Pediatric Fracture Management 2007

Pediatric Fracture
Management
Pediatric Fracture
Management
Atul R Bhaskar
FRCS (Orth), FRCS (Surg), MS (Orth), DNB, MCh (Orth) UK
Asst. Professor, KJ Somaiya Hospital and Research Center

Everad Nagar, Off Eastern Express Highway
Sion, Mumbai 400022
Hon. Consultant in Paediatric Orthopaedics
BSES MG Global Hospital, Andheri West, Mumbai
Dr LH Hiranandani Hospital, Powai, Mumbai
Guru Nanak Hospital, Bandra, Mumbai
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Pediatric Fracture Management
2007, Jaypee Brothers Medical Publishers
All rights reserved. No part of this publication should be reproduced, stored in a retrieval
system, or transmitted in any form or by any means: electronic, mechanical, photocopying,
recording, or otherwise, without the prior written permission of the author and the publisher.
This book has been published in good faith that the material provided by author is original.
Every effort is made to ensure accuracy of material, but the publisher, printer and author will
not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters
are to be settled under Delhi jurisdiction only.
First Edition: 2007
ISBN 81-8448-031-8
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd, Sector 60, Noida
I would like to dedicate this book

to
my parents and family
Foreword
About a third of all children will sustain a fracture, and as such the general
orthopaedists will treat many childhood injuries. Applying adult principles to
childhood injuries has a high chance of resulting in unnecessary open surgical
procedures and a worse outcome than if pediatric fracture management
principles had been adhered to. Thus, an easy to use reference of childhood
fractures is needed to allow physicians to provide the best care possible for
children. Despite the large number of fracture textbooks available, few
provide practical advice on how to manage childrens injuries in a succinct
and practical manner. While the general principles of childhood fracture
management have not changed, there have been substantial advances in
how these principles are applied to childhood fractures. Comprehensive
studies of patient outcome and the development of new fracture fixation
techniques have resulted in improved management techniques. Using
modern treatment approaches, bad outcomes should be very rare. It is
unusual that there is only one successful way to manage a fracture. The best
treatments for an injury will depend on the experience of the treating
physician, equipment and surgical instruments available, and the desires of
the patient. This text captures the advances in fracture management, and
presents them in a way that gives practical information on how to manage
childhood injuries. The treatment protocols are presented in a rationale and
easy to follow way, so that the novice can use this book to make practical
decisions on how to treat injuries. The experienced orthopaedic surgeon
can also use the information as a succinct review. Treatment options are
presented, so that the treating doctor can select between those that will
work best given their skill set, the environment they are working in, and
patient preferences. The practical information given in this text, it is poised
to become a widely used standard in the management of childrens fractures.
Benjamin Alman
Canadian Research Chair, AJ Latner Professor and
Chair of Orthopaedic Surgery, Vice Chair Research
Department of Surgery, University of Toronto
Head, Division of Orthopaedic Surgery and
Senior Scientist, Program in Developmental Biology
Hospital for Sick Children
Toronto, Ontario, Canada
Preface
Treatment of childrens fractures, unlike in adults, offers special challenges:
the dilemma of diagnosis, the problem of the acceptable position, the effect
of fracture on growth of child, and most importantly, the effect of growth on
fracture.
Most adult fractures cannot tolerate the rigors of conservative treatment,
and hence go under the knife to achieve timely union and anatomical
alignment.
It is the skeletal dynamics that makes management of childrens fractures
challenging. In the past, the acceptable position, as taught in residency was
partly a matter of conjecture and partly experience. The latter is important
as one may have seen different behavior patterns in fracture healing. Also,
experience, positive or otherwise, guides our opinion. The conjecture part
is more exacting now, as the Gurus of pediatric fracture management
have laid criteria for an acceptable position.
In treating pediatric fractures, age and timing of presentation has the
most significant impact on treatment options. A window period exists after
which intervention can produce more harm. This is particularly true for
fractures around the elbow region, and growth plate injuries
This book is an attempt to present the salient features of pediatric fracture
care both for the in-training residents, as well as for practising orthopedic
surgeons.
The book is divided into four main sections: upper limb, spine, pelvis
and acetabulum, and lower limb fractures. Each section has sub-headings
to cover all anatomical areas for easy reference to a particular fracture/topic.
Relevant remarks, features and complications are listed for easy reading.
Delayed presentation and neglected trauma constitute a bulk of pediatric
trauma practice in our teaching hospitals. It is only through pooling of clinical
cases and multicenter studies, that one can make sensible decisions in this
relatively difficult group.
I welcome any comments, suggestions, or a critique towards enhancing
the utility of this book. Kindly send your views to the publisher or e-mail to
me at <arb_25@yahoo.com>.
A comprehensive bibliography at the end provides additional information
for those who seek finer details.
Atul R Bhaskar
Acknowledgements
I am highly indebted to the staff at Division of Orthopedics, Hospital for Sick
Children, Toronto, Canada for their insightful comments during the weekly
trauma rounds. I would like to thank Dr Benjamin Alman, Dr James Wright,
Dr William Cole, Dr Douglas Hedden, Dr Andrew Howard, Dr John Wedge,
Dr Unni Narayan, and Dr Robert Salter, who, has an extremely keen eye for
detail in reading radiographs.
I would also like to thank my teachers at the KEM Hospital, Mumbai, for
stimulating my interest in orthopedics. My special thanks to my teachers at
the Yorkshire Orthopaedic Training Program who help shape my career.
I would like to thank Dr Rajeshwar Singh who has read, edited and
revised the manuscript. Mr Parde, artist, at the KJ Somaiya Hospital, for his
drawing and line diagrams.
Contents
Introduction ............................................................................. xv
1. Fractures of the Upper Extremity .......................................... 1
A. Clavicle
i. Shaft
ii. Medial end
iii. Distal end
B. Humerus
i. Proximal humeral fractures
ii. Diaphyseal humeral fractures
iii. Distal humeral fractures
a. Supracondylar fractures
b. Dual fractures
c. Intercondylar fractures
d. Transcondylar fractures
e. Lateral condyle fractures
f. Medial epicondyle fractures
g. Medial condyle fractures
C. Elbow Region
i. Elbow dislocations
ii. Pulled elbow
iii. Radial head and neck fractures
iv. Olecranon fractures
D. Forearm Fractures
i. Radius and Ulna fractures
ii. Radial head dislocation
iii. Monteggia fracture-dislocation
iv. Galleazzi fracture-dislocation
v. Distal radius fracture and epiphyseal injury
E. Hand Fracture
i. Hand injuries
ii. Phalangeal fractures
iii. Ulnar collateral ligament injury
iv. Radial collateral injury
v. Metacarpo-phalangeal and inter-phalangeal dislocations
vi. Scaphoid fracture
2. Spine Fractures .................................................................. 57
F. Cervical Spine
i. Rotatory subluxation
xiv PEDIATRIC FRACTURE MANAGEMENT
ii. Fracture of atlas

iii. Fracture of dens
iv. Subaxial spine injuries
v. Cervical end-plate injuries
G. Thoracolumbar Spine
i. Chance fracture
ii. Burst fracture
iii. End-plate injuries
3. Pelvic Ring Fractures .......................................................... 68
H. Avulsion Fractures
I. Acetabular Fractures
4. Fractures of the Lower Extremity ........................................ 74
J. Hip Dislocation
K. Femur Fractures
i. Proximal femur
ii. Subtrochanteric fractures
iii. Femoral shaft fractures
iv. Distal femoral fractures
L. Knee Dislocations
M. Patella Fracture
i. Fracture
ii. Dislocation
iii. Bipartite patella
N. Tibia Fracture
i. Upper tibial physis fracture
ii. Tibial tubercle fractures
iii. Tibial spine avulsion injury
iv. Tibial shaft fractures
v. Proximal metaphyseal fracture
O. Ankle Injuries
i. Distal tibial physeal fractures
ii. Triplane injury
P. Foot Injuries
i. Talus fractures
ii. Osteochondritis dissecans lesions of Talus
iii. Lisfrancs fracture dislocation
iv. Os Calcis fracture
Bibliography .......................................................................... 119
Index ..................................................................................... 127
Introduction
Children Versus Adults
There are Anatomical, Biochemical and Biomechanical Differences between
children and adult bones:
Anatomical
Presence of growth plate
Thick, vascular periosteum
Cambium layer has increased osteoblastic activity.
Biochemical
More collagen per unit area of mineralized bone
Collagen is mainly type 1
Biomechanical
Bone is more porous
The bone has lower modulus of elasticity
Lesser bending strength required to produce deformity.
Principles of Treatment in Children Fractures
Union is almost always possible
Angulation must be kept as small as possible
Malrotation is unacceptable at any age
The ability of the bones to remodel in the immature skeleton forms the
basis of limits of acceptability in children fracture.
This remodeling ability depends on:
o Age
o Anatomical location of fracture
o Degree of deformity
o Plane of fracture
o Movement of adjacent joints
Imaging Rules
Knowledge of ossification centers is essential when interpreting
radiographs in children (Fig. A).
The appearance and fusion of various ossification centers helps to
differentiate normal variants from abnormal lesions.
Never hesitate to ask for contra-lateral radiographs.
Beware of dual or multiple fractures in the same limb or at other sites
Fracture lesions are always larger than what appears on radiographs
because of presence of unossified cartilage
xvi PEDIATRIC FRACTURE MANAGEMENT
Fig. A: Ossification centers in the human fetus at the end of first trimester
Growth Plate (physis)

Main difference between children and adult bone is presence of a growth
plate (Fig. B).
It is the site of active bone formation until skeletal maturity.
Growth plate (physis) is influenced by both external and internal factors.
The mechanical forces, muscle action, hormones, and various growth
factors modulate the development of the physis.
Physis is the vulnerable area for injury in a child (Fig. C).
Growth plate injuries
can be missed; hence a
high index of suspicion
is required. Also, variations in physis appearance can lead to confusion in diagnosis.
Fig. B: Zones of the growth
plate. The site of separation in
fractures is usually the junction
between hypertropic zone and
zone of calcification where the
matrix is less dense to protect
against shear forces
INTRODUCTION xvii
Fig. C: Types of growth plate injuries. John Poland first described physeal injuries in
1898. Dr Salter and Dr Harris proposed a classification of physeal injuries in 1965
which remains popular to date
1
Fractures of the
Upper Extremity
2 PEDIATRIC FRACTURE MANAGEMENT
A. CLAVICLE
This is the first bone to undergo ossification, which is of intramembranous
type.
The clavicle arises from two primary ossification centers.
The secondary ossification center appears around 15-18 years at the
sternal end of the bone and this center fuses with the shaft at around
25 years of age.
i. Shaft Fractures
90 percent of the fractures occur in the middle third because of a natural
twist in the bone at this junction (Fig. 1.1).
Fractures can be greenstick or complete.
Fractures can be associated with birth injury (incidence: 2.2-4.8/100 live
births).
It is always wise to rule out other bony injuries and brachial plexus
involvement.
Fractures may be asymptomatic in neonates and young infants and may
present only as a late swelling because of callus formation.
Shaft fractures are a common cause of pseudoparalysis in infants.
Fig. 1.1: Fracture of midshaft of clavicle
FRACTURES OF THE UPPER EXTREMITY
Management
Diagnosis is usually clinical but can be confirmed with radiographs.
Almost all fractures heal without any treatment.
Older children may require maneuvers to regain length of bone (Fig.
1.2).
The callus formation over the subcutaneous bone can lead to prominence
in the clavicular area and the parents must be forewarned about this at
the time of diagnosis of injury.
The prominence due to the callus remodels in the following 6-12 months.
There is usually a bayonet apposition of fragments, but this is not associated
with any functional limitations in future.
Figure of 8 splint or a simple sling may be effective in young children
< 5 years to maintain alignment but the splint has to be tensioned daily
to prevent any displacement (Fig. 1.3).
Fig. 1.2: Manual reduction may be required for midshaft fractures
Fig. 1.3: Figure of 8 sling may be required to immobilize fracture and pain relief
Indications for Surgery
Open fractures.
Any associated neurovascular injury.
Threatened viability of overlying skin.
Polytrauma / floating scapula.
Non-union following conservative treatment.
Malalignment unacceptable to patient.
Complications
Neurovascular injury to the underlying structures depends on the severity
of trauma.
Non-union may occur because of gross displacement at fracture site,
comminution or soft tissue interposition.
ii. Fractures of the Medial (Sternal end) of Clavicle
This is a traumatic separation of the epiphysis of the sternal end of the
clavicle (Fig. 1.4).
It may mimic a sternoclavicular dislocation.
The displacement may be anterior or posterior.
Anterior dislocation can become recurrent.
Posterior displacement may be associated with cardiorespiratory
symptoms.
Fig. 1.4: Medial clavicular physeal injury in a 15-year-old boy. CT scan showing
posterior displacement of the clavicle
Management
Diagnosis may require special radiographs viz.
Apical lordotic view.
Hobbs superior-inferior view.
CT scan with reformatting.
Anterior displacement
Closed manipulation is always attempted and may suffice as the fracture
is easy to reduce and is also stable because of the intact posterior periosteal
sleeve.
Posterior displacement
Closed manipulation using a bolster in the interscapular area may be
attempted (Fig. 1.5).
Occasionally, towel clip can be used to hold the medial end as traction is
applied.
Open reduction with the help of cardiovascular surgeons can be
undertaken if there is intrathoracic compression.
Fixation can be achieved by heavy sutures or Dacron mesh. Threaded
wires have been used but several complications have been reported.
Tendon reconstruction has been described for recurrent instability.
Complications
Intrathoracic compression causing hemothorax/pneumothorax.

