Foot and toe injuries

Cite this article as:
Taskin Kadri. Foot and toe injuries, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32663

A child’s foot is significantly more cartilaginous than an adult foot, making foot fractures an uncommon injury in children. Foot fractures constitute about 5-8% of paediatric fractures. Evaluation and management of a paediatric foot injury requires an understanding of paediatric anatomy, a careful history, clinical examination, and potentially radiography.

Normal anatomy

The foot is anatomically divided into 3 sections: hindfoot, midfoot and forefoot.

The hindfoot includes the talus and calcaneus. The inferior surface of the talus is more prone to avascular necrosis due to its retrograde blood supply. The part of the calcaneus most prone to fracture is its large posterior facet.

The midfoot includes the navicular, cuboid and the three cuneiform bones.

The forefoot includes the metatarsals and phalanges.

Evaluation of foot injuries

History

The following specific enquiries should be made about the injury:

  • The mechanism of injury (high/low velocity, twisting, compression, direct blow)
  • Characteristics of pain (worse at the time of injury vs late onset)
  • Location of pain
  • Consistency and plausibility of the history, excluding concerns about non-accidental injury
  • The effect of the injury on the child (limping, the distance the child can move)
  • The efficacy of pain relief

Examination

Clinical examination should be tailored to the history.

Look

For external skin abrasions or obvious open fractures.

Feel

Palpation of the bones: tarsals, metatarsals, toes and the base of the 5th metatarsal.

Palpation for tenderness along the ligaments: deltoid ligament on medial side and anterior talofibular, calcaneofibular and posterior talofibular ligaments on the lateral side.

Move

The active movement should be followed by passive movement as much as pain allows.

The usual range of movements are: subtalar eversion (15-20°), subtalar inversion (35-40°), forefoot adduction (20°), forefoot abduction (10°), 1st metatarsal phalangeal (MTP) flexion (45°), 1st MTP extension (70-90°) and free motion of lesser toes.

Neurovascular examination

Two pulses: dorsalis pedis and posterior tibial.

Five sensory nerves: saphenous (medial calf and hindfoot), superficial peroneal (dorsum of the foot), deep peroneal (1st dorsal webspace), sural (lateral foot) and posterior tibial nerve (plantar foot and heel).

Imaging

The Ottawa foot rules can be applied to children. The rules have 97-100% sensitivity in paediatric injury investigation. According to the rules, x-rays of the foot are required if the child is unable to weight bear both immediately after the injury and in the ED, plus bony tenderness over the base of 5th metatarsal or the navicular.  

Accessory ossicles

Accessory foot ossicles can cause pain as a result of stress injuries. The navicular ossicles, arise either on the medial side of (os tibiale externum) or on the lateral tubercle of the navicular bone (os trigonum).

Os tibiale externum

This is an ossification centre that arises at the site of the tibialis posterior tendon on the medial side of the navicular bone. It becomes an accessory bone when it fails to fully ossify.  It is present in 4-14% of patients.

The usual presentation is in adolescence when the patient has pain from overuse, especially in athletes.

Os tibiale externum

Examination may reveal pes planus (flat foot). This happens as the tibialis posterior tendon, maintaining the medial longitudinal arch, attaches to the accessory bone rather than the navicular bone.

Investigations include plain films and, occasionally, MRI scan.  

Treatment is initially conservative with orthotics and casting. The ossicle is excised if these measures fail to resolve the pain.

Os trigonum

This is present in 10-25% of the population. It is often associated with heel pain in ballet dancers due to repetitive microtrauma.

Hindfoot fractures

These are rare, constituting only 0.008% of all paediatric fractures. Children usually present after falling from height or after a motor vehicle injury. The talus can be fractured in multiple places including avulsion fracture.

Case courtesy of Assoc Prof Craig Hacking, Radiopaedia.org. From the case rID: 77140

‘Snowboarder’s fracture’ is a fracture of the lateral process of the talus. The mechanism of injury involves dorsiflexion and inversion.

Do not miss: Snowboarder’s fractures are often misdiagnosed as an ankle sprain. If not evident on x-ray, a CT or MRI should be performed if there is clinical suspicion. Think carefully about the mechanism.

Calcaneus fractures typically occur due to axial loading and are frequently associated with vertebral compression fractures. Radiography should include AP, lateral and axial views. The axial view offers a better view of the fracture.

Treatment of talus and calcaneus fractures is dependent on the degree of displacement.

  • Non or minimally displaced avulsion fractures, or extra-articular fractures should be managed in a posterior short leg splint and should be non–weight bearing with crutches for 3 to 4 weeks.
  • Displaced fractures require reduction, by an orthopaedic surgeon, followed by immobilisation with a splint or cast. Severely displaced, comminuted or intra-articular fragments may require ORIF.

Midfoot fractures

These are also rare fractures and usually result from severe blunt injury. Most fractures are avulsion or stress fractures and are associated with other injuries.

Treatment depends on the severity of displacement of the fracture and associated injuries.

  • Non or minimally displaced fractures (the majority of these fractures) can be treated with a walking cast.
  • Displacement of the fracture fragment greater than 2mm should be managed with reduction and stabilisation before immobilisation.

Midfoot fractures have minimal long term sequelae.

Forefoot fractures

Forefoot fractures represent about 60% of paediatric foot fractures and can result from either direct or indirect trauma. They are easily missed: about 41% are missed due to high energy trauma causing other significant injuries.

Lisfranc fracture

Lisfranc fractures occur due to axial loading with forced plantar flexion (commonly seen in bicycle or horseback riders where a foot gets caught in a pedal or stirrup) or with a crush injury.

Clinical examination

  • Tenderness over the dorsum of the foot with swelling and inability to bear weight.
  • Plantar bruising is a consistent sign and if present should raise suspicion of the injury.  

Diagnosis is made with a weight bearing x-rays (as the fracture may not be evident on non-weight bearing views) – AP, lateral and oblique radiographs of the foot. The normal alignment of the foot should have the 2nd metatarsal aligning with the intermediate cuneiform on the dorsoplantar view and the 3rd metatarsal aligning with the lateral cuneiform on the oblique view. The Lisfranc ligament connects the cuneiforms to the 2nd metatarsal. Disruption of this ligament leaves the foot unstable and hence it is an important not to miss this injury. Due to the ligament attachment, there is often associated fracture of the bases of the 1st or 2nd metatarsal in a Lisfranc injury.

https://emergencymedicineireland.com/

Treatment depends on the degree of severity of the injury.

  • Partial tears with < 2mm malalignment require immobilisation or a walking boot for 4-6 weeks. The patient should be referred to orthopaedic surgeons within 3-5 days due to the high rate of late complications.
  • More severe injuries require operative treatment with internal fixation.

There is a high rate of residual pain in children with a Lisfranc injury.

Metatarsal fractures

Metatarsal fractures are associated with athletic activity and are becoming more common. The 5th metatarsal is the most commonly fractured metatarsal in paediatric patients. It can result from twisting, repetitive stress or direct trauma. 1st and 5th metatarsal fractures can be isolated whereas 2nd-4th metatarsal fractures often occur along with other metatarsal fractures. It is a frequently missed fracture on a radiograph.

Children younger than 5 years of age are more likely to be injured by a fall from height and fracture the 1st metatarsal. Older children are more likely to fracture it from falling from a standing position, during sports and tend to fracture the 5th metatarsal.

Pseudo-Jones fracture

A Pseudo-Jones fracture is an avulsion fracture of the base of the 5th metatarsal resulting from a twisting injury of the foot. The examination will reveal focal point tenderness. The patient should be immobilised for 3-4 weeks in a weight-bearing cast.

Treat with a short walking boot or hard sole shoe for 6 weeks. Follow-up with orthopaedic surgeons.

Jones fracture

The Jones fracture is a fracture of the metaphyseal-diaphyseal junction at the base of the 5th metatarsal bone. It is the most common of metatarsal fractures (40%), representing about 25% of all paediatric foot fractures.

Jones fracture (metaphyseal-diaphyseal junction fractures of the 5th metatarsal).

Fractures at or distal to the metaphyseal-diaphyseal junction require 6 weeks in a non–weight bearing cast, with crutches. All patients should be referred to orthopaedic surgeons as there is a high incidence of delayed union of the fracture. Many of these patients will require ORIF subsequently.

The apophysis of the base of the 5th metatarsal appears at age 10 for girls and at age 12 for boys. An unfused apophysis runs longitudinally whereas pseudo-Jones fracture runs transversely.

Normal apophysis of the 5th metarasal (note it runs longitudinally rather than transversely). Case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 8802

Toe fractures

Toes fractures are one of the most common fractures in the paediatric population. Phalangeal fractures constitute about 3-7% of all physeal fractures and are usually Salter-Harris I or II injuries. They are more common in boys than girls and are mostly closed in nature.

The patient may present with localised tenderness to the toe, a limp or inability to bear weight. Nail bed bleeding and bleeding from or around the nail fold should prompt the possibility of an open fracture through the nail bed. Alignment, rotation and neurovascular status should be checked.

Fractures of the 2nd-5th toes are usually treated by buddy strapping and weight bearing as much as possible. Healing can take up to 3-4 weeks. A hard-soled shoe or walking boot may be used for patient comfort. Follow-ups with orthopaedic surgeons can cease 3 weeks after the injury. If there is possible injury to physis then follow-up should continue for 1-2 years to detect abnormal growth.

The big toe

The big toe plays an important part in bearing weight. Fractures of the big toe are therefore managed slightly differently.  Salter-Harris III or IV fractures of the proximal phalanx of the hallux are often intra-articular.

Urgent orthopaedic consultation for closed or open reduction for K wiring if:

  • more than one third of the joint surface is involved or
  • displacement is more than 2-3mm

In other cases, toe platform cast or a walking boot is used.

The epiphysis of the proximal phalanx of the 1st toe is sometimes bipartite, simulating a Salter-Harris III fracture. If there is no tenderness on the 1st toe, no treatment is indicated.

Phalangeal open fractures require thorough irrigation and debridement in addition to antibiotics to avoid osteomyelitis.  A nail-bed injury to the germinal matrix will require surgical repair.

Long term complications include growth arrest and angular deformities from physeal injury, degenerative joint disease from intra-articular fractures and osteomyelitis from open fractures.

References

Boutis K: Paediatric metatarsal and toe fractures. Up to Date 2019

Boutis, K., 2021. UpToDate. [online] Uptodate.com. Available at: <https://www.uptodate.com/contents/foot-fractures-other-than-metatarsal-or-phalangeal-in-children> [Accessed 4 April 2021].

Boutis, K., 2021. UpToDate. [online] Uptodate.com. Available at: <https://www.uptodate.com/contents/foot-fractures-other-than-metatarsal-or-phalangeal-in-children> [Accessed 4 April 2021].

Eiff, M. and Hatch, R. Fracture management for primary care and emergency medicine. Elsevier.

Halai, M., Jamal, B., Rea, P., Qureshi, M. and Pillai, A., 2015. Acute fractures of the pediatric foot and ankle. World Journal of Pediatrics, 11(1), pp.14-20.

Horner K and Tavarez M, 2016. Paediatric Ankle and Foot Injuries. Clin Pediatr Emerg Med, 17 pp. 38-52

Juliano, P., 2018. Lateral Talar Process Fractures – FootEducation. [online] FootEducation. Available at: <https://footeducation.com/lateral-talar-process-fractures/> [Accessed 4 April 2021].

Malanga, G. and Ramirez – Del Toro, J., 2008. Common Injuries of the Foot and Ankle in the Child and Adolescent Athlete. Physical Medicine and Rehabilitation Clinics of North America, 19(2), pp.347-371.

Metaizeau, J. and Denis, D., 2019. Update on leg fractures in paediatric patients. Orthopaedics & Traumatology: Surgery & Research, 105(1), pp.S143-S151.

Smit, K. Foot Fractures – Phalanx | Pediatric Orthopaedic Society of North America (POSNA). [online] Posna.org. Available at: <https://posna.org/Physician-Education/Study-Guide/Foot-Fractures-Phalanx> [Accessed 4 April 2021].

Shoulder examination

Cite this article as:
Mark Webb. Shoulder examination, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31287

Johnny is five. He fell onto his outstretched arm and now is sat in your ED, crying and holding his shoulder adducted. Triage has been ace and given him analgesia so he is adequately comfortable before you examine him.

