 for girls and 11.2 years for boys.
The mean age at which ribiofibular overlap appeared on the
anreroposterior view was 5 years for borh sexes; on rhe mortise
FIGURE 25-1. Severe c1i·nical deformity in a 14-year-old boy with an
ankle fracture. It is obvious without radiographs that internal rotation view, it was 10 years for girls and 16 years for boys. The range
will be needed to reduce this fracture. of clear space measuremenrs in normal children was 2 to 8 mm,
 Chapter 25: Di)'fal TibiaL alld FibuLaI' Fmc(lIreJ 1123

A 8
FIGURE 25-2. A: Stress radiograph showing abnormal varus tilt in a 5-year-old who had sustained a
left ankle injury. Note the small avulsion fracture from the talus (arrow) and soft tissue swelling laterally.
B: Comparative stress radiograph of the right ankle.

with 23% of children having a clear space of greater than 6 mm, advantage over CT scans. CT evaluations involve less radiation
a distance considered abnormal in adults. ro the patient and in many insriwtions are now easier to obtain
Computed tomography (CT) is useful in the evaluation of than are plain comograms. Curs are generally made in the rrans-
intraanicular fractures, especially juvenile Tillaux and criplane verse plane. With t!lin CUtS localized ro the joim, it is possible
fractures (Fig. 25-4) (54). In the past, some physicians preferred to generate high-quality reconsrructions that allow evaluarion in
plain tomograms (126). A lower COSt appears co be rheir only the coronal and sagirral planes withour repositioning the ankJe.

A 8
FIGURE 25-3. A: Anteroposterior radiograph of a 10-year-girl after 12 weeks of immobilization for an
initially nondisplaced Salter-Harris type III fracture of the distal tibia. B: Stress view showing no motion
at the fracture site.
1124 Lower Extremity

A B

FIGURE 25-4. A: Anteroposterior view of a 13-year-

old boy with a tibial fracture extending into the
ankle joint. It is unclear on this view whether the
metaphyseal fracture is a separate injury or part of
the intraarticular fracture. B: Transverse (T scan a
few millimeters above the ankle joint confirmed the
triplane nature of this injury. C: Anteroposterior re-
construction from the (T scan shows 3 mm of dis-
c placement at the fracture site in the tibial epiphysis.

\'.«ith plain tomography the transverse anatomy can only be de- tion about the pattern of physeal disruption but also supplied
duced from the anteropostcrior and lateral tomograms. Three- early information about the possibility of growth ahnormaJity.
dimensional CT reconstructions rarely add further useful infor- Carey et al. obtained MRl studies on 14 paricms with known
mation. Othcr indications for CT scanning are discussed in the or suspected growth plare injury (20). The MRI dctected five
section on Treatment. radiographically occult fractures in the 14 patients, ch:tnged the
Magnetic resonance imaging, (MRl) has been reported to be Salter-Harris classification in 2 patients, and resulted in a change
occasionally helpful in the identification of osteochondral inju- in treatment plan in 5 of the 14 patients studied. These studies
ries to the joint surfaces in children with ankle fractures (66). would seem to comradict an earlier study by Petit et al. that
Smith and associates (Ill) found that oHour patients with acute showed only 1 patient in a serie of 29 patients in whom MRJ
(3-10 d:tys) physeal injuries. MRI showed rhar three hac! more revealed a diagnosis differenr ft'om rhar made on plain films
severe fractures than indicated on plain films (Fig. r -5). Early (96). Later ( 6 months after injury) scans have been reported
MRl studies (3-17 weeks after injury) not only added informa- useful for mapping physeal bars (42,52).
 Chapter 25: Dis/fll Tibial and Fibular Fractures 1125

A B
FIGURE 25-5. A: Follow-up radiograph of a 7-year-old boy 1 week after an initially nondisplaced Salter-
Harris type III fracture from a supination-inversion injury of the distal tibia. B: Because of the incomplete
ossification of this area and concern that the fracture might have displaced, magnetic resonance imaging
was performed. Note that the distance between the medial malleolus and the talus is greater than the
distance between the talus and the distal tibia or lateral malleolus. confirming displacement of the
fracture.

M CHANISM OF INJURY A D times seem incompatible with the position of the Foot on the
CLASSIFICATION ground. Because they are applicable to all physes, anatomic clas-
sifications are used mote Frequendy and are easier ro recall than
Classifications of ankle Ftactures are of (\'10 broad types: ana- mechanism-oF-injUlY classifications. Mechanism-oF-injury clas-
tomic (2,89,95,106,112) and mechanism-oF-injury (4,8,7ll. sifications are consideted by some to be more precise because
AnatOmic classifications divide Fractures intO groups based on rhey reflect nor only the anatomic Ftacture panern bur also the
the pans of the epiphyses or metaphyses that make up rhe frac- position of rhe Fragments in relation to each other. This increased
ture Fragments. Mechanism-oF-injury classifications are based on precision, how ver, may result in less rapid and possibly more
rhe narure of rhe Force rhar creares rhe Fraccures and oFren include conFusing communic:uion.
rhe position of the foot at the time the force is applied. Most Both anaromic and mechanism-oF-injUlY classiflcarions can
mechanism-of-injury classifications include the anaromic rype provide useful informarion For determining appropriate treat-
of injury produced by a particular mechanism. ment. The prognoses For growth and deFormiry have been pre-
Anatomic classifications (Fig. 25-6) are eFFective For rapid diered on the basis of both rypes of classification (62,63,112).
communication because most have Few groups without mul- A theoretical advantage of mechanism-oF-injury classifications is
tiword tides that require visualization of movemenrs thar some- thar identification of the force producing the injury might give

II III IV V
FIGURE 25-6. Salter-Harris anatomic classification as applied to injuries of the distal tibial epiphysis.
1126 Lower ExtremitJI

even more information about rhe possible developmenr of

growth arrest than anatomic classifications. For example, a Sal-
ter-Harris type III or IV fracture of the tibia produced by a
shearing or crushing force might be more likely to resulr in
growth arrest than is a similar injury produced by an avulsion
force (Fig. 25-7). However, it is difficult to establish that one
type ofclassification is superior to the other in this regard because
of the relatively small numbers of patients reported, the varying
ages of patients in most series, and questions abour the reproduc-
ibility of various c1assificarions.
An important benefit of mechanism-of-injury classifications
(Table 25-1) is that they provide clues that may be helpful in
planning closed reduction: the mechanism of injury is simply
reversed to reduce the fracture. Surgeons who rely on anaramic
classifications usually attempt to obtain reduction by returning
the displaced fragments direcdy ro their proper anatomic loca-
tions. In reality, surgeons who use either classification probably
reduce most fractures in similar manners.
Any classification system that cannot be easily remembered
and reproducibly applied will ultimately prove ra be less than
useful. Thomsen and co-workers (lI8) studied the reproducibil-
ity of the Lauge-Hansen (mechanism-of-injuIY) and Weber (ana-
ramic) classifications in a series of adulr ank.le fractures. After
FIGURE 25-7. Comminuted Salter-Harris type IV fracture of the distal all investigarars in the study had received a turarial on both
tibia and displaced Salter-Harris type I fracture of the distal fibula pro- systems and their application, they were asked ro classify 94
duced by an inversion (shearing) mechanism in a 10-year-old girl. fractures. On the first attempt, only the Weber classification
produced an acceptable level of interobserver agreement. On a
second attempt, the Weber classification and most of the Lauge-
Hansen classification achieved an acceptable level of inrerob-
servet agreement. These investigators concluded rhat aU fracture
classification systems should have demonstrably acceptable inrer-

TABLE 25-1. REPRESENTATIVE MECHANISM OF INJURY CLASSIFICATIONS

Applied Force

Ashhurst-Bromer (adult)
External Abduction Adduction Compression
rotation
Carothers-Crenshaw (child)
External Abduction Adduction Plantarflexion Compression
rotation
lauge-Hansen (adult)
Supination Pronation Supination Pronation
Eversion Abduction Adduction Compression Eversion
(external (external
rotation) rotation)
Dias-Tachdjian (child)
Supination Pronation Supination Supination Axial Juvenile Triplane
External (eversion Inversion Plantarflexion compression tillaux
rotation abduction) (adduction)
External
rotation

lauge-Hansen pronation: external rotation of foot, abduction of hindfoot, and eversion of forefoot. Lauge-Hansen supination: external fotation of
foot, adduction of hindfoot, and inversion of forefoot.
 Chapter 25: Distal Tibial and Fibular Fractures 1127

A B C o
Supination-inversion Pronation-eversion Supination- Supination-
external rotation plantar-flexion external rotation
FIGURE 25-8. Dias-Tachdjian classification of physeal injuries of the distal tibia and fibula.

observer agreemenr rates before they are adopted, an argumenr mechanisms of injury. Axial compression injury describes the
made even more fotcefully in an edirorial by Burstein (18). Vah- mechanism of injury but not the position of the foor. juvenile
vanen and AaJro (119) compared their abiliry ro classify 310 Tillaux and triplanefractures are believed to be caused by external
ankle fractures in children with the Weber, Lauge-Hansen, and rotation. The final category, other physeal injuries, includes di-
Salter-Harris classifications. They found that they were "largely verse injUrIes, many of which have no specific mechanism of
unsuccessful" using the Weber and Lauge-Hansen classifications lDJUry.
bur could easily classify the fracrures using the Salter-Harris
system.
The most widely accepted mechanism-of-injury classification Classificatioo of Ankle Fracture 10 Children
of ankJe fractures in children is that described by Dias and Tach- (Dias- Tachdjian)
djian (34) (Fig. 25-8), who modified the Lauge-Hansen classifi-
Supination-Inversion
cation based on their review of7l fractures. Their original classi-
fication (J 978) consisted of four rypes in which the first word Grade I: The adduction or inversion force avulses the disral
refers [Q rhe position of the foot at the rime of injury and the fibular epiphysis (SaJter-Harris rype 1 or II fracture). Occasion-
second word refers ro the force that produces the injUly. Four ally, the fracrure is transepiphyseaJ; rarely, the lareraJ ligamems
other rypes were subsequently added (116) (in 1985). Although fail.
these are designated differently, the first three have idemifiabJe Grade II (Fig. 25-9): Further inversion produces a cibial frac-

A,B CD
FIGURE 25-9. Variants of grade II supination-inversion injuries (Dias-Tachdjian classification). A: Salter-
Harris I fracture of the distal tibia and fibula. B: Salter-Harris I fibula, Salter-Harris II tibia fractures. C:
Salter-Harris I fibula, Salter-Harris III tibia fractures. D: Salter-Harris I fibula, Salter-Harris IV tibia fractures.
1128 Lower Extremity

FIGURE 25-10. Severe supination-inversion injury with displaced frac- FIGURE 25-11. Stage I supination-external rotation injury in a 10-
ture of the medial malleolus distal to the physis of the tibia. year-old child; the Salter-Harris type II fracture begins laterally.

