All right, good afternoon everyone. Thank you for for joining us. There's a busy afternoon, a lot of other great sessions going on, so feel free to kind of jump between, but I'm glad we've put together at least a topic that interests you enough to come check us out. My name is Jonathan Napolitano, the sports medicine provider at Nationwide Children's Hospital, where I did my sports medicine fellowship training. In pediatrics, I see a fair amount of fractures. However, there's very different practice groups. Our group, our sports medicine department, is through the department of pediatrics, whereas orthopedics is separately, so they manage a lot of the larger reductions and other fractures, but whenever you're doing sports medicine, it is inevitable that a fracture is going to sneak in the room. So, I'm the outgoing chair of the pediatric sports medicine member community. We have a new chair coming in, and over the past several years that we've chaired this group, we've done a pediatric pearls talk. It's always been very well supported and attended, and so we're excited that you guys are here. Joining me today, Dr. Scott Simpson. He's an associate director of the acute orthopedic injury clinic at Washington University in St. Louis. He's also their program director of their sports medicine fellowship and an assistant professor of orthopedic surgery, and he is certified, certificate of additional qualification, CAQ certification in sports medicine fellowship, and then also we have joining us is Alexandra Fogarty. She is currently a clinical fellow in pain medicine and mass general, but prior to that, she graduated that sports medicine fellowship at Washington University with Dr. Simpson and is eligible to take her CAQ sports medicine exam in the coming months. So, here's our outline of what we're going to talk about today. After my introduction, Scott is going to go over just an overview of what pediatric fractures are, what to look for, what not to miss, and then he'll roll right into his talk about lower limb specific fractures as well. Next, Alex will speak about the forearm wrist and hand, and then I will close us up with talking about the pediatric fractures of the elbow and shoulder girdle as well. We'll wrap up with some final thoughts and open it up to questions and answers. So, again, thank you all for joining us this afternoon. Hopefully, you get some great information from here. Save your questions to the end, and we'll put them all together. All right, so without further ado, I'll have Scott come up here and give us an introduction to pediatric fractures. Thank you. there. So thanks to John for putting this together. Thanks everybody for coming for this talk today. So excited to be talking about fractures since that is something I do a lot of. So acknowledgements. So both thanks to Dr. Napolitano for putting this session together and then also to Dr. Krabach. He was supposed to be here giving this intro talk but had to be out of town with USA Swimming. So he provided some of the slides I'm presenting. So thanks to him for that. So in terms of defining a fracture that may see intuitive but I think it's helpful to be specific about that. So a fracture of a bone is a disruption of the structural integrity of the bone. Fractures are a function of a stress applied to the bone stronger than the bone's intrinsic strength and ability essentially to resist that force. So it's a function of a force over a period of time and primarily what we're talking about are acute fractures with a high force over a short period of time but that can also be a lower force over a longer period of time like in a stress fracture. Specifically though for today we're really talking about this. So acute injury, high force, short period of time, more force than the bone can withstand and so the bone gives. As opposed to a stress fracture where it's a more gradual smaller stress over time that accumulatively will form a fracture left sort of unchecked. One key point when it comes to managing fractures in kids is that kids aren't just small adults. So bone is the relative weak point in musculoskeletal system in kids as opposed to in adults. We see a lot fewer tendon and ligament injuries in kids versus adults. I mean they happen in certain situations but it's definitely a lot less frequent. Bone injuries, fractures specifically are much more common. And that's largely because developing bones are structurally different. So kids have unique features to their bones, specifically physes and apophyses. So the physis is a true growth plate and that is the site of longitudinal growth of the bone and a very common site of fractures. An apophysis is a separate piece of bone. It's the origin or insertion of a tendon but it's not a site of longitudinal growth. So to be distinguished from a physis from a true growth plate. Both of those sets of structures will fuse by skeletal maturity and those happen at different rates. So closure of some of these structures starts around age 12, so pre-teen years. And certain growth plates, well certain apophyses in particular don't close until the 20s. So most notably the iliac crest apophysis doesn't close until the 20s. So you'll see what are theoretically pediatric injuries sometimes in kids who have finished longitudinal growth. So apophyses in particular can be complicated in certain sites. The pediatric elbow is sort of notorious for this. There's a lot of apophyses in the elbow and any one of them can be a site of an injury. So they're a little bit complicated and will sort of torture residents and fellows until they get used to managing these injuries. So specifically there's the lateral epicondylar apophysis, the capitellar apophysis, there are medial epicondylar, olecranon, and trochlear apophyses as well. And any of those are potential sites of injuries, some more common than others. Of note, the only true growth plate, the only true physis in the elbow is the proximal radius. So that's the only site where you'd see an actual Salter-Harris fracture, a true growth plate fracture. We'll talk about those in a little bit more detail in a bit. But that's really the only site of actual longitudinal growth in the pediatric elbow. So specifically naming the portions of a pediatric long bone, obviously important to be able to name the parts of the bone to be able to describe a fracture and know how it's potentially going to behave. So the physis is the gap in the bone at the end of the bone. The apophysis is the part just typically distal to that. And the metaphysis is the sort of neck of the bone and then the diaphysis is the shaft. So in terms of describing fractures, so that's one of the important parts of managing fractures is being able to adequately and accurately describe them. And that takes a lot of different ways of looking at it. So in particular, it starts with acuity. So knowing whether a fracture is acute, whether it's healing or whether it's potentially a stress fracture. A lot of the fractures I'm seeing are acute fractures, same day or pretty recent, but sometimes they're subacute. They've been sort of sitting on it for a couple of weeks. You want to describe whether a fracture is displaced or not and the overall morphology of the fracture. And that's sort of the big three there. So the overall morphology, you're describing the general pattern within these sort of accepted guidelines of what type of fracture you're seeing. So commonly those are transverse fractures, oblique fractures at an angle, buckle or what are sometimes called torus fractures, spiral fractures, green stick fractures, avulsion fractures where there's a piece of bone pulled off. And we'll show examples of all of these in a second. And then there are secondary fractures that are used to describe a fracture further. So whether there's angulation present, so whether there's a bend at the site of the break. And you can describe those in different ways. We'll talk about that in a little more detail in a second. Important to note whether a fracture has interarticular extension, so whether the break, the actual crack in the bone extends to the joint or not. And whether that results in any potential articular incongruence, so whether there's a step off within the joint is something to note. Comminution is a term referring to a break being in multiple pieces, a complex fracture that goes multiple directions. Impaction means a fracture is shortened or one part of the bone is pushed into another. There's rotation, which is sort of self-evident. Overlapping is when two separate parts of a break adjacent to the actual site of the fracture will overlap each other. And that can result in shortening, which is where the bone becomes shorter. There's translation, which is more of a side-to-side displacement. And we'll show examples of that, too. So this is a slide I got from Dr. Craibach. Thanks to him for putting this together pretty succinctly. But in that top left there, that's a transverse fracture. Obviously, you're seeing those two fragments completely separate. That line goes straight across, as opposed to an oblique fracture, which is what you're seeing next to that. Now that line's at an angle, but it's the same general idea. Going clockwise from there, a spiral fracture next. So you can tell that's in multiple dimensions. So it's separated from an oblique fracture, as you can see it at two different spots. That means it's circling around the bone, essentially. That's clearly a very common comminuted fracture. Not all comminuted fractures are quite that involved, but multiple pieces there, obviously. Intraarticular extension in that one on the top right. So that's a break of the distal radius that goes into the wrist joint. An impacted fracture now on the bottom left. So you're seeing a little bit of shortening where the metathesis is sort of pushed into the epiphysis in that part of the bone. Mostly specific to the spine, we talk