Joint examinations can be easily remembered by “look, feel, move” and special tests. It’s important that in addition to the joint you’re interested in that you also examine the joint above and below.

Look

  • Deformity
  • Swelling
  • Atrophy: Asymmetry  
  • Wounds
  • Bruising
  • Skin tenting (typically clavicular fractures, whereby the bony fragment is causing pressure on the skin and thought to cause skin necrosis, although this is controversial) 

A chaperone may be needed to expose the joint adequately in older children.

Feel

Feel for warmth, which could indicate septic arthritis.

From the front:

Start medially at sternoclavicular joint

Anatomy of the acromio-clavicular joint

From the back:

  • Scapula: spine, supraspinatus, infraspinatus muscle

Neurovascular assessment:

  • Check for distal pulses: brachial/ radial.
  • Always check the regimental patch for axillary nerve injury and document it.

Move

Assess for range of motion, both active and passive.

Girl flexing and extending at shoulder showing range of movement

Flexion: 180 degrees. Raise arm forward up until they point to the ceiling.

Extension: 45-60 degrees. Stretch the arm out behind them.

Girl showing range of adduction and abduction at the shoulder

ABduction: 150-160 degrees. Put arms out to the side like an aeroplane’s wings and then bring them above their head to point to the ceiling.

ADduction: 30-40 degrees. Put arms out to the side like an aeroplane’s wings and move them in front of their body so they cross over.

Girl showing range of internal and external rotation

External rotation: 90 degrees. Tuck their elbows to their side and swing the hands out.

Internal rotation: 70-90 degrees. Tuck elbows to the side and bring their hands across their tummy.

Scapula winging: Ask the child to push against the wall or your hand. If the scapula wings out this suggests long thoracic nerve pathology.

Some special tests

It is easy to get lost in the number of special tests when examining the shoulder and the trick is to perform those most relevant to the patient in front of you. Many are to test the integrity of the rotator cuff tendons, i.e. Supraspinatus, Infraspinatus, Teres minor and Subscapularis. (SITS)

Girl performing Apley scratch test

“Appley Scratch” test: (1) Ask the child to reach behind their back to touch the inferior border of the opposite scapula (internal rotation and aDDuction) and then (2) reach behind their head to touch the superior angle of the opposite scapula (external rotation an Abduction). A positive test of pain indicates tendinitis of the rotator cuff, usually supraspinatus.

Girl performing empty can test

Empty can test: Ask the child to hold their arm raised parallel to the ground and then point their thumbs towards the ground as if they were holding an empty can (this rotates the shoulder in full internal rotation while in abduction). Then push down on the child’s wrist while asking them to resist. A positive test is pain or weakness, suggestive of supraspinatus tear or suprascapular nerve neuropathy.

Girl performing lift off test

Lift off test: The child stands and places the back of their hand against their back. Put your hand against theirs, palm to palm, and ask them to push against you. A positive test is pain or weakness, indicating subscapularis muscle pathology.

Girl and boy performing scarf test

Scarf test: Ask the child to wrap their arm over the front of their neck reach down over their opposite shoulder towards the scapula (like a scarf). Pain over ACJ when doing this indicates ACJ pathology.

Although the standard approach to limb examination involves a LOOK, FEEL and MOVE (and special tests) structured assessment, in reality, if a young patient has a significant injury, a more pragmatic approach is needed. An X-ray may be warranted before a more thorough exam. This doesn’t mean that you can get away without a documented range of motion exam (even if you explain it is limited by pain) and neurovascular assessment.

Back to Johnny. You noticed a deformity over the middle third of the clavicle, but no skin tenting. He was neurovascularly intact and range of movement only marginally reduced by pain, so you discharged him with a broad arm sling and follow-up (or not) according to your local guidelines.

Selected references

Carson, S., Woolridge, D.P., Colletti, J. and Kilgore, K. (2006) Pediatric upper extremity injuries. Pediatric Clinical North American: 53(1) pp. 41-67

Chambers, P.N., Van Thiel, G.S. and Ferry, S.T. (2015) Clavicle Fracture more than a theoretical risk? A report of 2 Adolescent cases. The American Journal of Orthopedics. 44(10) 

https://fpnotebook.com/Ortho/Exam/ShldrExm.htm [Accessed April 2019]

McFarland, E.G., Garzon-Muvdi, J., Jia, X., Desai, P. and Petersen, S.A. (2010) Clinical and diagnostic tests for shoulder disorders: a critical review. British Journal of Sports Medicine. 44(5) pp. 328-32.

NationwideChildrens.org/Sports-Medicine

https://shouldercomplexgocatsnmu.weebly.com/range-of-motion.html [Accessed April 2019]

Proximal humeral fractures

Cite this article as:
PJ Whooley. Proximal humeral fractures, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31855

“Slow down!” Joel’s mom shouts at him as he whizzes past on his scooter. Joel turns to answer and doesn’t see the curb which he hits, goes flying and puts out his hand to stop himself. Mom is already running to find him holding his arm.

Proximal humeral fractures are uncommon, accounting for less than 5% of all paediatric fractures. The anatomic characteristics of the proximal humerus can explain the various fracture presentations, complications and outcomes.

Anatomy

Ossification centres

The proximal humeral physis has three ossification centres. Head, lesser tuberosity and greater tuberosity. The capital centres appear at 3 months whereas the two others appear at 1 year of age and fuse between 3 & 5 years to produce tuberosity ossification. By the time the child’s 6, the capital and tuberosity centres fuse into a single proximal epiphyseal centre. At this point it acquires a characteristic ‘tent’ or inverted V shape. This results also in a double contour that can complicate the interpretation of the images. The proximal physis accounts for approximately 80% of the longitudinal growth of the entire bone.

Periosteum

This thick sleeve of periosteum is present along the shaft and limits fracture displacement and promotes healing.

Nerves

The axillary nerve, which supplies the sensory innervation to the regimental badge area, is at potential risk in displaced proximal humeral fractures. However, axillary nerve damage is rare, the majority being only a temporary neuropraxias.

Epidemiology

Proximal humeral fractures show an early modest peak at 10-14 years of age, account for up to 3.5% of all fractures, followed by return to low levels in young adults and then a second increase in later adulthood.

These fractures account for a third of all humeral fractures in neonates and are the second most common birth injury after clavicular fractures.  However, they are still rare, occurring in only 0.03 per 1000 births.

The pattern of injury varies with age. Metaphyseal proximal humeral fractures are proportionately higher in pre-pubertal children, compared to a higher proportion of epiphyseal separation in adolescents.

As with any fracture, be aware of the potential of a non-accidental cause. These fractures, can be associated with physical abuse.

Mechanism of Injury

Indirect

Proximal humeral fractures in non-newborns commonly result from a fall backwards onto an outstretched hand with elbow extended and wrist dorsiflexed or a direct blow to the lateral aspect of the shoulder. Pathological fractures  can occur as the humerus is a common location of bone cysts and other benign lesions. This might occur with minimal trauma.

Birth injuries

The upper arm can be hyperextended or rotated during delivery, occurring more commonly in infants of diabetic mothers and with shoulder dystocia.

Clinical Evaluation

Newborns

Typically, a newborn with a proximal humeral fracture will hold their arm in extension. Consider these fractures if a history of birth trauma is given. If noted, then infection, clavicle fracture, shoulder dislocation and brachial plexus injuries need to be ruled out. These little ones may be irritable, particularly when the upper limb is moved.

Children and adolescents

As with other upper arm fractures, the typical presentation is with pain, dysfunction, bruising and swelling with a painful range of movement. Displaced fractures result in significant anterior swelling and altered shoulder appearance relative to the contralateral side.

A detailed distal neurovascular examination is needed including evaluation of the radial, ulnar, median, axillary and musculoskeletal nerves. Be particularly vigilant for any axillary nerve deficit with decreased sensation over the regimental badge area and loss of the deltoid muscle function (shoulder ABDuction).

Radiology

Proximal humeral fractures are identified on routine AP and axillary views of the humerus. If there is clinical concern of a dislocation then dedicated shoulder views should also be taken. If there is tenderness over the physis and no obvious fracture, a suspicion of a Salter Harris (SH) I fracture can be made. Imaging the contralateral humerus may be helpful to determine if there is any widening of the physis.

Patterns of fracture

There are two variations of proximal humeral fractures: metaphyseal and epiphyseal separation.

  • Metaphyseal fractures (70%) usually occur at the surgical neck, although can also occur at the metaphyseal-diaphyseal junction, typically a transverse or short oblique fracture. These fractures typically occur in 5-12 year olds.
  • Epiphyseal fractures (30%) occur in the under 5s and over 12s. The type of epiphyseal fracture depends on skeletal maturity.

SH I fractures are less common and can be seen at all ages before growth-plate closure, most commonly in <5 year olds.

SH II fractures are the most common type, chiefly in adolescents over the age of 12.

SH III & IV fractures are exceedingly rare.

A metaphyseal fracture at the surgical neck of the humerus
Epiphyseal Salter Harris II fracture of the proximal humerus in a 6 year old

Pathological fractures

40% of pathological fractures involve the proximal humerus. The leading cause is a unicameral bone cyst, as this lesion develops in the proximal humerus in 51% of cases. Other causes are aneurysmal bone cysts, non-ossifying fibromas, fibrous dysplasia and bone malignancies.

Displacement

If a proximal humeral fracture displaces, it usually does so in a varus direction, with the humeral head moving medially and posterior to the shaft. This occurs due to pectoralis major traction pulling the distal segment medially, while the rotator cuff and deltoid pull the proximal component superiorly in a tendency towards flexion and external rotation. Displacement is often absent or minimal in 40% of metaphyseal fractures, but is more common in epiphyseal injuries, occurring in up to 85%.

Proximal humerus fracture in an 11 year old with varus deformity

Classification

The Neer-Horowitz classification is the most frequently used classification system for this type of fracture. It divides the proximal humerus into 4 parts, classifying fracture by the degree of displacement as well as the fracture line, consisting of:

  1. Humeral head
  2. Greater tuberosity
  3. Lesser tuberosity
  4. Humeral shaft

One-part fractures involve 1 – 4 undisplaced parts (<1cm AND <45 degrees)

Two-part fractures account for 20% of proximal humeral fractures, involving 2 – 4 parts, 1 of which is displaced (i.e. >1cm OR >45 degrees)

  1. Surgical neck – most common
  2. Greater tuberosity – often seen with anterior shoulder dislocation. A lower threshold for displacement (>5 mm) has been proposed.
  3. Anatomical neck
  4. Lesser tuberosity

Three-part fractures account for 5% of proximal humeral fractures and involve 3 – 4 parts, 2 of which are displaced (i.e. > 1cm OR > 45 degrees)

  1. Greater tuberosity and shaft displaced with respect to lesser tuberosity and articular surface which remain together.
  2. Lesser tuberosity and shaft are displaced with respect to the greater tuberosity and articular surface which remain together.

Four-part fractures are uncommon, occurring in less than 1% of proximal humeral fractures. They involve more than 4 parts, 3 of which are displaced (i.e. >1 cm OR > 45 degrees with respect to the 4th). Four-part fractures require operative reduction.

Management

Initial treatment

Displaced fractures can be very painful so ensure pain is addressed with adequate analgesia.

The aim of immobilisation is to keep the elbow by the side, flexed to 90 degrees with the forearm against the torso. A simple sling is sufficient plus / minus a swathe for younger ages. Straps and adhesive tape can be used as described by Durrajer. Other options include a shoulder immobiliser or a U-shaped coaptation splint.

Neurovascular status must be checked before and after immobilisation.

Orthopaedic consultation should be obtained if there is:

  • associated shoulder dislocation
  • intra-articular (SH IV) fracture
  • completely displaced fracture in a child over 12 years.
  • associated neurovascular compromise
  • open fracture (rare)
  • evidence of compartment syndrome

Definitive Treatment

Newborns usually have SH I fractures, which have an excellent prognosis. A sling and a swathe is sufficient for up to 4 weeks. The primary role of follow up is to ensure there is no brachial plexus injury.

