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Childhood Fractures

Bowing fracture

Plastic deformation of the bone with bending. Numerous microfractures along the concave side of the bent bone.


Buckle fracture/Torus fracture

Buckling of the cortex. Metaphysis of long bones - dorsal distal radius. These can be subtle, only seen on one view. Distal cortex of long bones should have smooth, continuous curves (no angles).


Greenstick fracture

Incomplete cortical break on the convex side. Most common in the forearm and may be associated with a bowing fracture in the adjacent bone.


Toddler's fracture

Nondisplaced oblique fracture through the tibial shaft. This fracture is often subtle, only seen on one view.


Cuboid fracture

More common that previously suspected due to forced plantar flexion of the foot.


Salter-Harris Classifications


Salter-Harris Type I fracture

In children less than five years old. Fracture through the physis with separation of the epiphysis from the metaphysis. The fracture does not extend into the adjacent epiphysis or metaphysis. Good prognosis. In adolescent gymnasts, type I fractures through the distal radial physis can occur due to chronic compressive loading and shearing forces. Radiographic findings of physeal widening and metaphyseal irregularity in "gymnast's wrists" type I Salter-Harris fractures have been labeled "pseudorickets".


Salter-Harris type II fracture

The most common type, accounting for 75% of physeal injuries. The fracture extends from the physis into the metaphysis. Good prognosis. Hand and wrist. The segment of separated metaphyseal bone is referred to as the "Thurston-Holland" fragment.


Salter-Harris type III fracture

Intraarticular fracture of the epiphysis with extension through the physis. Amount of displacement/fragmentation = blood supply disruption = subsequent growth disturbance. The juvenile Tillaux fracture is a type III fracture of the distal tibia that occurs in adolescence. The physis of the distal tibia begins to fuse at the Kump bump, an undulation in the anteromedial part of the growth plate. The medial distal tibia has the features of an adult bone whereas the lateral remains immature. This predisposes the distal tibia to complex fractures. Radiologic evaluation is aimed at defining the number of fragments and the separation of the articular components (CT is often helpful). More that 2-3 mm of diastasis in any plane requires open reduction.


Salter-Harris type IV fracture

extends from the articular suface, crosses the epiphysis, extends through the full thickness of the physis and exits through the metaphysis. These are most common in the ankle and elbow. In the ankle the Triplane fracture occurs, the mechanism similar to the Tillaux fracture. In the triplane fracture there is a horizontal fracture through the physis, a coronal fracture through the metaphysis and a sagittal fracture through the epiphysis. The triplane fracture commonly appears as a type III fracture on the frontal radiograph and a type II fracture on the lateral radiograph (as the epiphyseal and metaphyseal fractures are in different planes).


Salter-Harris type V fracture

are rare, as they result in focal bone growth arrest. Crushing op physis. These injuries occur most commonly at the knee and ankle. A severe compressive force across the physis. Most often diagnosed in retrospect, once a bone growth disturbance is identified in a child with normal radiographs at the time of injury.


Apophyses

are growth centers like epiphyses, but do not contribute to longitudinal growth. These are most common in the pelvis.


Apophyseal avulsion fractures

are Salter-Harris type I fractures. Apophyseal avulsions are athletic injuries, as the apophyses are points for muscular attachment.


Elbow

The distal humerus broadens to form the medial and lateral epicondyles. Two depressions between these condyles: the coronoid fossa anteriorly and the olecranon fossa posteriorly. Each of these depressions contains a fat pad. On the true lateral radiograph, displacement of the fat pads indicates an elbow joint effusion. The anterior fat pad may be seen normally but is not displaced; whenever the posterior fat pad is visualized, this indicates a joint effusion. Fat pad displacement is a response to distention of the joint capsule and occurs in a variety of disorders: hemophilia, arthritis, acute pyoarthritis and fractures. An elbow joint effusion is often associated with a fracture, however an occult fracture should not always be suspected based on an effusion.


CRITOE

is useful to remember the order of ossification: - Capitellum (6 months-2years) - Radial head (3-6 years) - Internal (medial) epicondyle (4-7 years) - Trochlea (7-10 years) - Olecranon (6-12 years) - External (lateral) epicondyle (10-14 years) The ossification centers are usually ovoid and smooth with the exception of the trochlea, which can be fragmented and irregular. The knowledge of this ossification sequence is especially helpful in medial epicondyle injury. Anterior humeral line: drawn tangential to the anterior humeral cortex on a true lateral view, normally passes through the middle or posterior third of the ossified capitellum. This line is not helpful when the capitellum is small (child < 2 years). This line is important in evaluation for a supracondylar fracture. Radiocapitellar line: drawn bisecting the radial shaft, normally passes through the capitellum on all views; if it does not, suspect radial head or complete elbow joint dislocation. Coronoid line: drawn along the coronoid fossa and is concave anteriorly; an extension of this line touches or passes anterior to the developing capitellum. This line helps to demonstrate anterior or posterior displacement of the capitellum.


Supracondylar fracture

is the most common fracture of the pediatric elbow. This fracture is usually due to a fall on an outstretched hand (FOOSH injury). Joint effusion and abnormal anterior humeral line (intersecting the anterior third of the capitellum or passing anterior to the capitellum) due to dorsal displacement of the distal humerus. This fracture may be subtle, only seen on one view or occult. Follow-up radiographs in 7-10 days.


Lateral condyle fracture

is 2nd most common fx. It is usually a Salter-Harris type IV fracture, involving a small fragment of distal humeral metaphysis and unossified epiphysis. There is an elbow joint effusion. These fractures may be subtle on radiographs, with only a small sliver of bone separated from the metaphysis as the majority of the fracture is through the unossified distal humeral epiphysis.


The medial epicondyle

is an apophysis that may be avulsed due to pull of the flexor pronator tendon. A wide range of medial epicondyle injuries occurs: from simple separation of the epicondyle to complete dislocation and/or intra-articular entrapment of the epicondyle. Avulsions are best identified on the frontal view. If separated greater than 5 mm, open reduction and fixation are necessary. The entrapped medial epicondyle may be mistaken for the trochlear ossification center. However, if one remembers that the medial epicondyle ossifies before the trochlea (CRITOE), than a trochlear ossification center should never be present without a medial epicondylar ossification center.