37

Pediatric Trauma: Getting Through the Night

Susan A. Scherl, MD
Andrew H. Schmidt, MD

children (for example, compartment

Abstract syndrome, pelvic fractures with he-
As is the case in adults, the timing and type of emergent treatment of fractures in children
modynamic instability, and trau-
can be controversial. Some emergent conditions, such as compartment syndrome, pelvic
matic amputations and open frac-
fractures with hemodynamic instability, and open fractures, are managed similarly in
tures). Instead, it focuses on entities
adults and children. However, other types of fractures are unique to children or are man-
that are either unique to children or
aged differently in children and adults. To prevent complications, it is important to un-
are managed differently in children
derstand the appropriate treatment and timing of treatment of supracondylar humeral
and adults. Specifically, supracondy-
fractures and other specific elbow fractures, hip fractures and dislocations, and physeal
lar humeral fractures and other spe-
fractures about the knee in pediatric patients.
cific elbow fractures, hip fractures
Instr Course Lect 2010;59:455-463.
and dislocations, and physeal frac-
tures about the knee are discussed.
Although most orthopaedic sur- should have an understanding of
geons do not specialize in pediatrics, which pediatric fractures are emer- Supracondylar Humeral
almost all practicing orthopaedic gencies and why, how to treat these Fractures
surgeons, and certainly anyone on fractures or at least temporize before Supracondylar humeral fractures are
emergency trauma call, will be definitive treatment, and how and relatively common. They account
called on at some point to treat a why the treatment of children’s for 30% of extremity fractures in
child with a fracture. It is therefore fractures sometimes differs from children younger than 7 years and
imperative for practitioners to have that of adult fractures. 60% of elbow fractures in that age
some working knowledge of current This chapter does not address group. They are most common in
pediatric fracture care. At a mini- emergent problems that present and the first decade of life. Extension-
mum, all orthopaedic surgeons are managed similarly in adults and type injuries account for 96% of su-
pracondylar humeral fractures and
result from a fall on an outstretched
Dr. Scherl or an immediate family member is a board member, owner, officer, or committee member of the Ortho- arm that forces the elbow into hy-
paedic Trauma Association and the Pediatric Orthopaedic Society of North America; has received research or insti-
tutional support from Arthrex, the National Institutes of Health, Tornier, and ESKA; and has received nonincome perextension. The much less com-
support (such as equipment or services), commercially derived honoraria, or other non–research-related funding mon flexion-type injuries occur
(such as paid travel) from Lippincott Williams & Wilkins and UpTODATE. Dr. Schmidt or an immediate
family member is a board member, owner, officer, or committee member of the Orthopaedic Trauma Association; from a fall onto the point of the
has received royalties from Smith & Nephew; is a member of a speakers’ bureau or has made paid presentations on olecranon with the elbow flexed.
behalf of Synthes; serves as a paid consultant for or is an employee of Smith & Nephew, Twin Star Medical,
Medtronic, DigiMed, and AGA; serves as an unpaid consultant for Conventus Orthopedics and Anthem Ortho-
According to the commonly used
pedics; has received research or institutional support from Synthes, Smith & Nephew, Twin Star Medical, and Gartland classification,1 type I inju-
Medtronic; owns stock or stock options in Twin Star Medical, Conventus Orthopedics, and the International ries are nondisplaced; type II inju-
Spine and Orthopedic Institute; and has received nonincome support (such as equipment or services), commer-
cially derived honoraria, or other non–research-related funding (such as paid travel) from Thieme. ries are angulated posteriorly, but