Children and adolescents with minimally displaced fractures are usually managed with a sling or shoulder immobiliser. Gentle pendulum exercise is started between weeks 2 to 4 post injury and active range of movement at 4 to 6 weeks. We would expect near to normal function by 2 months.

Significantly displaced fractures in children 12 and under should be treated with a U-slab, sling and swathe.

Acceptable angulation

  • < 5 years – any degree is allowed as proximal humeral fractures in young children have excellent remodelling potential.         
  • 5 to 12 years – 40 to 70 degrees of angulation is acceptable
  • >12 years – up to 40 degrees of angulation or 2/3 displacement.

Operative

Fractures in which immobilisation would result in unacceptable alignment are managed with closed reduction +/- fixation. Open reduction and internal fixation (ORIF) is indicated if acceptable reduction is not possible due to soft tissue interposition. Most commonly this is caused by the long head of biceps tendon, but can also be caused by the joint capsule, infolded periosteum and deltoid muscle. ORIF is also indicated in open fractures, compound fractures and intra-articular displacement of the fracture.

Complications

Complicated are rare in children, but when do occur are more common in older children, with shortening of the humerus due to physeal damage. This usually has no functional affect. Radiographic malunion can occur but rarely has any functional affect.

Non accidental injury

And finally, as with any fracture, it is imperative that a mechanism inconsistent with an injury or fracture in an otherwise healthy child should prompt escalation and involve the child protection team.

Joel’s x-ray shows a proximal humeral fracture through the surgical neck, with 20 degrees of angulation. He’s placed in a shoulder immobiliser and followed-up in fracture clinic, where he’s advised to start gentle pendulum exercises after a couple of weeks. Two months later he’s back on his scooter, helmet on, flying down the pavement without a care in the world.

References

LA. Landin. Epidemiology of the children’s fractures. J Pediatric Orthop B. 1997;6(2):79

E.J. Ortiz, M.H. Isler, J.E. Navia, R. Canosa, Pathologic fractures in children. Clin Orthop Relat Res, 432 (2005), pp. 116-126

MW Shrader et al, Proximal humerus and humeral shaft fractures in children. Hand Clin 2007;23(4);431

Pectoral girdle, shoulder region and axilla | Clinical Gate

Femoral shaft fractures

Cite this article as:
Joanna Wawrzuta. Femoral shaft fractures, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32484

An 18-month-old boy presents to the emergency department at 1am in the morning, brought in by ambulance with leg pain and inability to mobilise, with crying when being moved or attempting to move. His father tells you that he fell downstairs when they forgot to close the stairgate. On examination, his right thigh is swollen, possibly shortened and he is clearly guarding it. Given your high clinical suspicion of a femur fracture, you prescribe simple and opiate analgesia and organise an x-ray.

Incidence

Femoral shaft fractures account for 1.5 – 2% of paediatric fracture presentations. The average number of annual cases is 20 per 100,000. Despite accounting for a small proportion of all fractures, they are the most common cause for hospitalisation for a fracture.

Femoral shaft fractures can happen at any age depending on mechanism however, there is a clear bimodal age distribution with increased rates in toddlers (between 2-4 years of age) and adolescents (approximately greater than 10 years of age).  Any femur fracture before ambulatory age is uncommon and should be treated as suspicious for non accidental injury (NAI). This is especially true for femoral fractures in children less than 12 months of age (more on this later).

History

Toddlers commonly present as a result of a fall of some kind – sometimes from a height, but it can be from as little as 60cm or less. They are often running, or falling after tripping on an object.

Adolescents, on the other hand, tend to fracture their femur as a result of high mechanism trauma, such as motor vehicle accident or a fall or jump from a significant height.

Regardless of age, patients typically report thigh pain, swelling and an inability to weight bear.

Ask about the mechanism of injury, if it was witnessed, and the time of the injury particularly in the younger age group (<5 years). An unclear history, an unwitnessed fall and delay to presentation are risks factors for NAI.

Examination

The limb deformity may be gross or subtle. Significant swelling results in a tense, or firm-feeling, thigh on palpation and/or a shortened limb. Sometimes the swelling can be very mild, particularly in a toddler, but a clue to injury is a child who is not moving the leg. Always check for neurovascular compromise and for other injuries. One study by Rewers et al. (2005), suggested that 28.6% of children with a femur fracture had another associated injury.

Investigations

Plain radiograph with AP and lateral views of the femur. Imaging the ipsilateral knee and hip is recommended to rule out associated injuries.

Classification

There is no universal classification system for femur fractures so \ use description characteristics, location, stability of the fracture and whether it is open or closed.

Descriptive examples include: transverse, spiral, oblique, comminuted, greenstick, displaced/nondisplaced.

Location: proximal, middle, distal third

Stability:  stable or unstable. Stable fractures are typically transverse or short oblique; while unstable fractures are long spiral and comminuted.

Note: long spiral fractures occur when the fracture length is more than twice the diameter of the bone at that level.

Management

General principles should be adhered to as for any ED presentation. Start with a primary and secondary survey. These injuries occur as a result of trauma and other significant and life-threatening injuries need to be excluded. Next is analgesia, fracture reduction then immobilisation.

Adequate analgesia can be achieved with intranasal, oral and intravenous medications. Start with simple analgesia first (paracetamol, NSAIDS) as they are easy and quick to administer. Then move on to opioids via the oral, IV or intranasal route. Consider benzodiazepines, particularly diazepam, if muscle spasm is an issue (which it often is). While analgesia is taking its effect, start setting up for a regional nerve block. This can be a femoral nerve block (usually under ultrasound guidance), fascia iliaca block (landmark or ultrasound-guided) or a haematoma block.

Once adequate analgesia has been given, it is time to reduce the fracture using skin traction. Generally, femoral fractures are not put in a backslab in ED unless a traction splint is not available and transfer of the patient is required.

Skin traction

Skin traction requires 10% of the patient’s weight to be applied through an appropriate traction mechanism. This may occur in the ED if there are adequately trained personnel and equipment available. There are also traction splints available that can be used pre-hospital or if a traction bed is not available. Sedation may be required to apply skin traction or a traction splint.

There is a variety of traction splint available. The most common in use are the Thomas splint, CT-6 splint and Kendrick splint. Others include the Slishman Traction Splint, Mustang traction splint, Sager splint, Hare Splint and Donway splint.  The Thomas splint is recommended for transfer and is available in a paediatric size.

Taken from https://www.embeds.co.uk/

In Queensland, the ambulance service uses the CT-6 splint. It can also be used in the paediatric population. Have a look at this video by Queensland Ambulance Service on its application. The Slishman traction splint and Mustang traction splint are not specifically designed for children but the linked videos demonstrate brilliantly on child volunteers how you can adapt them for kids.

Definitive management

Spica cast application is typically done under general anaesthetic by the orthopaedic surgeons depending on the age of the child. Older children will require other definitive management.

The table summarises the guidance from The American Academy of Orthopaedic Surgeons (AAOS) of management of femoral fractures by age.

Complications

The most common complication is leg length discrepancy. This occurs due to overgrowth in younger patients. Conversely, shortening can also be an issue but is acceptable up to 2-3cm. Other complications include: osteonecrosis of the femoral head, non union, malunion and re-fracture. In terms of osteonecrosis of the femoral head, this can depend on the surgical procedure performed.

A note about other femoral injuries

Other types of fractures of the femur include proximal fractures (including neck of femur), distal femoral physeal fractures and slipped capital femoral epiphysis (SCFE, also known as SUFE)

Proximal femur fractures are rare in paediatric populations accounting for <1% of fractures. They most commonly occur due to high energy trauma such as motor vehicle accident [1,4,8]. They can occur with a low impact mechanism, but if this occurs a pathological fracture should be considered. Proximal fractures tend to need operative management with an ORIF. The most common complication for a proximal femur fracture is avascular necrosis.

The do not miss bits

Non accidental injury

The incidence of NAI in children with femoral fractures has been reported between 12-60%. In one study by Rewers et al. (2005), it was found that in children less than 3 years of age, NAI was the second most common cause of femoral fractures. This is supported by Schwend et al. (2000), who suggested that a femur fracture in children who are not yet of walking age was the strongest predictor of abuse.

Vigilance is the key to detecting NAI. The best predictors for NAI include: An unclear history, particularly with respect to the mechanism, a suspicious history, an unwitnessed fall (particularly in the younger age group), young age, a delayed presentation (typically >24hours), and associated injuries particularly of chest, abdomen and pelvis if not associated with a high speed mechanism. They also include physical and/or radiographic evidence of prior injury (multiple different aged bruises, old healing fractures on XR). In one study, 53% of children who had been abused and had a femoral fracture had evidence of polytrauma. 62% had physical and/or radiographic evidence of prior trauma and 33% had history suspicious for abuse. In terms of the risk factors listed above, children who had no risks factors had a 4% chance of NAI being the cause of their fracture compared to 24% with one risk factor, and 87% if they had 2 risk factors.

Is the type of femoral fracture a predictor of NAI? There is no current evidence that supports it being a strong predictor. Some evidence suggests that fractures associated with NAI are more likely to found in the distal femur, compared to diaphyseal fracture alone. In contrast to popular belief, there is no current evidence to strongly support that spiral fractures are more likely to be associated with NAI.

In essence, never forget to consider NAI. It is easy to miss if it isn’t thought about as a differential.

Associated injuries

Remember secondary and tertiary survey. Subtle injuries can be missed in patients with high velocity mechanisms or significant life-threatening injuries.

Pathological fractures

These should be considered if a femoral fracture occurs as a result of a low mechanism trauma. Children with metabolic disorders or malignancy are also at higher risk.

Traction

If considering applying a traction splint, don’t forget to assess for ankle/foot fractures as these are a contraindication to application. This is because the ankle and foot are generally support sites for the traction splint.

A femoral nerve block was completed with good effect after some intranasal opioid analgesia. The case was discussed with the orthopaedic team and concerns raised around NAI given the child’s age. The case was also discussed with the hospital child protection team. Traction was applied in the ED under ketamine sedation before he was admitted under orthopaedics and a spica cast was applied in theatre under general anaesthesia.

  1. https://www.orthobullets.com/pediatrics/4019/femoral-shaft-fractures–pediatric?expandLeftMenu=true
  2. Wright JG, Wang EL, Owen JL, Stephens D, Graham HK, Hanlon M, Nattrass, GR, Reynolds RK, Coyte P. Treatments for paediatric femoral fractures: a randomised trial. Lancet 2005;365:1153-58.
  3. Capra L, Levin AV, Howard A, Shouldice M. Characteristics of femur fractures in ambulatory young children. Emerg Med J 2013;30:749-753.
  4. https://radiopaedia.org/cases/paediatric-neck-of-femur-fracture
  5. Baldwin K, Pandya NK, Wolfgruber H, Drummond DS, Hosalkar HS. Femur Fractures in the Pediatric Population. Abuse or Accidental Trauma? Clin Ortop Relat Res 2011; 469:798-804.
  6. Clarke NP, Shelton FM, Taylor CC, Khan T, Needhirajan S. The incidence of fractures in children under the age of 24months in relation to non-accidental injury. Injury 2012;43(6):762-5
  7. Wood JN, Fakeye O, Mondestin V, Rubin DM, Localio R, Feudtner C. Prevalence of abuse among young children with femur fractures: a systemic review. BMC Pediatrics 2014; 14:169
  8. Rewers A, Hedegaard H, Lezotte D, Meng K, Battan FK, Emery K, Hamman, RF. Childhood Femur Fractures, Associated Injuries, and Sociodemographic Risk Factors: A Population-Based Study. Pediatrics 2005; 115; e543.
  9. Davis DD, Ginglen JG, Kwon YH, et al. EMS Traction Splint. [Updated 2020 Jul 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan
  10. https://www.rch.org.au/clinicalguide/guideline_index/fractures/femoral_shaft_emergency/
  11. https://www.embeds.co.uk/2019/02/03/thomas-spint-how-to-apply/
  12. http://www.orthoguidelines.org/topic?id=1015
  13. Cooperman DR, Merten DF. Skeletal manifestations of child abuse. In: Reece RM, Christian CW, Eds. Child abuse: medical diagnosis and management, 3rd Ed. American Academy of Pediatrics, 2009;315.
  14. Hui C, Joughin E, Goldstein S, et al. Femoral fractures in children younger than three years: the role of nonaccidental injury. J Pediatr Orthop 2008;28:297-302.
  15. Shrader MW, Bernat nM and Segal. Suspected nonaccidental trauma and femoral shaft fractures in children. Orthopedics 2011; 34(5):360
  16. Schwend RM, Werth C, Johnston A. Femur shaft fractures in toddlers and young children: rarely from child abuse. J Pediatr Orthop 2000;20:475-81.
  17. Coffe C, Haley K, Hayes J, Groner JI. The risk of child abuse in infants and toddlers with lower extremity injuries. J Pediatr Surg. 2005; 40:120-123
  18. Son-Hing JP and Olgun DZ. The frequency of nonaccidental trauma in children under the age of 3 years with femur fractures: is there a better cutoff point for universal workups? J Pediatr Orthop B 2018; 27(4): 366-388
  19. Thompson NB, Kelly DM, Warner Jr WC, Rush JK, Moisan A, Hanna Jr WR, Beaty JH, Spence DD, Sawyer JR. Intraobserver and interobserve reliability and the rold of fracture morphology in classifying femoral shaft fractures in young children. J Pediatr Orthop 2014; 34(3):352-8
  20. Leaman LA, Henrikus WL and Bresnahan JJ. Identifying non-accidental fractures in children aged <2 years. J Child Orthop 2016; 10:335-341
  21. https://coreem.net/core/pediatric-femur-fractures/

