Fractures

Overview

Physical Examination

Evaluation: Imaging

Anteroposterior (AP) and lateral views are the most common.

Oblique views are helpful for fully disclosing the nature and extent of many fracture patterns, especially when the injury involves the ankle, elbow, hand (especially for scaphoid fracture), or foot. Oblique views are also helpful for detecting subtle spiral fractures where the AP and lateral views are normal, yet a fracture is strongly suspected.

Ankle AP mortise view is helpful since it includes distal tibia, distal fibula, talus, and proximal metatarsals.

Salter-Harris Classification System

This is the standard classification system for description of fractures involving the growth plate (also called physis or epiphyseal plate).


Prevalence of Fracture Types Using the Salter-Harris Classification System

 

Type I

Fracture through physis; extra-articular

Salter-Harris Type I on right distal tibia

Salter-Harris Type I on right proximal tibia

Salter-Harris Type I on left distal radial 

Type II

Fracture through physis and metaphysis

 

Salter-Harris Type II on distal femur

Type III

Fracture through epiphysis and physis

Salter-Harris Type III on distal tibia

Salter-Harris Type III on right distal tibia

 

 

Type IV

Fracture through epiphysis, physis, and metaphysis

 

Salter-Harris Type IV of base of proximal phalanx

Type V

Compression injury to physis without fracture. Rare and identifiable only in retrospect, when compression of the physis has led to growth disturbance.

Salter-Harris Type V on distal tibia

Salter-Harris V through medial aspect of left distal tibia

 


 

Fracture Patterns


1. Humerus fracture
1a. Proximal humerus fracture

Mechanism of Injury
The Mechanism of Injury is blunt trauma or indirect trauma (including overuse injury in throwers such as Little Leaguers shoulder.
Radiographs show mild widening of the physis and metaphyseal changes

 


Proximal humerus fracture

1b. Humerus shaft fracture

Mechanism of Injury
Often associated with trauma. Consider non-accidental trauma if less than three years of age and spiral fracture pattern.


Humerus shaft fracture


2. Elbow fractures
2a. Supracondylar fracture

Supracondylar fractures represent half of pediatric elbow fractures and most operated pediatric fracture.

garland class
Gartland Classification of Supracondylar Humerus Fracture
Image Source from Wikimedia Commons: https://upload.wikimedia.org/Wikimedia/commons/f/fc/Gartland_Classification.jpg

Mechanism of Injury

Associated Injuries

Radial nerve palsy is the second most common neuropraxia. On exam, patient is unable to extend wrist or digits.
Ulnar nerve palsy is seen with flexion-type injury patterns.

Evaluation: Imaging
AP and lateral view of the elbow x-rays show posterior fat pad sign : lucency along the posterior distal humerus and olecranon fossa is highly suggestive of occult fracture around the elbow.


Supracondylar humerus fracture


Supracondylar humerus fracture


Supracondylar humerus fracture

Management

2b. Medial epicondyle fracture

Mechanism of Injury
Injury can be a fall on an outstretched arm (most common), elbow dislocation, traumatic avulsion (usually occurs in overhead throwing).


Medial epicondyle fracture

Physical Examination
Tenderness over medial epicondyle.

2c. Lateral condyle fracture


Medial epicondyle fracture

Mechanism of Injury
Results from the pull of the common extensor musculature or fall on an outstretched hand.

Physical Examination
Swelling and tenderness to the lateral elbow is notable on exam. There is also increased pain upon wrist extension or flexion.

2d. Radial head / neck fractures (of the elbow)

Mechanism of Injury
Typically involves valgus loading injury of the elbow.

Physical Examination
There is swelling over lateral elbow. Pain is exacerbated upon forearm supination and pronation. Sometimes, there is referred pain to the wrist.

 

Radial head/neck fractures

 

 


3. Radius fractures
3a. Distal metaphysis (complete fracture)

Apex volar (Colles' fracture)
Apex dorsal (Smith's fracture)

3b. Distal metaphysis (incomplete fracture)

Torus/Buckle fracture (typically unicortical)

3c. Diaphysis

Plastic deformation: incomplete fracture with deforming force resulting in shape change of bone without clear fracture line, occurs along compression side.
Greenstick fracture: incomplete fracture resulting from failure along tension (convex) side.

 
Buckle /Torus fracture of the dorsolateral cortex of the distal radial metaphysis

 
Plastic deformation (bowing deformity) of the right radius
and an oblique mid-diaphyseal ulnar fracture
with posterior displacement of the distal fragment (one shaft-width)


4. Femoral shaft fracture

Abuse must be considered if child is less than five years of age, especially if present in a patient before walking age.   Femur fractures are the second most common child abuse associated fracture after humerus fractures.   (See also the section below on Non-accidental fractures.)

Symptoms
Patients typically present with thigh pain, inability to walk, report of leg deformity or instability.

Mechanism of Injury
The mechanisms of injury is correlated with age due to the increasing thickness of the cortical shaft during skeletal growth and maturity. Falls are the most common cause in toddlers. Whereas, high energy trauma is responsible for injury in adolescents, typically from motor vehicle collision. Fractures after minor trauma can be the result of a pathologic process (bone tumors, osteogenesis imperfecta, osteopenia).

Physical Examination
Examination reveals gross deformity, swelling of the thigh, and exquisite tenderness to affected area.