about compression fractures. That's a separate sort of topic. I'm not talking too much about that today. And then avulsion fractures. That picture's interesting. That might actually not be a true fracture. That might be a secondary growth center there. But at any rate, where there's a piece of bone pulled off, that's an avulsion fracture. And then a stress fracture. Again, not the focus of today's talk. We're talking primarily about acute fractures. But stress fractures in endurance athletes in particular are very common. We see a lot of those. So certain types of morphology to note. So green stick fracture. I won't talk too much about this because Dr. Fogarty is going to talk about this. But there's some risk of progressive angulation with these fractures. So it's worth noting. So specifically, you see cortical disruption on one side of a break and at least subtle angulation on the other. The key to that is it involves both sides of the bone. And this is primarily specific to the distal radius. Buckle and torus fractures. People use either term for it. I tend to call it a buckle fracture. But by definition, that's a stable fracture. It only involves one side of the bone. The other side of the bone, by definition, is intact with this. So it's a stable fracture. Angulation is another way to describe a fracture. So this is an angulated fracture. And there's two ways to describe angulation. My advice is pick one and stick with it. But you can either describe where the distal fragment of the bone is pointed. In this case, that would be distal folar. Or you can describe where the apex of the fracture, so the site of the fracture, where that is. So in this case, that's apex dorsal. Either is accurate. Either is commonplace. So here's a fracture that was angulated. And then the other term that comes up, so that middle picture to the right, now you're seeing a reduced fracture. So once it's been pushed back into place, you call it reduced, at least initially. In terms of determining acuity, so it's an acute fracture on the left. That's a patient of mine with a fracture at the proximal first metacarpal. And then as it's healing, that's a subacute fracture. And then a healing fracture, eventually you call it healed. So describing the acuity is helpful. Here's displacements on the left. That's a non-displaced fracture. That's either a buccal fracture or a green stick, depending on the lateral. But then you see a displaced fracture next to that clear displacement. There's separation of the fragments. Rotation is of note, in particular with hand fractures. So metacarpal fractures and finger fractures will tend to rotate. That's primarily something you're going to detect clinically. You can see rotation sometimes, especially if it's more pronounced on an x-ray. But a lot of the time, you're seeing that clinically rather than based on an x-ray. Something that's hard to assess initially, due to pain and limited range of motion, they may not want to flex because it hurts. So you may not necessarily see that rotation very easily. So something to watch. That picture on the bottom right there, that's what you're trying to avoid. So with crossover of the fingers, there's a rotational deformity there. It'll heal like that without surgery to put that back into normal alignment. That upper one, that's a fairly common pattern we'll see sometimes with saltohertz 2 fractures at the base of the proximal phalanx of the small finger. You'll see that increased abduction. That degree of it probably surgical, but lesser rotation there would be tolerable. In terms of shortenings, that's overlap at the site of a fracture leading to a change in the bone length when that heals. So the clinical significance of that varies by the site. Sometimes that's tolerable. Often in the clavicle, a little bit of shortening is no big deal. But other sites like the radius, it can be a problem. In particular, at the radius, it'll lead to what's called ulnar positive variance, a relative shortening of the radius with a longer ulna. And that can lead to issues down the road and can be a separate discrete surgical indication. It's also called bayonetting for obvious reasons. It looks like a bayonet on the end of a rifle. Translation, so that's a shifting sort of side to side. So you're seeing one piece shifted in relation to the other. That can be fairly profound and an indication for a reduction like that break on the left. Or it can be subtle and maybe something you could watch depending on the location. In terms of classifying physio fractures specifically, so that's the Salter-Harris classification system that some, I'm sure, are at least passingly familiar with. These are really common injuries in kids, and this is the accepted method of describing them. In terms of that picture on the right, so a Salter-Harris 1 fracture in the center at the top there, that's through the physis without extending sort of in or out either direction, relatively common pattern. A Salter-Harris 2 fracture is going to extend into the metaphysis. A Salter-Harris 3 fracture to the epiphysis. A Salter-Harris 4 fracture involves both going through the physis. And then a Salter-Harris 5 fracture is a crush injury of the physis. We really don't see those very commonly in the outpatient setting. That tends to be a higher level trauma. There's lots of different mnemonics for remembering these systems. If you're new to describing fractures, my advice is to pick one that works for you and just stick with it until it becomes second nature. But there's lots of different types of mnemonics. That's one there on the left. Here's two other versions that people will use to remember and describe physio fractures. They all work. Again, my advice is pick one and sort of stick with it until you don't need it. So Salter-Harris 2 fractures, it's a very common fracture pattern. Those two on the left are the same fractures. That's a Salter-Harris 2 fracture of the distal radius. That one on the right, a Salter-Harris 2 fracture of the fourth finger proximal phalanx. Fairly common fracture types. For the most part, those are stable. The majority of Salter-Harris 2 fractures won't result in physio disruption down the road, but they can. Immobilization, so a word on that. People will use these terms differently. So in different institutions, these terms may mean slightly different things. In general, a cast is probably a pretty accepted term. We're talking about a circumferential fiberglass cast. The lining varies somewhat. So you can either do a standard cotton lining or a waterproof lining. So a Gore-Tex lining, now you can flush water through it in the bath or the shower without having to worry about keeping it dry. A splint is going to be open on one end in our system. Those are either plaster. Sometimes you can do fiberglass or orthoglass splints. We'll use custom splints made by Occupational Therapy, too. All those get called and sort of lumped into the splint category. And then there's the typical braze fabric Velcros removable. So in terms of factors influencing fracture management, these are numerous. It's often a judgment call. Certainly no one 15-minute lecture is going to, you know, teach all of this, but some general principles. It's important to make a decision regarding the need for reduction of referral for potential surgery if these are injuries you're seeing on an outpatient basis. So factors that can influence that age. Again, this is to talk about pediatric fractures, but in general, older adults are more likely to tolerate displacement, angulation, et cetera, without necessarily having an issue down the road. In kids who are closer to skeletal maturity, the key there is that there's less time for corrective remodeling with growth. So you can tolerate less angulation or displacement than in a younger kid who has more time to remodel that. The distance from the physis is the other factor in kids. So fractures that are closer to the physis are more easily able to remodel with time, whereas more distant fractures from the physis has less ability to remodel that with additional growth. Fracture stability is something to note and assess when seeing an acute fracture. So you want to judge the likelihood of further angulation or displacement despite immobilization. That's a whole talk potentially unto itself, but something to note. Certain fractures are certainly a lot more likely than others for progressive displacement or angulation, and that's something to know. The risk for future complications, something else to bear in mind. So post-traumatic arthritis with intra-articular fractures, especially displaced ones, pain potentially or loss of function from malunion, limited range of motion, et cetera. So things to be thinking about even from, you know, day one when you see a fracture. In terms of general principles for fracture management, so in terms of the initial evaluation, that should include an evaluation of neurovascular status, skin integrity, adjacent for, or evaluation for adjacent soft tissue injuries. In general with x-rays, you need to see a fracture on at least two views to be able to adequately assess for the full sort of morphology and potential displacement of a fracture. Typically it's three for most joints or locations, usually an apilateral and oblique, but that's a little variable by site. In terms of initial immobilization for a fracture, so one key point is to not put a circumferential hard form of immobilization on a new fracture, especially within 24 hours. So you want to be able to accommodate fluctuant swelling, so in particular, cast applications should wait until that swelling stabilizes a bit, usually after about 24 hours. You can use a plaster splint initially, that's often what I do. It's open on one side, it'll accommodate fluctuant swelling without creating risk for increasing compartment pressure. In terms of the duration of immobilization for fractures, that's going