Compression of carotid and subclavian arteries.
Compression of trachea/esophagus.
Recurrent instability
Malunion
Fig. 1.5: Patient who underwent manipulation under anesthesia. Postreduction CT

scan at 6 weeks shows healing and minimal displacement
iii. Fractures of the Distal (Acromial end) of the Clavicle

It is a physeal injury seen in older children and adolescents. The thin
epiphysis/physis plate is still attached to the acromium but the metaphysis
separates and displaces superiorly. The inferior periosteal sleeve remains
intact (Fig. 1.6).
Also called as pseudo-subluxation of the acromio-clavicular joint.
The acromio-clavicular ligaments being strong in this age group, remain
intact.
Displacement depends on the severity of injury and superior periosteal
disruption.
Fig. 1.6: Fracture through physeal plate
Management
For the minimally displaced fractures a collar/cuff suffices.
For fractures that are displaced more than half of the height of the clavicle,
surgical intervention with soft-tissue repair. A threaded pin may be required
to secure fixation until healing occurs.
Complications
Displaced fractures, if left untreated, cause a bifid or Y shaped distal
clavicle. This can cause pain and the offending impingement and may
need subsequent treatment at a later stage.
B. HUMERUS
Proximal humerus ossification center present at 4-6 months of age. In
20 percent cases it may be present at birth.
The proximal physis contributes 80 percent of the length of the humerus.
The metaphysis is initially flat but later develops a triangular configuration
which fits in the inverted V-shaped notch of the epiphysis (cone-shaped
physis).
The greater tuberosity appears at 16-18 months and radiological fusion
between the two centers is seen at 4-7 years of age.
Closure of the epiphysis is seen at 12-14 years in girls and at 15-17 years
in boys.
i. Fractures of the Proximal Humerus Epiphysis
Seen in the first decade of life: If seen in children less than 18 months,
suspect child abuse.
Extremely rare in neonates.
Change may occur in fracture pattern which is related to development
of physeal shape that becomes more triangular and notched into the
physis.
The distal fragment is displaced anteriorly and the proximal fragment is
adducted and displaced posteriorly.
Diagnosis may be difficult in infants because of the small ossification center:
an MRI scan may be required for diagnosis.
As age advances the injury zone moves from the epiphysis to the
metaphysis. In late teens anterior dislocation of humeral head becomes
more frequent.
Anatomical classification is based on Salter-Harris system.
Type I: occurs in neonates and children less than 5 years.
Type II: seen in older children.
Type III/IV: rare; seen during epiphyseal closure.
Management
For greenstick / buckle fractures, treatment in sling or collar-cuff for three
weeks suffices.
Early shoulder motion should be encouraged.
Guidelines for acceptable position for treatment of displaced fractures:
In children < 5 years, 70 angulation and total displacement.
Between 5-12 years, 40 - 70 angulation, < 50 % apposition.
In children > 12 years, 40 angulation and > 50 % apposition.
Remodeling reported in nearly 100 percent children < 6 years with

untreated fracture. Some authors report that > 30 angulation with
< 2 years growth remaining will not remodel and need surgical
intervention.
A grading system has been proposed to quantify displacement.
Neer-Horwitz fracture classification to grade displacement
Grade
Displacement
I
< 5 mm shaft diameter
II
<1/3 shaft width
III
2/3 shaft width
IV
>2/3 shaft width
Excellent remodeling has been seen with up to 80 percent displacement
and even with 90 varus angulation. In children 6-12 years, complete
displacement will remodel into an acceptable position. Angulation can
be improved with hanging arm cast.
In the older children (> 12 years) and adolescents, closed reduction
may be attempted if displacement is grade III or IV. If the deformity or
angulation > 30 degrees persist then closed reduction and percutaneous
pinning can be done to hold the metaphyseal fragment (Fig. 1.7).
It is very rare for the biceps tendon to become entrapped, regardless of
the severity of the fracture displacement.
Complications
Limb length discrepancy: Shortening seen in grade II and III fractures if
child > 11 years old. No shortening seen in children < 11 years.
Varus angulation: May occur because of malunion or medial growth
arrest: rarely seen, as angular correction occurs with remodeling.
Axillary nerve injury: Usually transient and recovers spontaneously
Glenohumeral dislocation can be missed; hence radiographs must be
carefully assessed.
ALGORITHM FOR MANAGEMENT OF PROXIMAL

HUMERUS FRACTURES
Fig. 1.7: Proximal humerus fracture in a 15-year-old boy. In

this case the initial angulation was greater than 30 degrees.
Incomplete remodeling at one year after injury
11
ii. Diaphyseal Humerus Fractures

Rare in children as the epiphyses are more vulnerable (Figs 1.8 and
1.9).
More common in adolescents: If seen in younger children, suspect child
abuse (< 18 months).
Fig. 1.8: Birth fracture of mid-shaft of humerus
Fig. 1.9: Three-year-old boy with mid-shaft fracture: Typical varus angulation seen.
Six weeks later, good callus formation with remodeling seen
Fig. 1.10: Seven-year-old boy with spiral fracture of the humerus
Management
Isolated shaft fractures respond well to conservative treatment. A wellmolded U slab or a suitably modified shoulder sling suffices. There is
excellent remodeling with growth (Fig. 1.10).
Approximately 15-20 of angulation and 1-1.5 cm shortening is
compatible with good function.
Rule out bone pathology, i.e. unicameral bone cyst, fibrous dysplasia,
osteogenesis imperfecta.
Surgical options in older children with polytrauma and pathological
fracture include flexible nails, special humeral nails, plating and external
fixation.
Complications
Malunion : Usually well compensated by shoulder mobility.
Nerve Injury: Radial nerve may be injured at the time of injury or may
get subsequently involved as the fracture heals. In closed injuries no
treatment is required and in majority of cases the nerve recovers. If
recovery is not evident after the fracture has healed, nerve exploration
can be undertaken after six months.
iii. Distal Humerus Fractures
There is a change in bone morphology, from cylinder to pyramidal shape
The column concept in the supracondylar region is important, not only
for recognizing stability at the fracture site, but also useful in assessing
adequacy of fracture reduction.
13
Fig. 1.11: Normal elbow of 9-year-old boy. The appearance of ossific nucleus varies in
boys and girls. Knowledge of ossification centers is the key to understanding problems
around the elbow
The medial and lateral columns are separated by the olecranon fossa
posteriorly and the coronoid fossa anteriorly. The columns serve as fixation
sites for the K wires.
Ossification in the distal humerus is variable. The ossification centers
appear in the following sequence: Capitellum (3-4 months), radial head
(4-5 years), medial epicondyle (4-6 years), trochlea (at 8-9 years) and
lateral epicondyle (9-11 years). The trochlear center develops from
multiple foci. Asymmetrical epiphyseal ossification is relatively common:
hence, radiographs of the opposite extremity are useful but not always
reliable (Fig. 1.11).
The lateral epicondyle initially fuses with the capitellar physis at 14-16
years and then the combined mass fuses with the metaphysis.
The radial head epiphysis is usually seen at 5-7 years, and fusion occurs
around 12-15 years.
Knowledge of anatomical landmarks is important for radiological
interpretation (Figs 1.12 and 1.13).
Fig. 1.12: The distal humeurs is inclined

15-20 degrees anteriorly in relation to the
humeral shaft axis
Fig. 1.13: The ossific nucleus of the

capitellum is bisected by the humerus
shaft axis
a. Supracondylar Fractures
Account for 50-60 percent of elbow injuries in the 3 -10 years age group.
Classification: Extension type: 97%
Flexion type: 3%.
Extension Type: (Fig. 1.14)
Grade 1: Undisplaced/impacted beware of medial compression (cause of
cubitus varus) (Fig. 1.15).
Grade 2a: Posterior angulation (posterior cortical hinge intact) but no rotation.
Grade 2b: Posterior angulation with rotation of distal fragment.
Grade 3: Completely displaced fractures (1) posterolateral (2) posteromedial
Fig. 1.14: Three grades of supracondylar fractures with increasing severity of injury
15
Clinical assessment must include a thorough neurovascular examination

Inspection of skin for bruising and tenting due to underlying bony spike
In infants and young children it may be difficult to assess nerve function
and this observation must be documented.
Vascular assessment may be required with Doppler/Color Duplex scan
or angiography in select cases.
Baumanns angle is difficult to measure with the elbow flexed and in a
cast. Poor correlation between Baumanns angle and prediction of varus
angulation (Fig. 1.16).
Humeral-ulnar angle is easy to measure when elbow is being manipulated
under Carm or during follow-up radiographs.
Fig. 1.15: Medial

impaction with minimal
displacement. These
fractures have potential
for varus malunion
Fig. 1.16: Radiographic

technique for AP view of distal
humerus
Fig. 1.17: Baumanns angle: angle made by the perpendicular to humerus shaft axis
and line passing through lateral ossific nucleus. Normal angle is 11 -13 degrees
Management
Careful review of the X-ray in undisplaced cases to ensure that there is
no medial impaction and that the humero-capitellar angle is normal
(Baumanns angle) (Fig. 1.17).
Grade 1 and 2a fractures require plaster immobilization for 3-4 weeks.
Grade 2b fracture needs closed manipulation and percutaneous pinning
Grade 3 injuries may require closed manipulation or open reduction
(medial approach) with percutaneous pinning.
If patient needs to go to operation room for manipulation, consider
percutaneous fixation.
Usually two lateral pins or one medial and one lateral pin are sufficient to
maintain reduction.
Keep pins in place for three weeks.
Elbow motion improves over 6-12 months.
In case of delayed presentation, closed reduction is rarely successful and
open reduction can be undertaken upto two weeks after injury. An
extended medial approach or a posterior approach gives adequate
exposure.
Special Situations
Absent pulse and signs of ischemia: Open reduction from anterior
approach and exploration, possibly repair of brachial artery. May need
prophylactic fasciotomy.
Pulse palpable before reduction but disappears after manipulation
and percutaneous fixation: Reduce elbow flexion to see if pulse returns.
17
Assess perfusion status of limb, capillary circulation, redness and warmth. If

the hand is pink and capillary return is good, then reduce elbow flexion and
observe for 24-48 hours.
Any impending signs of ischemia warrant surgical exploration.
Pulseless but pink hand on presentation: Reduce fracture and fix
percutaneously. If hand remains pink and well perfused, observe for return
of pulsations. Usually pulse returns after a week or two. Any signs of ischemia
will need surgical intervention.
Late presentation: Displaced fractures presenting up to two weeks can be
reduced by closed manipulation and K wire fixation. In delayed cases,
repeated manipulation should be avoided.
Complications
Immediate complications
Vascular injury.
Nerve injury (7%): anterior interosseous nerve (5%), median nerve, radial
and ulnar nerve. With posterolateral displacement the ulnar nerve is at
risk, and with posteromedial displacement the median or radial nerve is
at risk.
Watch little finger when inserting medial pin, or use nerve stimulator
to locate nerve position. A mini-incision can be made medially to insert
the pin safely.
Nerve palsies almost always recover over a few months.
Compartment syndrome: Avoid extreme flexion position during
immobilization to avoid compression on the brachial vascular bundle.
Delayed complications
Varus malunion: Degree of varus depends on the initial displacement.
Till now considered to be a cosmetic problem, a new evidence suggests
that posterior instability of the shoulder can occur if varus deformity
remains uncorrected (Fig. 1.18).
Hyperextension of the elbow if the posterior tilt is left uncorrected.
Sequelae of compartment syndrome: Volkamanns contracture.
Cubitus varus deformity
Presents as loss of carrying angle.
Deformity increases with age.
Corrective osteotomy should normalize varus and internal rotation
deformity of distal humerus. Radiographs of the normal side are used
to measure the carrying angle and to plan extent of correction desired.
A lateral closing wedge osteotomy or a dome osteotomy with internal
fixation is advisable.
Fig. 1.18: Malunited supracondylar fracture causing cubitus varus deformity
Fig. 1.19: Flexion type supracondylar fracture treated by closed

manipulation and percutaneous Kwire fixation
19
FLEXION TYPE
These are very unstable because of anterior soft tissue disruption.
Can sometimes occur after forceful manipulation of extension type injury.
These require reduction with extension of elbow and almost always require
stabilization with K wires (Fig. 1.19).
Occasionally open reduction and internal fixation is required.
ALGORITHM FOR MANAGEMENT OF

SUPRACONDYLAR FRACTURE
CR: Closed reduction

ORIF: Open reduction and internal fixation
App: Approach
21
b. Dual Fractures
Supracondylar fracture and fracture of the distal radius in the same limb
is not unusual.
Always take radiographs of joints proximal and distal to fracture, and
X-ray the painful area.
There is an increased incidence of compartment syndrome with these
injuries.
Displaced fractures require stabilization (Fig. 1.20)
Fig. 1.20: Displaced supracondylar and distal radius fracture.

It is important to stabilize both fractures
c. Intercondylar Fractures
These are rare in younger children.

More common in adolescents.
Muscles origins can rotate condyles in displaced fractures.
Articular surface is usually intact.
Classification
Undisplaced.
Displaced and rotated.
Comminuted.
Management
In children > 10 years, interpret radiographs carefully to avoid missing
undisplaced intercondylar fractures.
CT scan or MRI scan may be required to better delineate fracture
configuration.
Intraoperative arthrogram is a useful investigation to delineate fracture
anatomy in select cases, and in the presence of swelling it can be done
through the olecranon fossa.
Treatment depends on the amount of fracture displacement.
Undisplaced or minimally displaced fractures can be treated in cast. If
doubt about stability then closed pinning is advocated.
Displaced fractures need open reduction to restore articular congruity
and stability. Posterior triceps splitting or triceps pull-down approach
provides good access.
d. Transcondylar Fractures
Most common in neonates, infants and young children because of the
vulnerability of the physis.
The entire distal humeral epiphysis is displaced medially.
These fractures are also seen in patients with child abuse and difficult
delivery.
Diagnosis can be easily overlooked as the distal humeral physis is largely
cartilaginous: Radiographs must therefore be interpreted carefully.
Look for displacement of capitellar ossific nucleus. In neonates and infants
only a flake of metaphyseal fragment may be visible.
Differentiate from elbow dislocation which is usually posterolateral and
radio-capitellar relationship is disturbed.
Intraoperative arthrogram may be required if diagnosis is in doubt.
Management
Decision based on amount of displacement of the distal fragment.
Closed/open reduction with percutaneous pinning is the preferred
treatment in unstable cases. Correct any varus tilt and rotation at the
time of manipulation.
23
Complications
Neurovascular injuries are rare.
Malunion: Varus deformity may be seen.
Lateral Condyle Injuries
Fig. 1.21: Displaced lateral condyle fracture with articular incongruity
Account for 15 - 20 percent of all elbow injuries.

Common between 3 and 10 years.
Complete fractures have an intra-articular extension and may lead to
joint instability (Fig. 1.21).
Classification
Based on amount of displacement.
Type 1: Undisplaced or incomplete fractures.
Type 2: Displaced but distal end hinged at the articular surface.
Type 3: Displaced and rotated fragment (Fig. 1.22).
All of these are physeal injuries. According to Salter-Harris classification,
these can be either 1) Type IV or 2) Type II configuration, depending on the
course of fracture line.
Type IV injuries involve only the capitellar physis and are more prone to
rotation and nonunion if untreated. Type II injuries involve the lateral half of
the trochlea and lead to joint instability if left untreated.
Management
Diagnosis requires careful interpretation of radiographs since in younger
children the ossification centers are not well developed.
Oblique radiographs and even an MRI scan may be required. A true
lateral radiograph may show loss of normal anterior capitellar tilt.
Only the truly undisplaced fracture can be treated conservatively by
above-elbow cast. Needs follow-up X-rays at one week intervals. Risk of
displacement is 10 percent. If in doubt, consider percutaneous fixation.
Type II fractures may have a lateral shift. There is an increased risk of
displacement in cast which is difficult to recognize even with weekly
radiographs. Nonunion may occur and, hence, percutaneous fixation is
safest.
Type III fractures flip and rotate in the joint and need open reduction
with pinning to restore stability and articular anatomy. Avoid extensive
soft tissue dissection.
Remove wires are six weeks in case of fresh fractures, and in case of
treatment of non-union, remove wires only if serial radiographs
demonstrate healing.
Complications
Delayed union/Nonunion: In delayed cases, if fracture is un-united,
operative intervention is undertaken to achieve union (Fig. 1.23).
Extensive dissection must be avoided to avoid avascular necrosis. In long
standing non-unions, fusion is attempted between the metaphyseal
component of the fragment and the diaphysis, even if the fragment is
malpositioned (Fig. 1.24). Later, once the physis have closed, corrective
osteotomy can be performed if patient is having functional problems.
Operative intervention can lead to some loss of elbow motion.
Most cases of delayed/nonunion are asymptomatic. Elbow instability may
occur with heavy activity. Elbow ROM is usually full and painless.
Rarely cubitus varus may be seen because of overgrowth of lateral condyle
Avascular necrosis of trochlea. This can be prevented, by minimizing
posterior soft tissue dissection. If fracture heals, AVN usually resolves.
Fish tail deformity may be seen on X-ray, but this is usually clinically
insignificant.
The metaphyseal flake may enlarge to cause prominence on lateral aspect
of elbow.
25
Non-union leading to late cubitus valgus and tardy ulnar nerve palsy
Corrective osteotomy is required to restore humeral-ulnar alignment and
improve ulnar nerve function. Several osteotomies have been described. A
dome osteotomy, through the posterior approach, with anterior transposition
of the ulnar nerve, gives good results, and prevents the formation of medial
prominence seen with closed wedged osteotomies.
Type-1: No displacement
Type-2: < 2 mm displacement
Type-3: Complete displacement

Fig. 1.22: Three grades of lateral condyle fracture,
based on amount of displacement
Fig. 1.23: Delayed presentation with nonunion: Treated by internal fixation;

fracture healed in 10 weeks
Fig. 1.24: Established nonunion treated by in situ screw

fixation and bone grafting
27
ALGORITHM FOR MANAGEMENT OF LATERAL

CONDYLE FRACTURES
*MRI/arthrogram can be used to demonstrate hinge stability.
29
f. Medial Epicondyle Injuries
Fig. 1.25: Displaced medial epicondylar fragment
Common in children between 10 and 15 years.