Toddler fracture

Cite this article as:
Rhiannon McClaren. Toddler fracture, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31170

A 2-year-old girl, Aila, presents to the emergency department with her mother. She had been running around at childcare playing with her friends when she fell over. She is upset, has refused to walk since and won’t weight bear on her right leg. On examination, there is no obvious swelling or deformity and on palpation and axial loading it appears that her pain is most likely localised to her right lower leg, but it’s hard to be sure.

A toddler’s fracture is a non-displaced spiral fracture of the distal two-thirds of the tibial shaft, with an intact fibula, occurring in children generally between the ages of 9 months and 3 years. The periosteum remains intact. It was first described in 1964 by Dunbar et al. It is thought to be due to new stresses on the bone due to increasing ambulation.

History and examination

The mechanism is usually trivial, a trip or a fall, and often involves a twisting mechanism. Sometimes a specific story of trauma is difficult to elicit. More commonly children present unwilling to bear weight or limping with non-specific examination findings. They may be tender to palpation of the tibia, have pain with dorsiflexion of the ankle or pain with gentle twisting of the lower leg. All joints of the lower limb should be examined. It is always worth examining both lower limbs as gait can be difficult to assess in toddlers and may be misleading regarding the side of the injury.

As part of a thorough history and examination, any history of fever, weight loss, recent illness, or recurrent presentations with minor injuries should be elicited. The child should have their spine and neurology examined as well as any bruising, petechiae, warmth and swelling of joints, and puncture wounds on the soles of the feet documented.

Imaging

Initial x-rays may show a non-displaced spiral fracture of the tibia, however, a fracture may not be seen despite multiple views. AP and lateral views should be adequate in children, however, an oblique view may help. A repeat x-ray in 1 week usually shows sclerosis or periosteal reaction. 

AP and Lateral of lower limb
Case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 9317
Periosteal reaction and callus formation in healing toddlers fracture
Case courtesy of Dr Sebastian Tschauner, Radiopaedia.org. From the case rID: 49123

But, a plain film x-ray may not be where it ends. Ultrasound is being explored as a possible diagnostic tool for toddler’s fracture, as sonography is used more and more for diagnosis of long bone fractures in children. The idea’s not a new one; a case report of three children in England in 2006 demonstrated that Point of Care Ultrasound Scan (POCUS) could be used to diagnose toddler’s fracture where initial x-rays did not show any fractures. They used the appearance of an elevated periosteum and a layer of low reflectivity superficial to the tibial cortex which suggests a fracture haematoma as a way of diagnosing an occult fracture. 

Cortical breach seen on ultrasound
Ultrasound image showing cortical breach in a toddler’s fracture. Image courtesy of Dr Casey Parker as found in Clinical Case 111: Toddler’s Tibia Tale published January 18, 2015, available at https://broomedocs.com/2015/01/clinical-case-111-toddlers-tibia-tale/

A recent pilot study by Carsen et al comparing ultrasound to radiographic diagnosis of toddler’s fractures looked at 27 children presenting with suspected toddler’s fractures. Five children had confirmed toddler’s fractures and of these five, three were identified correctly by x-ray at initial presentation and the other two were diagnosed with repeat x-ray at follow up appointments. All five children had their toddler’s fracture correctly identified using POCUS at their initial presentation. 

Radiograph showing Toddler fracture
AP x-ray of the same toddler’s fracture seen on ultrasound. Image courtesy of Dr Casey Parker as found in Clinical Case 111: Toddler’s Tibia Tale published January 18, 2015, available at https://broomedocs.com/2015/01/clinical-case-111-toddlers-tibia-tale/

Although there are limited studies evaluating the use of POCUS in the diagnosis of toddler’s fractures, the small number of studies and case studies available are promising. As a point of care test in someone with appropriate training, this is a convenient potential diagnostic tool, particularly given the potential to reduce radiation exposure for children.

Management

Toddler’s fractures do not need to be reduced and the management is largely supportive for 3-4 weeks. Standard treatment is a long leg back slab followed by a long leg walking cast. 

A number of retrospective studies have looked at rates of immobilising toddler’s fractures when the diagnosis is either confirmed or presumed. They show that children with confirmed toddler’s fractures are more likely to be immobilised. But… a series of 75 children with radiographic evidence of toddler’s fractures, by Schuh et al., looked outcome following a variety of treatments (cast/splint, controlled ankle movement boot, or no immobilisation). Those not immobilised had fewer follow up appointments and fewer repeat radiographs. Skin breakdown was reported in 17% of children, all of whom were in a splint or cast. Schuh et al. also found that children who were not immobilised walked much earlier than those who were immobilised in a controlled ankle movement (CAM) boot or splint. It was a mean of 4.1 days for the little ones not immobilised compared to 27.0 days for the smallies in a boot and a whopping 27.5 days for those in a cast or splint.  

Another retrospective study by Bauer and Lovejoy of 192 children, aged 9 months to 4 years, meeting criteria for a toddler’s fracture, showed an earlier return to weight-bearing in those immobilised with a CAM boot compared with a short leg cast (2.5 vs 2.8 weeks). Even when considering the seven children in this study who received no immobilisation, none of the fractures shifted. Sapru and Cooper also found that there were no complications with management in or out of a cast.  

There is now a move towards recommending immobilisation in a CAM boot or short leg cast or splint rather than in a long leg cast. Further studies are currently underway so watch this space!

What not to miss

A thorough history and examination should always be taken so as not to miss other diagnosis. If a child is not yet mobile, there must be a high suspicion for non-accidental injury. Fevers warrant consideration of septic arthritis or osteomyelitis. Malignancy and inflammatory conditions should also be considered. 

Aila’s initial x-ray showed a non-displaced spiral fracture of the distal third of her right tibia. She was placed in a long leg back slab and had a follow-up with the local orthopaedic service in the fracture clinic. Four weeks later she is running around and happily playing with her older brother.

 References

Alqarni, N., & Goldman, R. D. (2018). Management of toddler’s fractures. Canadian family physician Medecin de famille canadien64(10), 740–741. 

Bauer, J.M., Lovejoy, S.A. (2019) Toddler’s Fractures: Time to Weight-bear with Regard to Immobilization Type and Radiographic Monitoring. J Pediatr Orthop. Jul: 39(6), 314-317. 

Carsen, S., Doyle, M., Smit, K., Shefrin, A., Varshney, T. (2020) Point-of-care Ultrasound in the Emergency Department may provide more accurate diagnosis of toddler fractures than radiographs: A pilot study. Orthopaedic Proceedings. 102-B

Dunbar, J.S., Owen, H.F., Nogrady, M.B., McLeese, R., (1964) Obscure Tibial Fracture of Infants – The Toddler’s Fracture. Journal of the Canadian Association of Radiologists, Sep;15, 136-144. 

Fox, S. (2013) Toddler’s Fracture. Available at: https://pedemmorsels.com/toddlers-fracture/

Lewis, D. and Logan, P. (2006), Sonographic diagnosis of toddler’s fracture in the emergency department. J. Clin. Ultrasound. 34: 190-194. 

Pattishall, A.E. (2019) An updated approach to toddler fractures. J Urgent Care Med.  Available at: https://www.jucm.com/an-updated-approach-to-toddler-fractures/

Rasuli, B., Gaillard, F. Toddler Fracture. Available at: https://radiopaedia.org/articles/toddler-fracture

Royal Children’s Hospital Guidelines – Tibial Shaft Fractures. Available at: https://www.rch.org.au/clinicalguide/guideline_index/fractures/tibial_shaft_emergency/

Sapru, K., Cooper, J.G. (2014). Management of the Toddler’s fracture with and without initial radiological evidence. Eur J Emerg Med. Dec;21(6), 451-454. 

Schuh, A.M., Whitlock, K.B., Klein, E.J. (2016) Management of Toddler’s Fractures in the Pediatric Emergency Department. Pediatri Emerg Care.  Jul: 32(7), 452-454.

UpToDate – Tibial and fibular shaft fractures in children

Wang, C.C., Linden, K.L., Otero, H.J. (2017) Sonographic Evaluation of Fractures in Children. Journal of Diagnostic Medical Sonography. 33(3), 200-207. 

Wijtzes, N., Jacob, H., Knight, K., Thrust, S., Hann, G. (2020) Fifteen-minute consultation: The toddler’s fracture. Arch Dis Child Educ Pract Ed. 0, 1-6. 

Carpal injuries

Cite this article as:
Sian Edwards. Carpal injuries, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.29050

Injuries to the hands are extremely common in children and are a frequent reason for their attending the ED. While common, their management can be limited by difficulties in proper assessment as well as a paucity of evidence to guide treatment. That said, documented outcomes remain typically excellent so it seems we must be doing something right! Generally, training is provided with an adult focus, and while some principles from adult trauma can be applied, it is not uniform. As our post on radiographic findings demonstrates, the bones of children are different. This is significant because we know that missed injuries or delays in appropriate treatment can lead to long term loss of function; further compounded by the science that children heal faster and therefore our window for intervention is considerably shorter. Therefore, accurate assessment coupled with appropriate initial management and timely referral if necessary are essential.

As is not uncommon in the paediatric arena, evidence specific to this population is limited although it is stated that carpal fractures in children are being increasingly reported . Perhaps this is as we, as clinicians, get better at diagnosis and radiologists therefore see more and so naturally become more adept at interpreting them. Regardless of radiographic findings, diagnosis is primarily through clinical examination. 

While not exclusive to the teenage population, we can expect the majority of carpal injuries to occur in the older child; as children age, become braver and take on more activities with an increased likelihood of higher velocity falls. Falling onto an outstretched hand, otherwise widely known as a FOOSH injury, is a common mechanism, accounting for 30% of non-scaphoid carpal injuries.

Before we get in to it, we can take a moment to re-familiarise ourselves with the bones of the hand and wrist.

The carpus

The carpal bones are the eight bones of the wrist that articulate the forearm with the hand – this in itself seems confusing as they are quite clearly situated in what we call the hand but go with it. They are divided into the proximal and distal rows, collectively known as the carpus. Proximally we have scaphoid, lunate, triquetrum, pisiform and distally, trapezium, trapezoid, capitate, hamate. The carpal bones develop through the course of childhood and should all be visible on X-ray by approximately 8 years of age.

Literature suggests that carpal fractures account for around 8-19% of all hand injuries worldwide; as we’ve already touched on, the majority will be scaphoid fractures and ED’s are pretty used to dealing with these – they even get their own series of x-rays – for that reason, this post will give some time to carpal fractures NOT including the scaphoid.

What are we looking for on x-ray?