to be pretty widely variable. For a typical saltoharis 1, saltoharis 2 fracture, you're often talking four to six weeks, but that certainly depends a bit on the site too. And in general for fractures, it's a wide range. So for example, a distal radius buccal fracture, that's going to heal typically within three weeks. A scaphoid fracture can take 12, so there's pretty wide variability depending on the site. So one situation that comes up is a suspected occult fracture. So sufficient mechanism to have called a fracture, it's in particular around a physis, but you may not see it. X-rays can look normal. Sometimes you'll see a little subtle apophysial widening or a physial widening with a saltoharis 1 fracture, but certainly not always. The general principle there is to immobilize for typically about 10 to 14 days, so around two weeks, and then reevaluate that injury. If they're not sore, pretty much by definition, at that point they don't have a fracture, so we'll cut those loose, diagnose them with a healed sprain or contusion. If they're still sore, consider repeating x-rays and continue immobilization treating for a presumed fracture, even if those remain normal. So the potential for complications, the risk of growth arrest with physio fractures is certainly going to vary by site and by severity of injury, but it's something to bear in mind. So an example where it varies by location, it's very low risk for the distal fibula as a general rule, much higher for the distal tibia. That's in large part because the distal fibula is a minimally weight-bearing structure, but the risk there varies quite a bit. In general, there's very low risk for physio arrest with most saltoharris 1 and saltoharris 2 fractures, higher for saltoharris 3 and 4 fractures. The rate becomes reasonably high with those types of fractures. So it's not necessarily that there is intra-articular extension, but that's one way to think about it, is that fractures that extend to a joint, so your saltoharris 3 and 4 fractures are going to be a higher risk for growth arrest than ones that don't. In fractures that are deemed to be at risk for growth arrest, you want to repeat the x-rays. I do that typically at six months just to confirm there's normal growth occurring. So you always want to explain to the family we're doing this regardless of pain. We're doing it just to make sure there's not aberrant growth occurring. Compartment syndrome, more acutely, is one thing to watch for very carefully, it's potentially catastrophic if it's missed. It is uncommon with the level of trauma we see in the outpatient clinic, but certainly still something to bear in mind. There's the initial risk that occurs from bleeding associated with fractures and then subsequently from the swelling. Always important to get a thorough neurovascular exam with all fractures to just evaluate for the risk of that and monitor for development. In particular, that's the reason not to apply a cast too early. If you cast a fracture that's still going to swell, you can cause this by creating increased pressure. The other risk with fractures of note, I mean among others, complex regional pain syndrome. Some fractures will develop, some locations are more prone to that than others after a fracture and immobilization. Higher risk with more prolonged immobilization, so one reason to try and minimize that as much as possible. It's uncommon but it does come up sometimes. So in particular, there are sites that are more prone to compartment syndrome than others, the forearm and the lower leg in particular. The first sign to watch for with that is going to be pain out of proportion to an injury and then from there you can develop a limb that becomes cold, that loses color, they develop paresthesias, weakness and then ultimately pulselessness. If there's concern for this, it's a referral to the emergency room to evaluate this quickly and potentially perform fasciotomy if indicated. The other thing to watch for in pediatric fractures specifically are signs of child abuse. It's always important to maintain some vigilance with this, especially in younger kids who can't give you a reliable history. So the clues to this, inconsistencies or discrepancies in a caretaker's account of how an injury occurred, in particular a caregiver stating that the child injured themselves when they are, for example, not ambulatory, that's certainly unlikely and uncommon. Unwitnessed injuries are another red flag. Injuries inconsistent with a kid's developmental age or inconsistent with the stated mechanism of injury. On x-rays, concerning signs would be multiple fractures present, fractures in locations or patterns that differ from the history, fractures in varying degrees of healing, suggesting multiple injuries across time, fractures in specific locations, the ribs, the sternum, vertebrae and skull and the long bone or digit fractures in very young children because those are uncommon when they're not ambulatory. There's a specific pattern called a metaphyseal corner fracture that's also something to watch for, so that's the picture on the right right there. That pattern is uncommon absent a specific type of injury that is risky for an intentional injury. And then multiple rib fractures in a small kid, that's that picture on the left. So not pleasant to talk about but something to think about. Anytime you're seeing fractures, it's something to bear in mind. All right, one down. So we'll talk next more specifically about pediatric foot and ankle fractures. So again, we just went over some of this, but the basics of evaluation just starts with a good examination. Careful palpation is always important when you're evaluating any injury, a fracture specifically, but really in the foot and the ankle because these structures are pretty close together. Careful palpation is even more important. Always important to perform a neurovascular examination evaluating for a concomitant neurovascular injury or for developing or risk for compartment syndrome. Maintaining a broad differential to fractures are more common than other types of injuries in kids, but they're not obviously the only thing that happens. So considering alternative sprains, strains, tendon tears, ligament injuries, in particular looking for the Liz Frank injury, contusions or osteochondral lesions are all things that can sort of mimic a fracture. So of note, yeah, I'm not labeling a source of most of these images. They're my own, like this kid who was initially rather angry with me and then came around. Lateral ankle injuries. So physical fractures are common, in particular psoas fractures or the distal fibula. That presentation is obviously going to be lateral ankle pain. There's often swelling. The gait is frequently entalgic, but there's not typically difficulty actually bearing weight in these injuries. You know, the classic teaching in these is that the large majority of lateral ankle injuries represent a saltoharis 1 fracture, but there's been some fairly convincing research to challenge that assumption. So a couple of articles in particular looking at MRI of suspected saltoharis 1 fractures, the distal fibula, this one included, have shown other diagnoses to actually be more common. So in this case, bone contusion, lateral ligament sprains, and just a sort of a nonspecific joint diffusion was found to be more common than an actual saltoharis 1 fracture. Similar study, looking at MRI of suspected saltoharis 1 fractures, they found most of them to be sprains or bone contusions. And you'll see that bear out when you see these injuries. They're frequently healed by two weeks, which would be inconsistent with a fracture. That said, when they are stroke sore, I mean, these certainly happen. They're just probably less common than we used to think. So there is the adage again that kids don't sprain. And grain of salt with that, obviously, that's clearly inaccurate, at least when applied to the ankle. It is more accurate probably in other locations, like the wrist, where sprains are really quite uncommon and breaks are much more common. With careful palpation, you can potentially differentiate a saltoharis 1 fracture of the distal fibula versus a lateral ankle sprain. When they're diffusely sore, that's challenging. If it's more focal, sometimes you can make that distinction just with palpation. Differentiating a saltoharis 1 fracture versus a contusion that may be adjacent to the physis is a little more challenging. In terms of management, typically, again, place those in a walker boot for 10 to 14 days and then reevaluate. If they're still sore beyond the expected duration of healing of a saltoharis 1 fracture, you should be thinking about other things, perineal tendon tear, osteochondral lesion, etc., and that warrants an MRI to evaluate. So one thing I will mention is the lateral ankle versus the lateral hind foot in MNFIT. So anatomically, I see a lot of confusion among trainees with this, which is understandable. They're close together. A lot of injuries in this part of the foot get misdiagnosed as lateral ankle injuries, and the reason it matters is that the differential diagnosis is different. So I refer to this typically as the proximal dorsolateral foot, but it's the anterior hind foot and the proximal midfoot. And again, that's commonly mistaken for an injury of something like the ATFL in the lateral ankle. And it matters because there's some fairly common fractures in that area. So in particular, the anterior process of the calcaneus or the lateral process of the talus. The part of the foot we're talking about here is really sort of distal to the ATFL and proximal to the base of the fifth metatarsal, and usually a little bit more dorsal. One pretty common location for that is a strain of the extensor digitorum brevis muscle. So that's a pretty common injury. We see it all the time. There's commonly a little subtle avulsion fracture from the lateral