Evaluation: Imaging

X-rays:

Management

Complications


5. Tibia shaft fracture (Toddler fracture)

This type of fracture is also referred to as childhood accidental spiral tibial (CAST) fractures

Mechanism of Injury
The injury is low energy trauma with rotational component or hyperextension of the knee when landing from a jump.

Physical Examination
Child may limp or refuse to walk. Exam shows tenderness but no obvious swelling or deformity.

Evaluation: Imaging
X-ray may reveal nondisplaced spiral or oblique fracture (distal metaphyseal oblique proximal lateral to distal medial) of tibial shaft only. Fibula typically remains intact. Toddler fracture involves the distal half of tibia, unlike non-accidental injury, which typically involves proximal half of tibia.


Tibia shaft fracture (Toddler fracture)                  


6. Stress fracture

Stress fractures most commonly affect the long bones of the lower legs (more commonly the tibia) but can also involve the foot, hip, knee, or ankle.

Mechanism of Injury
Overuse injuries commonly cause abnormal stresses on trabecular bone resulting in microfractures, which subsequently propagates within the bone. Repetitive loads then exceed the threshold of intrinsic bone healing. This is commonly seen in young athletes.

Evaluation: Imaging
X-ray may be normal. Sometimes, injuries require bone scan to confirm diagnosis.


Stress Fracture


7. Scaphoid fracture

Mechanism of Injury
Most commonly via axial load across hyper-extended and radially deviated wrist.

Physical Examination:

 Evaluation: Imaging

 Management


Scaphoid Fracture


8. Phalanx / Finger fractures

Mechanism of Injury
Trauma, including sports, is the most common cause of injury.

Physical Examination
Examination reveals localized tenderness and/or deformity. Look carefully for open wounds.  

Evaluation: Imaging
Finger X-ray: Obtain AP and lateral views if there is a specific, localized area of pain.
Hand X-ray: Obtain hand x-ray if there are suspicion for carpal or metacarpal bone involvement.

 
Spiral Fracture on proximal phalanx of 2nd digit

Management

Splinting

Goals of splinting

 Equipment

TYPES OF SPLINTS

Splints for
Upper Extremities

Indication

Bulky hand compression dressing

Closed hand fractures

Colles splint

Distal forearm and wrist fractures

Dorsal or volar splint

Wrist fractures or injuries, fractures of 2nd - 5th metacarpals, soft tissue injuries of the hand

Figure-of-eight splint

Medial clavical fractures

Gutter splint

Phalangeal and metacarpal fractures

Posterior arm splint

Stable elbow and forearm injuries

Sling and swathe

Shoulder injuries, humeral injuries

Sugar tong splints

Proximal

Humeral fractures

Distal

Wrist fractures, distal forearm fractures

Double

Elbow fractures, forearm fractures

Reverse

Distal forearm fractures

Thumb spica splint

Scaphoid fractures, extra-articular fractures of the thumb metacarpal, ulnar collateral ligament injuries

Velpeau bandage

Shoulder injuries, humeral injuries

Volar finger splint

Fractures of distal phalanges and interphalangeal joints

Splints for
Lower Extremities

Indication

Buddy taping

Phalangeal fractures of the toes

Bulky foot compression dressing

Calcaneal fractures; foot injuries

Jones compression E

Knee and calf injuries

Knee splint

Knee injuries

Posterior ankle splint

Distal leg, ankle, tarsal, and metatarsal fractures; reduced dislocations; severe sprains

Stirrup splint

Ankle fractures

 

  alternative accessible content

Applying a Distal Sugar Tong Splint
a 7 minute video by S. Sanchez, UTMB

Compartment Syndrome

The muscle groups are divided in compartments and bound by rigid fascial membranes. Compartment syndrome occurs when increased pressure within a closed fascial compartment (often due to bleeding and edema collection) causes neurovascular compromise and muscle ischemia. Increased pressure, exacerbated by capillary leaking, first occludes venous outflow and only later occludes arterial flow to produce the classic signs and symptoms. Compartment syndrome is defined as pressure greater or equal to 30 mm Hg.

Symptoms: paresthesia and intense pain (aggravated by passive stretching of the muscles).

Signs: affected area is swollen & tense, pallor, and decreased pulses.

Common fractures prone to compartment syndrome

Other Complications Due to Fractures


Penetrating injuries

Fractures may cause penetrating injuries to surrounding structures. Any overlying bony structures, if bloody and fatty exudate is oozing, usually reflect communication with the medullary cavity of a fractured bone.  

In the knee joints, if serous or serosanguineous fluid flows during knee movement, this is suggestive of a penetration of the joint capsule. Air seen in the radiograph of the knee joint confirms the diagnosis. Absence does not rule out capsular penetration, but warrants exploration in the OR.


Neurovascular injury

Neuropraxia is a type of peripheral nerve injury that is classified as a transient conduction block of motor or sensory function. Although nerve degeneration does not occur, there can be a loss of motor function. Patients are usually able to fully recover within a period of weeks to months.

Although vascular injury can occur, there is rich collateral circulation that can maintain circulation.

Fractures associated with neurovascular injury include:


Additional Complications

QuickCheck

Value: 1

A 10-year old boy sustained an ankle injury in a fall while jogging. He was evaluated in the emergency department and diagnosed with a Salter-Harris type III fracture of the distal fibula. Which of the following findings is expected to be seen upon review of this patient's radiograph?