A B
FIGURE 25-12. Stage II supination-external rotation injury. A: Oblique fibular fracture is also visible
on anteroposterior view. B: Lateral view shows the posterior metaphyseal fragment and posterior dis-
placement.
 Chapur 25: Distal Tibia/and FibuLar Fractures 1129

rure, llsually a Sa her-Harris rype III or IV and rarely a Salrer- rhe fibula is produced, running from anteroinferior ro posrero-
Harris rype I or II injury, or rhe fracrure passes rhrough rhe superior (Fig. 25-12).
medial malleolus below the physis (Fig. 25-10).

Supination-Plantarflexion Pronation-Eversion-External Rotation

A Salrer-Harris rype 1 or II fracrure of rhe distal tibia occurs
The planrarflexion force displaces rhe epiphysis direcrly posre-
simulraneously wirh a rransverse fibular fracrure. The disral
riorly, resulring in a Salrer-Harris rype I or II fracrure. Fibular
tibial fragmenr is displaced larerally and the Thursron-Holland
fracrures were not reponed with this mechanism. The ribial frac-
fragment, when present, is lateral or posterolareral (Fig. 25-
rure usually is difficu!r ro see on anreroposrerior radiographs.
13). Less frequenrly, a transepiphyseal fracrure occurs rhrough
the medial malleolus (Salrer-Harris rype II). Such injuries
Supination-External Rotation may be associated with diastasis of rhe ankle joinr, which is
uncommon in chjldren.
Grade I: The exrernal rorarion force resulrs in a Salrer-Harris
rype II fracrure of rhe disral ribia (Fig. 25-11). The distal frag-
ment is displaced posteriorly, as in a supinarion-planrarflexion
Axial Compression
injury, bur rhe Thursron-Holland fragmenr is visible on the
anteroposrerior radiograph, wirh rhe fracrure line exrending This is a Salter-Harris rype V injury of the diml tibial physis.
proximally and medially. Occasionally, rhe distal ribial epiphysis lnitial radiographs usually show no abnormaliry, and the diagno-
is rotated bur nor displaced. sis is esrablished when growrh arresr is demonsrrared on follow-
Grade II: Wirh funher external rotation, a spiral fracrure of up radiographs.

A B
FIGURE 25-13. A: According to the Dias-Tachdjian classification, this injury in a 12-year-old boy would
be considered a pronation-eversion-external rotation injury resulting in a Salter-Harris type II fracture
of the distal tibia and a transverse fibular fracture. B: The anterior displacement of the epiphysis, visible
on the laterall view, however, makes external rotation an unlikely component of the mechanism of
injury; the mechanism is more likely pronation-dorsiflexion.
1130 Lower Extremity

Triplane Fracture
This group of fractures have the appearance of a Salter-Harris
type III fracture on the anteroposterior radiograph and of a Sal-
ter-Harris type II fracture on the lareral radiograph.

Other Physeallnjuries
These are rhe fractures that do not fit imo any of rhe orher
seven types (such as injuries ra the perichondral ring and suess
fractures) (Fig. 25-15).

Unusual Fracture Patterns

A number of accessory ossification centers and normal ana-
ramic variations may cause confusion in the interpreration of
plain films of the ankJe (Fig. 25-16). In a group of 100
children between rhe ages of 6 and 12 years, Powell (99)
found accessory ossificarion cenrers on rhe medial side (os
FIGURE 25-14. Salter-Harris type III fracture (juvenile Tillaux) (arrows) subtibiale) in 20% and on the lateral side (os subfibulare) in
of the anterolateral portion of the distal tibial epiphysis in a 13-year- 1%. If they are asympramatic on clinical examinarion, these
old girl. ossification centers are of Iircle concern, but renderness local-
ized ro rhem may indicare an injury. Stress views to determine
morion of the fragmenrs or bone scanning may occasionally
be considered if an injury ra an accessory ossification cemer
Juvenile Tillaux Fracture
is suspecred.
This is a Salter-Harris type III fracture involving rhe anrerolateral Clefts in rhe lateral side of the tibial epiphysis may simulare
distal tibia. The ponion of rhe physis not involved in the fracture juvenile TiLiaux fractures, and clefts in rhe medial side may simu-
is closed (Fig. 25-14). lare Salter-Harris type III fractures (65). The presence of rhese

A B
FIGURE 25-15. Stress fracture of the distal tibia in normal 13-year-old child who complained of pain
in his ankle after running. A: Initial radiographs were interpreted as being normal, although abnormal
widening of the tibial physis was present. The ankle was immobilized for 10 days. B: Six weeks later,
pain persisted and radiographs showed further widening and irregularity of the physis, with a faint
periosteal new bone formation (arrows) around the distal tibial metaphysis.
 Chaprer 25: Disral Tibial and Fibular Fractures 1131

Posteroinferior
tibiofibular
ligament
Inferior
transverse
ligament

Posterior
talo-tibial Talo-fibular
ligament ligament

Calcaneo-fibular
ligament
FIGURE 25-16. Secondary ossification center in the lateral malleolus FIGURE 25-18. Posterior view of the distal tibia and fibula and the
(arrows) of a 10-year-old girl. Note the smooth border of the fibula ligaments making up the ankle mortise.
and the ossification center. She also has a secondary ossification center
in the medial malleolus.

ANATOMY
c1efrs on a radiograph of a child wirh an ankle injury may resulr in The ankJe is rhe joinc rhat most closely approximares a hinge
overtrearmem if rhey are misdiagnosed as a fracture. Conversely, joint. Ie is rhe anicularion between rhe ralus and the ankle mor-
amibucing a painful irregularity in rhese areas to anatomic varia- tise, which is a syndesmosis consisting of rhe disral ribial articular
rion may lead to undemearmenc (Fig. 25-17). Orher anawmic surface, rhe medial malleolus, and the distal fibula or lareral
variarions include a bump on rhe disral fibula rhar simulares a malleolus.
corus fraccure and an apparent offser of rhe disral fibular epi- Ligamentous srrucrures bind the distal tibia and fibula ineo
physis rhar simulares a fracrure. rhe ankle monise (Fig. 25-]8). The ancerior and posrerior infe-

FIGURE 25-17. A: Mortise view of the ankle of a 10-

year-old girl who had slight swelling and tenderness at
the medial malleolus after an "ankle sprain." The ossicle
at the tip of the medial malleolus was correctly identi-
fied as an os subtibiale. Asubtle line extending from the
medial physis to just distal to the medial tibial plafond
(arrow) was believed to also be an anatomic variant. B:
Four weeks after injury, soreness persisted and radiog-
raphy clearly demonstrated a Salter-Harris type III frac-
c."B ture.
1132 Lower Extremify

Posterior
talo-tibial
ligament

1fJlr*"'-=::,,--!,l----,,,..-+---- Caleano-tibial
ligament

fiGURE 25-19. Medial view of the ankle

demonstrating the components of the
deltoid ligament.

rior ribiofibular ligamencs course inferiorly from the anterior tends down from the lateral malleolus along the posterior border
and posterior surfaces of the distal lateral tibia to tne antuior of rhe articular surface of rhe tibia, almost to the medial malleo-
and posterior surfaces of the LHel'al malleolus. The amerior liga- lus. This ligamenr serves as a pal·t of rhe articular surface for the
ment is imporranr in rhe pathornechanics of rransitional ankle talus. Between rhe anterior and posterior inferior tibiofibular
Fractures. Just anrerior to the posteroinferior tibiofibular liga- ligaments, the tibia and fibula are bound by the inrerosseous
mel1l is the broad, thick infel'ior transverse ligamenr, which ex- ligamenr, which is conrinuous with the inrerosseous membrane

Anterior talofibular
ligament
Posterior talofibular
ligament

Calcanofibular -------j--til11itJIft=::,I;>77:f1!
ligament

FIGURE 25-20. Lateral view of the ankle demonstrating the anterior and posterior talofibular ligaments
and the calcaneofibular ligament.
 Chapter 25: Distal Tibial alld Fibullll' Fractures 1133

above. This Iigamenr may be imporranr in the pathomechanics In childrm, all of the ligamentous structures that bind the
of what we nave termed incisura! fractures. medial and lateral malleoli to the talus and the distal tibial epi-
On the medial side of the ankle, the talus is bound to the physis to the distal fibular epiphysis are attached to the malleoli
ankle mortise by the deltoid ligament (Fig. 25-19). This liga- distal to the physes. Because the ligamenrs are stronger than the
menr arises from the medial malleolus and divides into superfi- physes, physeal fractures are more common than ligamentous
cial and deep layers. Three pans of the superficial layer are identi- injuries in children. When they accompany disral tibial physeal
fied by their attachments: tibionavicular, calcaneotibia!, and injuries, displaced diaphyseal £bular fractures are usually associ-
posterior ralotibial ligaments. The deep layer is known as the ated with injuries to and displacement of the entire distal tibial
anterior talotibial ligament, again reflecting its insertion and ori- epiphysis ratner than witn injuties to the ligamenrs, making
gin. On the lateral side, the anterior and posterior talofibular diastasis of the ankJe uncommon in children (Fig. 25-21).
ligamem, with the calcaneofibular ligamems, make up the lateral The distal tibial ossification center generally appears at 6 to
collateral ligament (Fig. 25-20). 24 months of age. lrs malleolar extension begins ro form around

FIGURE 25-21. A: Pronation-external rotation injury resulting in

a Salter-Harris type I fracture of the distal tibial physis. Band C:
Anteroposterior and lateral radiographs demonstrate satisfactory
A closed reduction.

B c
1134 Lower Extremity

A,B C,D
FIGURE 25-22. Closure of the distal tibial physis begins centrally (A), and extends medially (B) and then
laterally (C) before final closure (0).

rhe age of 7 years and is mawre or complere ar rhe age of 10 When can weight bearing be allowed'
years. The physis usually closes around rhe age of 15 years in How importanr is immediare reducrion of rhe ankle fracture,
girls and 17 years in boys. This process rakes approximarely 18 especially if orher injuries or logistical problems cxisr'
momhs and occurs firsr in the cemral part of rhe physis, exrend- Is a general anesthetic required or can some form of local
ing nexr ro rhe medial side, and finally ending larerally. This anesthesia or sedarion be as effective and safer for closed reduc-
asymmerric closure sequence is an importam anaromic feature rion'
of rhe growing ankle and is responsible for cerrain fracrure par- If closed reduction is incomplere, how much residual dis-
terns in adolescems (Fig. 25-22). placemem in each plane is acceptable?
The disral fibular ossificarion cemer appears around rhe age If open reduction is necessary, whar surgical approach is ap-
of 9 ro 24 momhs. Irs physis is locared ar rhe level of rhe an kle propriate?
joim. Closure of rhis physis generally follows closure of rhe disral How can rhe most anaromic reduction be ensured at the rime
ri bial physis by 12 ro 24 momhs. of surgery'
What rype of imernal fixation device is most appropriate?