Account for 10 percent of elbow fractures.
Usually a traction injury caused by valgus stress. The epicondyle is avulsed
from the medial condyle due to pull of flexor muscles (Fig. 1.25).
The elbow joint may dislocate, depending on increasing valgus force.
As the apophysis is mainly cartilaginous, the bony fragment appears small
on radiographs.
The epicondylar fragment may stay undisplaced or remain lying in the
joint, depending on the degree of soft tissue injury at the time of valgus
stress.
Ulnar nerve symptoms may be present at the time of injury.
Management
If fragment is undisplaced or minimally displaced (< 2 mm), immobilize
in an above-elbow cast, with the forearm in pronation for three weeks.
Open reduction and elbow arthrotomy is indicated if the fragment is
displaced or is trapped in the elbow joint. Fixation is achieved by K wire
or cannulated screw, depending on the size of the fragment (Figs 1.26A
and B).
B
Figs 1.26A and B: Displaced medial epicondyle fracture in a 9year-old girl. This required open reduction and internal fixation. Wires
were removed at six weeks
g. Medial Condylar Fractures

This is an extremely rare injury.
In any child less than 6 years with an epicondylar injury, always suspect
medial condyle fracture.
Since these are intra-articular fractures, internal fixation is required to
restore joint congruity (Figs 1.27 and 1.28).
Fig. 1.27: Displaced medial condyle fracture which was missed. Note the
established nonunion which required bone grafting and fixation
Fig. 1.28: Medial condyle malunion. Fragment has been

re-positioned and pinned
C. ELBOW REGION
i. Dislocations
Rare in young children.
Incidence increases after 10 years of age.
Classification
1. Posterior: (a) Posterolateral (b) Posteromedial (Fig. 1.29).
2. Anterior: Very rare.
3. Divergent: Also involves separation of proximal radioulnar joint.
31
Fig. 1.29: Posterior dislocation of elbow
Management
Differentiate between elbow dislocation and distal humerus fracture (Figs.
1.30 and 1.31).
Always assess neurovascular status before attempting reduction.
Always look for associated injuries: Medial epicondyle, radial head,
coronoid process and olecranon.
Closed manipulation is almost always successful and can be achieved
under sedation or with general anesthetic.
Nerve injury may occur in 10 percent, but recovery can still be expected
as usual.
Check post-reduction X-ray for position of medial epicondyle.
Assess neurovascular status after reduction.
Immobilize in a cast for about two weeks.
Open reduction is advisable if there is soft tissue interposition or if a
displaced bony fragment in the joint prevents accurate reduction.
Complications
Nerve injury: Ulnar and median nerve prone to injury.

Myositis ossificans.
Recurrent dislocation: Rare in children.
Elbow instability: Rare in children.
Median nerve entrapment: Undue pain after reduction and progressive
neurological loss. Matevs sign seen in late cases (impression of the nerve
on bone).
Ectopic calcification in joint capsule causing limitation of motion.
Recurrent dislocation, mainly due to medial instability.
33
Fig. 1.30: Radiocapitellar relationship is disrupted in elbow dislocations but

maintained in transcondylar fractures
Fig. 1.31: In transcondylar or supracondylar fractures the relationship

between capitellum and radial head axis is maintained
ii. Pulled Elbow

Common injury particularly in children < 5 years.
It is caused by radial head subluxation, when traction is applied to an
extended arm with the forearm pronated.
Recurrence is common in 30-40 percent of cases.
Management
Spontaneous reduction usually occurs in 24-48 hours if child is left alone.

Manipulation by rapid supination maneuver can be attempted.
Apply sling for comfort.
In rare cases, plaster immobilization for 2-3 weeks is required, especially
if there is recurrent dislocation.
iii. Radial Head and Neck Fractures
Common in childhood between 4 and 10 years (Fig. 1.32).

May involve epiphysis and metaphysis.
In neonates up to 15 degrees angulation is normal.
Radiographs must be carefully analyzed for other elbow injuries and
position of head fragment. Special oblique views may be required to
define anatomy.
Fig. 1.32: Fracture of radial neck with angulation
Late deformity depends on the degree of angulation/tilt and translation

at the fracture site.
Rare variety associated with posterior dislocation of the elbow which can
displace the head fragment and flip this piece through 180 degrees.
Open reduction generally associated with poor results.
35
Classification
Salter-Harris classification is commonly used. Type II and IV being the
commonest.
Based on degree of angulation of neck fragment: < 30, 30 - 60, >60
degrees (Fig. 1.33).
Translation is measured in millimeters. < 2 mm, 2 - 4 mm, > 4 mm.
Fig. 1.33: Different degrees of angulation in radial neck fractures
Management
For the minimally displaced fractures (< 2 mm translation, angulation
< 30) simple immobilization in a cast for two weeks is sufficient.
If angulation is > 30 degrees, closed manipulation should be attempted.
Often the angulation and displacement can be reduced to a satisfactory
position by direct pressure.
If angulation > 60 degrees and closed manipulation fails to restore stable
reduction, an open reduction through a lateral approach can be
attempted.
Fixation can be achieved with pins placed through the metaphyseal
fragment or with periosteal sutures.
Open reduction should not be attempted after 4-5 days, as delayed
surgery has high rate of complications.
Other techniques of reduction have also been described:
Use of intramedullary pre-bent K wire to rotate the radial head fragment.
Use of percutaneous wire as a joy-stick to reduce the fracture. Usually
two wires are required, one to stabilize and the other to push the fragment.
Use blunt end to wire of push (Figs 1.34A and B).
Even external pressure using the Eshmarch tourniquet bandage has been
successful.
Transcapsular reduction is performed after making skin incision. This
preserves the delicate capsule and periosteum and minimizes the
complication rate.
Avoid transcapitellar K - wire.
Fig. 1.34A: Joy stick technique of fracture reduction
Fig. 1.34B: Reduction complete with radial head fragment repositioned
37
Complications
Malunion, causing some loss of rotation.

Enlarged radial head.
Premature epiphyseal fusion causing cubitus valgus.
Open reduction can lead to myositis ossificans, synostosis and avascular
necrosis.
Nonunion in missed cases.
ALGORITHM FOR MANAGEMENT OF RADIAL HEAD FRACTURES
* MUA Manipulation under anesthesia
39
iv. Olecranon Fractures

Rare in children.
Commonly associated with other elbow injuries.
Fracture occurs through metaphyseal bone, apophysis and epiphyseal
plate.
Bipartite secondary ossification center may be mistaken for a fracture.
Fig. 1.35: Displaced olecranon fracture in a 6-year-old boy, treated by

internal fixation
Classification
Site of fracture: Metaphyseal, epiphyseal or apophyseal.
Based on fracture pattern: Transverse, Oblique, Comminuted
Intra-articular / Extra-articular.
Management
Most undisplaced fractures can be treated in cast with the elbow in 3040 degrees of flexion.
Displaced fractures need fixation with smooth pins and tension band
wiring to restore elbow stability (Figs 1.35 and 1.36).
Bioabsorbable pins with strong sutures are also a good option. This avoids
second surgery for metal removal.
Fig. 1.36: Comminuted olecranon fracture treated by

conventional tension band wiring principle
D. FOREARM (RADIUS AND ULNA)

Ossification: The distal radius ossification center appears at 6-12 months of
age and the ulnar center appears at around five years. Closure of the physeal
plate occurs usually around 14 years in girls and around 15 years in boys.
Any growth disturbance in the radius can lead to overgrowth of the ulna.
The maximum forearm growth and remodeling occur from the distal physis.
i. Radius and Ulna Fractures
Common in children after 5 years of age.
May involve one or both bones.
Always assess distal radio-ulna joint and proximal elbow joint (radiocapitellar).
No specific classification system but description of fracture is more
important.
Shaft fractures have a better prognosis in younger age, particularly distal
fracture with angulation less than 15 degrees.
41
Poor correlation between angular deformity and range of motion. A 10

angulation causes 20 limitation of rotation with no functional
consequences.
The remodeling potential depends on age at the time of injury, site of
fracture, degree of initial displacement and angulation.
Descriptive Features of Forearm Fractures:
Complete / Incomplete fracture.
Site of fracture-rule of thirds (proximal, middle and distal third fractures).
Amount of displacement (measured in percentage depending on width
of contact).
Amount of angulation (measured in degrees).
Direction of angulation (relation of distal fragment to proximal fragment
and not based on position of apex of angulation).
Integrity of distal radioulna joint and radiocapitellar joint.
Always assess rotation on radiographs (Figs 1.37 and 1.38).
Fig. 1.37: Concept of rotation: The bicipital tuberosity is 180 to

the radial styled on an AP view
Fig. 1.38: Relation of

bicipital tuberosity to hand
position: In supination, midprone and full pronation.
Accurate alignment must be
preserved to prevent deformity
Management
Depends of description of fracture pattern
Some guidelines have been proposed for closed treatment:
Complete greenstick fractures by overcorrecting deformity.
For volar angulation: Reduce by pronating the wrist (Fig. 1.39).
For dorsal angulation: Reduce by supinating the wrist (Fig. 1.40).
Prevent refracture by completing fracture during reduction.
Shortening with normal alignment and rotation is acceptable.
Bayonet apposition is acceptable if no rotation persists.
Maintain interosseous space and avoid any coronal plane angulation.
Monitor serial radiographs for the first three weeks.
Re-manipulate if there is progressive loss of position or if there is any
doubt about alignment.
Greater degree of angulation is acceptable in distal third fractures
Correction of metaphyseal fractures occurs at the rate of one degree
per month for two years. Average remodeling rate is 4.4 degrees per
year for mid-shaft fractures and 8.6 degrees per year for distal fractures.
Cast required for at least six weeks to prevent risk of refracture.
Fig. 1.39: Volar apex indicates a supination injury. Correct deformity by reversing
the force, i.e. pronate the distal fragment to restore rotational alignment
Fig. 1.40: Dorsal angulation is due to a pronation force and needs reversing of
deformity by supinating distal fragment
Acceptable limits of closed reduction for mid-shaft fractures
< 8 years
> 8 years
Displacement
Angulation
Rotation
Complete
Complete
15 degrees
10 degrees
45 degrees
30 degrees
43
Indication for open reduction and fixation:

open fractures.
presence of compartment syndrome.
soft tissue interposition (Fig. 1.41).
refracture with displacement.
when satisfactory alignment cannot be achieved by closed means.
Fig. 1.41: Displaced fracture of the forearm in a 9-year-old boy treated by flexible
intramedullary nails
Complications
Malunion (Fig. 1.42) and Malrotation (Fig. 1.43)
Re-displacement causing loss of reduction
Cross union, a rare complication, may occur following surgery and
repeated attempts at fracture manipulation.
Refracture.
Neurovascular injury.
Compartment syndrome.
Following open reduction scars, infection,
iatrogenic neuropathy,
and refracture, may
occur.
Fig. 1.42: Fractures tend to
displace in cast, hence, weekly
radiographs required to
prevent malunion
Fig. 1.43: 90 rotational malalignment in a midshaft fracture
ii. Dislocation of Radial Head

Isolated dislocation is rare.
Types: Congenital.
Traumatic.
Usually associated with ulna fracture that may be greenstick or may have
undergone plastic deformation. If a straight edge does not fit the ulna,
then it is bowed (Fig. 1.44).
Fig. 1.44: Isolated radial head dislocation. Look for the ulna bow with a straight ruler
Diagnosis based on careful interpretation of radiographs.

The classical sign Line drawn through radial head/shaft must cross the
capitellum in the lateral view in any position of elbow flexion must always
be sought (Fig. 1.45).
45
Congenital dislocation may be bilateral, there is adaptive malformation

of the radial head and capitellum and there is limitation of forearm
rotation.
Fig. 1.45: A line drawn along the radius axis will pass through the capitellum
in any position of elbow flexion
Management
True isolated acute traumatic dislocations can be reduced by closed
manipulation. Supination of the forearm and flexion of the elbow joint
may be sufficient to achieve reduction.
Always confirm reduction on radiographs.
iii. Monteggia Fracture-Dislocation
Defined as fracture of proximal ulna with dislocation/subluxation of radial
head (Fig. 1.46).
Any ulna fracture should arouse suspicion of a Monteggia injury
Common injury occurring around 7-10 years age
Fig. 1.46: Type I Monteggia fracture with anterior dislocation of radial head
Fig. 1.47: An old Monteggia fracture with anterior dislocation of radial head.
Ulnar fracture has healed
Always assess integrity of wrist joint.