calcaneus, as you see in the picture there. I think this is pretty significantly under-recognized. You don't really see much about this in the medical literature, but we really see it all the time. I think frequently those just get called lateral ankle sprains and they behave relatively similarly. So sort of never much bother correcting those. Cuboid is in the area there too, and that proximal dorsolateral foot. Those are relatively uncommon fractures and contusions. So the key is that the differential diagnosis is different, and to think about those two sites separately. So other distal fibula fractures. We talked about saltoheres 1 fractures. Saltoheres 2 fractures are fairly common as well of the distal fibula. Those can range from being pretty subtle, which are benign and will heal, you know, relatively quickly. The other pattern you'll see are these long oblique fractures of the distal fibula. These long saltoheres 2 fractures. That's this picture here. You typically see that only on the lateral view, but those can be pretty significant injuries. They can be a little bit more displaced and warrant watching closely. The key is to look closely at the lateral view, though. This particular fracture was a cult on the AP. You didn't see it. Saltoheres 3 fractures of the distal fibula. Relatively uncommon, but we see them occasionally. One thing that will mimic those is an avulsion of the perineal retinaculum. So those can be a little bit difficult to separate. Retinacular avulsions probably take a little bit longer to heal, and they tend to involve the tendons a little more directly. So some subtle distinctions, but overall similar. Those can both take a little while to heal. Distal tibia-physeal fractures are a little bit different. Those are typically more significant fractures than distal fibula fractures. There's a higher risk of growth aberrancy, and they typically require restriction of weight-bearing. Sometimes subtle Saltoheres 1 fractures you can get away without it, but a lot of the time you restrict weight-bearing with these injuries. There are also some unique considerations to distal tibial fractures as the physis begins to close. So beyond the sort of early teenage years, typically. And specifically talking about to lower triplane fractures. So these are two different types of fractures of the distal tibia. They can be subtle on x-rays, but they can lead to significant displacement at the fracture site and potential surgery or bad outcomes if it's missed. The key with these is that you may not see these real clearly on the x-rays, but it's often there if you look closely. Pains usually out of proportion to the relatively normal looking x-rays. They frequently have difficulty bearing weight, a lot of swelling, a lot of pain. So in those situations you want to look closely at the distal tibial epiphysis and those sort of pre-teen to mid-teenage kids. So here's the fracture on an x-ray. You can see that's really pretty subtle. There's a subtle lucency going through the distal tibia right there extending into the ankle joint. But if you look on the CT scan, it's much more clear. So these are frequently injuries where we're getting a CT scan to evaluate whether there's displacement there at the fracture site. If there's not, you can watch these closely. If there's true displacement, those are frequently surgical. So to low fractures in particular, this is a Salter-Harris 3 fracture of the closing distal tibial physis. That can be pretty subtle on x-rays, just like a more sort of garden variety Salter-Harris 3 fracture. The location's a little different. A typical sort of non-named Salter-Harris 3 fracture tends to be a little bit more medial, closer to the medial malleolus. These to low fractures are usually a little bit more directly anterior. Displacement can look pretty minimal on x-rays or not evident, but on a CT scan, so that's that middle image there, you can see more significant displacement. This particular patient required screw fixation as you can see with one of our pediatric surgeons. If there's displacement, these are surgical fractures. If not, you can watch them closely. Sometimes they do okay. Triplane fractures. So these are typically in slightly younger kids, just based on the degree of sort of early physio closure. That's when you'll see this. This is a complex Salter-Harris 4 fracture. These are usually less subtle. They're usually pretty clearly evident on x-rays. These are pretty much always surgical fractures. So the term triplane refers to the sort of three directions this break will go. So if you look at the middle picture there, you'll see it involving the distal tibial metaphysis posteriorly, and then it goes basically through the physis in an anterior direction and sort of out the front of the epiphysis, and that's that picture on the left there. Unstable fractures, generally speaking, require surgery. About half the time you'll also see an associated distal fibular fracture with this. Toddler fractures going sort of the other direction. These are pretty benign. So you'll see these in young kids, nine months to about three years old typically. This is a younger population than I typically see, but these are pretty common injuries. The mechanism most typically reported is going to be rotation. So the classic presentation for this is a kid goes down the slide with their parent, and they get their leg sort of intertwined with their parent's leg, twists, and they have a toddler's fracture. Treatment is really just a walker boot for comfort because these are stable. It's really more about comfort than anything else. They can be pretty subtle on x-rays, typically more apparent on a lateral view. Liz Frank injuries. So I mentioned these in a fracture talk because they're frequently associated with fractures. So these require a high index of suspicion with pain after an injury at the Liz Frank interval, so at that base of the first and second metatarsal. You can see fractures in that area, in particular of the second metatarsal. The Liz Frank ligament anatomically is connecting the medial cuneiform to the base of the second metatarsal, and its goal, its role, is to maintain the stability of the proximal forefoot. So it's essentially presenting, preventing lateral translation of the second through fifth metatarsals, which is exactly what you'll see if it's injured significantly. So one key when looking at these is you need weight-bearing x-rays if possible. So the force of weight-bearing puts a distracting force across the Liz Frank ligament, so you may miss that if they're not standing on it. Obviously some of these kids can't bear weight, but if they can, it's helpful to have them do that. A comparison x-ray to the other foot can also be helpful to evaluate for a side-to-side difference in the Liz Frank interval. If the x-ray is not diagnostic, always a role for an MRI to evaluate these injuries. So the mechanism of injury with a Liz Frank, there's actually three sort of discrete ways you can do this. The most significant is an axial load to a plantar flexed foot and ankle, so that's this picture here, somebody falling on the back of the foot or ankle. When somebody's in hyper plantar flexion is the way that the more significant injuries tend to happen. Or you can fall, you know, direct trauma from a fall from height would do it. A rotational force on a plantar flexed foot is the other way that this will happen. Those are usually lesser injuries, but still sometimes surgical. So here's that third mechanism, hyper plantar flexion and inversion. This was a ten-year-old kid I think that I saw. So you can see a small break at the base of the second metatarsal there, probably a little widening at that Liz Frank interval. Here's a much less subtle version of this, so a late adolescent now. And this was a football player, somebody fell on the back of his ankle. You're seeing lateral translation of the second through fifth metatarsals. A much larger gap there and two fractures there. So these are significant injuries. This is that same kid post-operatively. So these are bad injuries, thank you. Require a big surgery to fix these when they're bad, and that's after hardware removal on the right. I know the family, this kid's doing well, but these those are bad injuries. Toe fractures on the other end of the spectrum, those are very benign for the most part, especially lesser toe fractures, really immobilization. So the second through fifth toe immobilization there is really just for comfort and to make it easier to walk. Often I'll put those in a post-operative suit, so that short walker boot kind of thing, and then we'll switch them as their comfort improves to a half-length supportive insert. So these call it a turf toe plate, these go by different names, but this half steel insert with a felt pad minimizes the amount of immobilization while still supporting the toe. They can transition out of that as their pain resolves, kind of regardless of what their x-ray looks like. Great toe fractures are a little different, I watch those a little more closely. The great toes more significantly weight bearing, the majority of the body weight is going to go through the big toe. Those don't typically do as well with lesser immobilization, so I put those in a short boot and watch them a little closer. One other thing to note, see more fractures. So this is a specific type of a toe fracture or a finger fracture. So it's a physio fracture of the distal phalanx, and specifically there's displacement there. So these are usually saltohairs 2 fractures, and you'll see translation at the physis, so between the metaphysis and the epiphysis. What will happen with these is that it'll disrupt the skin underlying this, and create essentially an open fracture with risk for osteomyelitis. The problem is that sometimes these will spontaneously reduce, so you may not see that significant displacement, but if there's significant