AAOS Instructional Course Lectures, Volume 59, 2010 455

Trauma

the posterior cortex is intact; and apparent on Doppler examination ries are treated with closed reduc-
type III injuries are completely dis- after fracture reduction, because this tion and percutaneous pinning, with
placed, usually with the distal part of may indicate that the vascular bun- either two or three lateral pins or
the humerus and the elbow dis- dle has become entrapped in the crossed medial and lateral pins.
placed posteromedially. fracture site. The use of arteriogra- There is no substantial difference in
A patient with a supracondylar phy in children is controversial, as is the stability provided by the lateral
humeral fracture presents after a the management of the “pink, pulse- and crossed-pin methods if proper
specific injury; has pain, swelling, less hand;” the usual recommenda- technique and pin placement are
and a decreased range of motion of tion is observation without vascular used. The two lateral pins should
the elbow; and usually has pain exploration in such situations.3 be divergent, with one running up
when motion of the arm is at- Neurologic injury occurs in the lateral column and one crossing
tempted. There is tenderness over about 7% of patients. Most nerve in- over to the medial column. The two
the distal part of the humerus and, juries are neurapraxias that resolve pins should not cross at the fracture
typically, an obvious deformity. with time. The radial nerve is at the site; a third pin should be added
There may be ecchymosis or but- most risk of transection, which usu- when there is medial comminution
tonholing of the skin at the fracture ally occurs with open fractures. The or persistent instability with
site. The child holds the arm in ex- anterior interosseous nerve is the motion5-8 (Figure 1 and Table 1).
tension and pronated at the forearm. most frequently injured.4 This The timing of surgery for a dis-
A careful neurovascular examination nerve is injured when the postero- placed supracondylar humeral frac-
is imperative. On initial presenta- lateral part of the distal fracture frag- ture is controversial. A supracondylar
tion, the radial pulse may be absent ment compresses the nerve against humeral fracture is one of the classic
secondary to draping of the artery the anterior structures in the fore- pediatric orthopaedic emergencies,
over the spike of the proximal frac- arm. Injury to the anterior in- but the need to perform surgery in
ture fragment. Often, the pulse re- terosseous nerve results in weak the middle of the night for these
turns after fracture reduction. The flexion of the interphalangeal joint injuries has recently been challenged.
function of the median, ulnar, radial, of the thumb and the distal inter- Four retrospective studies showed
and anterior interosseous nerves phalangeal joint of the index finger. no increase in complications in chil-
must be documented and the fore- The radial nerve is more commonly dren for whom surgery had been
arm assessed for signs of ischemia or injured in patients with a postero- delayed more than 12 hours.9-12
compartment syndrome. medial fracture. The median nerve Another study showed a possible
AP and lateral radiographs of the is more commonly injured in those increase in the prevalence of com-
elbow should be obtained. Compar- with a posterolateral fracture, often partment syndrome in children
ison radiographs of the contralateral in association with a brachial artery with a delay of more than 22 hours
elbow can aid in interpreting the im- injury. A median nerve injury can before surgery.13 In the opinion
ages. On the lateral radiograph, a mask a compartment syndrome be- of the chapter’s authors, if a delay
line drawn along the anterior border cause of the associated sensory loss of 12 to 24 hours is necessary or
of the humerus should pass through in the forearm. Ulnar nerve injury inevitable, the outcome should not
the center of the capitellum if there is often iatrogenic, secondary to be adversely affected. However,
is no displacement. A posterior fat medial pin placement, but it also oc- waiting is not a better option. Sur-
pad sign (a radiolucent area seen curs in conjunction with a flexion- gery should not be delayed unless
posterior to the distal part of the hu- type supracondylar humeral frac- the child has normal neurovascular
merus, adjacent to the olecranon ture. function. Furthermore, surgery
fossa, on a plain lateral radiograph) The treatment of supracondylar should not be delayed if there is ex-
indicates a hemarthrosis and sug- humeral fractures depends on the cessive swelling or soft-tissue dam-
gests an occult elbow fracture.2 direction and degree of displace- age; the case must still be considered
Vascular injury occurs in approxi- ment. Gartland type I injuries may urgent, with the surgery being done
mately 1% of patients. Indications be treated, without reduction, in a at the earliest possible opportunity
for vascular exploration are clinically long arm cast with the elbow flexed the following morning and not after
obvious ischemia or loss of a pulse 90° to 110° for 3 to 4 weeks. Dis- the next day’s elective surgery
that had been previously palpable or placed Gartland type II and III inju- schedule, for example.