Always draw a line along the radius to check that it crosses the center of
the capitellum.
Classification
Based on direction of angulation at fracture site and position of radial head:
Type (1) Anterior angulation with anterior dislocation of radial head.
Type (2) Lateral angulation with lateral dislocation of radial head.
Type (3) Posterior angulation with posterior dislocation of radial head.
Type (4) Fracture of proximal radius-ulna with anterior radial head dislocation
Monteggia Equivalents
Isolated radial head dislocation.
Fracture of olecranon with radial head dislocation.
Fracture of ulna and diaphysis of radius with anterior dislocation of radial
head.
Management
Depends on direction of ulna angulation and direction of radial head
dislocation.
The goal is to stabilize the reduced radial head by anatomic reduction of
the ulna. Open reduction of the radial head is seldom needed in acute
cases.
47
For anterior or volar apex displacement: Closed manipulation with the

forearm in supination is usually successful in obtaining a reduction. The
elbow should be flexed beyond 90 degrees to relax the biceps tendon
and a cast applied to maintain the reduction.
Serial radiographs taken at one week intervals for 2 to 3 weeks are advised
to check the ulna alignment and the position of radial head.
For posterior or apex dorsal displacement: Closed manipulation with the
elbow in extension is required to maintain the position of the radial head.
Always check stability of radial head after reduction in different positions
of the elbow.
Open reduction is indicated, if attempts to maintain reduction by closed
means are not successful. If the ulna fracture is transverse, consider using
an intramedullary device to hold it. If the fracture is oblique and has
potential to shorten, use plate fixation.
Delayed presentation or missed Monteggias lesion:
In a chronic Monteggia lesion, the original cavity of the radiocapitellar
joint fills with fibrous tissue and the radial head becomes misshapen (Fig.
1.47).
Open reduction with an ulnar lengthening osteotomy is generally indicated
to obtain stable reduction of the radial head. This may be combined
with annular ligament reconstruction obtained from the triceps fascia
(Bell Tawse) or forearm fascia (Papendrea and Waters). Ligament
reconstruction can lead to loss of forearm pronation and hence it is
advisable to immobilize the forearm in neutral position in the postoperative
period (Fig. 1.48).
Usually after three years the dislocated radial head becomes distorted
and overgrown making reduction difficult and if not impossible.
In difficult situations even a radial shortening osteotomy may be required
to ensure reduction of radial head.
Complications
Malunion of ulna predisposing to recurrent radial head subluxation or
dislocation.
Injury to posterior interosseous nerve may occur as it is displaced by
dislocated radial head.
Ectopic bone formation and ankylosis may occur following surgery.
In late or missed cases, the radial head or capitellum may be deformed:
a poor result ensues even after reduction.
Fig. 1.48: Old untreated Monteggia fracture in a 7-year-old boy. This was treated
with proximal ulnar osteotomy and annular ligament reconstruction
iv. Galleazzis FractureDislocation

Defined as a fracture of the lower third of the radius with distal radioulna joint (DRUJ) disruption (Fig. 1.49).
As in Monteggia injury, there may be variants and fracture may involve
the distal ulna physis or metaphysis.
Wrist radiographs must be carefully inspected for DRUJ injury. A true
lateral radiograph may be required to see ulna head subluxation/
dislocation.
49
Fig. 1.49: Displacements produced by muscle

forces in a typical Galleazzi fracture dislocation
Management
Closed treatment is sufficient in undisplaced cases. Use long arm cast
and the forearm is maintained in supination after reduction (Fig. 1.50).
If any displacement of the radius precludes reduction of the distal radioulnar joint and hence consider closed manipulation with percutaneous
fixation, or even internal fixation to restore stability to the joint.
Fig. 1.50: Galleazzi fracture in a 9-year-old boy treated by

closed manipulation and casting
v. Distal Radial Fractures and Epiphyseal Injury

Constitute 20 percent of childrens fractures.
Salter-Harris type 2 fractures are most common (Fig. 1.51)
Type 3 and 4 injuries are rare and by definition involve the articular
surface.
The fragment is displaced dorsally and has a metaphyseal spike.
There may be associated fracture of the ulna styloid/epiphysis.
Potential for growth arrest exists
Growth arrest seen with severe injury or with repeated manipulations
and with open fractures.
Fig. 1.51: Salter-Harris Type II fracture in a 7-year-old boy.

This was treated by gentle manipulation. Avoid repeated
attempts as this will damage the growth plate
Management
Governed by the amount of displacement and angulation of the physis.

Closed manipulation is almost always successful.
Complete remodeling is seen in children up to 10 years of age.
About 50 percent apposition and 20 degrees angulation is acceptable.
Incomplete remodeling in dorso-volar plane does not effect wrist motion
or grip strength.
Radial deviation of the radius fragment > 15 degrees causes loss of
motion.
Repeat manipulations can lead to epiphyseal damage and growth arrest.
Observe symmetry of Park-Harris lines as the bone remodels.
Displaced metaphyseal fractures usually require stabilization to prevent
malunion (Figs 1.52A and B).
51
Fig. 1.52A: Displaced distal radial fracture
Fig. 1.52B: Fixation with cross K - wires
Treatment of growth arrest:

Difficult to identify early on.
Arrest of distal radius more common.
Results of bar excision are unpredictable.
Equalization procedures are more effective such as, ulnar shortening,
ulnar growth arrest or radial lengthening.
E. HAND AND WRIST FRACTURES

Ossification centers of the hand and carpus:
In neonates no secondary ossification centers are present in the carpus.
The capitate is the first bone to ossify at around 4 to 5 years of age.
Ossification thereafter involves the scaphoid and other carpal bones.
Lunate, Scaphoid and Pisiform have more than one center of ossification
The metacarpal ossification is variable. The second (index) metacarpal is
first to ossify, followed by the third (middle), fourth(ring) and fifth(little)
metacarpal. The first (thumb) metacarpal is the last to ossify and is the
only physis that is situated proximally.
i. Hand Injuries
Distal phalanx commonly involved in finger tip injuries.
Always assess extent of soft tissue injury, any associated tendon injury
and neurovascular status.
Ligaments are stronger than bone, hence physeal injuries more common
(Fig. 1.52).
Encourage early controlled motion to prevent dystrophic changes and
hand stiffness.
Malrotation will not remodel completely.
Callus is not seen before 3 months in shaft fractures.
Function of thumb with angular or rotational deformity is usually not
impaired.
Management
In finger tip injuries, repair of nail bed with absorbable sutures usually
suffices.
Use nail as scaffold to protect repair.
Physeal fracture of distal phalanx are similar to Mallet injuries and most
can be managed by closed techniques (Fig. 1.54).
Physeal injuries of the proximal phalanx are the common and need
closed reduction by maximally flexing the MCP joint to stabilize the
proximal fragment. Angulation up to 25 degrees in acceptable in the
plane of the joint.
In metacarpal and phalangeal shaft fractures, assess for shortening,
displacement, angulation and malrotation. Rotation must be assessed
clinically by noting the orientation of the nail beds of adjacent fingers.
53
Fig. 1.53: Various types of epiphyseal injuries of the metacarpals and phalanges
For metacarpal fractures, angular and rotational deformities should be

corrected. Accept 30 degrees of volar angulation in ring and small
metacarpal, upto 20 degrees in others. A 30 degrees thumb abduction is
an acceptable deformity.
Follow-up weekly for 3 weeks and re-manipulate fracture in sticky phase
if there is loss of alignment.
Adequate splinting usually results in uncomplicated healing.
Rotational malalignment is poorly tolerated and may need corrective
osteotomy to restore function.
Intra-articular (condylar) fractures need stable fixation and controlled
motion to achieve good function. Always take oblique (Brewerton) Xrays for proper assessment.
Metacarpal neck fractures, particularly in the little finger, can lead to loss
of knuckle prominence but this rarely compromises function.
ii. Phalangeal Fractures
Corner fractures: If more than 2 mm displacement and more than 10% of
the surface area, consider ORIF. Beware of 180 degrees displacement of the
fragment (Fig. 1.53).
Fig. 1.54: Type II Salter-Harris injury (Mallet equivalent)
PIP fracture dislocation: If stable early motion. If unstable but reducible,

apply traction device and early motion (Banjo brace, Ex fix, K wire and
rubber bands).
Distal tuft fractures: Open (Seymour fracture): Replace nail plate and splint,
rarely needs pinning.
Dislocation of CMC joints: Closed reduction and pinning may be required.
Thumb joint may need ORIF.
Bennett fracture may be seen as type II epiphyseal separation of the base of
metacarpal. Closed reduction is successful and considerable remodeling will
occur. Closed reduction and pinning is required if there type III injury and
articular incongruity.
iii. Ulnar Collateral Ligament Avulsion Fracture
More than 2 mm displacement, ORIF with pin.
Beware of 180 degrees rotational deformity of even a very small fragment.
iv. Radial Collateral Ligament
Cast treatment. ORIF rarely required.
v. Metacarpophalangeal and Interphalangeal Dislocations
Caused by hyperextension of the involved digit.

MCP dislocation more common than IP dislocation.
Majority of them can be reduced by closed manipulation (Fig. 1.55).
Complex dislocation (associated fracture, soft tissue entrapment) require
open reduction.
55
Fig. 1.55: MCP dislocation of the great thumb following a hyperextension injury.
This was treated by closed manipulation and casting for 4 weeks
Fig. 1.56: Scaphoid fracture treated by open reduction and fixation with
Herbert screw
vi. Scaphoid Fracture

Uncommon in children and mainly involve the distal pole.
Majority can be treated with cast immobilization.
Fractures through the waist can be associated with nonunion and hence,
need fixation.
As in adults, treat displacement more than 2 mm with ORIF (Fig. 1.56).
2
Spine Fractures
58
PEDIATRIC FRACTURE MANAGEMENT
DEVELOPMENT OF SPINE
Ossification
Separate center present for lateral mass of Atlas vertebra (C1).
In 20% of children, the anterior arch of Atlas may not ossify upto one
year of age, and ossification of posterior arch may not be complete
(radiological spina bifida).
Posterior arch closure occurs by four years of age.
Axis vertebra (C2): Separate ossification center present for body and
dens. This junctional synchondrosis disappears around 5-7 years of age.
Dens may remain bifid up to 3-4 years because of incomplete fusion.
Secondary ossification center develops at the tip of dens around 7 years
of age and fuses by 10-12 years.
In the remaining vertebrae, ossification (C3-L5) occurs from three centers.
One for the body (centrum), and two for the neural arches. Secondary
ossification centers appear at the tips of spinous and transverse processes
and also in the vertebral body apophysis (ring apophysis).
Spine Fractures: Pecularities in Children
Fracture and dislocations of the spine are rare in children.
Cervical spine injuries are more common because of the large head size
relative to the body.
Fractures must be distinguished from epiphyseal lines especially in the
cervical spine.
Always look for second fracture when one spine fracture is discovered.
Capsule and ligaments of facet joints are lax allowing considerable motion.
Facet joint orientation in cervical spine changes with maturity. Inclination
increases from 30 to 60. Hence, increased translation seen in the
immature spine.
As the injuries occur in the developing skeleton, there is potential for
remodeling and growth disturbances in the spine.
Large amount of displacement and angulation is possible in the pediatric
spine and occult fractures with spinal cord injury can occur (SCIWORA
Spinal Cord Injury Without Obvious Radiological Abnormality).
End plate injuries of the vertebral body are seen as widening of disk
space and soft tissue swelling if the secondary ossification center is not
present (6-12 years).
Apparent sub-axial (C2-C3) subluxation may be seen in 25 % of cases
especially in children less than 7 years. Up to 4 mm translation is normal
at C2-C3 and C3-C4 levels.
Cervical spine radiographs need careful interpretation and knowledge
of anatomical landmarks (Figs 2.1A and B)
SPINE FRACTURES
59
Normal anterior wedging of vertebrae may be mistaken for compression

fractures.
Radiologic Classification
No universally acceptable classification available to guide treatment.
Imaging studies show fracture morphology and may provide a clue to
mechanism of injury.
Radiological Feature
Mechanism of injury
Wedging of vertebral body

Unilateral / Bilateral facet dislocation
Widening of space between spinous processes
Fragment seen at Anterior-inferior edge of body
Compressive flexion
Flexion Rotation
Flexion Distraction
Hyperextension
Management
Clinical examination according to advanced trauma life support protocol.
Accurate record of the neurological status.
Radiological assessment with CT / MRI scans to define extent of bony
and soft tissue injury.
Treatment depends on type of injury.
For cervical spine fractures: Halo fixation, head halter traction or cranial
traction may be required depending on the
level of injury and age of child. In younger
childrens, more pins are required to get
stability of the halo ring.
SPECIFIC INJURIES
F. Cervical Spine
Fig. 2.1A: Relationship of various lines in the lateral

cervical spine radiograph. Note: The lines are parallel
in sagittal profile
60
Fig. 2.1B: Importance of various lines in the upper cervical spine radiograph
Chamberlains line is most easily reproducible to detect basilar invagination
ADI ( Atlanto-Dens interval) is 2-4 mm in normal radiographs
SAC ( Space available for cord) is usually more than 13 mm
i. Rotatory Subluxation of Cervical Spine

This may occur after a minor injury. It may be temporary because of muscle
spasm or fixed because of bony injury. Treatment with head halter traction,
till muscle spasm subsides, may be used and occasionally, reduction under
sedation may be required in severe cases. If symptoms persist, an in situ
fusion is advisable.
Fig. 2.2: Types of rotatory subluxation
Types of rotatory subluxation (Fig. 2.2)

Type A: Anterior rotatory fixation with no displacement (Fig. 2.3).
Type B: Anterior rotatory fixation with 3-5 mm displacement.
Type C: Anterior rotatory fixation with more than 5 mm displacement.
Type D: Rotatory fixation with posterior displacement.
SPINE FRACTURES
61
Fig. 2.3: Type A rotatory subluxation of the cervical spine in a 9-year-old girl
ii. C1: Fractures of the anterior and/or posterior arch (Figs 2.4 and
2.5).
Fig. 2.4: Fracture may involve anterior, posterior or both

depending on the mechanism of injury
Fig. 2.5: The atlas may get impacted by the occipital condyles
62
Fig. 2.6: Fracture dislocation of C2 over C3
iii. Dens Fracture

Rare in children.
Associated with major trauma (Fig. 2.6).
Missed cases may present with unstable cervical spine (child holding /
supporting head).
Pain with hyperextension of the neck may be indicative of dens fracture.
Avascular necrosis and nonunion are rare in children.
Management
Undisplaced fracture: Bed rest, cervical traction and a rigid collar are
usually sufficient.
Displaced fracture needs reduction under sedation and halo application
or Minerva cast, depending on the age of the child.
C1-C2 fusion may be required in displaced fractures and in cases of
nonunion.
iv. Fracture Dislocation of Subaxial Spine
Ligamentous laxity allows facet displacement which can be unilateral or
bilateral (Fig. 2.7).
Locked facets my present as fixed rotational deformity.
Posterior ligament disruption may occur in severe injuries.
Anterior compression fracture may be associated with facetal dislocation.
Management
SPINE FRACTURES
63
95% cases treated by non-operative means.

Occasionally closed reduction may be achieved and maintained using
halo traction or cervical tongs. Healing is usually uncomplicated and
posterior fusion may be rarely required for instability.
Burst fracture have potential for developing late kyphosis deformity.
Posterior decompression with laminectomy should be avoided, as this
increases the potential for future instability.
v. Cervical End-plate Injury
Fig. 2.7: Anterior compression fracture (left) and fracture subluxation (right).
In bifacetal dislocation, the anterior translation is more than 50 percent
Rare injury caused by sudden hyperextension of the neck.

Injury often involves the inferior end-plate which may or may not be
ossified. (Ossification of the end-plate occurs at around 10-12 years of
age.
Usually a type III or a type I injury of the growth plate.
Multiple level involvement is possible.
Occasionally, the fragment may be seen on good quality radiographs
and an MRI scan is usually required.
64
Halo Fixation
Essential component of cervical spine injury management.
Halo fixation pins should be inserted in the anterolateral and posterolateral
regions of the skull. Direct lateral and anterior placement should be
avoided because of the thin calvarium of the child.
Ideally 6-8 pins must be used to prevent pin loosening and infection.
Avoid over distraction when used in conjunction with traction or vest.
Complications include pin track infection, dural penetration, nerve injury
and brain abscess.
G. THORACOLUMBAR SPINE FRACTURES
Most result from major accidents.
Always rule out associated chest and abdominal injury.
Fractures can reduce spontaneously, hence, the injury may be less
apparent on radiographs.
Wedge compression fractures usually seen in thoracic spine.
Thoracolumbar junction more prone to injury due to increased motion
at this area. Flexion-rotation injury can lead to fracture/dislocations which
are unstable.
Instability of thoracic spine depends on the extent on ligamentous and
chondro-osseous injury (Fig. 2.8).
Fig. 2.8: Burst fracture of thoracolumbar spine.

In burst fracture, the middle column is disrupted
SPINE FRACTURES
65
i. Chance Fracture
Horizontal shear injury commonly seen in the T12-L2 area.