TREATMENT
Distal Tibial Physeal Fractures
Appropriare rrearmem of ankle fracrures in children depends on Salter-Harris Type I Fractures
rhe locarion of rhe fracrure, rhe degree of displacemem, and rhe
According ro Dias and Tachdjian (34,116), Salter-Harris rype
age of rhe child. Nondisplaced fracrures may be simply immobi-
I fractures of the disral tibia can be caused by any of four mecha-
lized. Closed reducrion and casr immobilization may be appro-
nisms: supinJrion-inversion, supination-plantarfJexion, supi-
priate for displaced fracrures; if rhe closed reduction cannor be
nation-external roration, or pronation-eversion-external rota-
maimained with casring, skeleral fixarion is necessary. If closed
rion. Spiegel and associ ares (112) reponed rhar rhese fractures
reducrion is nor possible, open reducrion is indicared, provided
accounted for 15.2% of 237 anlJe injuries in rheir series and
rhere is significam physeal or arricular displacemem, followed
occurred in children significantly younger (average age, 10.5
by imernal flxarion or casr immobilizarion.
years) rhan rhose wirh other Salter-Harris rypes of fractures.
The anaromic rype of rhe fracrure (usually defined by rhe
The mechanism of injury is deduced primarily by rhe direc-
Salter-Harris classification), rhe mechanism of injury, and rhe
amount of displacement of rhe fragmems are imporranr consid- rion of displacemem of rhe distal ribial epiphysis; for example,
straight posterior displacemem indic:lres a supinarion-plan-
erarions. When rhe arricular surface is disrupred, rhe amount of
rarOexion mechanism. The rype of :lssociared fibular fracture is
arricular srep-off or separarion musr be measured. The neurovas-
also indicative of the mechanism of injuty; for example, a high,
cular sraws of rhe limb or rhe sraws of rhe skin may require
oblique, or transverse fibular fracture indicares a pronation-ev-
emergency treatment of rhe fracwre and associated problems.
ersion-external injury, whereas a lower spiral fibular fracture
The general health of the pariem and the rime since injury also
indicates a supination-external rotarion injury. Lovell (77),
musr be considered.
Orher considerations in rrearmem decision making include Broocl< and Greer (J 6), and Nevelos and Colron (86) reponed
rhe following: unusual Salrer-Harris rype I fracrures in which rhe disral tibial
epiphysis was externally rotated 90 degrees without fracture of
Is a below-knee or above-knee cast appropriate? rhe fibula or displacement of rhe ribial epiphysis in any direction
How long should immobilization be cominued? in the rransverse plane.
 Chapter 25: Dh·tal TibiaL alltl Fibular Fractl/res 1135

Casr immobilizarion is generally sufficienr rrearmenr for non- eype II fractures were the most common injuries (44.8%). In
displaced Salrer-Harris eype I tracrures of the disral ribia. Recom- addi tion co the direction of displacement of the distal tibial
mended uearmenr ranges from a below-knee casr worn tor 4 epiphysis and the nature of any associated fibular fracture, the
weeks co a non-weight-bearing long cast worn for 3 weeks, location of the Thurscon-Holland fragment is helpful in deter-
followed by 3 weeks of immobilization in a shorr leg walking mining the mechanism of injury; for example, a lateral fragment
cast. Most displaced fracrures can be [('eated wirh closed reduc- indicates a pronarion-eversion-external [Otation injury; a pos-
tion and cast immobilizarion. An above-knee non-weighr-bear- teromedial fragment, a supination-external rotation injury; and
jng cast is preterable initially but can be changed to a shorr leg a posterior fragment, a supination-planrarflexion injury (Fig.
walking cast at 3 co 4 weeks. 25-23).
Nondisplaced fractures can be treated with cast immobiliza-
tion usually with an above-knee cast tor 3 co 4 weeks, foJJowed
Salter-Harris Type /I Fractures
by a below-knee walking casr for another 3 to 4 weeks.
Salter-Harris rype II fractures also can be caused by any of the Although most researchers agree rhat closed reducrion of sig-
tour mechanisms ot injury described by Dias and Tachdjian nificanrly displaced Salter-Harris rype II ankle fracrure should
(34). In the series of Spiegel and associates (l12), Salter-Harris be artempted, opinions differ as to whar degree of residual dis-

A B

FIGURE 25-23. A: Severe plantarflexion injury

with severe swelling of the ankle and foot; the
reduction obtained was unstable. B: The reduction
was stabilized by two transmetaphyseal screws
placed percutaneously. C: Anteroposterior view
c confirms an anatomic reduction.
1136 Lower Ev:tremity

placement or angularion is unacceprable and requires open re- ar follow-up in patienrs who had up to 12 degrees of rilr afrer
ducrion. Based on follow-up of 33 Salrer-Harris eype II ankle reducrion, even in parienrs as old as 13 years at the rime of injury.
fracrures, Carurhers and Crenshaw (21) concluded rhar "accu- Spiegel and associates (J 12), however, reported complicarions at
rare reposirion of rhe displaced epiphysis ar the expense of forced follow-up in 11 of 16 patients with Salter-Harris eype II ankle
or repeared manipulation or operative intervention is not indi- fractures. Because 6 of these 11 patienrs had angular deformities
cated since spontaneous realignment of the ankle occurs even that were attributed to lack of adequate reduction of rhe fracture,
late in the growing period." They found no residu<ll <lngularion Spiegel <lnd associares recommended "precise anatomic reduc-

A B

FIGURE 25·24. A: Severely displaced pronation-eversion -exter-

nal rotation injury. B: Closed reduction was unsuccessful and a
valgus tilt of the ankle mortise was noted. At surgery, soft tissue
was interposed laterally (arrows). C: Reduction completed and sta-
c bilized with two cancellous screws placed above the physis.
 Chapter 25: Distal Tibial and Fibular Fractures 1137

tion." Incomplete reduction is usually caused by interposition one in the emergency department group that required repeat
of soft tissue between the fracture fragments. Grace (46) reported manipulation. One patient in each group had a growth alter-
three patients in whom the imerposed soft tissue included the ation.
neurovascular bundle, resulting in circulatory embarrassment When dosed reductions are not performed under general
when closed reduction was attempted. In this situation, open anesthesia. they are usually performed under intravenous seda-
reduction and extraction of the soft tissue obviously is required. tion. Furia et aI. demonstrated significantly improved pain relief
A less definitive indication for open reduction is interposition with hematoma block for ankle fractures in a study comparing
of the periosteum, which causes physeaJ widening with no angu- patients treated with intravenous sedation to patients receiving
lation or with minimal angulation. Good results have been re- hematoma block (41). Intravenous regional anesthesia or Bier
poned after open reduction and extraction of the periosteal flap block also has been reported to be effective for pain relief in
(Fig. 25-24) (69). It is not clear that failure to extract the perios- lower extremity injuries (72).
teum in such cases results in problems sufficient co warrant oper-
ative treatment.
Salter-Harris Type fII and IV Fractures
Because offears of iatrogenic damage co the distal tibial physis
during closed reduction, many researchers recommend the use Salter-Harris type III and IV fractures are discussed together
of general anesthesia with adequate muscle relaxation for all pa- because their mechanism of injury is the same (supination-in-
tients with Salter-Hartis type II distal tibial fractures. However, version) and their treatment and prognosis are similar. Juvenile
no study has compared the frequency of growth abnormalities Tillaux and triplane fractures are considered separately. In the
in patients with these fractures reduced under sedation and local series of Spiegel and associates (112), 24.1 % of the fractures
analgesia to those with fractures reduced with the use of general were Salter-Harris type III injuries and 1.4% were type IV. These
anesthesia. I compared nine patients who underwent closed re- injuries are usually produced by the medial corner of the talus
duction in the emergency department with the use of sedation being driven into the junction of the distal tibial articular sutface
and hematoma block to nine patients who had closed reduction and the medial malleolus. As the talus shears off the medial
in the operating room with the use of general anesthesia. All malleolus, the physis also may be damaged (Fig. 25-25).
fractures were reduced with a single manipulation, except for Nondisplaced Salter-Harris type III and IV fractures can be

A B
FIGURE 25-25. A: Severe ankle injury sustained by an 8-year-old involved in a car accident. The antero-
posterior view in the splint does not clearly show the Salter-Harris type IV fracture of the tibia. The
dome of the talus appears abnormal. B: Computed tomography scan shows the displaced Salter-Harris
type IV fracture of the medial malleolus and a severe displaced intraarticular fracture of the body of
the talus. (Figure continues.)
1138 [olVer Extremity

C D
FIGURE 25-25. (continued) C and D: Open reduction of both fractures was performed and Herbert
screws were used for internal fixation. (Courtesy of Armen Kelikian, M.D.)

n'eated with above-knee cast immobilization, but care must be to rhe physis, and should avoid rhe physis and ankle joillt if
taken ro be sure no displacemenr is presenr, which may require possible (Fig. 25-28).
CT evalu:llion, and that no displacemenr occurs after casting, Oprions for internaJ flxarion include smoorh Kirschner wires,
which requires weekly radiographic evaluation for the first 2 small fragment corticaJ and cancellous screws, and 4-mm cannu-
weeks after casting. lated screws (Fig. 25-29). Several reports (7,11,17) have advo-
Displaced fractures require as anatomic a reduCtion as possi- cated the use of absorbable pins for imernal fixation of ankle
ble. failure to obtain anatomic reduction frequently results in fractures. Bem and colleagues (7) reported no complications or
anicular incongruity and posttraumatic arthritis, which often growth abnormalities after the use of absorbable pins with metal
becomes symptomatic 5 to 8 years after skeletal maturity (Fig. screw supplemenration for fixation of ('Ive ankle fractures in pa-
25-26) (23). The risk of growth arrest also has been linked to tients between the ages of 5 and 13 yeats. Tn reports of the use
the accuracy of reduction (70). Closed reduction may be at- of absorbable pins without supplemental metal fixation in adults
tempted but is likely to succeed only in minimally displaced (9,10,40,55), complications have included displacement
fractures. If closed reduction is obtained, it can be mainrained (14.5%), sterile Huid accumulation requiring incision and drain-
with a caSt or with percutaneous pins or screws supplemented age (8.1 %), pseudarthrosis (8%), distal tibiofibular synostosis
by a cast. (3.8%), and infection (J .6%). Bucholz and co-workers (Ill re-
If anaromic reduCtion cannot be obtained by closed methods, ported few complications in a series of fractures in adults fixed
open reduction and internal fixation should be performed. Lin- with absorbable screws made of polylactide and suggested that
tecum and Blasier described a technique of open reduction complications in earlier series might be related to the fact that
achieved through a limited exposure of the fracture with the those pins were made of pol}'glycoJide. A report in 1993 by
incision cenrered over the fracture site combined with percutane- Bostman and associates (11), however, included few complica-
ous cannulared screw fixation (74). This technique was per- tions in a slTics of fractures in children fixed with pol)'glycolide
formed on 13 patjenrs: 8 Salter-Harris IV fractures, 4 Salrer- pins. A follow-up report by Rokkanen et al. in 1996 reported
Harris III fractures, and 1 triplane fraCture. The investigators a 3.6% rate of infection and a 3.7% rate of fai lure of fixation
reported one growth arrest at follow-up averaging 12 months. (I03).
Beary and Linron (6) reported a Salter-Harris type III fracture The main advantage of absorbable pins and screws is thar
with an intraarticuJar fragment (Fig. 2')-27); these fractures re- hardware removal is avoided. Bostman compared the COSt effec-
quire open rcducrion for inspection of the joint to ensure thar tiveness of absorbable implants in 994 patients (j'eated with ab-
no osteochondral fragments are impeding reducrion. Imerna] sorbable implants to I, 173 patients treated with metallic im-
fixarion devices should be inserted within rhe epiphysis, parallel plants. To be cost effective, thl' hardware removal ratl'S required
 ChI/pur 25: Distal Tibial and Fibular Fractures 1139

A B

FIGURE 25-26. A: Displaced Salter-Harris type III supination-in-

version fracture in an 8-year-old girl who presented for treatment
2 weeks after injury. B: After cast removal 6 weeks after injury. C:
Two years after injury. Although the injury does not seem to have
interfered with growth, as evidenced by the Park-Harris growth
arrest line parallel to the physis (black arrow), her articular incon-
c gruity (white arrow) is associated with occasional mild ankle pain.
1140 Lower Extremity

A B

FIGURE 25-27. A: Salter-Harris type III fracture ofthe medial malleolus

and Salter-Harris type I fracture of the fibula in a 9-year-old girl. An
intraarticular fragment was visible only on a mortise view radiograph.
B: Computed tomography scan outlined the Salter-Harris type III frac-
ture of the medial malleolus and the fragment of bone. C: Two years
after excision of the osteochondral fragment, open reduction of the
malleolar fracture, and internal fixation. (A and B reprinted from Beaty
JH, Linton RC. Medial malleolar fracture in a child: a case report. J Bone
c Joint Surg [Am] 1988;70: 1254-1255; with permission.)