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Pediatric Trauma: Getting Through the Night Chapter 37

Vascular injury or interposition of Fortunately, complications are beneficial. Cubitus varus is caused
the neurovascular bundle are the infrequent after supracondylar by varus positioning of the fracture
two most definitive indications for humeral fractures, and most are fragment as well as residual rota-
open reduction.14 The antecubital avoided by attention to detail during tional deformity. Although cubitus
approach is useful in both cases. treatment.15,16 Ulnar nerve injury— varus is generally a cosmetic prob-
Although vascular compromise usu- usually a neurapraxia that resolves in lem, ulnar nerve palsy can occur
ally can be managed without the 3 to 6 months—is often the result of later; a distal humeral osteotomy is
need to operate on the artery, arterial medial pin placement. Occupational occasionally necessary. Loss of
repair may be needed and should be therapy during resolution may be reduction is usually a result of
planned for. An inability to achieve
an acceptable closed reduction be-
cause of lateral or medial soft-tissue
or periosteal interposition is another
indication for open reduction. An
approach from the affected side al-
lows removal of the offending soft
tissue.
The pins are removed in the phy-
sician’s office after periosteal new
bone is visible radiographically,
generally at 3 to 4 weeks. Additional
protective immobilization is usually
not necessary. Children generally
regain range of motion within about
3 to 4 weeks without physical thera-
py, although the last few degrees of
flexion may lag. Follow-up with ra-
Figure 1 AP (A) and lateral (B) radiographs showing fixation of a Gartland type III
diographs and physical examination
supracondylar humeral fracture with a three-lateral-pin construct. Note the diver-
is recommended at 3, 6, and 12 gence of the pins, with one going up the lateral column and two traversing the olec-
months after injury. ranon fossa to the medial column.

Table 1
Pearls and Pitfalls for Closed Reduction and Percutaneous Pinning of Supracondylar Humeral Fractures
Place the patient supine.
Flip the C-arm, bring it perpendicular to the operating room bed, and use it as a table.
Reduction maneuver: straight traction, adjustment of the distal fragment medially or laterally, flexion of the elbow while pushing the distal
fragment anteriorly, forearm pronation to “lock” the fragment in place
If no assistance is available, secure the arm in the reduced, flexed position with a roll of gauze.
Use 4-inch (10.2-cm) long, 0.062-inch (1.57-mm) diameter Kirschner wires.
Insert two pins from the lateral side.
If the fracture remains unstable, insert an additional pin: either a third lateral pin or a medial pin.
The medial pin can be inserted through a mini-open incision to ensure that the starting point is directly on the medial epicondyle and the
ulnar nerve is out of the way.
Extend the arm to insert a medial pin; this drops the ulnar nerve posteriorly, further out of the way.
If the patient wakes up with an ulnar nerve palsy, first simply pull the medial pin.
Pay careful attention to rotational alignment; malrotation causes cubitus varus.
Splint with the elbow in 70° to 90° of flexion, in a posterior mold with side slabs.
Do not change the splint until it is time to pull the pin; doing so causes the child unnecessary discomfort and anxiety.
Leave the ends of the pins long enough to grab and pull out with your fingers; children do not like to be approached with pliers.