skin disruption there's risk of that having occurred. Treatment of these is a little controversial. Some surgeons will wash these out pretty quickly. Sometimes you can watch them closely. If there's not significant displacement and no more than relatively minor skin disruption, I'll put these in antibiotics and watch them sometimes, but you got to be a little bit careful with these because there is some risk for a more significant infection. So briefly we'll talk about a couple things that can mimic fractures. So there's a few different things that'll get mistaken for a fracture. So one is a cleft epiphysis. So that's at the base of the great toe, proximal phalanx typically. It's just an anatomic variant. That's that lower picture there. It's not a fracture, it's just the way that kid was born and developed. If you repeat x-rays on that, you'll see it doesn't change. That sometimes hard to assess fully in the setting of an injury in that area, but if that looks exactly the same on repeat x-rays, it's probably that. An accessory navicular is another very common sort of fracture mimicker. We'll see a lot of acute injuries in kids where it's the initial onset of pain at the medial navicular in the setting of an accessory navicular, so an extra bone, an extra growth plate, or an extra ossification center at that medial navicular. The key is that the pain's right there at the medial navicular. It's not dorsally in the navicular, it's not elsewhere. It's isolated to that medial portion of the navicular, and you'll see this on x-rays. Sometimes it's occult or really subtle on x-rays. Radiology will frequently not comment on these. And then the fifth menotarsal apotheosis. So not all kids will develop this. That's that upper picture there. But the fifth menotarsal apotheosis is where the perineus brevis tendon attaches to the base of the fifth menotarsal. And when that's present, it's a potential site for an injury. You can avulse it, or you can have chronic apotheositis there, otherwise known as Iceland's disease or Iceland's apotheositis, but the key is it's not a transverse fracture. So a fracture at the base of the fifth menotarsal is different. I'll show that on the next slide, but here's an accessory navicular, so that extra piece of bone right there, not to be mistaken for a fracture. So at the base of the fifth menotarsal, the apotheosis is longitudinal. It's along the length of the orientation of the menotarsal, whereas a true fracture is transverse. So that picture on the right, that's a fracture going across the base of the fifth menotarsal. On the left, that's an apotheosis. Could be an apophysial avulsion, which is technically a fracture, but separate from a transverse fracture. All right, good afternoon. So my name is Alex, I'm a former sports medicine fellow at Wash U with Dr. Simpson. Today I'm going to be reviewing some of the very common upper extremity pediatric fractures. This is not going to be super comprehensive in the nature of the space that we have today, but my hope is that this will at least deliver some high yield pearls to make it a little bit more easy to interpret these really common fracture patterns. Before I dive in, just wanted to again thank Dr. Simpson and Dr. Napolitano for putting this talk together and certainly for providing a lot of images today for this talk. So the focus of my section today will really be on distal radius fractures. We'll see if we'll be able to get to other content as well, but we'll start with this. So distal radius fractures, just from a history standpoint, most commonly occur as a result of a fall in an extended wrist. So from an epidemiology standpoint, more commonly the non-dominant hand is thought to be involved, and about 70% of the cases in some studies are in boys as opposed to girls, but this can be seen of course in both genders pretty commonly. And as Dr. Simpson alluded to before, children have kind of different, you know, they're not small adults, they have different characteristics than adults from a fracture standpoint. So when we think about children growing, the bone, especially at the distal metathesis, tends to be more porous. So as a result of that, the bone is what tends to be injured first as compared to the ligaments and the surrounding soft tissues, which may be the case in adults. So something to bear in mind. With regards to physical exam, so one of our major jobs is of course to make sure that the patient is stable to be managed in a non-operative orthopedic setting. So what does that mean? We're firstly going to inspect and look for any puncture wounds that might be suggestive of an open fracture. We're also going to make sure that this patient is neurovascularly intact. If they certainly fail those two criteria, then they may need to be referred to a higher level of care. But that being said, for your common bread-and-butter distal radius fractures, you may expect to see some deformity, some swelling, some ecchymosis. And in some studies, the painful dorsiflexion is thought to be the most sensitive physical exam finding for a distal radius fracture, and ecchymosis the most specific. So let's dive into some common types of distal radius fractures. So I'll start with the buccal fracture. So from a terminology standpoint, one thing that can be confusing is that some texts will refer to a distal radius buccal fracture as a torus fracture. Torus meaning bull. So I put some pictures here of bulls because allegedly the reason why this was named after as a torus fracture is because the fracture pattern resembles the horns of a bull. I'll leave that to your imagination when we review the imaging later. It's important to just bear in mind that each institution might refer to a buccal fracture versus a torus fracture, and they may be in use interchangeably. But depending on the training of the different sports medicine providers and the surgeons in your center, the use of these words might be different. So always worth clarifying amongst the people that you work with, specifically your radiologists and your surgeons. In terms of mechanism, the idea here is that the the trabecular bone will essentially fail and you'll have compression of one of the sides. So the cortex will will compress down and then bulge outwards. And this is a really common fracture pattern. In one study, up to 50% of fractures seen at a certain center in the pediatric population were buccal fractures. So let's look at some imaging. So here what we have is an AP on the left and then an oblique view of a wrist fracture. You can see there's a subtle outpouching of trabecular bone on the left side of the screen on the AP view. This is even more pronounced when you look at the oblique view where this outpouching is much more visible. I think this speaks to the fact that in order to correctly diagnose fractures, we often need to have more than one view. And this is something that's not done in all centers, especially if they're not used to seeing fractures. So making sure that we have at least an AP, ideally an oblique and definitely a lateral, is standard of care. So here's another example. So if you look at the AP view, the screen on the left, it's really hard to see really anything. It looks pretty normal. Then you look at the lateral and you can see that there's a very clear outpouching, I should say kind of bent appearance of the of the cortex of the bone, which corresponds to that area of focal compression. So without this lateral image, it might be pretty easy to miss this type of fracture. So bear that in mind. Ideally three views for these common pediatric distal radius fractures. Now outside of x-ray, I won't spend too much time on this, but there are emerging imaging modalities that may be used more frequently, especially by people who are trained in physiatry who have more experience with musculoskeletal ultrasound. This one study looked at comparing basically the diagnostic sensitivity and specificity of using ultrasound to diagnose a pediatric wrist fracture, buckle fracture, and 97% sensitivity and 95% specificity compared to radiographs. But it's important to note that this does take some training because certainly the physis can be mistaken for a fracture line, so keep that in mind. In terms of treatment for these fractures, so a little bit potentially of historical controversy here. One thing that's not controversial though is that this is a fracture and fractures heal with immobilization. These are generally stable fractures, so typically we have to talk to patients about and their families about what makes sense from an immobilization standpoint for them. That being said, you know, there are some more recent studies that have come out. This one that I've mentioned here in 2022 actually studied 965 children in the NHS system and randomized patients to either a splint versus a cast to see how they did. And essentially there was no difference in terms of pain, complications, return to play, or quality of life measures in either of these groups. So something to keep in mind. This study did mention that parents generally seem to prefer casting, maybe because their children are more rambunctious, but older studies have certainly not shown that to necessarily be the case where sometimes splinting is thought to be more preferable. How do we reconcile this in real life? Likely it's a good idea to have just a frank conversation with the patient and their family about what makes sense, given the activity level of the children and their propensity for further injury. In terms of follow-up, so this is definitely also an area of maybe emerging evidence, shall we say. Historically, typically, re-examination of these fractures at about two to three weeks was really recommended, with potentially the option of allowing patients to cancel that visit if people were doing well. With the idea of hopefully enabling some form of immobilization up to four weeks. Now most recently