A B
FIGURE 25-28. A: Grade II supination-inversion injury in a 12-year-old girl, resulting in a displaced
Salter-Harris type IV fracture of the distal tibia and a nondisplaced Salter-Harris type I fracture of the
distal fibula. B: After anatomic open reduction and stable internal fixation.
 Chapter 25: Distal TibiaL and Fibula/" Fractures 1141

A B

FIGURE 25-29. A: Supination-inversion injury with a Sal-

ter-Harris type III fracture of the medial malleolus. B: Six
months after open reduction and internal fixation with two
transepiphyseal cannulated screws. C: Eighteen months
after injury, the fracture has healed with no evidence of
growth arrest or angular deformity. Arrows note normal,
c symmetrical Park-Harris growth arrest line.
1142 Lower Extremity

mobilization in 26 of 27 patiems with injuries involving the

medial side of the tibia; only 1 patient required surgery. In con-
rrast, 5 ro 11 patients with injuries involving the Jater'al side had
persistent symptoms that required excision.
Injuries ro the perichondral ring of the distal tibial and fibular
physes, with physeal disruption, have been described. Most of
these injuries are caused by skiving of the bone by machinery
sucb as lawn mowers. They may result in growth arrest or retar-
darion and in angular deformities (see section on Open Fractures
and Lawn Mower Injuries).

~ AUTHOR'S PREFERRED METHOD

V OF TREATMENT

FIGURE 25-]0. Compression-type injury of the tibial physis. Early phy- Salter-Harris Type I and II Fractures of the
seal arrest can cause leg length discrepancy. Distal Tibia
r prefer to treat nondisplaced Salter-Harris rype I and II fractures
initially with above-knee cast immobilization. Non-weight
bearing is continued unril 3 to 4 weeks postinjury, when the
were calcuJared to range from 19% for metacarpaJ fractures to
cast is changed to a below-knee walking cast that is worn for an
54(~h for trimalleolar fractures (12). At this time, the use of
additional 3 to 4 weeks. Follow-up radiographs are obtained
absorbable pins remains investigational.
every 6 months for 2 years or unril a Park-Harris growth arrest
line parallel to the physis is visible and there is no evidence of
Salter-Harris Type V Fractures physeal deformiry.
For displaced fractures in children with at least 2 years of
Salter-Harris rype V fractures of the ankle are believed to be growth remaining, my objective is ro obtain no more than 15
caused by severe axial compression and crushing of the physis degrees of plamar tilt for posteriorly displaced fractures, 10 de-
(Fig. 25-30). As originally described, these injuries are not associ- grees of valgus for laterally displaced fractures, and 0 degrees of
ated with displacement of the epiphysis relative (Q the metaphy- varus for medially displaced fractures (Fig. 25-31). For children
sis, which make diagnosis of acute injury impossible from plain with 2 years or less of growth remaining, rhe amounr of accept-
radiographs; the diagnosis can only be made on follow-up radio- able angulation is reduced ro less than 5 degrees. I prefer ro
graphs when premature physeal closure is evident. Spiegel and attempt reduction of markedly displaced fractures with the use
associates (112) have designated comminuted fractures that are of general anesthesia wirh good muscle relaxation and image
orherwise unclassifiable as Salter-Harris type V injuries. inrensifler conuo!. In children with mildly displaced fractures,
The incidence of Salter-Harris type V ankle fractures is diffI- especially if anesthesia is not going ro be available for many
cult to establish because of the difficulty of diagnosing acute hours, r occasionally make one arrempt at gende closed reduction
injuries. Spiegel and associates (112) included two type V frac- under a hemaroma block supplemenred as needed by weJl-moni-
tures in their series, but both were comminllted fractures rather rored inrravenous sedation. Once adequately reduced, the frac-
than the classic crush injury. tures are usually stable and a long-leg cast can be used for immo-
Because of the uncerrain nature of this injury, no specific bilizarion. Rare]y, for markedly unstabJe fractures or severe soft
treatmenr recommendations have been formulated. Treatmenr tissue injuries that require multiple debridemenrs, percuraneous
is usmlly directed primarily roward the sequelae of growth arrest screws are used when the Thursron-Holland fragment is large
thaI invariably follows Salter-Harris rype V fractures. Perhaps enough ro accept screw fixation. When the fragment is roo small,
more sophisticated scanning techniques will eventually allow smooth wire fixation across the physis is the only alternative.
idenriflcation and localization of areas of physeal injury so that Repeated attempts at closed manipulation of these fracrures may
itTcparable damaged cells can be removed and replaced with incrcasc the risk of growth abnormality and should be avoided.
inrerposition materials ro prevenr growth problems, hut at pres- In patients with fractures that are not seen until 7 to 10 days
ent this diagnosis is made only several months after injury. after injury, residual displacement is probably best accepted. If
growth does not sufficiently correct malunion, corrective osteot-
omy can be performed later.
Other Fractures of the Distal Tibia
I have found that open reduction of these fracrures is rarely
Accessory ossification cenrers of the distal tibia (os subtibiale) indicated. The exception usually has been pronation-ever-
and distal fibula (os fibulare) are common and may be injured. sion -external rotation fractures with interposed soft tissue. For
Treatment usually consists of cast immobilization for 3 to 4 fracrures with lateral and posterior displacement, an anteromed-
weeks. Ogden and Lee (90) reporred good results after cast im- ial incision is made and any interposed soft tissues, such as perios-
 Chapfer 25: Disw! Tibial and Fibular Fractures 1143

A B

c
FIGURE 25-31. A: Displaced pronation-eversion-external rotation fracture of the distal tibia in a 12-
year-old boy was treated with closed reduction and cast immobilization. B: After cast removal a 10
degree valgus tilt was present. C: At maturity, the deformity has completely resolved.

reum or rendons, are extracted beFore the Fracture is reduced. rhree modiflcarions. First, aFrcr casr applicacion J confirm rhe
Even rhough reduction is usually stable, I generally use internal reduccion of rhe FracCLIre Fragments with CT scanning. Second,
tlx<!cion rhrough rhe meraphyseal Fragment, avoiding rixarion these patients are examined more frequenrly (once a wcck) for
across rhe physis iF possible. the first 3 weeks after cast application to ensure thar rhe frag-
menrs do nor become displaced. Third, these patients are exam-
Salter~Harris Types III and IV Fractures of ined every 6 to 12 months after cast removal for a minimum
the Distal Tibia of 24 to 36 monrhs to detect any growth abnormality.
Generally, only truly nondisplaced Salter-Harris types JI] and
T rcacmenr of nondisplaced Salcer-Harris eype III and IV frac- IV fractures, or those with I mm or less of displacement, can
rures is rhe same as For nondisplaced type I and I J Fracrures wirh be treated closed. Fracrures wich 2 mm or more of dispJacement
1144 Lower Extremity

require open reducrion and inrernal f1xarion wirh anaromic tures rhar are seen more than 7 days afrer injury, I accepr up
alignmenr of rhe physis and fracrure fragmenrs. ro 2 mm of displacemenr wirhom attempring closed or open
For fracrures wirh 2 mm or less of displacemenr, closed reduc- reducrion (Fig. 25-32). Reliable patiems whose fractures are
rion is arrempred in rhe operaring room wjrh rhe use of general fixed wirh screws can be immobilized in below-knee casrs.
anesrhesia. Afrer rhe exrremiry is prepared and draped, gentle Above-knee casts are used for all other parienrs.
longirudinal rracrion is applied ro rhe foor, followed by eversion Fracrures wirh more rhan 2 mm of displacemenr should be
of rhe foor and direcr digiral pressure over the medial malleolus. reduced, regardless ofwhether rhe fracwre is acure or nor. Closed
If image inrensiflcarion confirms anaromic reducrjon, rhe frac- reducrion can be attempred, bur rhese fractures usually require
wre may be fixed wirh two percuraneous smoorh wires placed open reduction. Occasionally, primary debridemem of callus
in rhe epiphysis parallel ro the physis. Reducrion is confirmed and sofr rissue back ro normal-appearing physis and far grafring
by a shorr, continuous fluoroscopic examination. Cannulated have been successful for fracrures rhat are more rhan 7 days old
screws can be inserted if me epiphysis is large enough. For frac- (Fig. 25-33).