Associated with seat belt injury.
Assess abdominal injury.
These injuries involves all three columns through bone or soft tissues.
Usually unstable and requires instrumentation to restore stability (Fig.
2.9).
ii. Burst Fractures

Seen with severe trauma.
There is disruption of vertebral body and end plate causing instability.
Aim is to achieve mechanical stability and prevent further neurological
damage (Fig. 2.10).
Fixation should be considered to restore alignment and stability and
provide optimum environment for neurological recovery.
iii. Endplate Injuries (Apophyseal injuries)
Seen in young adults or adolescents engaged in sports, weight-lifting
and gymnastics.
Common in the lumbar spine.
CT / MRI may be required to delineate these injuries.
May cause nerve root or cord compression.
The displaced fragment may ossify and present as a hard disk causing
spinal stenosis.
Operative intervention may be required if there is spinal stenosis and
neurological deficit.
Management
Bed rest suffices for most stable injuries.
An hyperextension cast or brace can be used for wedge compression
injury after 3-4 weeks of rest.
Operative decompression may be required to restore mechanical stability
and prevent neurological compromise in some cases.
Thoracolumbar fractures are usually unstable and require early fusion
Burst fractures require anterior column reconstruction and restoration of
posterior tension band by instrumentation.
Compression fractures can lead to late kyphosis, hence follow-up is
warranted until skeletal maturity.
66
Fig. 2.9: Unstable Chances fracture at L2-L3 level in a 14-year-old boy.

Flexion view revealed instability which was treated by posterior instrumentation
Complications
Neurological injury.
Deformity: More than 30% compression can lead to late kyphosis and
back pain due to instability.
Back pain.
SPINE FRACTURES
Fig. 2.10: Burst fracture in a 12-year-old girl. Note the

disruption of middle column on CT scan. She was treated
with bed rest and orthosis. Fracture remodeling seen in
radiograph one year later
67
3
Pelvic Ring
Fractures
PELVIC RING FRACTURES
69
PELVIC FRACTURE
Uncommon in children.
Association of severe trauma with visceral injury is more common in
children than in adult injuries.
The immature bone in a childs pelvis is more porous allowing for plastic
deformation and greenstick injuries.
Because of joint laxity, the pelvis bone can undergo major distortion
without fracture and single fractures can also occur in the pelvic ring.
Displaced ramus fracture can hinge at the triradiate cartilage.
Growth plates can also be injured causing late deformity.
Ossification
Each hemipelvis comprises of three secondary ossification centers which
coalesce to form the triradiate cartilage (ilium, ischium and pubis).
The three arms of the triradiate cartilage meet in the center of the
acetabulum.
The secondary ossification commences in the periphery.
Ossification centers are also present at the margins of the acetabulum
Fusion of the triradiate cartilage occurs around 14 years in girls and
16 years in boys.
The secondary center for the iliac crest appears around 13 years and
advances from anterior to posterior direction, and fusion occurs at around
17 years of age.
Fig. 3.1: Disruption of the pelvic ring with fracture of pubic rami
Classification
Tarode and Zieg: Based on fracture pattern:
A. Stable fractures: Pelvic ring is intact.
B. Unstable fractures: Disruption of pelvic ring (anterior, posterior, or both)
(Fig. 3.1)
70
C. Fracture of the acetabulum involving the triradiate cartilage (Fig. 3.2).

D. Avulsion and apophyseal fractures.
Fracture Pattern Depends on the Mechanism of Injury
Anterior-Posterior compression injury

Lateral compression injury
Shear injury
Combination of forces.
Stability of pelvic ring: Depends on the bony configuration of each hemipelvis

and the integrity of its ligamentous attachments.
Stable injuries have no disruption of the ligaments and the hemipelvis is
not displaced.
Rotational instability occurs when there is anterior (bony or ligamentous)
disruption and only the posterior ligaments remain intact.
Vertical instability occurs because of shearing injury and the entire
hemipelvis moves proximally suggesting both anterior and posterior bony
or soft tissue disruption.
Diagnosis may be made with plain radiographs. Imaging studies should
include inlet and outlet view. Assess pelvic symmetry by Keshishyans
method.
Keshishyans method: Using
a true AP pelvic X-ray,
diagonal lines are drawn
from the lowest point of
each sacroiliac joint to the
contralateral triradiate
cartilage. Line lengths are
compared as a ratio. In a
normal child the lines are
within 4 mm of each other.
CT scan with reconstruction
gives accurate imaging of
the extent of posterior injury
and any associated fractures.
Fig. 3.2: Types of injury to the
triradiate cartilage. Digital/highresolution radiographs and CT scan
is required to diagnose these
injuries
71
Management
Usually conservative, operative intervention may be required in unstable
fractures.
For unstable, open book type anterior injuries with hemodynamic
compromise, an external fixator may be required. In children and
adolescents the fixation pins are inserted in the bare area between the
antero superior iliac spine and anterior-inferior iliac spine to avoid the
growth plate.
Femoral traction can be used when there is vertical displacement of the
hemipelvis or with rotationally unstable injury presenting with limb length
discrepancy.
Limited internal fixation, either across the symphysis or sacroiliac joint,
can also be used if there is gross instability, and in individuals with
polytrauma.
Complications
Acute hemorrhage and hypotensive shock.

Neurological injury.
Genitourinary injury.
Limb length discrepancy.
Malunion.
H. AVULSION FRACTURE OF THE PELVIS

Common avulsion sites in the bony pelvis
are the sites of major musculotendinous
attachments (Fig. 3.3).
ASIS (Anterior superior iliac spine)
Sartorius (32%).
AIIS (Anterior inferior iliac spine)
Rectus femoris (18%).
Ischial tuberosity
Hamstrings / Adductor magnus (38%).
Fig. 3.3: Sites of avulsion fractures of the

pelvis due to abnormal muscle pull
72
Mainly seen in adolescents and those engaged in sports activities.

May occur as acute injury or because of repetitive stress.
Avulsion may occur prior to secondary ossification through the chondroosseous area.
Management
Usually conservative
Occasionally large ischial/ilial spine fragment may need internal fixation
if displaced > 2 cm.
I. ACETABULAR FRACTURES
Can occur with pelvic fractures or with/without hip dislocation.
Injury to the triradiate cartilage can be overlooked, hence, the need for
high-resolution radiographs or CT scan (Fig. 3.4).
Premature closure and late bony bridge formation of the triradiate cartilage
can cause acetabular dysplasia and subluxation of femoral head.
Fig. 3.4: Pelvic injury can involve the triradiate cartilage as

shown on this CT scan
Classification
Peripheral: Anterior/ Posterior rim or wall.
The extent of these fractures depends on the ossification of the peripheral
rim.
Central: Triradiate injury.
Suspect if ramus fracture is displaced, as the fragment can hinge at the
triradiate cartilage.
73
Management
Conservative treatment is sufficient in most undisplaced fractures.
Large bony fragment needs internal fixation to preserve joint stability
Intra-articular fragments needs arthrotomy and fixation depending on
size/site.
Traction can be used to reduce displaced fragments to < 2 mm.
4
Fractures of the
Lower Extremity
FRACTURES OF THE LOWER EXTREMITY
75
J. HIP DISLOCATION
Majority (85%) are posterior dislocations.
Hip dislocations can occur without radiological evidence of acetabular
fracture because of pliable cartilaginous components and labrum
Younger children (< 7 years) require less trauma than older children for
hip dislocation because of lax ligaments, chondrous acetabulum, and
pliable cartilage.
10-14 % cases have associated fractures (acetabulum, femur)
Assess neurological status pre-and post-reduction (sciatic nerve)
High resolution radiographs /CT scan required to assess intra-articular
injury/acetabular rim fragments.
MRI scan to assess labral tears.
Poor results associated with an older child with severe trauma, or due to
delay in reduction and incongruous reduction.
Classification
Depends on the direction of dislocation (position of the femoral head relative
to the pelvis).
Posterior - 87%.may be associated with acetabular rim fractures.
Anterior 5 %.
Central 7%.
Inferior 1 %.
Stewart-Milford classification of hip dislocation with acetabular fractures
I. Minor rim disruption.
II. Major rim disruption causing hip instability.
III. After reduction, fracture neck of femur or head of femur visualized on
radiographs.
Management
Early reduction (within 6 hours).
Post-reduction: Hip should be stable with good range of motion.
Post-reduction radiograph should show concentric hip joint. Any joint
asymmetry should arouse suspicion of intra-articular soft tissue or
osteocartilaginous fragment entrapment.
Always assess sciatic nerve function after hip joint reduction.
Open reduction is advisable in delayed presentations in, irreducible and
incongruous reduction, in unstable reduction, and any associated major
rim fracture of the acetabulum.
76
In children < 6 years use Hip Spica for 4-6 weeks.

In older children, bed rest for three weeks, followed by partial weight
bearing for three weeks. Avoid hip flexion > 60 degrees if there is
associated posterior wall fracture.
Bone scan is not a consistently reliable technique for predicting epiphyseal
necrosis. MRI may be useful only in late cases (after one year)
Asymptomatic coxa magna in excess of 2 mm compared to opposite side
may be seen in young children following the dislocation.
Complications
Avascular necrosis: (Incidence 4-10 %) persistent joint irritability, stiffness
and pain may herald onset of AVN of femoral head. Radiographic
evidence seen in six months in symptomatic cases. Incidence increases
with age. MRI is sensitive to detect early changes.
Sciatic nerve injury: (Incidence 8-10% in adults) approximately 5%
incidence in children. Majority show spontaneous recovery. Neurolysis is
advisable if no improvement seen in 3-6 months.
Recurrent dislocation: Seen in young children (< 7 years). May be
associated with inadequate soft tissue healing, or missed rim fractures.
Chondrolysis of hip joint.
Myositis ossificans is rare in children in adults incidence is 5-15%.
Incongruous reduction.
Late osteoarthritis.
K. FEMUR FRACTURES (PROXIMAL, SHAFT AND DISTAL FEMUR
FRACTURES)
Commonly occurring long bone fracture.
Pathologic fractures can occur with minimal trauma.
The femur is circumferentially surrounded by muscle compartments which
provide good vascularity and a better healing potential.
The muscle forces at different levels determine the extent of displacement
of the fracture fragments.
Union is not a problem and treatment must be directed at preventing
malunion.
Proximal femoral epiphysis is vulnerable to ischemia.
The proximal femoral epiphysis and the trochanteric apophysis are
covered with cartilage and are in continuity posteriorly-superiorly. The
vascular channels also course in this direction. Growth of this cartilage
increases the diameter of the femoral neck and decreases the femoral
neck anteversion (Fig. 4.1).
77
The distal femoral physis contributes 70% to the length of femur, and
40% to the length of the leg.
Proximal physis contributes 15% growth to the lower extremity.
Fig. 4.1: Growth and development of the proximal femur
Ossification
Secondary ossification of the proximal epiphysis appears between 4-6
months and this ossific nucleus increases in size.
Ossification in the greater trochanter begins at 5-7 years and fuses at
around 16 years.
Apophysis of the lesser trochanter seen during adolescence and fusion
occurs around 17 years of age.
Distal femoral epiphysis is present at birth, and fusion occurs around 15
years in girls and 17 years in boys.
Distal femoral physis is undulated in shape and this allows for better
stress distribution.
i. Proximal Femur Fractures
Classification of femoral neck fractures depends on the location of the fracture
line. (Delbet / Colonna) (Fig. 4.2)
I. Transepiphyseal through the physeal plate of cartilage.
II. Transcervical through the femoral neck.
III. Cervicotronchanteric through base of neck.
IV. Intertrochanteric through the intertrochanteric line (between the lesser
and greater trochanters).
78
Type I:
Transepiphyseal
Type II: Transcervical
Type III: Cervicotrochanteric fracture

Fig. 4.2: Types of proximal femur fractures
Management
Early treatment for type I and type II injuries (within six hours) reduces
incidence of avascular necrosis.
Perform gentle reduction maneuvers and avoid excessive attempts at
closed reduction.
During operative treatment, perform anterior capsulotomy to decrease
tamponade effect; this may help reduce incidence of AVN.
Closed reduction and spica casting is required for undisplaced fractures,
and if Pauwels fracture angle is < 40 degrees. Ensure there is no varus
malalignment at the fracture site.
Closed reduction and percutaneous fixation with cannulated screws is
advisable for displaced fractures, and in cases, where the Pauwels fracture
angle is > 40 degrees (Fig. 4.3).
Open reduction if closed reduction fails.
79
Fig. 4.3: Transcervical fracture in a 13-year-old girl. This was treated by closed
reduction and percutaneous fixation with two cannulated screw. An anterior
capsulotomy was also performed. Follow-up X-rays at six months show good union
Tips during surgery:

Avoid fracture distraction.
Avoid joint transgression with implants.
Femoral neck hard enough to hold fixation, and central placement of
implant gives good purchase.
Choice of fixation depends on the age of the child: For children < 3
years use smooth pins and for older children use smooth pins or
cannulated screws. In a adolescents, a 6.5 mm cancellous screw can
be used.
Avoid crossing the physis with threaded pins or DHS.
Use 6-8 weeks of spica cost to protect the fixation.
80
Complications
Avascular necrosis of femoral head: Related to severity of injury, initial
displacement, timing of treatment and adequacy of reduction. Rate of
AVN is highest for type I injury (>80%), for type II it is 40%, and for type
III and IV 10% and 3% respectively (Fig. 4.4).
AVN classified by Ratliff: Type I: Total involvement of epiphysis.
Type II: Involvement of epiphysis and neck fragment. Type III: Total
involvement of epiphysis, neck and metaphysic. Type IV: Metaphyseal
involvement, but epiphysis intact (Fig. 4.5).
Lower incidence with age <10 years. Usually seen by 6-12 months
on radiographs.
If there is segmental collapse of the femoral head, consider vascularized
fibula graft, or rotational osteotomy, depending on the extent of involvement of the femoral head.
Fig. 4.4: Avascular necrosis of femoral head seen after treatment
Fig. 4.5: Types of AVN of the proximal femur as described by Ratliff
81
Malunion: Coxa vara deformity is the commonest and may occur because
of loss of position after reduction, or because of premature fusion (23%)
and avascular necrosis of physis.
In a young child, if the neck-shaft angle is >120 degrees, this will
remodel. If angle is about 110 degrees, this will not remodel completely
and a valgus osteotomy should be considered.
Limb length discrepancy (LLD) can occur because of premature growth
arrest and coxa vara. It depends on the amount of growth remaining. A
LLD of 2 cm is seen in approximately 13 percent of cases. LLD is more
severe in a very young child and with AVN.
Delayed union commonly seen with transcervical type fractures, if Pauwel
angle is more than 60 degrees and if the fracture is fixed in distraction. To
achieve union, valgus osteotomy and bone grafting are advisable.
ii. Subtrochanteric Fractures
Rare in children.
Common with pre-existing pathological bone lesions.
Displacement of fragments influenced by muscle attachment.
Proximal fragment is flexed, abducted and externally rotated and the
distal fragment is adducted and extended (Fig. 4.6).
Treatment is directed mainly to overcome the deforming forces of the
muscles.
Fig. 4.6: Subtrochanteric fracture due to road

accident in a 7-year-old boy
82
Management
The aim is to avoid malunion, both angular and rotational.
Avoid varus of the proximal fragment.
Alignment can be achieved and maintained by traction (90-90), hip spica,
external fixation, plates and screws, and flexible nail.
Choice of treatment depends on the age of child.
10-15 mm shortening acceptable in children below ten years of age.
iii. Femoral Shaft Fractures
Highest incidence between 2 and 5 years.
Always take radiographs of the hip and knee joint to exclude other injuries.
Classification
Descriptive terminology used rather than specific classification:
Complete / Incomplete fracture.
Site of fracture rule of thirds (proximal, middle and distal third fractures)
Type of fracture (spiral, transverse, oblique, comminuted).
Amount of displacement (measured in percentage depending on width
of contact).
Amount of angulation (measured in degrees).
Direction of angulation (based on relation of distal fragment to proximal
fragment, and not on the position of apex of angulation).
Management
Factors that influence treatment:
Age, size and weight of the child.
Level of fracture and whether it is an open or closed injury.
Any underlying bone pathology or neuromuscular status (e.g. cerebral
palsy, myelomeningocele, poliomyelitis).
Multiple injuries.
Principles of treatment
Choose simplest treatment that will give optimum results.
Absolute anatomical reduction is not necessary.
Assess rotational and longitudinal alignment.
The aim is to prevent malunion and gross LLD.
Acceptable shortening is 10 mm in children > 10 years, and ~ 15 mm in
children < 10 years.
83
Acceptable malunion in any plane is ~ 10 degrees in child > 10 years.