there has been this minimalist approach to distal radius buccal fracture management that has emerged as a result of several studies, one of which I've cited here, where they looked at 42 patients and they gave all these distal radius buccal patients a removable wrist brace and they did not schedule any follow-ups. And ideally here, the idea here was to see whether or not they were going to do poorly as a result of not having that physician contact point and that scheduled physical exam. And everybody did quite well in this study, so this has led to a lot of other organizations stating that maybe we should be more minimalistic in our approach, maybe we should be limiting the amount of follow-up intervals that we have for these patients, likely putting them all into splints, as long as they meet the criteria for having a very typical distal radius buccal fracture. So certainly I think a lot of people practice differently in this area. One thing to bear in mind is if the patient has a very classic presentation and the radiographs are really classic, there is likely a role for being minimalistic. Having a touch point, at least by telephone with the parents at a two-week mark, is likely an intelligent thing to do so that that way if something was missed, at least you have the opportunity to re-evaluate and bring the patient back in. But if they're doing really well, it's likely reasonable to let them follow up with their pediatrician for other things and not necessarily have them come back into clinic. The risk though that you run is that people are maybe less used to diagnosing these fractures. Maybe there was a secondary injury that was missed or maybe there was a green stick fracture that was missed which should be managed more aggressively. And that's where sometimes these guidelines struggle a little bit. So moving on next to the green stick fracture. So this is a really common fracture one to be familiar with. So as this image would suggest, this is where the bone bends rather than is crushed. So there'll be kind of a snap on one side where you actually have a cortical disruption and on the contralateral side you'll have basically compression of the bone. A green stick fracture theoretically is unicortical as well versus a complete fracture which is sort of a different animal is bicortical. So let's look at some examples. So this is an image from the internet here. So you can see an AP and then a lateral view of the wrist. On the AP you can see there's a clear fracture line there. It becomes more impressive on the lateral though and that's where you can really make the diagnosis of a green stick. So you have disruption of the cortex on one side and you have compression on the contralateral side. Here's another example pretty much showing a very very similar thing. So we have the AP view and then we have a lateral which really demonstrates again that unicortical disruption and the focal compression on the contralateral cortex. And this is yet another example. On the left hand side of the screen this is a lateral view and if you can imagine here that if you were just looking if you were just looking at the I guess on the far left hand of the screen the the cortical disruption that looks like bone compression and you didn't look at anything else you might think that this looks a lot like a buckle fracture. So hence the need to be very scrupulous in the way that you look at these these images because we certainly wouldn't want to miss a green stick fracture and manage it as a buckle fracture. But here you can see on the lateral that you do see that cortical disruption on the contralateral aspect and then that's also pretty clear here in the AP. So in terms of managing these so so unlike the buckle fracture where for the most part they're all they're all stable and they can be typically just immobilized right away we have to consider the degree of ambu angulation in these particular fractures. So the amount of angulation is is dependent on a couple of variables and there's a lot of different citations for this. So I think it's really important to familiarize yourself what what is the practice in your particular institution and what are your surgeons comfortable with. But generally some big picture principles are as Dr. Simpson alluded to younger patients tend to tolerate more angulation and if the fracture is closer to the physis it will tend to remodel more easily. Fractures that have angulation that is disproportionate may need to be reduced either with closed reduction or more rarely open reduction with the surgeon. But if we do determine that their angulation is acceptable initially we may immobilize these in what's called a sugar tongue splint which is what's demonstrated here above to allow essentially immobilization through the elbow and give the swelling the opportunity to continue to balloon out and then we can put them in either a short or a long-arm cast for at least six weeks thereafter once the swelling has stabilized. There is some variability in the literature as to whether or not to place them in a short or a long-arm cast but our practice was to place them in a long-arm cast to prevent any further angulation. So from an expectation standpoint should definitely keep in mind that we need to mobilize these for about six weeks. Some studies suggest the role for serial radiographs every couple of weeks just to make sure that the fractures don't continue to displace. So in one review looking at 311 of these all comers of distal radius fractures the one type of fracture that typically tended to displace even after two weeks of immobilization was the green stick hence the need for a follow-up and hence the need for follow-up radiographs as well. The last distal radius fracture that I'll talk about today are Salter Harris 1 & 2. We talked about what these are briefly so I won't review that but remember that the physis is definitely a unique piece of anatomy to the pediatric population and on exam as opposed to some of the other fractures that we've mentioned it's gonna hurt right over top of the physis. So familiarizing yourself with where those physes are is definitely a very helpful tip for your physical exam. So this is an image from a textbook here highlighting what they called as a Salter Harris 1 fracture. So this is a patient that has tenderness over the distal radius physis and on the AP view it doesn't really look like anything's wrong and then when you check the lateral there is some subtle widening of that physis corresponding to a Salter Harris 1 but it's also very common that these fractures are can be occult so if you don't see anything on the x-ray and the clinical history and the physical exam is supportive of this diagnosis you can still presumptively diagnose a Salter Harris 1. This is an example of a Salter Harris 2 from the same fracture textbook here. Again the Salter Harris 2 is going to have a fragment of a fracture or fracture line that extends up towards the metaphysis or more proximally. Less common but certainly it is possible for these to be displaced or angulated and again the amount of angulation that's tolerable depends on the resource that you read but non-displaced fractures certainly can be treated initially with a splint or a cast. In terms of these occult Salter Harris 1s as I alluded to before if they do have tenderness in the right place but they have normal radiographs typically the practice is to mobilize them for two weeks bring them back to the office and then re-examine them. Certainly if they have no tenderness on exam at the two week mark likely they sustained a soft tissue injury not a fracture but if they do have continued tenderness it makes sense to continue to mobilize them for a period of up to four weeks and then you can also consider repeat radiographs but that's a little bit provider dependent. The repeat radiographs might be useful in the fact that they would show bony healing which might help you consolidate your diagnosis. Then in terms of follow-up for these fractures as I alluded to we basically want to continue to mobilize them for four to six weeks. In terms of growth arrests so every time we talk about an injury to the physis this is the big question that sometimes parents will ask you you know is my child's arm going to grow the same length as the other side. With these Salter Harris 1 and Salter Harris 2 fractures the likelihood of there being growth disturbance or growth arrest is very low. So this one retrospective study looking at 381 children in 2021 found the rate of growth arrest for Salter Harris 2 fractures to only be 1.3 so corresponding to five cases and they argued that there's likely low utility and re-imaging to look for growth arrest because that is undue radiation to the patient and also very costly to the medical system. Conversely though you know Salter Harris 3 and 4 fractures which we didn't cover here I'm certainly do have a higher rate of growth disturbance so making sure that we're getting repeat radiographs at the 6 to 12 month interval makes some sense certainly in that population. All right so there are a number of slides here that highlight some interesting clinical cases that I will not have time to go through today but certainly these will be on the app for you to peruse later I will pass it on to Dr. Napolitano. All right thanks Scott and Alex and again thank you all for for bearing with us I know it's a long conference and a long session and a lot of detail here too so I'm gonna jump ahead to where my talk starts and so so I'll kind of wrap things up with us we'll talk a little bit about elbow shoulder and then just some final principles going forward so I'll start with some anatomy understanding the growth of the upper extremity a bit more and then look at these fractures about these joints as we discussed. So this is a very helpful image for me both in my own education but then also in explaining this to to families