A B

FIGURE 25·32. A: Salter-Harris type III fracture after

supination-inversion injury of the distal tibia in a 10-
year-old girl demonstrates 2 mm of displacement 4
weeks after injury. B: After 8 weeks of cast immobili-
zation, healing is apparent but there is a suggestion
of early physeal bar formation. C: Nine months later,
growth is normal, as evidenced by the Park-Harris
c growth arrest line parallel to the physis.
 Chapter 25: DistaL TibiaL and Fibular hactures 1145

A;S c
FIGURE 25·33. A: Eight-year-old girl who presented 10 days after a displaced Salter-Harris type IV
fracture of the distal tibia. B: At open reduction, comminution of the physis was noted. The physis was
debrided and a fat graft was inserted before reduction and internal fixation of the fracture. C: Three
years after injury there is no evidence of physeal bar formation or growth abnormality.

important to view both the lateral and anteroposterior projec-

OPERATIVE TREATMENT tions because of the curved shape of the distal tibial articular
surface. If the fragment is large enough, 4-mm cannulated lag
Open Reduction and Internal Fixation of screws are inserted through the epiphyseal fragment (Fig. 25-
Salter-Harris Type III or IV Fracture of the 28); if the fragment is tOO small for screws, smoorh Kirschner
Distal Tibia wires are Llsed. The reducrion and the position of the internal
fixarion are checked through the arthrotomy. In fractures with
The patient is placed supine on an operating table [hat is radiolu-
a significant Thursron-Holland fragment, a metaphyseal screw
cent at the lower extremity. After exsanguination of the extremity
and inflation of the tourniquet, a hockey stick incision is made,
extending from approximately 4 cm above the ankle joint to I
cm posterior to the tip of the medial malleolus (Fig. 25-34).
Alternatively, if more anterior exposure is required, a 4- to G-
cm rransverse incision is made from the posterior aspect of the
medial malleolus to the anterior aspect of the ankle. The saphe-
nous vein is idenrified, dissected free, and retracted. The fracture
site is idenrified, and an anreromedial capsulotomy of the anlJe
I
joinr is performed. The arthrotomy is continuous with the frac- I

(J
ture line and the traumatic disruption of periosteum and peri- I
chondral ring. The fracture surfaces are exposed and gently
cleaned with irrigation and forceps (curettage is not used).
For Salter-Harris type IV fractures, the periosteum may be
elevated several millimeters from the metaphyseal fracture edges.
I prefer not to excise rhe metaphyseal portion of a Salter-Harris
\ ,
"- .....
type IV ftagment. The epiphyseal edges and joint surfaces are .....
examined through the arthrotomy. The perichondral ring should
not be elevated from the physis. For Salter-Harris type III frac-
tures, the reduction is evaluated by checking the joint surface
and epiphyseal fracture edges through the arthrotomy. The epi-
physeal fragment is grasped with a small towel clip or reduction
forceps, and the fracture is reduced (Fig. 25-35). Internal fixation FIGURE 25-34. Anteromedial surgical approach for reduction of a Sal-
is performed under direct vision and fluoroscopic control. It is ter-Harris type IV fracture of the medial malleolus.
1146 Lower Extremity

using a subcmicular suture for the skin. A well-padded above-

knee cast is applied.
The patient is kept non-weight bearing for 3 weeks, and
then the cast is changed to a below-knee walking cast, which is
worn for an additional 3 weeks. Frequent follow-up evaluations
(eveLy 3 months for the first year and yearly thereafrer) are neces-
sary to detect growth abnormalities until skeletal maturiry.

Fractures Involving the Distal Fibula

Fractures involving the fibular physis are most commonly Salter-
Harris rype I or II fractures that are caused by a supination-in-
version injUlY. Isolated fibular fractures are usually minimally
displaced and can be treated with immobilizarion in a below-
knee cast for 4 to 6 weeks. Significantly displaced fibular frac-
tures accompany Salter-Harris rypes III and IV tibial fractures
and usually reduce when the tibial fracture is reduced. Internal
fixation of the tibial fracture generally results in stabiliry of the
fibular fracture such that cast immobilization is sufficient. If the
FIGURE 25-35. Technique for reduction of a Salter-Harris type IV frac- fibular fracture is unstable after reduction and fixation of the
ture of the distal tibia.
tibial fracrure, fixation wirh a smoorh intramedullary or
obliquely inserted Kirschner wire is recommended. In older ado-
lescenrs in whom growrh is not a considerarion, an intramedul-
lary rod or plate-and-screw device may be used as in adults (Fig.
may be used if a gap exisrs after the epiphyseal screws are inserted. 25-36).
After reductiorl of the tibial fracrure, the associared Salter-Harris Avulsion fractures from the lateral malleolus are seen in chil-
rype I or II fibular fracture usually reduces arld is stable. If it is dren with inversion sprain-rype injuries to the ankle. These may
not, closed reductiorl and flxatiorl with percutarleous oblique fail to unite with cast immobilization. Patients with such non-
smooth Kirschrler wires are performed. The WOLlrld is closed unions may have pain without associated instability. In such

A B
FIGURE 25-36. A: Salter-Harris type II fracture of the distal fibula in a 15-year-old. B: Lateral view shows
the fibular metaphyseal fragment (arrow). Considerable soft tissue swelling was noted in the medial
aspect of the ankle. (Figure continues.)
 Chapter 25: Distal Tibial and Fibular Fmctllres 1147

C D
FIGURE 25-36. (continued) C: Stress films showed complete disruption of the deltoid ligament. D: The
fibular fracture was fixed with a cannulated screw; the deltoid ligament was not repaired.

patients simple excision of the ununited fragment usually relieves tures has been labeled transitional ftactures because they occur
their pain (30,50). When the nonunions are associated with during the transition from a skeletaJly immature ankle to a skele-
instability, reconstruction of one or more of the lateral ankle tally mature ankle.
ligaments is required (see senion on Lateral Ankle Sprains). Classification of these fractures is even more confusing than
that of other distal tibial fractures. Advocates of mechanism-
of-injLllY systems agree that most juvenile Tillaux and triplane
fractures are caused by external rocation, but they di~agl'ee as to
~ AUTHOR'S PREFERRED METHOD
,~ 0 F TREATMENT the position of the foot at the time of the injury (32,33,98).
Some researchers (33) classify juvenile TiJlaux fractures as stage
I usually rrcat nondisplaced fibular physeal fractures wirh immo- I injuries, with further external rotation causing rriplane frac-
bilization in a below-knee walking cast for 3 to 4 weeks. I Ilave tures, and still further external rotation causing stage II injuries
atrempted closed reduction of displaced Salter-Harris types I with fibular fracture. Others emphasize the extent of physeaJ
and II fibular fractures, but when reduction was unsuccessful, T closure as the only determinant of fracture pattern (26).
have accepted up to 50% displacement without problems at Advocates of anatomic classifications are handicapped by the
long-term follow-up (Fig. 25-37). Dias (32), however, reporred different anatomic configurations triplane fractures may exhibit
a patient with a symptomatic spike that required excision after on different radiographic projections, making tomography, CT
inadequate reduction. I have nor found open reduction of iso- scanning, or exami nation at open reduction necessalY to deter-
lared physeal fibular fractures necessary but would nor hesi tate mine fracture anatomy and number of fragments. Because these
to perform open redunion of a displaced Salrer-Harris type III fractures occur near the end of growth, growth disturbance is
or IV fracrure if necessary. rarely significant. Therefore, anatomic classification is more use-
ful for descriptive purposes than For prognosis.

Juvenile Tillaux and Triplane Fractures Juvenile Tillaux Fractures

Because the disral tibial physis closes in an asymmerric pattern This fracture is the adolcscl:nt counterpart of the Fracture de-
over a period of about 18 months, injuries sustained during this scribed in adults by the French surgeon Tillaux. It occurs when
period can produce fracture patterns that are not seen in younger with external rotation of the foot, the anteroinferior tibiofibular
children wjth completely open physes (78). This group of frac- ligament through its arrachments ro the anterolateral ribia
1148 Lower Extremity

A B
FIGURE 25-37. A: Lateral radiograph of a 13-year-old girl who was seen 7 days after an inversion sprain
of the ankle; the Salter-Harris type I fracture of the distal fibula is displaced 50%. Closed reduction was
unsuccessful. B: Six months after injury, remodeling is complete at the fracture site and the patient is
asymptomatic.

avulses a fragment of bone corresponding to the porrion of the apparenr diastasis of rhe ankle joint (113). To allow measure-
disral ribia! physis rhar is sri II open (Fig. 25-38). In rhe series menr of displacement from plain films, the x-ray beam would
of Spiegel and associares (I12), rhese fracrures occurred in 2.9% have ro be directly in line wirh the fracture sire, which makes
of parienrs. CT conflrmarion of reducrion mandatory afrer all closed reduc-
Tillaux fracrures may be isolared injuries or may be associared rions of rnese fractures.
wirh ipsilareral tibial shafr fractures (28). The fibula usually pre-
venrs marked displacemenr of the fracrure, and clinical deformiry
Treatment
is generally absenr. Swelling is usually slighr, and local tenderness
is ar rhe anrerior lareral joinr line, in conrrasr ro anlde sprains, Borh below-knee and above-knee casts have been used for immo-
where the tenderness rends [0 be below rhe level of rhe ankle bilizarion of nondispJaced juvenile Tillaux and rriplane fracrures.
joinr. Fracrurcs wirh more tnan 2 mm of displacemenr require closed
A monise view is essenrial [0 obrain a view of rhe disral or open reducrion. Closed reducrion is arrempted by internally
ribial epiphysis rhat is unobsrrucred by the fibula (Fig. 25-39). rorating rhe foor and applying direct pressure over the anrerolar-
Sreinlauf et a!. reported a patienr in whom rhe Tillaux fragment eral ribia. If necessaJY, percuraneous pins can be used for srabili-
became enrrapped berween rhe disral ribia and fibula, producing zarion of rhe reducrion. If closed reducrion is nor successful,

FIGURE 25-38. Juvenile Tillaux fracture. Mechanism of in-

jury, the anteroinferior tibiofibular ligament avulses a frag-
ment of the lateral epiphysis (A) corresponding to the por-
A,S tion of the physis that is still open (8).
 Chapter 25: Distf11 Tibini and Fibular Fractures 1149

FIGURE 25-40. Technique of placement of percutaneous pins for ma-

FIGURE 25-39. Anteroposterior mortise view of a 14-year-old who sus" nipulation of a juvenile Tillaux fracture.
tained a juvenile Tillaux fracture.

nor a concern, rhe screw does nor have ro be inrraepiphyseal. If

open reducrion is required. Occasionally, percuraneously in-
closed reducrion is unsuccessful bur residual displacemenr is nor
serred pins can be used ro manipulare rhe displaced fragmenr severe, r occasionally inserr one or cwo smooch pins into rhe
inro anaromic posirion and rhen advanced (Q fix rhe fragmenr
Tillaux fragmenr under fluoroscopic conrrol (Fig. 25-40) and
in place (l08).
use rhem to arrempr ro guide rhe fragmenr inro proper posirion
(Fig. 25-41). Cannulared screw guide pins may nor be sriff
enough for rhis purpose. and a larger pin may be required. If
~ AUTHOR'S PREFERRED METHOD successful, rhe pins are advancecl and one or cwo screws are
\...~ OF TREATMENT inserred (Fig. 25-42). If reducrion is nor successf"ul, open reduc-
rion is performed rhrough an anrerolareral approach and a can-
For nondisplaced fracrures and fracrures displaced less rhan 2 nulared or cancellous screw is inserred for fixarion (Fig. 25-43).
mm, I prefer immobilizarion in an above-knee casr wirh rhe
In rhe anrerolareral approach, be sure ro idenrifY rhe superficial
knee flexed 30 degrees and rhe foor internally rmared. If rhe
perineal nerve ro prevenr injury. A shorr leg, non-weighr-bear-
posirion appears acceprable on plain films, CT scanning in rhe
ing casr is worn for 3 weeks, followed by a weighr-bearing casr
rransverse plane wirh coronal and sagirral reconsrrucrions is used
for anorher 3 weeks.
to confirm acceprable reducrion. For fracrures wirh more rhan
2 mm of inirial displacemenr, manipularion may be arrempred
by inrernal rorarion of rhe foor and applicarion of direcr pressure Fractures of the Incisura
over rhe anrerolareral joinr line. If reducrion is nor obrained wirh Ar my insrirurion we have seen fWO parienrs wirh whar we have
rhis maneuver, reducrion can be arrempred by dorsi.flexing rhe rermed incisura I fracrures. On anreroposrerior and monise
pronared foor and rhen inrernally roracing rhe foor (79). Again, views, rhese parienrs appeared ro have Tillaux fracrures wirh
if rhe reducrion appears adequare on plain radiographs, CT scan-
ning is used for conflrmarion. I prefer ro immobilize pacienrs
wirh rhese injuries in a long-leg casr wirh rhe knee flexed and
rhe foor inrernally rmared.