Acceptable malunion in any plane is ~ 15 degrees in child < 10 years.
Remodeling potential is 85% for angular deformity and 55 % for rotational
correction.
Recommendations based on age of patient:
Neonate-24 months (10 kg)
Byrants traction
Spica cast in 24-48 hours if shortening
< 1.5 cm
Traction 7-10 days, followed by spica cost
if shortening anticipated > 2 cm
Pavlik harness in a non-ambulator (Figs 4.7A
and B
2-5 years
Thomas splint traction

Skeletal traction/Spica if shor tening
> 2-3 cm
External Fixator (polytrauma)
6-11 years
Thomas splint traction

Flexible nails/Skeletal traction / Hip Spica
(Fig. 4.8)
External Fixator
> 12 years
Flexible nails
Plates and screws
External Fixator
Intramedullary nail (trochanteric insertion)
Fig. 4.7A: Birth fracture of femur in a neonate
84
Fig. 4.7B: Treatment in Pavlik harness: The flexion and abduction

straps in the harness align the distal fragment to the proximal fragment
Fig. 4.8: Mid-shaft femoral fracture in a 10-year-old boy treated

with flexible nails
85
Complications
LLD because of failure to recognize acceptable guidelines or due to
unpredictable growth stimulation. In infants, fracture healing occurs early
and in adolescents, the growth stimulation is not dramatic, and, hence,
excessive shortening (> 15 mm) must not be accepted at the extremes of
age. Most of the overgrowth occurs in the first 18 months. Overgrowth
occurs as a result of increased blood flow, loss of periosteal tension and
stimulation of physis. Tibial overgrowth can also occur.
Delayed union
Malunion: Varus / valgus or procurvatum / recurvatum
Refracture
Neurovascular injury
Torsional deformities.
86
AGE-BASED ALGORITHM FOR TREATMENT OF FEMORAL

SHAFT FRACTURES IN CHILDREN
Limits of acceptability in femoral shaft fractures in children.
iv. Distal Femoral Fractures
Fig. 4.9: Types of distal femur epiphyseal injury:

Type II and IV are the common types
Fig. 4.10: Type II displaced Salter-Harris fracture in a

12-year-old girl
87
88
Constitute 1 percent of all fractures in children.

Can occur during traumatic delivery.
Fracture can be extra-articular or intra-articular.
Muscle attachments (gastrocnemius and adductor magnus) cause
angulation and deformity of distal fragment.
Accurate assessment of distal circulation is important because of the
proximity of popliteal neurovascular bundle to the fracture site.
Classification
Salter-Harris classification is used (Fig. 4.9).
Type I: Common in infants and adolescents
Type II: Seen when growth plate matures between 5 and 12 years (Fig.
4.10).
Type III and IV have intra-articular extension.
Fig. 4.11: Type II Salter-Harris injury treated by open reduction and fixation
Management
All undisplaced fractures can be treated by cast immobilization with knee
flexed. Avoid stress views to detect unstable fracture configuration
In infants a hip spica may be required to control fragment position
Any displaced fractures require adequate reduction to prevent malunion.
Skeletal traction may be required to restore alignment (Fig. 4.11).
Physeal injuries are susceptible to malreduction (Fig. 4.12).
89
Type III and IV fractures require anatomical restoration of joint surface.

Closed / open reduction and smooth wires or cannulated screws provide
adequate fixation.
Examine knee joint after fracture fixation to assess for intra-articular injury
Complications
Growth disturbance: Occurs due to physeal injury and may be partial or
complete. It may lead to angular deformity or limb length discrepancy,
depending on the extent of physeal involvement.
Risk of LLD > 1 cm is 46% and > 2.5 cm is 29%.
Risk of angular deformity is 26-33%. If the area of physeal arrest is less
than 50 percent, then consider bar excision and fat interposition. For
established angular deformity, a re-alignment osteotomy is preferable.
Complete epiphyseodesis must be done at the same time to prevent
recurrence.
Fig. 4.12: Type II Salter-Harris injury in a 12-year-old boy. Initial reduction

was unacceptable, hence he underwent open reduction and internal fixation
90
L. KNEE DISLOCATIONS
Associated with severe injury.
Differentiate from distal femoral epiphyseal injury.
50 % incidence of concurrent vascular injury (high index of suspicion).
Management
Early closed reduction and external immobilization by cast or by external
fixator.
Check for adequacy of distal circulation. If prompt restoration of circulation
is not observed after reduction, consider vascular exploration. Timing is
critical and vascular study must not delay surgery for more than 6 hours
following injury.
Usually ACL / PCL or both may be ruptured, but ligament repair not
essential in acute stage.
M. PATELLA
i. Patella Fracture
Fig. 4.13: Fracture of lower pole in a 10-year-old boy
Rare in children. In very young children (< 4 years), a patella fracture

can be missed since the bone is unossified
Patella cartilage is thick, and articular continuity is maintained with minimal
osseous separation
91
Classification
Undisplaced retinacular continuity maintained.
Displaced transverse, comminuted or stellate fractures.
Fracture may occur through the upper pole, body of patella or through the
lower pole (Fig. 4.13).
Sleeve fracture: Occurs classically in the lower pole at the junction between
subchondral bone and unossified cartilage. This injury can be easily missed,
as only a small osseous fragment may be present (Fig. 4.14).
Management
Undisplaced fractures require immobilization for 4-6 weeks in cylinder
cast.
Fig. 4.14: Sleeve fracture of the patella

repaired with absorbable suture. A stainless
steel wire is used to protect the repair for 6-8
weeks. Fracture healing is rapid as this is an
epiphyseal injury
92
Displaced fractures are associated with retinacular disruption and loss of

extensor mechanism continuity.
Tension band wiring using heavy sutures or a stainless steel wire is a
useful technique to restore anatomic continuity in displaced fractures.
ii. Patella Dislocation
Acute /recurrent/habitual.
Acute patella dislocation is usually lateral and associated with a history
of injury.
High resolution radiographs /CT scan may be required to detect
osteochondral fragments.
Management
Closed manipulation and immobilization in a cylinder cast for four weeks
to ensure soft-tissue healing.
Large osteochondral fragment may need internal fixation.
iii. Bipartite Patella
Occurs because of varying ossification in the patella.
Usually seen at the supero-lateral corner.
Bipartite patella can also occur following acute / repetitive stress injury.
Management
If the supero-lateral fragment is small and causing pain, it can be excised.
A large fragment causing articular step at patello-femoral joint should be
fixed with a screw.
N. TIBIA FRACTURE
Ossification
The secondary ossification center may be present in the neonate or usually
develops within the first three months.
The tibial tuberosity is level with the physis at birth and then extends
distally with growth.
A secondary ossification center develops in the distal portion of the
tuberosity. This ossification center extends proximally and is continuous
with the main tibial epiphysis. The fusion of proximal end occurs at around
14 years in girls, and 17 years in boys.
93
Fig. 4.15: Pattern of ossification in the proximal tibial physis.

The center for tibial tuberosity appears later at around 7-8 years
The physis of the proximal tibia first closes in the center and then proceeds
centrifugally (Fig. 4.15).
The part under the tuberosity is the last to close and fusion of this
apophysis occurs from proximal-distal direction.
The distal tibial epiphysis appears in the second year of life. The medial
malleolus extends distally around 7 - 8 years of age.
Closure of the distal tibial physis follows a peculiar pattern. The physis
closes in the mid portion initially, and then in medial to lateral direction,
especially posteriorly and this fusion occurs over 18 months. The anterolateral part is last to close.
Complete fusion occurs at around 15 years in girls and around 17 years
in boys.
The distal fibular physis appears around 2-3 years of age and closes later
than tibial physis. The distal fibular physis may have an irregular
appearance. The level of the fibular physis progresses distally with growth.
i. Fracture of Upper Tibial Physis
Medial and lateral collateral ligaments attach distal to the epiphysis
protecting physis from injury.
94
Bimodal distribution of injury: Young children 2-5 years old and during
adolescence.
Multiplanar orientation of the physis protects from injury; however, if
anatomical reduction is not obtained, there is a greater risk of physeal
arrest.
Assess neurovascular status because of proximity of popliteal vessels (Fig.
4.16).
Fig. 4.16: Proximity of neurovascular structures to the proximal

tibial physis. The distal fragment can impale the popliteal vessels
ii. Tibial Tubercle

Classification (Fig. 4.17)
Type I: Minimal displacement through distal portion of ossified tubercle.
Type II: Hinged displacement without joint involvement.
Type III: Fracture line exits in the joint with displacement and rotation of
fragment. Seen in adolescents when posterior part of the physis is fused
(Fig. 4.18).
Avulsion commonly seen in adolescents during jumping because of pull
of quadriceps. - An Osgood Schlatter lesion may predispose avulsion of
tibial tubercle.
Loss of knee extension can occur if fragment remains displaced.
Because of presence of unossified cartilage, size of avulsed fragment is
usually larger than that seen on radiographs.
95
Fig. 4.17: Type of avulsion of tibial tuberosity depends on the degree of its
ossification
Fig. 4.18: Type III avulsion injury of tibial tuberosity
Management
Type I: Cylinder cast immobilization for 4-6 weeks.
Type II: Closed reduction with K wire fixation or screw fixation.
Type III: Open reduction and internal fixation with screws. Arthrotomy to
assess meniscal injury.
Follow the child till skeletal maturity as physeal arrest is frequent (16%).
96
iii. Tibial Spine Avulsion Injury
Equivalent of adult ACL injury.

Seen around 8-14 years of age.
Anterior eminence involved more than posterior.
Injury caused by hyperextension of knee with some twisting.
Avulsion occurs because of the pull of the anterior cruciate ligament.
As the ligament is stronger than bone, failure occurs through the cancellous
bone of the tibial spine.
High resolution radiographs required to visualize the fragment.
CT / MRI may be required to reveal extent of displacement.
Meyers / McKeevers Classification (Fig. 4.19)
Type I: Undisplaced / minimal displacement of the tibial spine.
Type II: Tibial spine fragment is elevated anteriorly and the posterior
cartilaginous hinge remains intact.
Type III: Tibial spine fragment is completely displaced.
Fig. 4.19: Types of tibial spine injury
Management
Examination under anesthesia (EUA) to assess stability and aspiration of
knee joint can be performed to reduce swelling.
Type I injury, immobilization in slight flexion for 3-4 weeks is sufficient.
97
Fig. 4.20: Type II avulsion injury of the tibia spine
Type II injury, closed manipulation with hyperextension of the knee may

reduce the fragment. In some cases knee flexion will effect a reduction
and in such cases the knee can be immobilized at about at degrees of
flexion. Arthroscopy can be performed to clear soft tissue obstruction to
reduction (usually the medial meniscus) and if the reduced fragment is
stable, immobilize knee in cast (Fig. 4.20).
If unsuccessful, then open reduction or arthroscopic fixation is advisable.
Type III injuries need open reduction and internal fixation to replace the
fragment and restore continuity of the anterior cruciate ligament. After
surgery, usually 4-6 weeks of cast immobilization is required.
Asymptomatic laxity in the knee may persist despite fixation of fragment.
Complications
Overgrowth of fragment.
Knee stiffness which may occur after arthroscopic surgery.
98
ALGORITHM FOR MANAGEMENT OF TIBIAL SPINE INJURIES
99
iv. Fractures of Tibia

Diaphyseal fractures
Common in toddlers.
Isolated tibia fractures common in early childhood (Fig. 4.21).
Injury may be closed or open.
Healing decreases with age.
Fig. 4.21: Fracture of tibial diaphysis. Fibula may be occasionally spared.
Classification
Based on:
Fracture configuration: Transverse/Oblique/Spiral.
Level of fracture governed by Rule of thirds.
Degree of comminution: Butterfly fragment, multiple fragments or
segmental fracture.
Management
Closed reduction is usually sufficient for most tibial fractures.
Occasionally, wedging of cast may be required to restore alignment.
Correct angulation and malrotation to achieve good alignment.
100
Correct any varus > 10 degrees in child older than 10 years.

10 degrees valgus acceptable.
Remodeling takes several months and rarely occurs after 18 months.
After fracture healing the child tends to walk with leg in external rotation
but this improves with time.
Occasionally closed manipulation and percutaneous fixation or flexible
nails may be needed for unstable fractures.
In adolescents, closed manipulation and intramedullary fixation or internal
fixation may be required to achieve alignment.
External fixation can be used for open fractures.
Fig. 4.22: A grade II open fracture treated by debridement and flexible nails
in a 9-year-old boy
For open fractures:

Debride all open wounds.
Clean wounds can be closed loosely over a suction drain.
Reassess all dirty wounds in 48 hours and obtain soft-tissue cover if
possible.
Transcutaneous fixation and immobilization gives good results in young
children (Fig. 4.22).
External fixation is good but associated with greater complications (Fig.
4.23).
Union time is twice that of closed fracture (approximately 15-16 weeks).
101
Complications
Delayed union: Fracture remains un-united up to 6 months. Rare after
closed injury, but with open fracture the incidence is 5-36%.
Nonunion: More with high energy fractures and open injuries.
Angular deformity: More than 10 degrees in any plane.
Infection.
Compartment syndrome.
Pain at fracture site may continue after healing for many months, and
may restrict sports activities.
Fig. 4.23: Grade II open fracture in a 11-year-old boy treated by

debridement and external fixator. Union was seen at 16 weeks
102
ALGORITHM FOR MANAGEMENT OF TIBIAL SHAFT FRACTURE

IN CHILDREN
103
v. Proximal Tibial Metaphyseal Fractures

Usually greenstick or undisplaced fracture in mild valgus.
Seen in children 3-10 years old.
May be associated with metaphyseal fractures of the fibula.
Management
Correct any valgus angulation present
Use long leg cast for 4-5 weeks with knee in extension and molding to
correct any valgus deformity
Spontaneous resolution of valgus deformity occurs in most cases.
Complication
Progressive valgus angulation may be seen after a few months, and rarely
increases after 12-18 months. Remodeling may take up to 4 years.
The etiology of this deformity is unknown. Possible hypotheses include:
asymmetrical physeal stimulation, soft tissue interposition (pes anserinus),
loss of restrain because of periosteal damage, overgrowth on medial side.
Deformity may be seen despite adequate reduction. No current means
of predicting whether or not asymmetrical growth will occur.
Corrective osteotomy may be done near skeletal maturity, only if deformity
is static and interferes with function.
O. ANKLE INJURIES AND DISTAL TIBIAL FRACTURES
Ankle ligaments medial (deltoid) and lateral (talo-fibular and calcaneofibular) have their origin distal to the physis.
In younger children, physis more likely to fail as ligaments are resilient to
mechanical forces.
Tibio-fibular syndesmosis must be assessed to rule out diastasis. A stress
mortise view or true lateral radiograph with external rotation stress is
more accurate as posterior displacement of the fibula is easily visualized
Fracture pattern depends on the mechanism of injury and the maturity
of the growth plate.
Salter-Harris classification used to define physeal/metaphyseal fractures.
Fracture may be extra-articular or may have intra-articular extension.
104
i. Distal Tibial Fracture
Fig. 4.24: Pattern of distal medial tibial physeal injury, Types II, III, and IV depending
on amount of inversion of foot at the time of injury
Classification: (Salter-Harris) (Fig. 4.24)

Type I injury: Rare, usually minimally displaced injury and caused by
rotational force.
Type II injury: Caused by supination / external rotation force. There may
be a medial or lateral metaphyseal spike. The fibula may be intact.
Type III injury: (Tillaux fracture) an intra-articular fracture caused by
avulsion injury to the anterior-inferior tibiofibular ligament. Variable part
of the antero-lateral epiphysis involved. The intra-articular portion may
be undisplaced.
Type IV injury: An intra-articular fracture that involves part of physis and
metaphysis.
Type V: Injuries can only be diagnosed retrospectively as damage to
physeal cells may present as partial / complete growth arrest at a later
date.
When the injury involves the peripheral part of the physis (zone of ranvier)
a sub-periosteal hematoma can give rise to peripheral bar formation (Rang
Type VI).
DIAS-TACHDJIAN CLASSIFICATION (PEDIATRIC COUNTERPART
OF LAUGE-HANSEN CLASSIFICATION)
Supination Inversion (Fig. 4.25)
This is a crushing injury, characterized by avulsion injury of fibular physis
and either a type III or type IV Salter-Harris injury to the medial side. Overall
deformity is that of varus angulation.
105
Fig. 4.25: Supination inversion injury
Pronation Eversion External Rotation (Fig. 4.26)

This is usually a type I or type II Salter-Harris injury on the medial side with
incomplete fracture of the fibular diaphysis. Periosteal interposition on the
medial side can prevent a closed reduction. Overall fracture deformity is that
of valgus angulation.
Fig. 4.26: Pronation external rotation injury
106
Supination External Rotation (Fig. 4.27)

This is usually a type I or type II fracture on the medial side with spiral
fracture of the fibular diaphysis. The overall deformity is that of external
rotation.
Fig. 4.27: Supination external rotation injury.