as well as understanding the the various FICEs role in growth so the humerus for example 80% of the length of that bone is coming from that proximal FICEs so injuries to that proximal humeral FICEs are a lot more concerning than the distal humerus conversely the radius 25% at the proximal radius where 75% of the distal radius so while a gymnast wrist or Salter-Harris one fracture of the distal radius may be relatively benign it's also responsible for 75% of the growth of that radius so an injury that causes premature growth arrest there is going to leave to alterations of that and so I think that's really helpful to understand when making your judgments of kind of what hill to die on right these these distal fibula fractures as Scott had mentioned right where it's not a weight-bearing bone number one but number two it's it's only responsible for 40% of the length of that so someone's near skeletal maturity we're not as concerned about that the elbow is probably the most complex joint in the pediatric radiographs and it's because of these various ossification centers so so in a map mnemonic to think about here is is cryto so that's capitellum radial head internal epicondyle trochlea olecranon and then the external epicondyle you know so these order cry toe this is the order in which they appear 1 3 5 7 9 11 years old and then however it'd be too easy if they actually fused in that same order but they don't so so they're different for for boys and girls but also kind of completely out of order so I think about this is the distal radio excuse me the distal humerus fuses first that's the the capitellum and the trochlea followed by the external epicondyle in that first group of fusion and then the next group is the distal radius, as well as the olecranon, and then finally is that medial epicondyle. And so that's why we see, as in our previous Pediatric Pearls talks, we talked a lot about apophysitis. So little e-gelbo is that chronic traction injury at that medial epicondyle apophysis, and that can be seen all the way to skeletal maturity as late as 18 years old in a male. So our first case that I wanna go over, this is a six-year-old who had a fall from a tree on their way down. They grabbed onto a branch, and that elbow and wrist were forced from flexion into extension. So they had elbow pain, swelling, and limited range of motion. These are their radiographs. So thinking about this, all right, I can see the distal humerus. I got the capitellum. Below that looks like the radius of the radial head. Maybe this is the trochlea here with the yellow arrow. But I got a whole ton of swelling there over that medial elbow. And if we go back to our crito, CR, so capitellum radius, next should be internal epicondyle. And you don't see it at all here. So actually what's happened in this patient is their internal epicondyle was evolved, right, in that pulled extension of that wrist. It pulled the medial flexors right off of there, and it got incarcerated down into the joint. This may be able to be reduced in the emergency room by, again, just extending those flexors to try to pull and free it and allow it to come back, but this may also require an open reduction as well. So it's really important to think about that order of what those areas ossify, because if you were just assuming that to be a trochlea, you missed a significant injury through there. So that could be one example, but there's several other types of elbow-type dislocation-type things that I wouldn't really call them all dislocations. Here's another image where, again, that it looks like the medial epicondyle or internal epicondyle has kind of evolved and pulled back into here. That's what the black arrow is. So the first elbow dislocation mimicker is what's called nursemaid's elbow. And yes, I practice pediatric sports medicine, but my youngest patients that we see in clinic are technically five and rarely five. I see mainly adolescents. So I don't see these in clinic. These are presenting to our urgent cares in ER, and this technically isn't an elbow dislocation, but it's a subluxation of the annular ligament around that radial head. The mechanism here is super important to think about. So this is traction of that arm, right? Arms swinging down, holding onto parents' arms, and then there's a rotation, quickly jerked away. That is gonna be well greater than the risk of a fall. So if you have a little toddler here who is holding their arm and unwilling to move it, you've gotta figure out that mechanism. Were they being swung around and that happened? Then you can be pretty sure that this is likely a nursemaid's. If they tripped and fell onto themselves, don't go tugging and pulling and trying to reduce their elbow because you're manipulating what's likely a distal radius fracture. So thinking about x-rays. So this child present will, they'll have an extended elbow and their hand will be kind of pronated over. And because it's a subluxation, recurrence here is quite common. So the reduction technique that's frequently described is this supination and elbow flexion to get that radius to come back over. However, there's been subsequent literature and a lot of anecdotal evidence that really advocates for this hyperpronation technique where that wrist is forced even a little bit more into pronation. But again, using this upper hand to palpate the radius as we're rotating there and kind of forcing it back into where it needs to be. So a true elbow dislocation, you know, a radial capitellar or ulnar trochlear is seen in a much older individual. So these are the adolescents who I see. So 10 to 15 years old. Boys more common than girls. The most likely mechanism here is a Fuchs injury. That elbow can be swollen. It'll be held in that 90 degree of flexion and really can't move or any type of pain with any types of movement. And you'll see a shortened appearance of the forearm. So two arm, you know, held out in front of you, you'll see one looks shorter. A reduction technique here is actually very similar to this first mechanism of this nursemaid's elbow where you can basically kind of try to bring that elbow back up into flexion. While you're doing that though, that posterior hand, that hand down in this position, the hand that's around the elbow is what I'm trying to say, that you're gonna put your finger back behind that olecranon and trying to push that olecranon forward as you're bringing the elbow up. So these can be reduced acutely. If their palpation reveals no specific bony tenderness. However, if you're concerned about another fracture, this should be done after an initial radiograph is obtained. So this patient is a five-year-old. She's playing on the jungle gym. She falls out onto an outstretched hand. She has pain and swelling of her elbow. And this is how she comes in. Well, that looks like a deformity. Is that a elbow dislocation? No, not in this age group, right? So she's five years old and the most common fracture in this age group is a supracondylar fracture, which is something quite serious and something that we don't want to miss. So 98% of these are extension fractures with that foosh type injury. But you also want to think about the associated injuries, vascular and neurologic compromise is very common, but can also be associated with an ipsilateral distal radius fracture. So here's what happens in that supracondylar fracture, right, you got three different nerves that are all really crossing across the same area where you have this supracondylar fracture and they're all vulnerable. So a complete neurologic exam is really good and really important to be done. This book advocates for the rock, paper, scissor test because you can test each of those and then that okay sign to really check out your anterior interosseous, which can be injured in as much as 6% of supracondylar fractures. The supracondylar fractures are rated in the group of type one, two, and three. So a type one fracture may be very subtle or an occult fracture without displacement and your diagnosis may just be this posterior fat pad sign, right, so you see the, I was gonna say hypoechoic, but you see this radiolucent area in the back here, so that's showing that the fat pad is elevated and there's fluid behind the elbow. You may see an anterior fat pad in a normal elbow and that is not as helpful as a posterior fat pad. Type two injury, what actually this is, is it's tilted backwards. So if we look at the next little animation here, you can see that this line along the anterior humerus does not go through the capitellum. That capitellum is pushed back behind here and so that is this type two fracture. So type one fractures, as a lot of our, Scott and Alex both highlighted, is really the role of using a splint for these acute fractures because of the amount of swelling so a posterior splint for a week to allow that swelling to calm down and then re-X-raying it, but a type one fracture here may be as few as three weeks of immobilization, whereas a type twos and types threes definitely need to see orthopedics because they gotta figure out is this stable or does this need to be surgically reduced or pinned to fixate it to keep it in there. Those pins can be removed after four weeks and starting to range that right away. So even though these injuries seem quite severe, you can see that their time of immobilization is relatively short and that's because the elbow gets stiff very, very fast and the longer you immobilize that, you may ultimately lose end range motion. You'll keep your functional range in the elbow, but you're gonna get a lot of parents who'll come back, you know, I can't get that elbow extended that final five degrees. And so we try to limit the amount of time that we have that elbow immobilized. But also when you're on the field and you're assessing someone, this X-ray here, all these little rivets, those are football shoulder pads, right? So you can suspect that there might be an