a OPERATIVE TREATMENT

Fixation of Juvenile Tillaux Fracture

If radiographs or CT scan afrer casring show an unacceprable
redunion, rhe parienr is raken ro rhe operaring room, where
closed reducrion is again arrempred. If reducrion is confirmed by
C-arm fluoroscopy in all projenions, a percuraneous cannulared FIGURE 25-41. Advancement of pin after reduction of juvenile Tillaux
screw is inserted for fixarion. Because preservarion of growrh is fracture.
1150 Lower Extremity

the fracrured piece appearing smaller than usual and essentially

nonclisplaced (Fig. 25-44). CT scans revealed thaI' the fracture
line did not extend through the anrerior cortex, as is seen in a
typical TiJlaux fracture (Fig. 25-45). It would rherefore appear
thaI' rhe fragment could nor have been avulsed by rhe anterior
tibiofibular ligament, the accepted mechanism of injury for a
Tillaux fracture. It is my hypothesis rhat the fragment is avulsed
by rhe intraosseous ligament and represents the pediacric equiva-
lenr of an adult diastasis injulY.
Both of these patients were treated elsewhere with cast immo-
bilization initially. Casting was continued for 12 weeks. At rhat
FIGURE 25-42. Percutaneous insertion of 4.0-mm cannulated screw
over pin that has been advanced into the medial distal tibia after reduc-
time, the patients demonstrated no bony healing. Cast immobi-
tion of the juvenile Tillaux fracture fragment. lization was discontinued and rehabilitation begun. The patients
were symptom free 2 years postinjury despire lack of bony union.
It is therefore my Feeling at this time rhat nonoperarive treatment
of this injury is indicated if the mortise is not widened.

A B

FIGURE 25-43. A and B: Displaced juvenile Tillaux frac-

ture. Closed reduction was not successful. C: After open
reduction and internal fixation with a small fragment
c screw.
 C!Jrtpur 25: Disl d 7'ibirtf and Fibular Fractf.lrf'S 1151

A c

FIGURE 25-44. Anteroposterior (A), lateral (6), and oblique (C) views
ofthe ankle demonstrating an apparent small juvenile Tillaux fracture
B in a 14-year-old girl.
1152 Lower E'(tremity

FIGURE 25-47. Anatomy of a two-part lateral triplane fracture (left

ankle). Note the large posterolateral epiphyseal fragment with its pos-
terior metaphyseal fragment. The anterior portion of the medial malle-
olus remains intact.

such fracrures and coined rhe rerm triplane fracture. He described

rhe fracture as consisring of rhree major fragments: (a) the ,1l1ter-
olareral quadrant of the disral tibial epiphysis, (b) rhe medial
and posterior porrions of rhe epiphysis in addirion ro a posrerior
meraphyseal spike, and (c) rhe ribial meraphysis. However, in
rheir 1978 report of 15 such fractures, Cooperman and associares
(27) concluded rhat, based on romographic studies, mosr were
FIGURE 25-45. Computed tomography scan at the level of the tibiota· two-part fracrures produced by exrernaJ rorarion (Fig. 25-47).
lar joint demonstrates that the fracture fragment does not include the
attachment of the anterior inferior tibiofibular ligament.
Variarions in fracrure parrerns were arrribured ro rhe exrent of
physeal closure ar the rime of injUlY. Karrholm and colleagues
reponed rhar CT evaJuarion of four adolescents wirh rriplane
fracrures confirmed rhe exisrence of two-part and rhree-parr frac-
rures and aJso revealed four-parr fracrures (62) (Fig. 25-48).
Triplane Fractures
Denton and Fischer (31) described a two-parr medial rriplane
Karrholm attribures rhe original descriprion of rhis injury ro fracture rhat rhey believed was caused by adduction and axial
Barr! (5), in 1954, and nores rhar Gerner-Smidr (44), in 1963, loading, and Peito and associates (92) reponed a three-parr me-
described rriplane and Tillaux fracrures as differenr srages of rhe dial triplane fracrure. In rhe series of Spiegel and associares, 7.3%
same injury. In 1957, Johnson and Fahl (58) described a rriplane were triplane fracrures (12).
fracture in their report of27 physeal ankle injuries and reported Von Laer (122) described a subgroup of two-parr and rhree-
rhar rhey had seen 10 such fractures. Despire these earlier reports, part triplane fracrures in which the fracrure line on rhe antero-
the nature of triplane fractures was nor appreciated unril Marm- posterior radiograph did nor exrend inro rhe ankle joint bur
or's (81) report in 1970 of an irreducible ankle fraoure rhar at
surgelY was found ro consist of three parts (Fig. 25-46). Two
years afrer Marmor's report, Lynn (78) reported twO additional

FIGURE 25-46. Anatomy of a three-part lateral triplane fracture (left FIGURE 25-48. Anatomy of a four-part lateral triplane fracture (left
ankle). Note the large epiphyseal fragment with its metaphyseal com- ankle). The anterior epiphysis has split into two fragments and the pos-
ponent and the smaller anterolateral epiphyseal fragment. terior epiphysis is the larger fragment with its metaphyseal component.
 Chapter 25: DistaL TibiaL and FibuLar Fractures 1153

A B

c
FIGURE 25-49. A and B: Anteroposterior and lateral
radiographs of an "intra malleolar" variant triplane
fracture in a 14-year-old boy. (and 0: (T scans dem-
onstrate extraarticular nature of the fracture. D

into the medial malleolus instead (Fig. 25-49). Feldman and co- Karrholm reviewed 209 triplane fracture patients and Found
workers also reported a case of an extraarticuJar tripJane fracture that the mean age at the time of injury was 14.8 years for boys
in a skeletally immature patient (38). Shin er al. reponed five and 12.8 years for girls (60). This rype of injury did not occur
patients with intramalleolar tripJane variants (l09). They di- in children undet 10 or over 16.7 years. Patients with tripJane
vided these into three rypes: rype I, an intramalleolar intraarricu- fractures may have completely open physes. Swelling is usually
lar fracture: rype II, an intramalleolar, intraanicular fracture ou[- more severe rhan with Tillaux fractures, and deformiry may be
side the weight-bearing surface; and rype [II, an intramalJeoJar, more severe, especially jf the fibula is also frac[Ured. Radio-
extraarticular fracture (Fig. 25-50). These researchers found that graphic views should include anteroposterior, lateral, and mor-
CT scans with three-dimensional reconstruction were helpful in rise views. Rapatiz et al. found that 48% of triplane fractures
determining displacement and deciding if surgery is indicated. were associated with fibular fracture and 8.5% were associated
with ipsilateral tibial shaft fracture (10 I). Healy et al. reported
a trip lane fracture associated with a proximal fibula fracture and
syndesmotic injury (Masionneuve equivalent) (53). Failure to
detect such injury may lead to chronic instabiliry. Therefore,
tenderness proximal to the ankle should be sought; if found, it
is certainly an indication for radiography of the proximal leg.
CT has largely replaced plain tomography for evaluation of the
articular surface and the fracture anatomy and should be rou-
tinely performed (Fig. 25-51).

Treatment
Nondisplaced triplane fractures (those with <2 mm of displace-
A B c
ment) as well as extraarticular fractures can be treated with long
FIGURE 25-50. Schematic drawing of the immature distal tibial physis leg cast immobilization with the foot in internal rotation for
demonstrating types I, II, and III intramalleolar triplane fractures. A:
Type I intramalleolar, intraarticular fracture at the junction of the tibial lateral fractures and in eversion for medial fractures. Fractures
plafond and the medial malleolus. B: Type II intramalleolar, intraarticu- with more than 2 mm of displacement (65% of the injuries in
lar fracture outside the weight-bearing zone of the tibial plafond. C: Karrholm's series) require reduction; this may be attempted in
Type III intra malleolar, extraarticular fracture. (Adapted from Shin A,
Moran ME, Wenger DR. Intra malleolar triplane fractures. J Pediatr Or- the emergency department or in the operating room with the
thop 1997; 17: 352-355; with permission.) use of general anesthesia. Closed reduction of lateral triplane
1154 Lower Extremity

A B

C D
FIGURE 25-51. Computed tomography scanning of a three-part triplane fracture. A: Coronal cut shows
lateral epiphyseal fragment. B: Sagittal cut shows posterior displacement of the epiphyseal-metaphyseal
fragment. C: Horizontal cut through the epiphysis shows displacement of the lateral epiphyseal fragment
(arrows). D: Horizontal cut through the metaphysis shows the fibular fracture and the displaced metaph-
yseal fragment (arrows).

fractures is attempted by internally rotating the foor. Based on arthroscope in an anterolateral portal and an anreromedial POrtal
the mechanism of injury, the most logical maneuver for reduc- used for inflow, twO pins were inserted laterally into the epiphy-
rion of medi:ll triplane fracwres is abducrion. If closed reducrion seal Fragment and used co maneuver ir inco proper position under
is shown to be adequare by image intensification as is the case direct arthroscopic vision. The pins were then advanced For fixa-
about half the time, a long leg cast is applied or percutaneous tion of the fragment.
screws are inserted for fixation if necessary. If closed reduction
is unsuccessful, open reduction is required. This can be accom-
plished through an anterolateral approach for lateral triplane • AUTHOR'S PREFERRED METHOD
fractures or through an anteromediaJ approach for medial tri- ,~ OF TREATMENT
plane fractures. Additional incisions are frequently necessary for
adequate exposure. For nondisplaced or minimally displaced (Jess than 2 mm) frac-
Whipple and associates (J 24) described arthroscopic reduc- tures, I prefer immobilization in a long-leg cast with the knee
tion of two-pan triplane fractures in t\vo patients. With the flexed 30 to 40 degrees. The position of the foot is determined
 Chapter 25: Distal Tibial find Fibular Fractures 1155

by whether the fracture is I:tteral (internal rotation) or medial and any interposed periosteum is removed. The fracture is re-
(eversion). A CT son is obtained immediately after casting to duced, and reduction is confirmed by direCt observation through
document adequate reduction. Plain films or CT scans are ob- an anreromedial arthrotomy and by image intensification. Two
tained approximately 7 days after cast application to verify that 4-mm cancellous screws are inserted from medial to lateral or
displacemell( has not recurred. At 3 to 4 weeks, the cast is from anterior to posterior or both, depending on the fracture
changed to a below-knee walking cast, which is worn another pattern (Fig. 25-52). Anterior-to-posterior screw placement may
3 to 4 weeks. require an additional anterolateral incision, or the screws may
For fractures with more than 2 mm of displacement, I usually be inserted percutaneously.
attempt closed reduction with sedation in the emergency depart- For two-part lateral triplane fractures, I prefer a hockey stick
menr. An above-knee cast is applied. If plain radiographs show anterolateral approach. The fracture is reduced and srabilized
satisfactory reducrion, a CT scan is obtained. If reduction is with two screws placed from lateral to medial or from anterior
acceptable, treatment is the same as For nondisplaced fractures. to posterior or both, and reduction is confirmed through direct
If the reduction is unacceptable, closed reduction is attempted observation and by image intensification.
in the operating room with the use of general anesthesia. If Fractures with three or more parts may occasionally require
fluoroscopy shows an acceptable reduction, percutaneous screws more exposure for reduction and internal fixation. If the fibula is
are inserted, avoiding the physis, and a short leg cast is applied. fracrured, posterior exposure of the tibial fracture can be readily
IFclosed reduction is unacceptable, open reduction is performed. obtained by detaching the anterior and posterior inferior tibio-
Preoperarive CT scanning may be helpful for evaluating rhe fibular ligaments and rurning down the distal fibula on the lateral
position of the fracture fragments in the anteroposterior and collateral ligament (Fig. 25-53). If the fibula is nor fractured, a
lateral planes and for determining the appropriate skin incisions. fibular osteotomy may be performed. Careful dissection is neces-
salY to avoid iatrogenic fractures through the physis of the fibula.
Medial exposure is obtained through an anteromedial or postero-