Note the spiral configuration of the fracture site
Supination Plantarflexion (Fig. 4.28)

This is a usually a type II Salter-Harris injury with posterior translation of the
distal fragment.
Fig. 4.28: Supination plantarflexion injury
107
Management
Majority of these injuries can be managed by non-operative means.
Failure to achieve alignment and periosteal interposition into physis require
open reduction to prevent a growth arrest.
Type III and IV fractures of medial malleolus are caused by supination
inversion injury. Usually need ORIF to reduce articular step (Fig. 4.29).
The newer imaging methods such as CT and MRI have enhanced the
evaluation of growth plate complications (Figs 4.30 and 4.31).
During ORIF if the the metaphyseal fragment is comminuted and small
then it discarded, to prevent peripheral a bony bar formation (Fig. 4.32).
Fig. 4.29: Type IV injury of medial

malleolus
Fig. 4.30: Type IV injury of distal tibial physis and type I injury of
fibular physis. This injury can be best delineated by a CT Scan
108
Fig. 4.31: Displaced type III injury of the distal tibia (Tillaux fracture) in a
11-year-old boy, treated by internal fixation
Fig. 4.32: Type IV injury of medial malleolus complicated by growth arrest
109
Fig. 4.33: Pattern of triplane fracture of the ankle
ii. Triplane Fracture of the Ankle

Triplane injury seen due to peculiar closure of distal tibial physis which
progresses from postero-medial to antero-lateral direction.
Fracture occurs in three planes: Sagittal, transverse, and coronal.
May be in 2 or 3 parts depending on the number of fragments (Fig.
4.33).
Two parts: if medial malleolus and tibial shaft are in continuity and the anterolateral fragment and posterior metaphyseal fragment are in continuity (Fig.
4.34).
Three parts: If the antero-lateral fragment and tibial shaft fragments are
separate.
CT scan is important to delineate fracture anatomy and to help in surgical
planning.
Fig. 4.34: Type II and type IV injury constitute part of the triplane injury pattern
110
Management
Closed reduction suffices for undisplaced fracture pattern.
If there is an articular step > 2 mm or soft tissue interposition which
prevents closed reduction ORIF is required to restore the articular
congruity. Two separate incisions may be required to fix the antero-lateral
and posterior-medial fragments (Figs 4.35 and 4.36).
Bivalve cast after fixation, as considerable swelling can occur in the
postoperative period.
Fig. 4.35: Triplane fracture with fibula fracture in a 12-year-old boy. Fibula may be
fixed first to restore length to the leg and effect an indirect reduction of the tibial fragment
Complications
Growth arrest with varus deformity (Salter-Harris III or IV injury to medial
malleolus).
Following physeal fractures around distal tibia / fibula, look for ParkHarris growth arrest lines on follow-up radiographs. These lines represent
transient calcification of physeal cartilage during injury. If the lines are
parallel to the physis, growth potential is not affected. If there has been
physeal damage, the line may be tented or angular depending on the
site of growth arrest.
Overgrowth of medial malleolus.
Loose body in ankle.
Limitation of ankle dorsiflexion.
111
Fig. 4.36: Triplane injury in a 13-year-old boy. This patient required

open reduction and internal fixation
P. FRACTURES OF THE FOOT

Ossification (Fig. 4.37)
The ossification centers of the talus and calcaneum are present at birth.
The ossific nucleus of the cuboid appears after birth.
The lateral cuneiform appears first, followed by the middle and the medial
cuneiform.
112
Fig. 4.37: Order of appearance of ossification centers

in the foot
Calcaneal ossification is variable and expands centrifugally. The initial

ossification begins under the talus and extends in other directions. The
secondary ossification seen in the calcaneal apophysis appears around
6-10 years of age and fusion occurs around 12-16 years in girls and
15-18 years in boys. The posterior apophysis is responsible for posterior
elongation of the calcaneum. Ossification center may be bifid in certain
syndromes (e.g. Larsens syndrome)
In the talus bone, the ossification starts in the head and neck region and
extends into the body.
The ossification centers in the foot are eccentric and therefore their shapes
do not resemble adult bone until the second decade.
Injury may involve ossified cartilage of the bones: Plain radiographs are
therefore less reliable. CT, or even MRI scan, may be required to make a
diagnosis.
Variations in ossification can occur and, hence, radiographs need careful
interpretation (Figs 4.38 and 4.39).
Cysts may be seen in the calcaneum and talus because of trabecular
remodeling and injuries through these may cause pathological fractures.
Stress fractures of calcaneum and metatarsals seen in adolescents and
these can mimic infection or tumor.
113
Foot growth:
There is rapid decrease in the rate of growth of foot from infancy until
five years. After five years, the annual increase in the length of the foot
approximates 1 cm.
By 12 years, foot size is similar in girls and boys, thereafter the boys feet
continue to grow during the next 2 to 3 years.
The size of the foot reaches adult dimensions by around 10-12 years
and, hence, injury after age 10 years causes fewer disturbances in final
foot length (approximately 10% reduction in foot length).
Fig. 4.38: Type III Salter-Harris injury

of the proximal phalanx of the great toe
Fig. 4.39: Avulsion injury of the base of fifth

metacarpal. Os vesalinum is a normal variant
which may be present at that site in some
cases
i. Talar Fractures
Rare injury in children.

Majority caused by forced dorsiflexion of foot.
Adult pattern not seen until ossification is complete.
Ossification starts in head and neck part and later extends into the body.
Any injury which causes avascular necrosis will spare the unossified
cartilage.
The subchondral area is last to ossify, hence, Hawkins sign is less reliable
for AVN in children.
114
Classification
Talar neck fractures: (Fig. 4.40)
a. Vertical fracture through the talar neck.
b. Vertical fracture through the talar neck with subtalar joint subluxation/
dislocation.
c. Fracture through the talar neck with disruption of talar body from ankle
and subtalar joint.
Talar body fracture: (Fig. 4.41)
a. Transchondral or compression fracture of the talar dome.
b. Shearing fracture with either coronal or horizontal split.
c. Fracture of the lateral process.
d. Fracture of the posterior tuberosity.
e. Crush fracture.
Fig. 4.40: Talar neck fracture: Undisplaced to complete displacement
Fig. 4.41: Types of talar body fracture. Note the association with subtalar and
ankle joint dislocation
Management
For undisplaced fractures or minimally displaced fractures, a non-weightbearing below-knee cast for 4-6 week is adequate, followed by 2 weeks
in a walking cast.
115
Closed manipulation is advisable if there is displacement > 3 mm or > 5

degrees varus angulation present in the talar neck. If the fracture is unstable
when the foot is dorsiflexed to a neutral position, 4-6 weeks of
immobilization in plantar-flexion may be necessary.
An open reduction and internal fixation is advisable if the reduction is
unstable or fracture alignment is unsatisfactory. A dorsal-medial skin
incision on the medial side of the extensor hallucis longus (to avoid injury
to dorsalis pedis vessel) gives good exposure.
Complications
Avascular necrosis:
also seen in children due to disruption of blood supply.
can cause delayed ossification or even complete destruction of ossific
center.
In children less than 10 years, there is more unossified cartilage present,
hence AVN is infrequent.
Hawkins sign is unreliable in children less than < 10 years as
ossification has not occurred in the subchondral area.
Malunion: Varus malunion of talar neck occurs if displacement is not
recognized or the fracture is poorly reduced.
Avulsions Fractures
Occur at site of ligamentous attachments.
Can be missed because of cartilaginous insertion areas and diagnosed
late when ossification seen in the avulsed fragment.
True ligament injury less likely in children less than 10 years old.
ii. Osteochondritis Dissecans Lesion
Traumatic OCD lesion of the talus usually involves the lateral dome.
Usually involve children less than 10 years old.
CT / MRI required to delineate lesion.
Classification (Fig. 4.42)
I: Subchondral lucency.
II: Partially detached fragment.
III: Fragment loose but lying in the crater.
IV: Loose body in the joint.
Management
For undisplaced lesions, non-weight-bearing ambulation till the lesion
heals sufficiently.
116
Fig. 4.42: Stages in the development of osteochondral fractures
If the lesion is displaced and patient is symptomatic, either excision or

internal fixation of fragment depending on size is recommended. Curetting
of the base after excision allows formation of stable fibrocartilage which
functionally replaces the fragment.
iii. Lisfrancs Fracture Dislocation
Tarso-metatarsal joint dislocation seen commonly in adolescents.

Injury can be missed hence careful interpretation of radiographs is required
Maintain high index of suspicion in any foot injury with gross swelling
CT/MRI scans may be required
Management
Plain radiographs may show subtle signs:
Widening of first and

second metatarsal
Flake sign: avulsion of
fragment from medial
cuneiform indicating disruption of Lisfrancs
ligament.
Rule out compartment syndrome

The key is to stabilize the proximal part of second metacarpal (Fig. 4.43)
Closed reduction and percutaneous pinning, or open reduction and screw
fixation, may be required to restore stability (a single trans-articular screw
after removing the interposed ligament is sufficient)
117
Fig. 4.43: Lisfrancs injury in a 14-year-old boy, treated by closed

reduction and percutaneous fixation
iv. Calcaneum
Os calcis fractures are rare in children.

Suspect os calcis fracture in a limping child with history of fall.
Stress fractures can occur in children.
Severs injury which was thought to be a traction apophysitis is in fact a
stress fracture of the metaphyseal trabeculae due to overuse.
Fracture can be missed on plain radiograph as large part of the bone is
unossified.
Always look for associated spine injury.
Fracture of the anterior process of os calcis is common and usually misdiagnosed as ankle sprain. An oblique X-ray is helpful to make the diagnosis.
Classification (Wiley and Profitt) (Fig. 4.44)
Fractures not involving subtalar joint: Posterior tuberosity avulsion
fracture
Avulsion of anterior process
Fractures involving subtalar joint:
Undisplaced
Tongue shaped fracture
Centro-lateral fracture with
displacement
Sustentaculum tali fracture
Comminuted fracture
118
Fig. 4.44: Types of os calcis fracture: Extra-articular fractures

spare the sub-talar joint
Management
High resolution radiographs required to define injury and intra-articular
involvement.
CT scan reveals extent of fracture line and comminution which is not
easily visualized on plain radiographs.
Bohlers angle is less reliable in children because of unossified cartilage.
For undisplaced fractures: Cast for 4-6 weeks.
Encourage early motion for minimum joint
displacement.
For displaced fractures: In child < 10 years, because of good remodeling
potential, up to 2 mm subtalar malalignment is acceptable.
In adolescents an intra-articular displacement > 2 mm requires open
reduction to restore joint congruity.
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120
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Elbow Dislocation
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Radial Neck
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42. Lincoln T, Mubarak SJ: Isolated traumatic radial head dislocation. J Pediatr
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Lateral Condyle
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Displaced Lateral Condylar Fractures of the Humerus in Children. J Pediatr Orthop
2001;21:566.
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children. J Pediart Orthop 1991;11:195.
Forearm
50. Boyer B, Overton B, Schrader W: Position of Immobilization for Pediatric Forearm
Fractures. J Pediatr Orthop 2002;22:185.
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Distal Radius
56. Friberg S. Remodelling after distal forearm fractures in children (II). The final
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Scand 1979;50:531-9.
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57. Houshain S, Koch AH, Morten L, et al. Remodeling of Salter-Harris epiphyseal

plate injury of the distal radius. J Pediatr Orthop 2004;24(5):472-6.
58. Salter RB, Harris WR. Injuries involving the epiphyseal plate. J Bone Joint Surg
1963;45:587-622.
Monteggia Fracture
59. Hui JH, Sulaiman AR, Lee HC, et al: Open reduction and annular ligament
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61. Rodgers WB, Waters PM, Hall JE. Chronic Monteggia lesions in children.
Complications and results of reconstruction. J Bone Joint Surg 1996;78A:1322.
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Bone Joint Surg 1992;74B:436.
Hand Fractures
63. Benson LS, Dandera LA, Davis HW: Hand injuries in children presenting to a
paediatric emergency department. Annals of Emergency Medicine 1993;
22(10):1519.
64. Fischer MD, McElfresh EC: Physeal and periphyseal injuries of the hand. Patterns
of injury and results of treatment. Hand Clinics 1994;10(2):287-301.
65. Hastings H, Simmons BP: Hand fractures in children. Clin Orthop 1984;188:120.
66. Inglefield CJ, DArcangelo M, Kohle PS: Injuries to nail bed in childhood. Jour of
Hand Surg (Br) 1995;20(2):258-61.
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Treatment. J Pediatr Orthop 2003;23(2):216-21.
Spine Fractures
Cervical Spine
68. Cattell HS, Filtzer DL. Pseudosubluxaiton and other normal variations in the cervical
spine in children. A study of 168 children. J Bone Joint Surg A 1965;(47)1295:309
69. Dormans JP. Evaluation of children with suspected cervical spine injury. J Bone
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70. Fielding JW, Hawkins RJ. Atlanto-axial rotatory fixation. (Fixed rotatory subluxation
of the atlanto-axial joint. J Bone Joint Surg A 1977;59:37-44.
71. Henrys P, Lyne DL, Lifton C. Clinical review of cervical spine injuries in children.
Clin Orthop 1977;129:172-6.
Thoracolumbar Spine
72. Denis F. The three column spine and its significance in the classification of acute
thoracolumbar spine injuries. Spine 1983;8:817-31.
73. Govendar S, Charles RW, Rasool MN. Spinal injuries in children. Injury,
1990;21:403-6.
124
74. Ken T, Francois L, ONeil J, et al. Multiple-level thoracolumbar burst fractures in

teenaged patients. J Pediatr Orthop 2003;23(1):119-23.
75. Mcphee IB. Spinal fractures and dislocations in children and adolescents. Spine
1981;6:533-37.
Fractures of the Lower Extremity