elbow dislocation based on the mechanism, the shortened appearance, but if you're palpating up and down your humerus and up and down your radius and you find other palpations or other soreness, don't try to reduce an elbow. You'll often feel kind of this, it's kind of a creepy feeling, but this is like crepitus within the skin of a fracture. So don't mistake a dislocation for a fracture when you don't have X-ray vision. All right, this case, this is a 13-year-old gymnast here. She's doing a vault and she has this acute valgus collapse of the elbow. So that elbow coming valgusly loaded, she has pain, swelling and ecchymosis all immediately, pain and laxity with valgus stress. What do we think that soft tissue injury is? Valgus stress. All right, that's a UCL injury unless otherwise said. So you can confirm that with dynamic ultrasound. However, what if this gymnast is a nine-year-old and then her pain and swelling, instead of medially, maybe laterally, she's got difficulty supinating and pronating, all that same vault mechanism, all that same valgus load, but the difference here is this becomes a radial head fracture because the laxity of the ligaments on the medial side are able to stretch and kind of rebound and recoil well. However, that compressive force on the radial neck there, this little beaking that you see, that is a radial neck fracture. And so then again, that is a non-displaced fracture, but something that certainly needs immobilized. That's it for the elbow. I'll jump up to the shoulder here. Proximal humerus fractures scare the heck out of me because they look gross, but every time I talk to my colleagues in orthopedics or others, they're like, oh yeah, that's fine, don't worry about it. And sure enough, these kids do incredibly well. So it's 2% of fractures frequently seen in adolescents. You can have them associated with salted hair is two fracture like this one on this slide. It can be a fall or it can also be kind of a direct blow to the shoulder. So the remodeling here is why these do so well. Again, remember 80% of the length of the humerus happens at this proximal physis. So being able to completely remodel in this area is a really good indication. So these are traditionally graded on this article from 1965. Dr. Neer and Dr. Horwitz, his impingement test, or his name extends past the impingement testing. So they look at this level of displacement. If you remember from Scott's lecture, displacement is kind of that side to side overlap, thinking about grading this almost like a listhesis, right? So one third of the shaft, two thirds of the shaft, listhesis, quarter, half, et cetera. But these are how we grade these as far as the amount of displacement. Since Neer and Horwitz, there's countless other criteria and ways to grade these, but acceptable alignment, this is just kind of a good way to think about this. Again, this is the ones that freak me out. 10 years old, really any angulation, they're just gonna be fine. They got another eight years of growing here and they're just gonna all be just fine. So 10 to 12, you know, you gotta be a little bit more scrupulous about how much angulation, but 60 to 75 degrees, that's a steep angulation. Whereas if you're closer to 12 or older, you wanna look at, you know, 45 degrees or less, which again, still is no small amount. So non-operative management in those type ones and type twos, again, slinging them for only three to four weeks. Sling and not a cast. So there's no way you're gonna get a cast around the shoulder girdle to really immobilize this. The really, the only role of a cast, and sometimes we'll do this, is called a hanging arm cast, where you're gonna put a cast around their, you know, elbow and forearm, just to give them some weight and traction to allow that fracture to kind of remodel a little bit or tug back down before it remodels, I should say. But surgery that, you know, can be indicated here as well. So if you have that complete displacement, that overlap, significant shortening, especially if you're over that, you know, 10, 11 years old, that's certainly surgical indications as well. My last topic I wanna talk about here briefly is clavicle fractures. So clavicle fractures, very common in young athletes. They can be up to 15% of the fractures that we see, and I probably see it's a greater percentage of the fractures that end up in my clinic, most commonly in the middle thirds. Back in the day, they'd say, you know, if the two ends of clavicle are in the same room, they're gonna heal fine, which, for the most part, if you're still looking at those kids under 10 years old, that's still the case. There's been a lot of biomechanical studies, however, since then, I'd say, you know, significant clavicle shortening can impact the biomechanics, putting some extra stress on the AC and glenohumeral joints. So when is an ORIF indicated? So of course, if there's an open fracture, skin compromise, if there's complete displacement, so again, no overlap at all, or if there's this Z-combination, as you can see in the top picture, or if there's shortening upwards of two centimeters, those can be indications for an ORIF. But how about these kids, are they gonna remodel? You know, it's interesting that they actually found that 80% of that clavicle length is reached by nine years old in girls and 12 years old in boys. So there's not as much remodeling potential here as we had previously thought. So why would you do surgery? These two studies showed that there were great outcomes from an ORIF, you know, with greater patient satisfaction, good return to sport, and no non-union. However, that first study showed that in the non-operative group, five out of their groups had some non-union and four ultimately ended up with a subsequent surgery. However, this study followed this and found that kind of regardless of the age and the sport and what they're doing, you know, they can be treated pretty equally comparing surgical versus non-surgical. So here's the argument, right? Is with a non-surgical healing, there's gonna be a bump or a change in the orientation of the bone. You may be more prominent, it may be less prominent, but it'll be asymmetric. So if your patient has goals of being, you know, a collarbone model, they gotta have that conversation. But the alternative here is a scar right over this area too. So it's cosmetically different either way and it's reason to have this conversation. Surgeries can have risks of infection. Non-operative management may have risk of non-union. So it's not a clear decision either way. So when you put it all together, there's not a specific criteria that you can use to consistently apply these guidelines. So just having that shared decision-making conversations with the family, how much remodeling are they gonna have, and then talking openly with your surgeons as well. So some final comments about the children's fractures. These age-related fracture patterns are really helpful. So infants tend to most frequently fracture in the diaphysis as the physis is really quite strong. The children, middle-aged children, kind of more metaphyseal fractures, whereas the adolescents are these epiphyseal, Salter-Harris-type injuries. As you saw in most of our talks, as far as amount of immobilization, a lot of this healing happens relatively quickly in these growing bones, so three to four weeks. And so the reduction being done quickly and a short term of immobilization, the challenge becomes, all right, maybe it's healed, but when are we able to progress back to sports? And that takes a little bit longer for a lot of these where I'm going closer to two months for a lot of fractures to get back out of a cast. So 50% of that remodeling is gonna happen in the first six months, but you're gonna show an X-ray to a family and you're gonna say, yeah, it's looking great, and they're gonna say, but look at the deformity. And that continues happening after six months into 18 months, and it just keeps going from there. So five final factors, thinking about the years of remaining growth, looking at some resources to figure out how much growth does this patient have, what bone is it at, is it proximal humerus versus distal radius, where in the position of this bone, the plane of motion that they had their injury, is this likely to become more angulated, apex, polar, dorsally, what's the fissile status, are they still growing, and is it injured, is there a risk of fissile arrest, and then what is the growth potential of that nearby fissus. So the final thoughts that I had here is, as one of my mentors mentioned in his talk yesterday, Ken Mountner said, just when you're practicing sports medicine, understand to stay in your lane. We just gave you an hour and a half lecture about how to manage fractures. Don't take this and say, now I'm an expert in it. This is gonna come with practice and exposure, and use the resources you have. These are two great textbooks that I have in clinic with me that I'm frequently referencing, but the one that I reference more than that is my phone. I'm talking frequently with my surgeons about, hey, how does this look to you, do you have any follow-up suggestions, do you need to see this one, what would you recommend for me, and then document that too, right, because based on the level of training that you have, where you are, the amount of experience you have, you can be liable for malpractice for these because of the fact that there's a lot of changes in pediatric growth over time. So again, shared decision-making, documentation are all super, super important. So what are we here, it's 4.30, so we're exactly right at time, but I'd love to take a couple of questions, but again, thank you guys for joining us. Thank you.

pediatric fractures

types of fractures

children

foot fractures

ankle fractures

toe fractures

fracture management

child abuse

fracture treatment options

age-based fracture patterns

complications