a
medial incision. Reduction and internal fixation are performed
in a stepwise fashion. For typical three-pan fractures, I prefer
OPERATIVE TREATMENT
to reduce the Salter-Harris type II fracture first and provisionally
fix it to rhe distal tibia through the metaphyseal fragment. Usu-
Open Reduction of Triplane Fracture
ally, the Salrer-Harris type III fragment can rhen be reduced
The patient is placed supine on a radiolucent operating table and provisionally fixed to the stabilized type II fragmeIl( (Fig.
with padded elevation behind the hip on the affected side. The 25-54). Occasionally, the order of reduction and fixation should
surgical approach depends on the fracture anatomy as deter- be reversed. Fracwres with four or more fragments require addi-
mined by the preoperative CT scan. I prefer to approach a two- tional steps, but r have foulld ir easier to fix the Salter-Harris
parr media] triplane fracture through a hockey stick anteromedial type II or IV fragmeIl( through the metaphysis to the distal tibia
incision. The fracture fragments are irrigated to remove debris, before attaching the Salter-Harris type III fragment or fragmeIl(s

I .
••
A B
FIGURE 25-52. A and B: Irreducible three-part triplane fracture in a 13-year-old girl. (Figure continues.)
1156 Lower Extremity

c D
FIGURE 25-52. (continued) C and 0: After open reduction and internal fixation. Note anterior-to-poste-
rior and medial-to-Iateral screw placement that avoids the physis.

(Fig. 25-55). After reduction, reliable patiems may be treated (37,47). Approximarely 25,000 lawn mower injuries occur each
with immobilizarion in a shorr-leg cast for 6 ro 8 weeks, with year, 20% of which are in children. Riding lawn mowers are
weight bearing allowed ar 3 ro 4 weeks. associated wirh the mosr severe injuries, requiring more surgical
procedures and resulring in more funcrionallimirations (1,3,35,
39,105,123). Loder et al. reviewed] 44 children injured by lawn
Open Fractures and Lawn Mower Injuries
mowers (75). The average age at rhe time of injury was 7 years.
Severe open ankJe fractures are ofren produced by high-velocity The child was a bystander in 84 Clses. Sixry-seven children re-
moror vehicular accidents or lawn mower injuries (Fig. 25-56) quired ampurarion. Soft-tissue infecrion occurred in 8 of 118
and osteomyelitis in 6 of 117.
Principles of rreannenr are rhe same as in adulrs: copious
irrigarion and debridemenr, retanus roxoicl, and imravcnous an-
ribiotics. Gaglani er al. reponed the bacreriologic fi.ndings in
three children wirh infections secondary ro lawn mower injuries
(43). They found rhar organisms infecring the wounds were
frequently differem from those found on initial debridement.
Gram-negative organisms were common, and all three patients
were infecred with fungi as well. In children witl1 lawn mower
injuries, grass, dirt, and debris are blown inro rhe wound under
pressure, and removal of these embedded foreign objects requires
meticulous mechanical debridemenr.
In most patients, rhe arricular surface and physis should be
aligned and fixed with smooth pins rhat do nor cross rhe physis
ar the time of initial treatment. Exposed physeal surfaces should
be covered with local fat ro help prevenr union of the meraphysis
to rhe epiphysis. An external fi.xaror may be used if necessary, but
small pins should be used through rhe 01 raphysis and epiphysis,
avoiding the physis (56,59,76,102,104). Wound closure may be
a problem in cases with signifi.canr soft: tissue injury and exposed
bone. Skin coverage with local rissue is ideal, bur iflocal cowrage
FIGURE 25-53. Transfibular approach to a complex lateral triplane is nor possible, splir-thickness skin grafting is generally the next
fracture. choice. Free vascular naps and rotational flaps may be ['equi['ed
 Chapter 25: Distal Tibial and Fibular Fracmres 1157

A B

c D
FIGURE 25-54. Open reduction and internal fixation of a three-part lateral triplane fracture. A and B:
Reduction and fixation of the Salter-Harris type II fragment to the metaphysis. C and D: Reduction and
internal fixation of the Salter-Harris type III fragment to the Salter-Harris type II fragment.

for adequate coverage. Klein et al. reporred on cwo patienrs who Lateral Ankle Sprains
had associated vascular injury precluding such Raps. The injUlY
In L984, Valwanen published a prospective scudy of 559 chil-
was covered successfully with local advancement Raps made pos-
dren who preseIHed with severe supination injuries or sprains
sible by mulriple relaxing incisions (68) Mooney er al. reported
of the ankle (I 20). Forry patienrs, 28 boys and 12 girls, with
the use of cross-extremity Raps for such cases (85). They found
an average age of 12 years (range 5- 14) were surgically explored.
external fixation for linkage of rhe lower extremities during the
The indications for surgery included swelling, pain over the alHe-
procedure to be valuable. Mrer fixation removal, range of motion
recurned. rior talofibular ligamenr, limp, clinical iostabiliry, and, when
Vosburgh and associates (J 23) reporred 33 patienrs wirh lawn visible, a displaced avulsion fracwre. Such fracrures were visible
mower injuries to rhe foor and ankle. They found that the most radiographically in only 8 patients but were found at surgery in
severe injuries were to the posterior-plantar aspect of the foot 19. Thirry-six ankles were found co have injUlY of the ancerior
and ankle. Of their patienrs, five required split-thickness skin talofibular ligament at surgery. Only 16 of these had either a
grafts and one required a vascularized flap for soft tissue coverage. positive lateral or anterior drawer stress tesc. At follow-up all
Two ultimately required Syme amputation. Four of the patients patieIHs were pain free and none complained of instability. Based
had complete disruption of the Achilles tendon. Three had no on the incidence of residual disability after such injuries in adults
repair or reconstrucrion of the triceps surae tendon, and one reporred in the literacure (21 %-58%), these researchers sug-
had delayed reconstruction 3 monrhs after injury. Vosburgh and gested primary surgical repair.
associates (123) speculared rhar dense scarring in the posterior Busconi and Pappas reported 60 skeleta.lly immature children
ankle results in a "physiologic tendon" and rhat exccnsive recon- with chronic ankle pain and instabiliry (19). Fifty of these chil-
structive surgeJY is not always necessary for satisfactory function. dren responded co rehabilitation, but 10 had persistent symp-
Boyer et al. reported on a patienr with deltOid ligament loss due coms. AJrhough 3 of these patients' initial radiographs were
to a severe grinding injuJY dut required a free plancaris tendon within normallimi t5, all patiencs wirh persisreIH sympcoms even-
graft co reconstruct the ligamenr (J 4). Sofr tissue coverage was wally were found to have ununited osteochondral fractures of
achieved using a free muscle rransfer. the fibular epiphysis. All 10 patienrs with persistem sympcoms
1158 l.ower Earemi~y

A B

C 0
FIGURE 25-55. A and B: Irreducible three-part lateral triplane fracture in a 14-year-old boy. C and D:
After open reduction through a transfibular approach and internal fixation with anterior-to-posterior
and lateral-to-medial screws.
 C/)apta 25: Distal Tibial and Fibular Fractures 1159

over the anterior talofibular ligament with little or no tenderness

over the open fibular physis. The presence on the otherwise
normal radiograph of an avulsion fracture of either the tip of
the fibula or the lateral aspect of the talus is also consistent
with this diagnosis. When routine views fail ro demonstrate such
avulsion fractures, the views described by Haraguchi et al. may
be helpful (49).
Because chronic pain and instabiliry do not always complicate
such injuries, I treat rhese injuries nonoperatively when they
are seen acutely. Patients who have persistent complaints after
adequate rehabilitation following such treatment are neated with
excision of any ununited fragments and Brosnom reconstruction
as necessary.

Ankle Dislocations
Nusem et aL reponed on a 12-year-old girl who was seen with
a posterior dislocation of rhe ankle without associared fracture
(88). This was a closed injury and resulted from forced inversion
of a maximally plantar flexed foot. The dislocation was reduced
under intravenous sedation and the ankle immobilized in a shorr
leg cast for 5 weeks. The patient was asymptomatic at follow-
up 4 years postinjury. The inversion sness views ar that time
revealed only a 3 degree increase in laxiry compared with the
uninjured side. The anterior drawer sign was negative. There
A was no evidence of avascular necrosis of the talus on follow-up
radiographs.

REHABILITATION
For patients neared with casr immobilization, quadriceps, ham-
string, and abductor exercises are begun as soon as pain and
swelling allow. Usually a below-knee cast is worn during the last
2 ro 3 weeks of immobilization, and weight bearing to tolerance
is allowed during this time. After immobilization is discontin-
ued, ankle range-of-motion exercises and strengthening exercises
are begun. Protective splinting or bracing is usually nor required
after cast removal. Running is restricted until the patient demon-
strates an essentially full, painless range of ankle and foot motion
and can walk without a limp. Running progresses from jogging
to more strenuous running and jumping as soreness and endur-
ance dictate. For athletes, unrestricted running and jumping
abiliry should be achieved before return to spons. Patients should
B be able ro hop on the injured side equal to the noninjured side.
FIGURE 25-56. A: Severe lawn mower injury in a 5-year-old boy. B:
Protective measures such as caping or bracing are recommended
One year after initial treatment with debridement, free flap, and skin initially for return to most spons.
graft coverage. Most patients with physeal ankle fractures recover quickly
and require li[[le or no formal physical therapy. For this reason,
and because of compliance considerations, fractures created with
internal fixation are usually ptotected with below-knee casting
were rreated with excision of the ununited osteochondral frac- instead of starting an early range-of-motion program in a remov-
rure and a Brostrom reconsrruction of the lateral collateral liga- able splint.
ment. All were able to return ro activities, and none reponed Reflex sympathetic dystrophy occasionally develops after
furrher pain or instabiliry. these injuries and is treated initially with an intensive formal
rt is my opinion thaI' the diagnosis of an acute ankle sprain physical therapy regimen that encourages range of motion and
in a child with an open fibular physis is reasonable when the weight bearing (125). For patients who do not respond quickly
child has tenderness well localized to the rip of the fibula or ro such a program, I have had good success with a brief hospital
1160 LOWfrExtrell1ity

admission for physical therapy in associarion with cominuous

epidural analgesia.