While the AP view allows clear visualization of all of the carpal bones and would appear the ‘easier’ view, particularly to those less experienced with interpreting these x-rays, the lateral view is good for assessing the distal wrist, carpal bones and proximal metacarpals – it can appear confusing at first due to the overlapping bones. Regardless, both radiographs must be evaluated together. As always, we are tracing each individual bone looking for obvious breaks in the cortex before then looking for uniformity of the joint spaces; abnormally widened spaces are often indicative of ligamentous injury however abnormally narrow spaces are often the result of radiographic projection rather than injury. It is often helpful to sit back from the image and see it in its entirety as well as a close-up view.

Image adapted from a case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 37947

Recommended questions to ask when looking at the carpal bones:

  • Is the scapho-lunate distance less than 2mm wide? – if NO then suspect a tear of this ligament.
  • Is there a bony fragment lying posterior to the carpal bones? if YES, then suspect triquetral fracture.
  • Is there a bone sitting in the cup of the lunate? If NO, think carpal dislocation involving the lunate.

After the scaphoid bone, the triquetrum is the most commonly fractured bone in isolation with the trapezoid bone being the least frequently fractured. Each will now get it’s moment to shine as we take a minute to go through them.

Triquetral

Triquestral
Triquetral bone

Triquetral fractures usually occur on the dorsal aspect of the bone and are often the result of perilunate fracture dislocation as well as fracture of distal radius and ulna; they account for about 20% of all carpal fractures and are regularly missed.  These may occur by means of impingement from ulnar styloid, shear forces or avulsion from strong ligamentous attachments. The usual mechanism is a FOOSH whilst in ulnar deviation, and less commonly a direct blow to the dorsum of the hand. It is best seen on a lateral projection where the avulsed flake of bone may be seen lying posteriorly to the triquetrum – look for pooping duck sign on the image.

Image adapted from a case courtesy of Dr Maulik S Patel, Radiopaedia.org. From the case rID: 16046
Case courtesy of Dr Matt Skalski, Radiopaedia.org. From the case rID: 57109

Hamate

The hamate

Hamate fractures are rare, only accounting for approximately 2% of carpal fractures, potentially due to under reporting. They generally don’t happen in isolation, often being associated with dorsal fracture dislocation of 4th and 5th carpometacarpal (CMC) joints, ulnar nerve injury and flexor tendon rupture, especially of 4th and 5th fingers. Common mechanisms are from blunt trauma e.g. fist punch, falls and through impact from racquet sports.

Image adapted from a case courtesy of Andrew Murphy, Radiopaedia.org. From the case rID: 46110

Capitate

Capitate

Like hamate fractures, capitate fractures are also frequent injuries which seldom occur in isolation. A capitate fracture is uncommon, accounting for approximately 1.3% of carpal fractures and can be associated with a scaphoid fracture. It is uncommon to have a combined capitate-hamate fracture. The primary mechanism is a FOOSH with the wrist in hyperextension. Injury can result in ‘scaphoid capitate’ syndrome (1-2% incidence) where the capitate actually rotates by 180o – this latter presentation will need open reduction.

Image adapted from a case courtesy of Dr Bahman Rasuli, Radiopaedia.org. From the case rID: 65954

Lunate

Lunate

Lunate fractures account for about 1% of carpal fractures, and like its predecessors rarely occur independently. They are associated with injuries to the distal radius, carpus or metacarpals. Subluxations / dislocations of the carpus are most commonly centred around the lunate bone and key to their detection is the apple, cup, saucer analogy- the cup of the lunate should never be empty – the distal radius, lunate and capitate articulate with each other in a straight line on the lateral radiograph, so when examining the image, if the capitate (apple) is not sitting in the cup of the lunate on the saucer of the radius then injury is present. Failure to recognise this anatomy means that dislocations are often overlooked. Where scapho-lunate ligament injury has occurred, missed diagnosis can lead to chronic pain around the joint due to its instability. In the younger population, surgery will be considered to restore full function and relieve pain.

Normal capitate – lunate – radius alignment. Image adapted from a case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 37947
Perilunate dislocation. Image adapted from a case courtesy of Dr Ian Bickle, Radiopaedia.org. From the case rID: 46714
Image adapted from a case courtesy of Dr Henry Knipe, Radiopaedia.org. From the case rID: 70427

More commonly, injury can occur at the scapho-luncate ligament – on x-ray, expect to see a widened joint space which is often referred to as the “Terry Thomas” or “Madonna” sign (named for the gap between the front teeth) demonstrating such injury. While conservative management may often be trialled, surgical reconstruction can be needed.

Image adapted from a case courtesy of Dr Ian Bickle, Radiopaedia.org. From the case rID: 46695

Trapezium

Trapezium

Trapezium fractures comprise between 3% and 5% of all carpal fractures and <1% of all hand injuries; they can occur in isolation or in combination with another carpal bone e.g. fracture of the 1st metacarpal base and/or subluxation or dislocation of the 1st carpometacarpal (CMC) joint although this is extremely rare. They are often the result of high energy trauma, usually involving axial loading force. Isolated trapezium fractures can be easily missed on x-ray due to the overlying bones, particularly on AP view.

Image adapted from a case courtesy of Amanda Er, Radiopaedia.org. From the case rID: 74739

Pisiform

Pisiform

Pisiform fractures account for 0.2% of all carpal fractures and of those, half are in association with other carpal injuries; rarely it may dislocate without fracture and displace radially. Its rarity is attributed to the sturdy ligaments that encase it.

Image adapted from a case courtesy of Dr Garth Kruger, Radiopaedia.org. From the case rID: 29263

Trapezoid

Trapezoid bone

Trapezoid fractures are incredibly rare, with only about 10 cases reported in the literature. Their anatomic location and stable articulation with the 2nd metacarpal together with their strong ligamentous attachments to neighbouring carpal bones are thought to be responsible for the low incidence of fracture.

Image adapted from a case courtesy of Dr Bruno Di Muzio, Radiopaedia.org. From the case rID: 46412

So how do we manage these injuries?

Inevitably there will be some local differences, but the general principles are:

  • Closed manipulation can prove difficult and often unsuccessful so orthopaedic review is required if displacement exists.
  • If no displacement, and no concern about ligamentous injury, then conservative management is often indicated. There is frequently no requirement to formally immobilise so analgesia may be the only treatment. 
  • If carpal subluxation is suspected, always refer to the orthopaedic team for specialist evaluation. If you are unsure, the literature discusses obtaining a radiograph of the uninjured hand to use as comparison – this is not always a well received request so do consider utilising your local reporting radiologist, and if unavailable or in doubt then refer for follow up.

The take home

So, what essentially is our take home message? We need to keep in mind that carpal fractures, dislocations and ligamentous injuries do occur in children, albeit rarely. We need the ability to recognise the ‘normal’ so we can pick out the ‘abnormal’. As with all injuries, diagnosis should be mainly clinical with the x-ray being our confirmation. As cannot be said enough, if it presents like a fracture, or considerations of acute injury like swelling and pain inhibit your ability to confidently exclude it, then treat it as such and refer onwards to the specialists that can!

References

Armstrong M and Oyinkansola Adeogun BS (2009). Tendon injuries in the Pediatric Hand. The Journal of Craniofacial Injury. 20(4) : 1005-1010.

El-Feky M and Weerakkody Y (a). Trapezium fracture, accessed from https://radiopaedia.org/articles/trapezium-fracture?lang=gb accessed on 30/06/2020.

El-Feky M and Weerakkody Y (b). Pisiform fracture accessed from https://radiopaedia.org/articles/pisiform-fracture?lang=gb accessed on 30/06/2020.

Filho, R. L. R. et al. (2020). Capitate and Hamate Fracture. Case Study. Ortopedia, traumatologia, rehabilitacja. 22(2), pp. 143–149. doi: 10.5604/01.3001.0014.1185.

Foley K and Patel S (2012). Fractures of the scaphoid, capitate and triquetrum in a child: a case report. Journal of Orthopaedic Surgery. 20(1): pp 103-104.

Hacking C and Knipe H (). Carpometacarpal joint dislocation accessed from https://radiopaedia.org/articles/carpometacarpal-joint-dislocation?lang=gb accessed on 12/06/2020

Hacking C and Radswiki et al. Triquetral Fracture. Accessed from https://radiopaedia.org/articles/triquetral-fracture?lang=gb accessed on 30/06/2020.

Kam MLW, Sreedharan S, Teoh LC and Chew WYC (2011) ‘Severe Isolated Trapezoid Fracture:: A Case Report’, Hand Surgery, 16(2), pp. 185–187. doi: 10.1142/S0218810411005321.

Kose, O., Keskinbora, M. and Guler, F. (2015) ‘Carpometacarpal dislocation of the thumb associated with fracture of the trapezium’, Journal of orthopaedics and traumatology : official journal of the Italian Society of Orthopaedics and Traumatology, 16(2), pp. 161–165. doi: 10.1007/s10195-014-0288-9.

Maloney E, Zbojniewicz A, Nguyen J, Luo Y and Thapa M (2018). Anatomy and injuries of the paediatric wrist: beyond the basics. Pediatric Radiology. 48 : pp764-782.

Murphy A and Knipe H. Hamate fractures. Accessed from https://radiopaedia.org/articles/hook-of-hamate-fracture?lang=gb accessed on 30/06/2020.

Raghupathi AK, Kumar P (2014). Nonscaphoid Carpal Injuries – Incidence and associated injuries. Journal of Orthopaedics. II: 91-95.

Rasoli, S., Ricks, M. and Packer, G. (2012) ‘Isolated displaced non-union of a triquetral body fracture: a case report’, Journal of medical case reports, 6, p. 54. doi: 10.1186/1752-1947-6-54.

Shah S, Rochette L and Smith G (2012). Epidemiology of pediatric hand injuries presenting to United States emergency departments, 1990-2009. Journal of Trauma and Acute Care. 72(6) : pp 1688-1694.

Wahba G and Cheung K (2018). Paediatric hand injuries: clinical review. Canadian Family Physician. 64: pp 803-810.

Humeral shaft injuries

Cite this article as:
PJ Whooley. Humeral shaft injuries, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.29682

Six-year-old Rosie was running in from the back yard when she just tripped over the skateboard that her mum had told her to tidy up. She landed directly onto her left arm. She was brought to the ED and it was noted she was unable to extend her left wrist and she had pins and needles over the back of her hand. 

Humeral shaft fractures are uncommon, accounting for less than 10% of paediatric fractures. Children have a great ability to remodel and heal with little or no deformity despite significant displacement and angulation therefore most of these fractures can be managed with simple immobilization. 

Anatomy

The thick periosteal sleeve of the humerus limits the displacement of humeral fractures and promotes excellent healing. The main anatomical feature that is important to remember is the radial nerve, which curves around the back of the mid humerus and is at risk of injury. That said, injuries of the radial nerve secondary to humeral fractures are rarely associated with long-term deficits with the majority being temporary neuropraxia.

Mechanism of injury

Neonates – hyper extension or rotation as they pass through the birth canal. The typical fracture is a transverse midshaft fracture. 

Older children – Fall on an outstretched hand (FOOSH), a direct blow to the upper arm or high energy trauma such as a motor vehicle collision. 

Adapted from Orthobullets.com 

Pathological fracture – suggested when a midshaft humeral fracture occurs after only minimal trauma. The humerus is a common site for bone cysts and other benign lesions. These occur most commonly in children 3-12 years of age. 

Case courtesy of Dr. Hani Makky Al-Salam, Radiopaedia.org. From the case rID: 13537

Non accidental injury – Is the mechanism inconsistent with the injury or is there a fracture in a healthy child younger than 3 years? This should raise concern for child abuse. These fractures can be transverse fractures from a direct blow or an oblique or spiral fracture caused by traction with humeral twisting. 

Evaluation

These injuries often present with mid arm pain and swelling. If a humeral fracture is present with no visible deformity, it is typically minimally displaced. 

Determine if there is any distal neurovascular compromise (check out the elbow examination post for some top tips on neurovascular assessment in upper limb injuries). Vascular injuries are extremely rare but midshaft fractures are associated with radial nerve injuries in 5% of fractures. This will be evident with paraesthesia / numbness in the dorsum of the hand between the 1st and 2nd metacarpal and motor deficit with reduced thumb and wrist extension and reduced forearm supination. 

Radiology

Typical Anterior-posterior (AP) and lateral views are sufficient. A prominent vascular groove in the distal humerus is commonly seen on plain film and should not be confused with a fracture line. 