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Trauma

technical problems with pin place- Fractures of the without opening the fracture. Be-
ment.16 Pin site infections are rare. Lateral Condyle cause fractures of the lateral condyle
Seventeen percent of elbow frac- are not likely to be associated with
Transphyseal Elbow Fractures tures in children are fractures of the neurovascular injury, they are con-
The prevalence of transphyseal frac- lateral condyle. The peak incidence sidered urgent but not in need of
tures of the distal part of the hu- is between 5 and 10 years of age. emergent surgical treatment.
merus is unknown, as these injuries These injuries are caused by varus Fractures of the lateral condyle
are sometimes missed or misdiag- stress to an extended elbow with the are prone to late complications, in-
nosed. They occur primarily in chil- forearm in supination. Children cluding late displacement; malunion
dren younger than 4 years. They oc- with a fracture of the lateral condyle and nonunion, even after appropri-
cur as a result of a fall on an present with lateral swelling and ate fixation; growth disturbance; late
outstretched arm but may be the re- pain in the elbow. These fractures deformity; and loss of motion. Par-
sult of abuse if the child is not yet are much less likely to be associated ents should be warned of these pos-
walking; a high index of suspicion with neurovascular injury than are sibilities at the time of injury.
should be maintained in such cases. supracondylar humeral fractures.
The fractures usually have a Salter- AP and lateral radiographs of the el- Monteggia
Harris type I or II pattern.17 The di- bow are essential. Sometimes, ob- Fracture-Dislocations
agnosis of transphyseal elbow frac- lique radiographs help to visualize Monteggia fractures involve the
ture should be considered when a the fracture. Fractures of the lateral proximal part of the ulna and are as-
very young child presents with pain, condyle are often mistaken for sociated with a dislocation of the ra-
swelling, and decreased use of the “chip” or “avulsion” fractures in dial head. They are rare in children,
upper extremity. These injuries are very young children because most of accounting for about 0.4% of all
frequently mistaken for elbow dislo- the distal fracture fragment, includ- forearm fractures. The peak inci-
cations. ing its articular surface, is not ossi- dence is between 4 and 10 years of
Because these fractures occur fied. Although fractures of the lat- age. The Bado classification is used
in very young children in whom eral condyle may be classified with to describe these injuries in children
much of the distal part of the hu- the Salter-Harris classification or the as well as in adults.19 Bado type I in-
merus (often including the capitel- anatomically based Milch classifica- juries, which involve anterior angu-
lum) is not yet ossified, radiographs tion, many pediatric orthopaedic lation of the ulna and anterior dislo-
may be difficult to interpret. When surgeons classify them simply on cation of the radial head, are the
the elbow is dislocated, the normal the basis of whether they are dis- most common variant in children,
radiocapitellar relationship is dis- placed because displacement dic- accounting for 70% of the fractures.
rupted, but it is preserved with a tates treatment.17,18 Monteggia fractures in children are
transphyseal fracture. An arthro- Nondisplaced fractures of the lat- easy to miss. On all radiographic
gram, a MRI scan, or a sonogram, eral condyle may be treated in a long views, a line drawn through the cen-
all of which allow visualization of arm cast with the elbow in 90° of ter of the radial head should pass
the nonossified capitellum, may aid flexion. Frequent follow-up and re- through the center of the capitel-
in the diagnosis. A closed reduction, peat imaging are necessary to watch lum. Any deviation from this is not
with or without percutaneous pin- for late displacement and the subse- normal and requires further evalua-
ning, is needed. Often, these inju- quent need for surgical treatment. tion. “Pure” radial head dislocations
ries present late, when there is al- Displaced fractures are best treated may not exist in children; therefore,
ready a periosteal reaction indicating with an open reduction and pinning it is advisable to look for plastic de-
healing. Reduction is not indicated with two or three lateral pins. Direct formation of the ulna in children
in these cases. visualization before pinning is nec- with a dislocated radial head.
The most common complication essary to ensure an anatomic re- Monteggia fractures can usually
is malunion as a result of a late diag- duction of the articular surface. An be treated with closed reduction
nosis. Luckily, there is substantial arthrogram can be made for mini- (probably best performed with the
remodeling potential in young chil- mally displaced fractures, and, if the patient under general anesthesia)
dren. Rarely, osteonecrosis of the articular surface of the humerus is and immobilization with the elbow
trochlea occurs. congruent, the pins may be placed in 90° to 110° of flexion and the

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Pediatric Trauma: Getting Through the Night Chapter 37