Pelvis
76. Garvin KL, McCarthy RE, Barnes CL, et al. Pediatric pelvic ring fractures. J Pediatr
Orthop 1990;10:577-82.
77. Nierenberg G, Volpin G, Bialik V, et al. Pelvic fractures in children: a follow-up in
20 children treated conservatively. J Pediatr Orthop B 1993;1:140-2.
78. Sundar M, Carty H. Avulsion fractures of the pelvis in children: A report of 32
fractures and their outcome. Skeletal Radiol 1994;23:85-90.
79. Torode I, Zieg D. Pelvic fractures in children. J Pediatr Orthop 1985;5:76-84.
80. Wade RS, Oakley M, Morgan S. Pediatric pelvic fractures: an update. J Pediatr
Orthop 2004;24(1):130-5.
Hip Dislocations
81. Mehlman CT, Hubbard GW, Crawford AH, et al. Traumatic hip dislocation in
children. Long-term follow-up of 42 patients. Clin Orthop 2000;99:68-79.
82. Tornetta P, Mostafavi HR. Hip dislocations: Current treatment regimens. J Am
Acad Orthop Surg 1997;5:27-36.
83. Vialle R, Odent T, Pannier S, et al. Traumatic hip dislocation in childhood. J Pediatr
Orthop 2005;25(2):138-44.
Femoral Neck Fractures

84. Canale ST, Bourland WL. Fracture of the neck and intertrochanteric region of the
femur in children. J Bone Joint Surg 1997;59A:431.
85. Davison RL, Weinstein SL. Hip fractures in children: A long-term follow-up study.
J Pediatr Orthop 1992;12:235.
86. Forlin E, Guille J, Kumar J. Complications associated with fracture of the neck of
the femur in children. J Pediatr Orthop 1992;12:503.
87. Hughes LO, Beaty JH. Current concept review: Fractures of the head and neck of
the femur in children. J Bone Joint Surg 1984;66A:647.
88. Soon KS, Soo YK, Won SS. Arthrotomy and open reduction of the displaced
fracture of the femoral neck in children. J Pediatr Orthop 2001;10(3):205-10.
Femur
89. Agus H, Kalenderer O, Eryanilmaz, et al. Biological Internal Fixation of Comminuted
Femur Shaft Fractures by Bridge Plating in Children.J Pediatr Orthop 2003;23:184.
90. Blasier R, Aronson J, Tursky EA. External fixation of paediatric femur fractures. J
Pediatr Orthop 1997;17:342.
91. Buehler KC, Thompson J, Sponseller P, et al. A prospective study of early spica
casting outcomes in the treatment of femoral shaft fractures in children. J Pediatr
Orthop 1995;15:30.
92. Canale ST, Bourland WL. Fracture of the femur in children. J Bone Joint Surg
1995;77A:294.
BIBLIOGRAPHY
125
93. Flynn J, Hresko T, Reynolds, et al. Titanium Elastic Nails for Pediatric Femur
Fractures: A Multicenter Study of Early Results with Analysis of Complications. J
Pediatr Orthop 2001;21:4.
94. Momberger N, Stevens P, Smith J, et al. Intramedullary Nailing of Femoral Fractures
in Adolescents. J Pediatr Orthop 2000;20:482.
95. Sanders JO, Browne R, Mooney J, et al. Treatment of Femoral Fractures in Children
by Pediatric Orthopedists: Results of a 1998 Survey. J Pediatr Orthop 2001;21:436.
Distal Femur
96. Beaty JH, Kumar A. Fractures about the knee in children. J Bone and Joint Surg
1994;76A(12):1870-80.
97. Graham JM, Gross RH. Distal femoral physeal problem fractures. Clin Orthop
1990;255:51-3.
98. Lombardo SJ, Harvey JP Jr. Fractures of the distal femoral epiphyses. Factors
influencing prognosis: A review of 34 cases. J Bone and Joint Surg 1977;59A(6):
742-51.
Tibia
99. Christie MJ, Dvonch VM. Tibial tuberosity avulsion fracture in adolescents. J Pediatr
Orthop 1981;1:391-4.
100. Hand WL, Hand CR, Dunn AW. Avulsion fractures of the tibial tubercle. J Bone
Joint Surg 1971;53A:1579-83.
101. Herring JA, Moseley CD. Post-traumatic valgus deformity of the tibia. J Pediatr
Orthop 1981;1:435.
102. Shelton WR, Canale ST. Fractures of the tibia through the proximal tibial epiphyseal
cartilage. J Bone Joint Surg 1979;61A:167-73.
Tibial Spine
103. Mclennan JG. Lessons learned after second-look Arthroscopy in type III fractures
of the tibial spine. J Pediatr Orthop 1995;15:59.
104. Ogden JA, Tross RB, Murphy MJ. Fractures of the tibia tuberosity in adolescents.
J Bone Joint Surg 1980;62A:205.
105. Rapariz J, Ocete G, Gonzalez, et al. Distal tibial tri-plane fractures: Long-term
follow-up. J Pediatr Orthop 1990;10:592.
Distal Tibial Fractures

106. Ertl JP, Barrack RL, Alexander AH. Triplane fracture of the distal epiphysis. Longterm follow-up. J Bone Joint Surg (Am) 1988;70:967-76.
107. Karrholm J, Hanssan LI, Laurin S. Computed tomography of intra-articular
supination-eversion fractures of the ankle in adolescents. J Pediatr Orthop
1981;16:113-8
108. Nenopoulos SP, Papavasiliou VA. Outcome of Physeal and Epiphyseal injuries of
the distal tibia with intra-articular involvement. J Pediatr Orthop 2005;25(4):51822.
109. Spiegel PG, Cooperman DR, Laros GS. Epiphyseal fractures of the distal ends of
the tibia and fibula. A retrospective study of 237 cases in children. J Bone Joint
Surg (Am) 1978;60:1046-50.
126
Calcaneum
110. Brunet J. Calcaneal fractures in children. J Bone Joint Surg 2000;82B:211.
111. Inokuchi S, Usami N, Hiraishi E, et al. Calcaneal fractures in children. J Pediatr
Orthop 1998;18:469.
112. Ogden JA, Ganey TM, Hill JD. Severs Injury. A stress fracture of the immature
calcaneal metaphysis. J Pediatr Orthop 2004;24(5):488-92.
113. Pickle A, Benaroch TE, Guy P, et al. Clinical outcome of Pediatric Calcaneal fractures
treated with open reduction and internal fixation: J Pediatr Orthop 2004;24:178.
114. Schmidt T, Weiner D. Calcaneal fractrures in children. An evaluation of nature of
the injury in 56 children. Clin Orthop 1982;171:150.
115. Wiley JJ, Profitt A. Fracture of the os calcis in children. Clin Orthop 1984;188:1318.
Talus
116. Canale ST, Kelly FB Jr. Fractures of the neck of the talus. Long-term evaluation of
71 cases. J Bone Joint Surg 1978;60A:143-56.
117. Hawkins LG. Fractures of the neck of the talus. J Bone Joint Surg 1970;52A:9911002.
118. Letts RM, Davidson D, Aboubaker A. Osteochondritis dissecans of the talus in
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119. Mazel C, Rigault P, Padovani JP, et al. Fractures of the talus in children. Apropos of
23 cases. Rev Chir Orthop 1986;72:183-95.
120. Myerson MS, Fisher RT, Burgess AR, et al. Fracture dislocations of the
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Index
A
Acetabular fractures 72
classification 72
management 73
Age-based algorithm for treatment of
femoral shaft fractures in children 86
Algorithm for management of lateral
condyle fractures 28
Algorithm for management of proximal
humerus fractures 9
Algorithm for management of radial head
fractures 38
Algorithm for management of
supracondylar fracture 20
Algorithm for management of tibial shaft
fracture in children 102
Algorithm for management of tibial spine
injuries 98
Ankle injuries and distal tibial fractures 103
distal tibial fracture 104
classification 104
Avulsion fracture of the pelvis 71
management 72
C
Clavicle 2
fractures of the distal (acromial end) of
the clavicle 6
complications 6
management 6
fractures of the medical (sternal end)
of clavicle 4
complications 5
management 5
shaft fractures 2
complications 4
management 3
D
Development of spine 58
ossification 58
radiologic classification 59
management 59
spine fractures: Peculiarities in children
58
Dias-Tachdjian classification (pediatric
counterpart of Lauge-Hansen
classification) 104
pronation eversion external rotation
105
supination external rotation 106
supination inversion 104
supination plantarflexion 106
management 107
E
Elbow region 31
dislocations 31
complications 32
management 32
olecranon fractures 39
classification 39
management 39
pulled elbow 33
management 34
radial head and neck fractures 34
classification 35
complications 37
management 35
F
Femur fractures (proximal, shaft and distal
femur fractures) 76
distal femoral fractures 87
classification 88
complications 89
management 88
femoral shaft fractures 82
classification 82
complications 85
management 82
proximal femur fractures 77
classification 77

complications 80
management 78
subtrochanteric fractures 81
management 82
Flexion type 19
Forearm (radius and ulna) 40
dislocation of radial head 44
management 45
distal radial fractures and epiphyseal
injury 50
management 50
Galleazzis fracture-dislocation 48
management 49
Monteggia fracture-dislocation 45
classification 46
complications 47
management 46
radius and ulna fractures 40
complications 43
management 42
Fractures of the foot 111
calcaneum 117
classification 117
management 118
Lisfrancs fracture dislocation 116
management 116
osteochondritis dissecans lesion 115
classification 115
management 115
talar body fracture 114
complications 115
management 114
talar fractures 113
classification 114
talar neck fractures 114
Fractures of the lower extremity 74
Fractures of the upper extremity 1
H
Hand and wrist fractures 52
hand injuries 52
management 52
metacarpophalangeal and
interphalangeal dislocations 54
phalangeal fractures 53
radial collateral ligament 54
scaphoid fracture 56
ulnar collateral ligament avulsion
fracture 54
Hip dislocation 75
classification 75
complications 76
management 75
Humerus 7
diaphyseal humerus fractures 11
complications 12
management 12
distal humerus fractures 12
dual fractures 21
intercondylar fractures 21
medial condylar fractures 30
medial epicondyle injuries 29
transcondylar fractures 22
fractures of the proximal humerus
epiphysis 7
complications 8
management 7
K
Knee dislocations 90
management 90
P
Patella 90
bipartite patella 92
management 92
patella dislocation 92
management 92
patella fracture 90
classification 91
management 91
Pauwels fracture angle 78
Pelvic fracture 69
classification 69
fracture pattern depends on the
mechanism of injury 70
ossification 69
complications 71
management 71
Pelvic ring fractures 68
S
Specific injuries 59
cervical spine 59
cervical end-plate injury 63
dens fracture 62
INDEX
fracture dislocation of subaxial
spine 62
rotatory subluxation of cervical
spine 60
Spine fractures 57
T
Thoracolumbar spine fractures 64
burst fractures 65
chance fracture 65
endplate injuries (apophyseal injuries)
65
complications 66
management 65
Tibia fracture 92
fracture of upper tibial physis 93
129
fractures of tibia 99
classification 99
complications 101
management 99
proximal tibial metaphyseal fractures
103
complication 103
management 103
tibial spine avulsion injury 96
complications 97
management 96
Meyers/McKeevers classification
96
tibial tubercle 94
classification 94
management 95

Pediatric Fracture Management 2007

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Pediatric Fracture Management 2007

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Pediatric Fracture

Asst. Professor, KJ Somaiya Hospital and Research Center

I would like to dedicate this book

xiv PEDIATRIC FRACTURE MANAGEMENT

ii. Fracture of atlas

xvi PEDIATRIC FRACTURE MANAGEMENT

Growth Plate (physis)

2 PEDIATRIC FRACTURE MANAGEMENT

Fig. 1.1: Fracture of midshaft of clavicle

FRACTURES OF THE UPPER EXTREMITY

Fig. 1.2: Manual reduction may be required for midshaft fractures

4 PEDIATRIC FRACTURE MANAGEMENT

Indications for Surgery

FRACTURES OF THE UPPER EXTREMITY

Intrathoracic compression causing hemothorax/pneumothorax.

Fig. 1.5: Patient who underwent manipulation under anesthesia. Postreduction CT

6 PEDIATRIC FRACTURE MANAGEMENT

iii. Fractures of the Distal (Acromial end) of the Clavicle

Fig. 1.6: Fracture through physeal plate

FRACTURES OF THE UPPER EXTREMITY

8 PEDIATRIC FRACTURE MANAGEMENT

Remodeling reported in nearly 100 percent children < 6 years with

FRACTURES OF THE UPPER EXTREMITY

ALGORITHM FOR MANAGEMENT OF PROXIMAL

10 PEDIATRIC FRACTURE MANAGEMENT

Fig. 1.7: Proximal humerus fracture in a 15-year-old boy. In

FRACTURES OF THE UPPER EXTREMITY

ii. Diaphyseal Humerus Fractures

Fig. 1.8: Birth fracture of mid-shaft of humerus

12 PEDIATRIC FRACTURE MANAGEMENT

Fig. 1.10: Seven-year-old boy with spiral fracture of the humerus

FRACTURES OF THE UPPER EXTREMITY

14 PEDIATRIC FRACTURE MANAGEMENT

Fig. 1.12: The distal humeurs is inclined

Fig. 1.13: The ossific nucleus of the

FRACTURES OF THE UPPER EXTREMITY

Clinical assessment must include a thorough neurovascular examination

Fig. 1.15: Medial

Fig. 1.16: Radiographic

16 PEDIATRIC FRACTURE MANAGEMENT

FRACTURES OF THE UPPER EXTREMITY

Assess perfusion status of limb, capillary circulation, redness and warmth. If

18 PEDIATRIC FRACTURE MANAGEMENT

Fig. 1.18: Malunited supracondylar fracture causing cubitus varus deformity

Fig. 1.19: Flexion type supracondylar fracture treated by closed

FRACTURES OF THE UPPER EXTREMITY

20 PEDIATRIC FRACTURE MANAGEMENT

ALGORITHM FOR MANAGEMENT OF

CR: Closed reduction

FRACTURES OF THE UPPER EXTREMITY

Fig. 1.20: Displaced supracondylar and distal radius fracture.

These are rare in younger children.

22 PEDIATRIC FRACTURE MANAGEMENT

FRACTURES OF THE UPPER EXTREMITY

Fig. 1.21: Displaced lateral condyle fracture with articular incongruity

Account for 15 - 20 percent of all elbow injuries.

24 PEDIATRIC FRACTURE MANAGEMENT

FRACTURES OF THE UPPER EXTREMITY

Type-2: < 2 mm displacement

Type-3: Complete displacement

26 PEDIATRIC FRACTURE MANAGEMENT

Fig. 1.23: Delayed presentation with nonunion: Treated by internal fixation;

FRACTURES OF THE UPPER EXTREMITY

Fig. 1.24: Established nonunion treated by in situ screw