Case courtesy of Kellie Grant, Radiopaedia.org. From the case rID: 39526

Describing humeral fractures

There are four key descriptors of humeral fractures:

  1. Anatomical location: proximal, middle or distal third
  2. Fracture pattern: spiral, short oblique, transverse or comminuted
  3. Degree of displacement and angulation
  4. Presence of soft tissue damage: is the fracture open or closed?

Analgesia and immobilisation

Give early analgesia. These are sore and children often require opiate analgesia such as intranasal fentanyl or diamorphine, which are safe to give if there is no facial trauma or signs of head injury present. 

Immobilization in a sling and swathe or shoulder immobilizer enhances patient comfort and reduces the chance of further fracture displacement. Be sure to check for and document any neurovascular deficit pre and post immobilization.

Infants – sling and a swathe for 4 weeks is sufficient regardless of the degree of displacement.

Older children – In incomplete fractures then a sling and swathe, a collar and cuff sling or a shoulder immobiliser can be used. 

Complete and moderately displaced fractures are better managed in a hanging U-slab. This uses gravity to decrease the deformity by relaxing the muscles and also improves the child’s comfort. Provided there is no radial nerve injury, the fracture can be reduced under procedural sedation to improve clinical alignment. After reduction, the child is placed in a U-slab or coaptation splint for 2 weeks. In the fracture clinic, they will then be reassessed and braced in a functional clamshell brace until approximately 4 weeks.

Hanging U-slab

Refer for orthopaedic assessment in ED if there are any of the following features present:

  • Compound fracture with neurovascular compromise
  • Open fracture
  • 100% displacement
  • Fracture with clinical deformity 
  • Angulation more than 20° in children and 10° in adolescents
  • Compartment syndrome (rare in midshaft humeral fractures)

Operative management involves open reduction and internal fixation. It is indicated in many of the above but also the multiply injured patient to aid in early ambulation including concomitant forearm fractures resulting in a “floating elbow”.  

‘Floating elbow’ in a child with concomitant humeral and forearm fractures. Image from Orthobullets.com

Outcomes

  • Malunion is common, but there’s usually little functional loss. These remodel well.
  • Initial fracture shortening may be compensated for by later overgrowth
  • Nonunion is uncommon
  • Radial nerve palsy is less common, and when occurs, is usually a temporary neuropraxia

Rosie was brought to theatre for an open reduction of her left midshaft humerus fracture. The radial nerve was trapped in the fracture line but not severed. After a few weeks of physio Rosie has regained full movement of her wrist and hand and she loves the fact that she has a scar on her arm. Skateboards have been banned from the house…

References

  1. JC. Cheng, JY. Shen. Limb fracture pattern in different pediatric age groups: a study of 3,350 children. J Orthop Trauma. 1993;7(1):15
  2. S. Carson, DP. Woolridge, J. Colletti, K. Kilgore, Pediatric upper extremity injuries. Pediatr Clin North Am. 2006 Feb;53(1):41-67, v.
  3. Figure 3 – Case courtesy of Dr Hani Salam, <ahref=”https://radiopaedia.org/”>Radiopaedia.org</a>. From the case <ahref=”https://radiopaedia.org/cases/13537″>rID: 13537</a>
  4. https://emedicine.medscape.com/article/1231103-overview
  5. https://www.rch.org.au/clinicalguide/guideline_index/fractures/Humeral_shaft_fractures_Emergency_Department/

Midshaft radius and ulna fractures

Cite this article as:
Rie Yoshida. Midshaft radius and ulna fractures, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.21902

Alvaro is a 12-year-old boy who presents to the ED with a painful and swollen right arm. He was trying out his new skateboard and fell whilst trying to master the kickflip. (He tells you it’s not cool to say he’s been skateboarding: “It’s skating, but not the on-ice kind, that’s not cool either.”)

On examination, he is tender in the middle third of his right forearm with swelling and some mild deformity.  There are no open wounds. There is pain on forearm rotation with limited pronation and supination but a good range of movement at the wrist and elbow.  There are no signs of neurovascular compromise or compartment syndrome. 

You top him up with some intranasal fentanyl and send him for an x-ray. His AP film shows a greenstick in the middle third of the ulna. 

Case courtesy of Dr. Jeremy Jones, Radiopaedia.org. From the case rID: 66836

But when you look at his lateral you do a double-take. There’s pretty significant angulation with radial bowing. You always make sure you look at both x-ray views but this really shows why that’s so important.

Case courtesy of Dr. Jeremy Jones, Radiopaedia.org. From the case rID: 66836

You know that ulna fractures can be associated with radial head dislocations as part of the Monteggia fracture-dislocation pattern so send Alvaro back for an elbow x-ray.  Radio-capitellar alignment is maintained so you’re happy this isn’t a Monteggia injury but given the significant ulna angulation, you give your orthopaedic on-call colleague a ring.

 

Epidemiology

Forearm fractures are the most common fractures in children, representing 40% of all childhood fractures. Although the majority of these occur at the distal end of the forearm, 20% are located at the midshaft and often involve both bones.  Peak incidence occurs between ages 10-14.

 

Anatomy

The radius and ulna are connected by an interosseous membrane and meet at the distal and proximal radioulnar joints at the wrist and elbow.  Due to these connections, a break in one bone is often accompanied by a break in the other.  It is also important to look at the proximal and distal radioulnar joints to identify Monteggia and Galeazzi fracture-dislocations.

Mechanism

Midshaft radius and ulna fractures usually occur due to a fall from a height onto the forearm or an outstretched hand or direct blow to the forearm.

 

Examination findings

Examine the forearm, wrist and elbow joint.  You may find swelling and possible deformity with tenderness of the forearm. Check for any open wounds and check the tetanus status of the child.

The range of movement will be reduced, particularly with forearm pronation and supination. Check for signs of neurovascular compromise or compartment syndrome.

 

Investigations

For all midshaft forearm injuries, order true AP and lateral x-rays of the forearm including the wrist and elbow (including distal humerus). Note: 5% of forearm fractures are associated with supracondylar fractures.

In a true AP x-ray, the distal radius (R) and ulna (U) should be visualized with minimal overlap. The trochlea (T) and capitellum (C) should be seen in profile, as long as the child is old enough for them to have both to have ossified.

In a true lateral, the distal radius (R) and ulna (U) will be superimposed at the wrist.  If there is no plastic deformity the posterior border of the ulna is straight, sitting on an imaginary horizontal line, and the radius is bowed. The trochlea and capitellum will be superimposed at the elbow (denoted by *).

True AP: Case courtesy of Dr. Aditya Shetty, Radiopedia.org, rID:31106 True lateral: Case courtesy of Dr. James Hayes and Dr. Aditya Shetty, Radiopedia.org, rID:31107

 

Classification

The Rule of Fours can be used to describe the fracture and identify the correct fracture pattern.

There are 4 types of fracture patterns:

  • Plastic deformation: there is bowing of the bone with no cortex disruption. It’s most commonly seen in the ulna and is easily missed on x-ray. A top tip for spotting on x-ray: on the lateral view, a normal ulna has a straight posterior border.  But if the posterior border does not sit nicely on a horizontal line there is plastic deformation.

  • Greenstick fractures: there is a break on one side of one bone that does not extend all the way through the bone.
  • Complete fractures: there is a fracture through both cortices of the radius and/or ulna, often with displacement.
  • Comminuted fractures: these are fractures with multiple bony fragments. They are uncommon in midshaft fractures in children.

 

Treatment

The vast majority of paediatric forearm fractures can be managed non-operatively, with closed reduction and casting.

Firstly, check whether the fracture needs to be referred to the orthopaedic team. Any fracture with complications, either a plastic, comminuted or open fracture or one with neurovascular compromise, compartment syndrome or associated Monteggia or Galeazzi dislocation, must be referred to the on-call orthopaedic clinician.

Next, assess the degree of angulation. If the child is under 5 years of age, up to 20 degrees angulation is acceptable; aged 5 – 9 up to 15 degrees is allowable; and in children 10 years and older fractures with angulation of up to 10 degrees will remodel without manipulation. Fractures that are more angulated than this will need to be reduced.

Closed reduction should be performed by an experienced ED practitioner or clinician or by the orthopaedic team.  It may be done either under procedural sedation in the ED or in theatre with image intensification if this fails (or if the fracture is complicated).  Always, always, reassess neurovascular status and repeat an x-ray after manipulation to reassess the degree of angulation and ensure no further complication has arisen. And finally, an above-elbow (long arm) cast should be applied with follow-up in fracture clinic within a week.

 

Indications for orthopaedic referral

  • Open fracture
  • Neurovascular compromise
  • Compartment syndrome
  • Comminuted fracture
  • Monteggia or Galeazzi fracture
  • Failed reduction or unable to perform in the ED

 

Top tips

  • Always check both lateral and AP films. Alignment can look deceptively good in one plain and very angulated in another.
  • If a break in one forearm bone is identified, remember to look at the other bone and the radioulnar joints. Don’t forget forearm fractures are associated with supracondylar fractures and can be complicated by Monteggia or Galeazzi fracture-dislocations.

 

Alvaro’s ulna greenstick fracture had over 10 degrees of angulation and you and your orthopaedic colleague agree a closed reduction in ED is called for.  You manage Alvaro’s procedural sedation while the orthopaedic doctor re-moulds the fracture and places Alvaro in an above elbow backslab.  Post-reduction films show good alignment.  A few months later you’re walking past the local skate park and you smile to yourself as you see Alvaro with his skateboard (correction, on his board). He gives you a grin as he spins into a kickflip.

 

Selected References

Vopat, Matthew L et al. “Treatment of diaphyseal forearm fractures in children.” Orthopedic reviews vol. 6,2 5325. 24 Jun. 2014, doi:10.4081/or.2014.5325

Orthobullets Both Bone Forearm Fracture – Pediatric https://www.orthobullets.com/pediatrics/4126/both-bone-forearm-fracture–pediatric

Schweich P. Midshaft forearm fractures in children. Post TW (Ed). UpToDate, Waltham, MA. 2019.

Price CT. Acceptable alignment of forearm fractures in children: Open reduction indications. J Pediat Ortho 2010; 30: S82-4.

Clavicle fractures

Cite this article as:
PJ Whooley. Clavicle fractures, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.29144

Darragh is a 7 year old who needed to get his ball back from his neighbour. He decided to jump the tall fence but fell before he got over the top and landed on his right shoulder. Mum brings him in and he is holding right arm to his side and not happy when you try and examine his shoulder. The ED doctor has ordered an x-ray.

Epidemiology

Clavicular fractures are the most common shoulder fracture in children (8% to 15% of all paediatric fractures). They are common during delivery too and occur in 0.5% of all normal and 1.6% of breech deliveries, accounting for 90% of obstetric fractures.

Anatomy

80% of clavicular growth occurs at the medial epiphysis. It ossifies between 12-19 years of age and fuses fully by 22-25 years. The clavicle is the first bone in the body to ossify (intrauterine week 5), but the medial clavicular epiphysis is the last to appear and close. There are multiple ligamentous connections that are relevant.

Mechanism of injury

There are two mechanisms of injury: indirect and direct.

Indirect injuries commonly occur after a fall onto an outstretched hand (FOOSH).

Direct fractures are sustained from direct trauma to the clavicle or acromion and are associated with a higher incidence of injury to underlying neurovascular and pulmonary structures.

Evaluation

Children typically present with a painful, palpable and tender mass. There is usually a discrete tender swelling, but tenderness may be diffuse in the cases of a plastic bowing. Bony crepitus and ecchymosis are often present. It is important to ensure there is no overlying skin compromise.

Assess neurovascular status as although brachial plexus and subclavian artery injuries are rare, they can occur and will require urgent orthopaedic intervention.

In the setting of direct trauma, assess the child’s respiratory status. Rarely medial clavicular fractures may be associated with tracheal compression in the setting of significant posterior displacement.

Radiology

Clavicle plain films are often sufficient rather than full shoulder x-rays. Often a single view might be all that is obtained. The diagnosis may be made as an incidental finding on other x-rays such as a chest x-ray. In the trauma setting, 2 views are ideally better than one: a frontal view and a cephalic tilt (15-45 degree).