forearm in full supination. Reduc-

Table 2
tion is achieved by first correcting Pearls and Pitfalls for Pediatric Hip Fractures
the ulnar deformity, then reducing The goal of treatment is anatomic reduction of the proximal part of the femur.
the radial head, and finally relieving An anterolateral (Watson-Jones) surgical approach is used for open reduction.
the deforming forces by positioning Consider internal fixation for nondisplaced fractures to avoid late displacement and the
the elbow in flexion and the forearm subsequent development of coxa vara.
in supination. Plastic deformation of Advise parents before treatment about the potential for serious late complications.
the ulna is sometimes particularly Do not compromise fracture stability/fixation to protect the physis; cross it with fixation
difficult to reduce. pins if necessary.
Associated neurovascular injuries The proximal femoral physis grows only 1/8 inch (3 mm) per year. If a limb-length
discrepancy occurs, it can be readily managed.
are rare. A late diagnosis can be asso-
Internal fixation options:
ciated with so much fracture healing 0 to 3 years of age: smooth pins (5/64 inch [2 mm] or 3/32 inch [2.4 mm]) or
that an osteotomy of the ulna, open cannulated screws (3.5 or 4.0 mm)
4 to 8 years of age: cannulated screws (4.0 or 4.5 mm) or a pediatric hip-compression
reduction of the radial head, and an- screw
nular ligament reconstruction are Older than 8 years: cannulated screws (6.5 or 7.3 mm) or a hip-compression screw
necessary. Pediatric bone is often denser than adult bone; consider predrilling and tapping.
Consider using a supplemental hip spica cast in children younger than 8 years.
Hip Fractures Remove hardware in approximately 1 year.
Femoral neck and intertrochanteric Pathologic fractures may require additional treatment.
femoral fractures are rare in chil- Osteonecrosis is probably predetermined by the fracture “personality.” However, these
dren, accounting for less than 1% of fractures are still considered emergent; treatment should not be delayed unless
medically necessary.
all childhood fractures.20 They are
Consider hip joint aspiration when a fracture is treated closed.
usually caused by high-energy
trauma, and associated injuries, in-
cluding other fractures, head inju- crosis is lower than the risk with tions are evident within 6 to
ries, and abdominal injuries, are type I and II fractures, it is still real. 9 months after the injury. Necrosis
common. Proximal femoral frac- Type IV fractures are intertrochan- of the femoral head is the most seri-
tures in children are classified ac- teric. This is an uncommon variant, ous complication and is in large part
cording to the scheme first reported is associated with the fewest compli- a function of the initial fracture pat-
in the French literature by Delbet in cations, and healing is rapid. tern. Coxa vara and coxa valga result
1907 and popularized by Colonna in Transphyseal separations (type I) from malunion, as does limb-length
1929.21 In this classification, type I are treated with either closed or discrepancy. Nonunion is rare but
consists of transphyseal separation. open reduction and transphyseal can occur. Late arthritis can develop
This is an uncommon variant, ac- pinning22-24 (Table 2). Femoral secondary to osteonecrosis and
counting for 7% of these fractures. neck fractures (type II) are also malunion.
Fifty percent of type I fractures oc- treated with closed or open reduc-
cur with a femoral head dislocation, tion and pin fixation of the femoral Hip Dislocations
there is an extremely high rate of os- neck. Cervicotrochanteric fractures Hip dislocations are uncommon in
teonecrosis (up to 100%), and there (type III) are treated similarly but children, but they are more com-
is a high rate of growth arrest. also can be managed with a spica cast mon than hip fractures. They
Type II fractures are transcervical, if the fracture is not displaced. Inter- can occur with relatively minor
and they are the most common, ac- trochanteric fractures (type IV) can trauma. Most (90%) are posterior,
counting for 50% of these fractures. be treated with either a spica cast or and 15% to 20% are associated with
Up to 80% of type II fractures are internal fixation with a pediatric hip a hip fracture. Hip dislocations are
displaced, and there is a high rate of screw, depending on the size of the usually easy to diagnose on the basis
osteonecrosis (40% to 50%). Type III child and the degree of displace- of the history, physical examination,
fractures are cervicotrochanteric, ment. an AP radiograph of the pelvis, and a
and account for 31% of these frac- Hip fractures in children are as- cross-table lateral radiograph of
tures. Fifty percent are displaced, sociated with an overall complica- the hip. Typically, with a posterior
and, although the risk of osteone- tion rate of 60%. Most complica- dislocation, the hip is flexed,

AAOS Instructional Course Lectures, Volume 59, 2010 459

Trauma

Figure 2 A, AP radiograph of the pelvis, showing a dislocation of the left hip sustained by a 13-year-old boy while playing foot-
ball. B, AP radiograph of the left hip, made after an attempt at closed reduction in the emergency department with the patient un-
der sedation. Note the resultant displaced transphyseal fracture of the femoral head. C, Lateral radiograph of the left hip, made
immediately following open reduction and internal fixation of the fracture-dislocation.