PROGNOSIS AND COMPLICATIONS

Delayed Union and Nonunion
Delayed union and nonunion are rare after distal tibial physeal
fracrures (Fig. 25-57). Dias (32) reponed on one parient with
a delayed union and one patient with a previous physeal bar
excision who had a nonunion that healed after open reduction,
internal fixation, and bone grafting. Siffert (10) reported non-
union in a patient with avascular necrosis of the distal tibial
epiphysis. I have seen rwo younger patients with Salter-Harris
type TIl fractures that appeared to be progressing to nonunion.
Because neither patient had any complaints of pain or any evi-
dence of progressive displacemem of the fracwre and stress views
showed no instability, no rreatmenr was undertaken. Both frac-
tures eventually united (Fig. 25-58). I have seen one patient
with a nonunion afrer open reducrion and internal fixation in A
whom pin flxarion and casr immobilization were discontinued
premarurely. The fracture healed after repeat open reduction
and imernal fixation.

Deformity Secondary to Malunion

Rotational malunion usually occurs after rriplane fracrures that
are either incompletely reduced or are initially immobilized in
below-knee casts. It also has been reported after Salter-Harris

B
fiGURE 25-58. Nonunion and delayed union. A: Ten-year-old girl with
incomplete healing of a supination-inversion Salter-Harris type III frac-
ture of the distal tibia aher 12 weeks of cast immobilization. B: Sixteen
months after injury, the fracture united without further immobiliza-
tion; no physeal bar formation or growth abnormality has occurred.

type I and II injuries. Derotarional osteotomy may be performed

for extraarticular fractures if discomfort and stiffness occur. Gu-
ille et al. reported a rotational malunion of lateral malleolar
fracrure that led to a stress fracture of the distal fibula that went
FIGURE 25-57. Complex nonunion of a Salter-Harris type 111 fracture on to delayed union (48). Their patient required correerion of
of the medial malleolus in an 8-year-old boy. Note that the distal tibial
epiphysis is in valgus, whereas the talus is in varus. (Courtesy of Brent thc malroratcd distal fibula and hone graFting of the delayed
Broztman, M.D.) union site.
 Chapter 25: Distal Tibial/md Fibular Fractures 1161

Anterior angulation or plantarflexion deformity usually oc- intraarticular fractures because it cannot correct the joinc incon-
curs after supination-plantarflexion Salter-Harris type II frac- gruity thar results from malunion (Fig. 25-60).
tures. Theoretically, an equinus deformity might occur if the
angulation exceeds rhe range of ankle dorsiflexion before frac-
Growth Auest
tLlre, bur rhis is rare, probably because the deformity is in the
plane of joint motion and tends to remodel wirh growth. Deformity caused by growth arrest usually occurs after Salrer-
Valgus deformity is most common after external rotation Sal- Harris types III and IV fractures in which a physeal bar develops
ter-Hanis type II fractures. The degree to which rhe deformity at the fracture site, leading to varus deformity that progresses
may spontaneously resolve or remodel with growth is contl'over- with continued growth. Spiegel and associates (112) reported
sial. Caruthers and Crenshaw (21) reported resolution of a 12 growth problems in 9 of 66 patients with Salter-Harris type II
degree valgus defotmity in a 13~-year-old boy, but Spiegel and fractures.
associates (112) reponed persiS[enr residual deformity in a signif- Earlier reports (21,29) attributed the development of physeal
icant number of their patients (Fig. 25-59). Varus deformity bars to crushing of the physis at the rime of injury, but more
mosr often results from growth abnormality and infrequently is recent reports (58,70) discount this explanation and claim that
with anatomic reduction (open reduction and internal fixation
the result of simple malunion.
if needed), the incidence of physeal bar formation can be de-
If significant angular deformity persists at the completion of
creased. The validity of this claim is difficult to determine from
growth, supramalleolar osreotomy should be performed. Moon
published reports. One problem is the small numbers of parienrs
et aJ. followed nine children with posttraumatic varus deformi-
in all series and the even smaller numbers within each group in
ties of the ankle secondary to supination inversion injuries (84).
each series. Another problem is the age of rhe patienrs in opera-
These patients went on to develop meclial subluxation of their
tive and nonoperative groups in rhe various series; for example,
ankles wirh associated internal rotational deformity. Takakura
many children reported to do well with a particular treatment
et al. described successful open wedge osteotomy for varus defor-
method have so little growth remaining that treatment may have
mity in nine patients (117). Scheffer and Peterson recommend had little or no effect on growth.
opening wedge osteotomy when the angular deformity is 25 Kling and co-workers (70) reported physeal bars in twO of
degrees or less and the limb length discrepancy is or will be five patients treated nonoperatively and in none of three patients
25 mm or less at maturity (107). Preoperative planning should treated operatively in children 10 years of age and younger.
include templaring rhe various types of osteotomies to determine However, in my experience with eight patients, twO of five
which technique will mainrain the proper mechanical alignment u'eated operatively developed physeaJ bars, whereas none of the
of rhe tibia and ankle joint and will not make rhe malleoli unduly three patients treated nonoperatively had physeal bars. This sup-
prominent. Osteotomy is nor recommended for malunion of portS the conclusion of Cass and Peterson (22), Ogden (89),
and others that growth problems after these injuries may not
always be prevented by open reduction and internal fixation.
Open reduction of displaced Salter-Harris type III and IV ankle
fractures would seem advisable to restore joint congruity, regard-
less of whether growth potential can be preserved.
Harris growth lines have been reported to be reliable predic-
tors of growth abnormality (57), but I have found that although
lines parallel to the physis are reliable, lines that appear to diverge
from the physis may be misleading (Fig. 25-61). Harcke and
colleagues reported early detection of growrh arrest wirh bone
scanning techniques (51).
Spontaneous resolution of physeal bars has been reported
(13,24), but is rare. Most patients require excision of small bony
bars and may require correction of significant angular deformity
with osteotomy (Fig. 25-62). Epiphisiodesis may be required as
well in the margin at large physeal bridges. The evaluation and
treatment of physeal bars, angular deformity, and leg-length dis-
crepancy are discussed in Chapter 5.
Karrholm and co-workers (64) reponed progressive ankle de-
formity caused by complere growth arrest of the fibula with
normal growth of the tibia (Fig. 25-63). They found that contin-
ued fibular growth with complete arrest of tibial growth was
usually compensated by proximal migration of the fibula so that
varus deformity did not occur.
FIGURE 25-59. Radiograph of a 14·year-old boy, 4 months after pro-
nation-eversion-external rotation injury, reveals 16 degrees of valgus Because the amount of growth remaining in the distal tibial
angulation. physis is small (~0.25 inch per year) in most older patients with
1162 Lower Extremity

A,B c

o E
FIGURE 25-60. A: This apparently nondisplaced medial malleolus fracture in an ll-year-old boy was
treated with immobilization in a long leg cast. B: Fourteen months after injury, there is a clear medial
osseous bridge and asymmetric growth of the Park-Harris growth arrest lines (black arrows). Note the
early inhibition of growth on the subchondral surface of the fracture (open arrow). C: Five years after
injury, the varus deformity has increased significantly and fibular overgrowth is apparent. 0: The defor-
mity was treated with a medial opening-wedge osteotomy of the tibia, an osteotomy of the fibula, and
epiphysiodesis of the most lateral portion of the tibial physis and fibula. E: Three months after surgery,
the osteotomies are healed and the varus deformity is corrected; the joint surface remains irregular.
(Courtesy of Earl A. Stanley, Jr., M.D.)
 Chapter 25: Distal Tibial find Fibular FractureJ 1163

B
FIGURE 25-61. A: Six months after cast immobilization of a nondisplaced supination-inversion Salter-
Harris type III fracture of the right distal tibia in an 8-year-old boy. The Park-Harris growth arrest line
(arrow) appears to end in the physis medially and diverge from the physis laterally. B: Two years later,
no physeal bar is present and growth is normal.

FIGURE 25-62. A: One year after

open reduction and internal fixa-
tion of a Salter-Harris type III frac-
ture of the distal tibia in a 7-year-
old boy, varus deformity has been
caused by a physeal bar. B: Two
years after excision of the physeal
bar and insertion of cranioplast,
satisfactory growth has resumed
A,S and the deformity has resolved.
1164 Lower Extremit)'

these injuries, the amount of leg length discrepancy resulting

from complete growth arrest tends to be relatively small. Treat-
ment may be required if the anticipated discrepancy is projected
to be clinically signifJcant (Fig. 25-64).

Arthritis
Epiphyseal ankle fractures that do not extend into the joint have
a low risk of posttraumatic arthritis, but injuries that extend
into the joint may produce this complication. Caterini and co-
workers (23) found that 8 of 68 (12%) patients had pain and
stiffness that began 5 to 8 years after skeletal maturity. Errl and
associates found that 18 to 36 months after injUlY 20 patients
with triplane fractures were asymptomatic, but at 36 months
to 13 years after injulY only 8 of 15 patients evaluated were
asym promatic (36).
Ramsey and Hamilton (100) demonstrated in a cadaver study
that 1 mm of lateral talar displacement decreases tibiotalar con-
tact area by 42%, which greatly increases the stress on this
weight-bearing joint. More recently, Michelson and collcague~
(83) reported that a cadavet study using unconstrained speci-
FIGURE 25-63. Valgus deformity of the ankle, lateral displacement of mens suggested that some lateral talar displacement occurs with
the talus with widening of the joint medially, and severe shortening normal weigh.t bearing. Because of their findings, they ques-
of the fibula after early physeal arrest in a child who sustained an ankle tioned the current criterion of2 mm of displacement for unstable
injury at 6 years of age. (Courtesy of James Roach, M.D.)
ankle fractures. However, the results of Ramsey and Hamilron's
study correlate well with orher studies that have shown increased
symptoms in patients in whom more than 2 mm of displacement
was accepted (23,36).

A B
FIGURE 25-64. A: Stage II supination-inversion injury in an ll-year-old child. Salter-Harris III fracture
of the medial malleolus and a Salter-Harris I fracture of the fibula. B: After open reduction and internal
fixation. (Figure continues.)
 Chapter 25: Disttll Tibial and Fibula/" Fractll/"es 1165

t t .

c D
FIGURE 25-64. (continued) C: At 14 months postinjury, the distal fibular physis is completely closed.
The Park-Harris growth arrest lines (arrows) in the tibia are asymmetric, indicating a possible arrest of
the medial physis. D: Three years later, the lateral malleolus is short, mild varus deformity is present,
and the medial physis is partially closed. The child had a leg length discrepancy of 2.4 em. (Courtesy of
Douglas Hyde, M.D.)

A,B c
FIGURE 25-65. A: A 12-year-old girl with ankle pain 6 months after open reduction of severe open
comminuted fractures of the distal tibia and fibula. Note the sclerosis and collapse of the distal lateral
tibial epiphysis. B: Magnetic resonance imaging demonstrates lack of marrow signal from the tibial
epiphysis. C: Five years after osteotomy for correction of the valgus deformity the patient's pain was
relieved but joint motion remains limited.
1166 Lower extremity

Avascular Necrosis of the Distal Tibial