In most cases, clavicle fractures are easily identified on plain x-ray. There is commonly displacement of the fracture; the medial fragment is pulled upwards by the sternocleidomastoid while the distal fragment is pulled downwards by the weight of the arm. Occult fractures may also be present. When describing a clavicle fractures note the location of the fracture along the shaft. The Allman Classification of clavicle fractures separates the segments into thirds.

Look for angulation and/or displacement of the fracture. Is it comminuted?  If there is shortening, measure, and document the degree of overlap (> or < 2cm), sometimes best seen on a PA chest x-ray.

Note any relevant negatives and associated findings. Comment on any variation in sternoclavicular (SC) joint, acromioclavicular (AC) and coracoclavicular (CC) alignment and distances.

Normal acromio-clavicular alignment

Midshaft clavicular fractures

Midshaft clavicular fractures are the most common paediatric shoulder fractures, accounting for 10-15% of all fractures. Half of these are in children <10 years. They almost always heal but if they don’t, the malunion is usually not of clinical significance. There is excellent remodeling within one year and complications are very uncommon. Thankfully, like many other children’s fractures, they commonly fracture in a greenstick pattern.

Operative management is reserved for adults and children over the age of 10 years, particularly if the clavicle is significantly shortened or displaced.

Case courtesy of Dr Ian Bickle, Radiopaedia.org. From the case rID: 53795

Neer classification of midshaft fractures

  • Non-displaced: If there is less than 100% displacement, these are managed conservatively
  • Displaced: If there is greater than 100% displacement, the non-union rate is 4.5%. These are managed operatively.

Medial Clavicular Injuries

Medial clavicular injuries are much less common in children. Most medial clavicular injuries are Salter-Harris type I or II.

True sternoclavicular (SC) joint dislocations, though rare, may occur and in the case of posterior dislocations, 30% are associated with life-threatening mediastinal injuries.

I’ll take a minute to describe this as it’s an important point. In SC joint dislocations, the clavicle typically displaces anteriorly in up to 90% of cases.

If concerned, then x-raying both sides (called a serendipity view) would help make a diagnosis.  If there remains concern, then a CT scan of the SC joint can be helpful, and is generally favoured as the imaging modality of choice.

Clinical image showing a protrusion over the right SCJ. Corresponding AP plain film demonstrating widening of the SCJ. From brownemblog.com

Most children with an anterior SC joint dislocation can be managed with a sling or collar and cuff.

Much less often the clavicle moves posteriorly in relation to the sternum, especially in the setting of tremendous force applied to the shoulder or the medial clavicle. If there is no evidence of medial epiphyseal fracture but pain and swelling is present you must consider a dislocation. Posterior dislocations can present with pain over the anterior chest, increased on shoulder movement. A dislocation may impact the structures behind including the trachea and blood vessels in that region. Hoarseness could indicate a recurrent laryngeal nerve injury or airway compromise.

SC joint dislocations are classified as Grades I-V, with Grade V being a posterior dislocation. Any child with a suspected posterior SC joint dislocations should be referred to the on-call orthopaedic team – these are orthopaedic emergencies, with CT angiograms favoured to characterise the extent of vascular injury and operative reduction performed, often in consultation with vascular surgeons.

Lateral third clavicle fractures

These can be easily confused with acromioclavicular (AC) joint injuries. Both present clinically with pain and tenderness around the AC joint plus swelling and bruising. The ‘cross-arm test’ (ABDuction across the chest) results in increased pain in both conditions. Little or no deformity may be seen on x-ray unless a Salter-Harris II fracture is present.

Management

Nonoperative management involves sling immobilisation with gentle range of motion exercise at 2-4 weeks and strengthening at 6-10 weeks. This is indicated in fractures of the middle 1/3, if there is shortening and displacement that is under 2cm with no neurology.

Operative management, open reduction and internal fixation (ORIF), is indicated in open fractures, displaced fractures with skin compromise and/or subclavian artery or vein injury and in major trauma with a floating shoulder where the clavicle and scapular neck are both fractured.

Complications

Non-union can occur in up to 5% of all types of clavicular fractures. Clavicular injuries that are most at risk of non-union include comminuted fractures and 100% displaced fractures with shortening that is over 2cm, resulting in decreased shoulder strength and endurance. Children over the age of 10 with displaced clavicular fractures will often have a face to face consultation in fracture clinic to discuss operative options to optimize outcome.

Who doesn’t need follow-up?

Children under 10 with an undisplaced fracture don’t need follow-up (although some places offer virtual follow-up), with simple management with a broad arm sling for 2 weeks and no contact sports for another 6 weeks after the sling is removed. It’s important to tell the child’s parents that a lump will form at the fracture site and will last for about a year. Give safety netting advice to return if they develop any sensory changes.

Thankfully Darragh only suffered a midclavicular greenstick fracture with minimal angulation. His arm was placed in a broad arm sling and his parents were told to keep it on for 2 weeks and no fence vaulting for a couple of months! As Darragh’s only 7 years old and his fracture was not significantly displaced, his parents were reassured that it would heal nicely. Most importantly he eventually got his ball back. Phew!

References

JS. Zember, ZS Rosenberg, S. Kwong, SP. Kothary, MA. Bedoya. Normal Skeletal Maturation and Imaging Pitfalls in the Pediatric Shoulder.  Radiographics. 2015 Jul-Aug;35(4):1108-22

https://radiopaedia.org/articles/paediatric-shoulder-radiograph-an-approach

Acromio-clavicular joint injuries

Cite this article as:
PJ Whooley. Acromio-clavicular joint injuries, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.29623

John went in for the ball but was tackled off it and ended up falling onto his shoulder to the ground. He was able to finish the game but had a lot of pain when he stretched his arm across the front of his chest.

AC joint anatomy

The acromioclavicular (AC) joint combines the distal clavicle and the acromion (the superolateral part of the scapula). The joint is supported by a ligament complex as well as the surrounding fascia and muscles. The main ligaments involved are the acromioclavicular ligaments and the coracoclavicular (CC) ligament. The CC ligament is made up of the lateral trapezoid ligament and the medial conoid ligament. 

Mechanism of injury

Injury to the AC joint means disruption of the AC ligaments with or without disruption of the CC ligament. It occurs in up to 10% shoulder girdle injuries and is more common in athletes. Injury typically occurs from a direct blow or following a fall onto the superior or lateral part of the shoulder with the arm adducted. This results in the acromion being forced inferiorly and medially to the clavicle. Injury with a low force causes an AC sprain, with progressively increased force causing AC ligament rupture and then additional sprain and rupture of the CC ligaments. 

Examination 

AC joint injury presents with pain and tenderness over a possibly swollen AC joint. The pain may also be referred to the trapezius muscle. When compared to the contralateral side there may be an abnormal contour. 

If the diagnosis is in doubt you can perform the crossbody ADDuction (Scarf test) to compress the AC Joint. If this is painful, this is suggests AC joint injury. A careful distal neurovascular exam of the involved extremity shoulder be performed, documenting radial, ulnar and median nerve function (take a look at the examining paediatric elbow post for top tips on conducting a proper neurovascular assessment in upper limb injuries).

Young boy trying to hurt his sister (and failing)

It is important to rule out atraumatic distal clavicle osteolysis, a repetitive stress injury in young athletes who do high level upper weight training.

AC injury infographic

Radiology

There are two approaches to plain film imaging in suspected AC joint injury:

  • a single AP view including both AC joints 
  • one AP view of each shoulder comparing affected with the unaffected side

This image from Orthobullets.com shows AC joint widening on the left compared to a normal AC joint on the right.

If there is still some doubt the AC joints can be better seen on Zanca views using a 10-15 degrees of cephalic tilt. Stress views are often used with weights in each hand to determine AC joint instability. This is important also to out-rule coracoid fractures often seen in stress overuse as in young athletes who do repetitive weight training.

Zanca views of the left shoulder. In these images, the ACJ has not become widened on weight-bearing indicating a normal AC joint, with no injury. Case courtesy of Dr Henry Knipe, Radiopaedia.org. From the case rID: 68155

Look carefully at the clavicle for any associated occult clavicle fractures.

Classification

Paediatric AC joint injuries are classified as grades I – VI by the Rockwood classification

In the ED, the most common injuries, occurring after minor trauma, are types I to III, ranging from stretching of the AC ligament to complete tear with clavicle lifting: 

  • I – AC ligament sprain with intact periosteal sleeve
  • II – Partial periosteal sleeve disruption with AC Joint widening (CC distance <25% contralateral side)
  • III – Disrupted periosteal sleeve with superior (upwards) displacement of the clavicle, with between 25 – 100% displacement

Types IV to VI typically occur after high energy trauma and need surgical intervention:

  • IV – Distal clavicle displaced posteriorly through the trapezius
  • V – Deltoid and trapezius detachment and clavicle displacement >100%
  • VI – Clavicle displaced inferiorly under the coracoid

Management

Rockwood Grades I – III AC joint injuries: Non-operative management is the mainstay as these are low energy injuries. Analgesia, ice and rest in a sling or figure-of-eight braces followed by gentle range of motion exercise once the pain has settled. Early rehabilitation with cautious exercise results in earlier return of normal shoulder range of motion, with functional motion by 6 weeks and normal activity by 12 weeks. The lower the grade the earlier the return to normal function. Caution needs to be taken to avoid manoeuvres that that strain the ligaments and cause pain. Avoid cross-body ADDuction, extreme internal rotation (i.e. behind the back) and overhead movements.

Rockwood Grades IV to VI injuries: Operative management is indicated in grades IV to VI but also in Grade III that have failed non operative treatment or in elite athletes and for cosmesis.

Complications

Up to 30 – 50% of patients with AC joint injuries complain of residual pain. 

John thankfully only had a Grade II AC joint injury and wore a shoulder immobilizer for 3 weeks. He’s already back training but is a little more cautious when he goes in for the tackle. 

References

AD. Mazzocca, RA. Arciero, J. Bicos. Evaluation and treatment of acromioclavicular joint injuries. Am J Sports Med 2007;35:316-329.

JD. Gorbaty, JE Hsu. AO. Gee.  Classifications in Brief: Rockwood Classification of Acromioclavicular Joint Separations. Clin Orthop Relat Res. 2017 Jan; 475(1): 283–

S. Evrim. N. Aydin, OM. Topkar. Acromioclavicular joint injuries: diagnosis, classification and ligamentoplasty procedures. EFORT Open Rev 2018;3:426-433

Talk ortho like a pro

Talk ortho like a pro

Cite this article as:
Orla Callender. Talk ortho like a pro, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.30463

Clear and structured communication between the emergency and orthopaedic team is paramount to ensuring a smooth transfer of care for children with fractures and traumatic injuries. Use this checklist to structure your referrals to ortho like a pro, and test your x-ray interpretation skills with the quiz below.

History

Injury is force meets child; child is damaged. Force causes an easy-to-remember event – shock, pain, ‘crack’, blood, fear – so there will always be a history of an injury. When taking a history, remember the six honest men: when, how, where, what, who and why.

In addition to a full history of presenting complaint and past medical, vaccination and developmental history, a trauma history should include:

  • Date and time of injury
  • Exact mechanism of injury when possible, preferably in parent’s or child’s own words
  • Environment in which the injury occurred
  • Symptoms at time of injury and subsequently
  • Hand dominance for upper limb injury
  • Analgesia administered
  • Fasting status
  • Relevant past medical history such as bleeding disorders

Sadly, we must always remain vigilant for signs of non-accidental injury (NAI). The presenting injury needs to reasonably fit with the account as to the mechanism of injury.

Examination

Whilst the majority of the examination of a traumatic injury is centred on the affected site, the examination must always include:

The examination should be broken down into:

  • Inspection
  • Palpation
  • Movements and gait
  • Neurovascular status
  • Special tests

Imaging

Fractures can generally be identified on an AP and lateral radiograph. Use a systematic approach and apply the rule of two’s.

Apply rule of twos:

  • Two views as standard; occasionally other views may be required
  • Two joints viewed
  • Two sides where comparison of normal is necessary
  • Two occasions before and after procedures or in specific instances (such as when a scaphoid fracture is suspected)

A fracture may appear as a lucency (black line) where a fracture results in separation of bone fragments or as a dense (white) line where fragments overlap. If bone fragments are impacted, then increased density occurs which may be the only radiological evidence that a fracture exists.