adducted, and internally rotated. spica cast or hip abduction brace is Distal Femoral
With an anterior dislocation, the hip used for 6 weeks. Physeal Fractures
is extended, abducted, and exter- Femoral head necrosis develops These fractures are usually hyperex-
nally rotated. after 10% to 16% of hip dislocations. tension injuries, but they can be
A closed reduction should be per- Some patients experience a transient caused by a hyperflexion force.
formed with the patient under gen- sciatic neurapraxia. Recurrent dislo- They are a childhood analog of a
eral anesthesia and with the use of cation is rare in children. knee dislocation, and injury to the
muscle relaxation to minimize the neurovascular structures is a risk.
risk of creating a transphyseal fracture Physeal Fractures Motor and sensory function and
when the femoral head contacts the About the Knee vascular supply to the distal part of
acetabular rim (Figure 2). Preferably, Physeal fractures about the knee are the lower limb should be carefully
the reduction should be performed relatively rare; they account for 1% examined. As is the case for a patient
within 6 hours after the injury, to re- to 6% of physeal injuries in children. with a neurovascular injury after
duce the chance of subsequent fem- The Salter-Harris system is used to a supracondylar fracture, insuffi-
oral head necrosis. The reduction classify these injuries.17 Fractures ciency of the vascular supply to the
maneuver for a posterior dislocation through the growth plate should be distal part of the lower limb requires
involves anterior traction with the anatomically reduced if the child has emergent care.
hip and knee flexed. Longitudinal more than 2 years of growth re- Treatment of the fracture de-
traction with the hip extended and maining; restoration of the articular pends on the fracture pattern, the
the knee slightly flexed is used for an surface is critical to achieve a good amount of displacement, and the
anterior dislocation. If it is irreduc- outcome. Salter-Harris type I and II nature of the physeal injury, as de-
ible, proceed to open reduction fractures can be treated with closed scribed according to the Salter-
from the direction of the disloca- reduction and cast immobilization Harris classification17 (Table 3).
tion. After reduction, the stability or with closed reduction and percu- Salter-Harris type I fractures that are
and congruency of the joint should taneous pin or screw fixation. Salter- not displaced can be treated in a long
be assessed. If there is any doubt Harris type III and IV fractures are leg cast, with or without a pelvic
about the quality of the reduction, a best treated with an open reduction band, for 4 to 6 weeks. The preva-
CT scan should be performed to and percutaneous or internal fixa- lence of growth arrest is low after
identify interposed soft tissue or tion, usually with screws that do not such injuries. Displaced Salter-
intra-articular loose fragments. A cross the physis. Harris type I fractures should be re-

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Pediatric Trauma: Getting Through the Night Chapter 37

duced (usually with a closed reduc- (Thurston-Holland) fragment, if it to determine if there is a growth
tion), and cross-pins should be is large enough, and parallel to the disturbance, and the patient and
placed to maintain the reduction. physis (Figure 4). Placing pins or parents should be advised of this
Reduction should be achieved, with screws across the physis should be risk at the initial assessment.
the patient under general anesthesia, avoided whenever possible.
by applying traction in extension Salter-Harris type III and IV frac- Proximal Tibial Fractures
supplemented by slight flexion or tures have intra-articular extensions, Fractures through the growth plate
extension of the distal fragment as and should be reduced with an open of the proximal part of the tibia are
needed. Cross-pin fixation is ac- procedure and internally fixed with uncommon but, like distal femoral
complished with smooth Steinmann pins or screws placed parallel to the physeal injuries, they are a child-
pins that cross proximal to the frac- physis. Crossing the physis with hood analog of a knee dislocation
ture site. The pins are typically in- hardware should be avoided when- and can therefore be associated with
serted retrograde, from distal to ever possible. All patients with neurovascular injury or compart-
proximal, starting just posterior to physeal injuries should be followed ment syndrome.
the midpoint of the condyle and
aiming 10° anteriorly. Alternatively, Table 3
they may be inserted antegrade, from Pearls and Pitfalls for Pediatric Distal Femoral Fractures
proximal to distal. This method is Salter-Harris fractures are more common than ligamentous injuries in children.
technically more demanding, but the Nondisplaced Salter-Harris type I fractures may present with normal radiographs, and a
advantage is that pins do not pass high index of suspicion must be maintained if there is clinical evidence of the fracture
(tenderness over the physis).
through the joint (Figure 3). The
At a minimum, obtain orthogonal (AP and lateral) radiographs of the knee.
pins may be buried or be left outside
Obtain additional views, and contralateral comparisons, as needed.
the skin and can be removed in
The use of stress radiographs is controversial.
4 weeks. The rate of growth arrest in
Never hesitate to treat a presumed Salter-Harris type I fracture on the basis of clinical
association with displaced injuries is findings.
high (up to 40%). The findings on physical examination are similar for all of these injuries. There is pain and
Salter-Harris type II fractures are knee effusion with or without an inability to bear weight, deformity, and point
treated with closed reduction and tenderness.

percutaneous pin fixation. To treat Distal femoral physeal fractures in particular are associated with a high rate of postinjury
premature growth arrest.
these fractures, pins or screws
should be placed in the metaphyseal

Figure 3 A, Lateral radiograph of a displaced Salter-Harris type I fracture of the distal part of the femur in a 12-year-old boy. AP
(B) and lateral (C) radiographs of the knee, made after closed reduction and antegrade percutaneous pin fixation.

AAOS Instructional Course Lectures, Volume 59, 2010 461

Trauma

Figure 4 A, AP and lateral radiographs of a completely displaced Salter-Harris type II fracture of the distal part of the femur in
an 11-year-old boy. B, Radiographs made immediately after open reduction and internal fixation with the use of two screws
placed across the metaphyseal component of the fracture (the Thurston-Holland fragment).

pulseless pink hand in pediatric su-

Table 4
Pearls and Pitfalls for Pediatric Proximal Tibial Fractures pracondylar fractures of humerus.
J Pediatr Orthop 1997;17:303-310.
Physeal injuries about the knee are relatively uncommon.
4. Lyons ST, Quinn M, Stanitski CL:
Non–intra-articular (Salter-Harris type I and II) fractures can often be treated nonsurgically.
Neurovascular injuries in type III hu-
Most intra-articular (Salter-Harris type III and IV) fractures require surgical treatment. meral supracondylar fractures in chil-
One should not hesitate to open a Salter-Harris type I or II fracture if an adequate closed dren. Clin Orthop Relat Res 2000;376:
reduction cannot be achieved.
62-67.
These fractures have a guarded prognosis. The prevalence of growth arrest is high. Parents
must be informed of this at the time of injury. 5. Davis RT, Gorczyca JT, Pugh K: Su-
Beware of neurovascular injury and compartment syndrome. pracondylar humerus fractures in
children: Comparison of operative
treatment methods. Clin Orthop Relat
Res 2000;376:49-55.
Most Salter-Harris type I and II drome, osteonecrosis, or growth ar-
6. Skaggs DL, Cluck MW, Mostofi A,
injuries can be treated with closed rest, which may be avoided by Flynn JM, Kay RM: Lateral-entry pin
reduction and cast immobilization timely and accurate reduction and fixation in the management of supra-
or percutaneous pinning (Table 4). fixation. condylar fractures in children. J Bone
Salter-Harris type III and IV frac- Joint Surg Am 2004;86-A:702-707.
tures require open reduction and in- 7. Skaggs DL, Hale JM, Bassett J, Ka-
ternal fixation.
References
minsky C, Kay RM, Tolo VT: Opera-
1. Gartland JJ: Management of supra- tive treatment of supracondylar frac-
Summary condylar fractures of the humerus in tures of the humerus in children: The
Pediatric fractures that require con- children. Surg Gynecol Obstet 1959; consequences of pin placement.
109:145-154. J Bone Joint Surg Am 2001;83-A:
sideration for an emergent trip to
2. Skaggs DL, Mirzayan R: The poste- 735-740.
the operating room include supra-
rior fat pad sign in association with 8. Thomson JD, Stricker SJ, Wil-
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compromise and compartment syn-

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Pediatric Trauma: Getting Through the Night Chapter 37

fect of surgical delay on perioperative supracondylar fractures in children: 19. Bado JL: The Monteggia lesion. Clin
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