Sometimes, there is no direct evidence of a fracture and instead, we need to rely on indirect evidence. Looking for radiological soft tissue signs can provide clues to fractures. These include displacement of the elbow fat pads or the presence of a fluid level.

The AABCS approach, described by Touquet in 1995, can be used to carry out a structured interpretation of a limb x-ray.

Key points:
•   Examine the entire radiograph in detail before concentrating on the area of concern – Look at the whole x-ray and the x-ray as a whole
•   Remind yourself of mechanism of injury – Are the radiographic findings relevant to patient history? How do the findings correlate with clinical findings? Do you need to re-examine the patient?
•   Take an x-ray before and after procedures
•   Get help – If the x-ray doesn’t look right ask someone else, and ensure there is a backup reporting system in place
•   Document both what you see and what you don’t see on the x-ray

Describing fractures

Fractures are described systematically. Start with the site (name and part/portion of bone), then extent (fracture type/line, open/closed, articular involvement), then describe the distal fragment (displacement and angulation). Describe any involvement of the skin and damage to related tendons and structures such as nerves or blood vessels.

Describing the site

Long bones are often described based on thirds: proximal, middle (diaphyseal) and distal segment. Including nearby anatomical landmarks (head, neck, body /shaft, base, condyle, epicondyle, trochanter, tuberosity etc.) helps describe the area of interest.

In paediatrics, fractures are described including the anatomical divisions of the bone segments: the epiphysis, the epiphyseal plate, the metaphysis and the diaphysis.

  • The diaphysis is the shaft of the bone
  • The physis is the growth plate. Also known as the epiphyseal plate, the physis occurs only in skeletally immature patients and is a hyaline cartilage plate in the metaphysis, at the end of a long bone.
  • The metaphysis lies between the diaphysis and the physis. An easy way to remember this is to think of the word metamorphosis – a change; the metaphysis is the area of change between the physis – the growth plate – and the diaphysis – the shaft. The metaphysis is only used to describe a bone before it matures – it is the growing end of the long bone. Metaphyseal fractures are almost pathognomonic of NAI. They are also known as corner fractures, bucket handle fractures or metaphyseal lesions
  • The epiphysis sits above the growth plate – epi (Greek for over or upon – like the epidermis) – physis – upon the physis

Describing the extent

For revision of specific terms to use to describe the type of fracture, see the fracture terminology glossary below. Key characteristics to add include whether the fracture is open or closed, and whether the fracture is intra-articular (inside the joint capsule) or extra-articular. Extra-articular fractures are usually less complicated.

Describing the distal fragment

There is a convention to ensure that the same injury is described in the same way: angulation, displacement, and dislocation are described by where the distal fracture fragment is in relation to the proximal fragment, or in the direction of the fracture apex.

Displacement is the loss of axial alignment: dorsal (posterior), volar (anterior) or lateral displacement of the distal fragment with respect to the proximal fragment. The degree of displacement can be roughly estimated from the percentage of the fracture surfaces in contact. Where none of the fracture surfaces are in contact, the fracture is described as having ‘no bony opposition’ or being ‘completely off-ended’, and are potentially unstable. Displacement is usually accompanied by some degree of angulation, rotation or change in bone length.

Angulation is the angle created between the distal fragment and the proximal fragment as a result of the fracture. The anatomical reference point is the long axis. Angulation is described using words like: dorsal / palmar; varus / valgus; radial /ulnar. It may be described either by reference to the direction in which the apex of the fracture points (apex volar or apex dorsal) or by indicating the direction of the tilt of the distal fragment. Medial angulation can be termed ‘varus’, and lateral angulation can be termed ‘valgus’. To measure angulation, one line is drawn through the midline of the shaft. A second line is then drawn through the midline of the fragment and the angle can now be measured.

Rotation is present when a fracture fragment has rotated on its long axis relative to the other. It may be with or without accompanying displacement or angulation. It is more readily diagnosed on clinical examination.

Finally, perfecting your referral

Referrals to the orthopaedic team, using a framework like the ISBAR tool, should start with the child’s name, hospital number and who is attending with the patient. Then proceed to give a history, including a full history of the presentation, hand dominance, fasting status and any relevant clinical risk factors such as bleeding disorders. Describe your clinical findings, including neurovascular examination, and then the radiological findings in the order of:

  • the bone(s) involved
  • part of bone
  • type of fracture
  • fracture line
  • extent of deformity and angulation
  • and any associated clinical findings

Describe any other investigations, management to date and on-going treatment. Summarise events that have occurred before referral – analgesia, backslab casts, splints, antibiotics, tetanus boosters, wound cleansing, dressings etc.

As with any good referral, be clear about why the child is being referred. It may be reasonable to transfer full care of a child. Or, the referral may simply be to gain a second opinion on the diagnosis followed by management. Be clear about the type of care expected. And finally, discuss whether you feel the referral is urgent or not. It should be stated how quickly you expect the patient to be seen. Do you feel they need to be seen urgently, soon or routinely?

At this stage, a management plan and expected outcome can be discussed and agreed. This information can then be reiterated to the child and family. Make sure everything is clearly and concisely documented.

Done!

Fracture terminology

Non-displaced fracture: A fracture where the pieces of the bone line-up.

Displaced fracture: The pieces of the bone are out of line.

Closed fracture: Either the skin is intact or, if there are wounds, these are superficial or unrelated to the fracture.

Open / compound fracture: A wound is in continuity with the fracture site.

Unstable fracture: A fracture with a tendency to displace after reduction.

Complete fracture: The fracture line extends across the bone from one cortex to the other separating the bone into two complete and separate fragments.

Greenstick fracture: Only one cortex is fractured.

Torus / buckle: Buckling of the cortex with no break.

Comminuted: There are more than two fragments.

Transverse fracture: A fracture across the bone.

Oblique fracture: A fracture at an angle to the length of the bone.

Spiral fracture: A fracture that curves around the bone diameter.

Depressed: A portion of bone is forced below the level of the surrounding bone.

Avulsion fracture: The muscle have torn off the portion of bone to which is attached.

Stress fracture: Tiny cracks in the bone caused by repetitive injuries. A cortical break is not always seen but there is greying of the cortex due to callus formation.

Pathological fracture: A fracture arising within abnormal bone weakened by benign or malignant cysts or tumours.

Impacted fractures: One fracture fragment is driven into the other.

Plastic deformation: Deformation of bone without fracture of the cortex.

Epiphyseal fractures: A fracture to the growing end of a juvenile bone that involves the growth plate. Use the Salter-Harris classification if the fracture involves the epiphyseal plate.

Fractures don’t always occur in isolation – a joint may be involved.

Fracture-dislocation: A dislocation is complicated by a fracture of one of the bony components of the joint, such as a Galeazzi or Monteggia fracture-dislocation.

Subluxation: The articulating surfaces of a joint are no longer congruous, but loss of contact is not complete.

Dislocation: Complete loss of contact between the articulating surface of a joint. Displacement of one or more bones at a joint.

References

Bickley S. & Szilagyi P. (2003) Bates’ Guide to Physical Examination and History Taking (8th edn.) Philadelphia. J.B. Lippincott, Philadelphia.

Davis, F.C.W., 2003. Minor Trauma in Children. A pocket guide. London: Arnold.

Duderstadt, K. 2006. Pediatric Physical Examination. Mosby. Elsevier.

Purcell, D. 2003. Minor Injuries. A Clinical Guide. Edinburgh: Churchill Livingstone.

Larsen, D. & Morris, P. 2006. Limb X-ray Interpretation. Whurr Publishers Limited.

McRae, R. 2003. Pocketbook of Orthopaedics and Fractures. 3rd ed. Edinburgh: Churchill Livingstone.

Raby, N., Berman, L. & De Lacey, G., 2001. Accident & Emergency Radiology. A Survival Guide. Edinburgh: W.B. Saunders.

Touquet et al, 1995. The 10 Commandments of Accident and Emergency Radiology. BMJ 1995; 311: 571.

Image source for final quiz case: https://radiopaedia.org/cases/2c1840c5145638e56f599031f23dd0c8?lang=us

Wrist x-rays

Cite this article as:
Sian Edwards. Wrist x-rays, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.29082

The wrist is one of the most commonly requested X-Rays in the children’s emergency department. Wrist views are requested when injury to the distal radius/ulna or carpal bones are suspected. Below is a systematic approach to interpretation.

The wrist series examines the carpal bones (scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate and hamate), the radiocarpal joint and the distal radius and ulna. 

There are eight carpal bones present and each one is named according to its shape:

  1. Scaphoid (boat-shaped)
  2. Lunate (crescent moon-shaped)
  3. Triquetrum (pyramidal)
  4. Pisiform (pea-shaped)
  5. Trapezium (irregular trapezium-shaped)
  6. Trapezoid (wedge-shaped)
  7. Capitate (head-shaped) – *the largest of the carpal bones
  8. Hamate (wedge-shaped with a bony extension, or ‘hook’)
Labelled XR of carpus
AP
Proximal carpal rowDistal carpal row
ScaphoidTrapezium
LunateTrapezoid
TriquetrumCapitate
PisiformHamate

How to best remember the carpal bones

There are many mnemonics around – some too rude for mention here! You will need to find the one that works for you… here’s one that’s super suited for clinicians working with kids:

Sam Likes To Push The Toy Car Hard

Failing that, save an image to your phone for quick reference!

Mnemonic for remembering carpal bones

Ossification

The carpal bones are formed entirely from cartilage at birth – this is important from a radiological viewpoint as it means they are not visible on x-ray initially. They begin to ossify from about 1-2 months of age and are fully developed by the age of 8-12 years. Although there is variability in the timing, the order is always the same.

  1. Capitate 1-3 months
  2. Hamate 2-4 months
  3. Triquetrum 2-3 years
  4. Lunate 2-4 years
  5. Scaphoid 4-6 years
  6. Trapezium 4-6 years
  7. Trapezoid 4-6 years
  8. Pisiform – 8-12 years

Generally, on x-ray, one carpal bone is visible every year until full development – this acts as a handy (pun intended) ageing tool!

On requesting wrist X-Rays, most commonly you will receive posteroanterior and lateral projections, with oblique views forming part of the series usually when carpal injury is suspected.

1. Check the soft tissues

Look for signs of swelling or any incidental findings.

2. Trace the bony cortices

Trace each bone in turn to look for breaks or irregularities in the cortex.

Look closely at the distal radius, proximal carpal row (especially the scaphoid) and the proximal metacarpals. Disruptions in the cortex may be very subtle as in the case of this torus fracture (aka a buckle fracture)

Buckle fracture of radius
Buckle fracture

3. Check bony alignment

On the AP view:

The distal radial articular surface should curve round the carpals with the articular surface getting more distal towards the ulnar styloid. The articular surfaces of the proximal and distal carpal rows should form three smooth arcs – these can be traced on the AP film.

The spacing between all carpal bones should be 1-2mm.

If the arc is broken or there is widening or lack of uniformity between the spaces, think about carpal dislocation.

The articular cortex at the base of each metacarpal parallels the articular surface of the adjacent carpal bone.

The carpo-metacarpo (CMC) joint spaces should be clearly seen and of uniform width (1-2mm).

The 2nd to 5th CMC joints are visualised as a zigzag tram line – on a normal view, there will always be the “light of day” seen between the bases of the 4th and 5th metacarpals and the hamate bone. If this is narrowed, think dislocation of the 4th or 5th metacarpal.

Labelled AP view of wrist
AP view

On the lateral view:

The distal radius, lunate and capitate should articulate with each other in a straight line on the lateral x-ray – the apple, cup, saucer analogy – the cup of the lunate should never be empty.

Lateral view of carpus
Normal capitate – lunate – radius alignment. Image adapted from a case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 37947

If the cup is empty, this suggests a perilunate dislocation.

Perilunate dislocation
Perilunate dislocation. Image adapted from a case courtesy of Dr Ian Bickle, Radiopaedia.org. From the case rID: 46714
The apple and cup model of perilunate dislocation
The slipped cup of the perilunate dislocation

References

https://radiopaedia.org/articles/wrist-radiograph-an-approach?lang=gb