Pelvic Avulsion Fractures

Avulsion fractures of the pelvis are a relatively common injury in children. The most common avulsion injuries in the pelvis occur at the ischial tuberosity (hamstring and adductor tendon attachment) and the anterosuperior iliac spine (quadriceps/rectus femoris attachment) (Herring, 2002) (see Figure 1A and B). They can also occur at the iliac crest and at the lesser trochanter of the femur (iliopsoas attachment). The highest incidence of pelvic avulsion fractures occurs in boys between the age of 12 and 14 years just prior to apophyseal closure (Sunder & Carty, 1994). The most frequent cause of injury is a sudden forceful muscle contraction (such as making a quick turn, kicking a ball, or sprinting). The powerful contraction of the attached muscle will often cause an avulsion of the muscle from the bone. Although acute avulsion fractures of the pelvis are more common, chronic repetitive trauma can also cause a similar injury. Overuse injuries of the hip in adults often lead to a tendonitis or a bursitis, whereas an apophysitis or avulsion injury is much more common in children and adolescents (see Figure 2).

Figure 1. (A and B). Ischial tuberosity avulsion fractures (hamstring attachment).

Figure 2. A. CT scan with 3D reconstruction of right anterior superior iliac spine avulsion fracture. Used with permission from White, J (2002). B. Location of common pelvic avulsion fractures [Used with permission from

A physical examination usually reveals localized tenderness at the avulsion site. Pain is also aggravated by passive motion of the hip that places tension on the attached muscle (i.e., patients with ischial tuberosity avulsion fractures usually have pain with hamstring stretching and hip flexion/abduction). Patients also frequently demonstrate an antalgic gait and have pain during their activity or sport. An anteroposterior radiograph of the pelvis usually reveals the avulsed fragment. Comparative views of the contralateral side are often helpful in confirming the diagnosis and avoiding further unnecessary advanced imaging studies.

This injury is usually treated symptomatically and often involves rest, application of ice, and relaxation of the involved tendon (O'Kane, 1999). Conservative treatment of pelvic avulsion fractures is usually successful. Crutches are often needed for several weeks to reduce symptoms and rest the extremity involved. Complications following pelvic avulsion fractures in children are rare, and most patients will have decreased symptoms in approximately 2-4 weeks. To avoid reinjury or chronic apophysitis, the injury should heal completely before the patient returns to normal activities. This will often require 2-3 months of activity modifications/rest from the sport. A physical therapy program with conditioning, strengthening, and gentle stretching is often needed prior to resuming competitive sports (Boyd, Peirce, & Batt, 1997). Nurses and nurse practitioners can have a key role in educating both patients and parents about the importance of rest from activity with this type of injury. With the increasing expectations among higher level/elite athletes, orthopaedic surgeons may occasionally consider operative intervention for larger, displaced pelvic avulsion fractures. However, numerous studies have failed to substantiate improved outcomes with surgical fixation of the avulsion fragment (Cimerman, Smrkolj, & Veselko, 1995; Rosenberg, Noiman, & Edleson, 1996; Sunder & Carty, 1994).

Femoral Neck Fractures

Femoral neck fractures are an uncommon injury in children (approximately 1% of all pediatric fractures) and are usually associated with high-energy trauma. This is in marked contrast to hip fractures in elderly patients, in whom minor torsional forces acting on osteoporotic bone can often cause a hip fracture. Common mechanisms of injury in children include a fall from a height, a pedestrian versus motor vehicle collision, a motor vehicle crash, or a fall from a bicycle. When assessing a young patient with a known or suspected femoral neck fracture, providers must always rule out nonmusculoskeletal injuries to the chest, head, or abdomen. Femoral neck fractures can also be seen occasionally in young patients with fibrous dysplasia, osteogenesis imperfecta, or large unicameral bone cysts (which weakens the surrounding bone). They are also seen in patients with neuromuscular disease and underlying osteopenia/osteoporosis. If the trauma is significant, but the history is not consistent, nonaccidental trauma (NAT) should always be considered (Swischuk, 2003). Proximal femur fractures in children have a relatively high complication rate and require urgent referral to a pediatric orthopaedic specialist for definitive operative management.

Femoral neck fractures are frequently classified into four types depending on their location (Delbet, 1928). A type I fracture is a transepiphyseal separation of the femoral head. This is the least common type of proximal femur fracture in children (Herring & McCarthy, 1986). This fracture is very difficult to appreciate in newborns and infants because the femoral head is unossified and cannot be seen on radiographs. Type I fractures can be associated with nonaccidental abuse/trauma, especially in the infant and toddler population (Staheli, 2001). With this type of femoral neck fracture, there is an associated dislocation of the femoral head in nearly 50% of the cases. With a concurrent femoral head dislocation, there is nearly 100% incidence of osteonecrosis/avascular necrosis (AVN) and premature physeal closure with this fracture (Gray, 2002). A type II femoral neck fracture occurs at the transcervical region (midportion of femoral neck). This is the most common type of femoral neck fracture, accounting for approximately 40-50% of hip fractures, in skeletally immature patients (Gerber, Lehmann, & Ganz, 1985) (see Figure 3). This type of femoral neck fracture also has a very high association with secondary AVN of the femoral head (approximately 50%). Type III fractures occur at the cervicotrochanteric region of the proximal femur (base of the femoral neck). The overall reported incidence of this femoral neck fracture is between 25 and 35% in children with AVN occurring in approximately 25% of these cases (Herring, 2002). A type IV femoral neck fracture occurs at the intertrochanteric region (between the greater and lesser trochanter). Overall, these fractures are much less common and have a much lower incidence of AVN (approximately 10%).

Figure 3. Minimally displaced type II femoral neck fracture in a 17-year-old ambulatory female with encephalocele/cerebral palsy.

Children with femoral neck fractures will usually hold the hip in a fixed position with varying amounts of external rotation, abduction, and flexion. On physical examination, this position allows for maximum relief of hip irritability due to capsular distention by fracture hematoma (Shah, Eissler, & Radomisli, 2002). In general, the patient will be unable to move the hip actively or bear weight on the affected side. Anteroposterior and lateral (if tolerated) radiographs should be obtained and the patient should be referred urgently to a pediatric orthopaedic surgeon for definitive management.

Treatment of pediatric femoral neck fractures depends upon the age of the child, the type of fracture, and the amount of displacement of the fracture (Herring, 2002). The overall goal of treatment is to provide fracture fragment stability through an anatomic reduction while avoiding complications that are common with this injury. Nearly all pediatric femoral neck fractures are now treated in the operating room under general anesthesia and fluoroscopic guidance. Following closed/open reduction of the fracture, the surgeon will often need to place internal fixation to prevent displacement (see Figure 4). In younger children, many surgeons will use smooth pins for fixation. They will then supplement it with a spica body cast and immobilize the patient for approximately 6-8 weeks. Smooth pins are usually used in the younger pediatric population as they can cross the physis with a relatively low incidence of subsequent growth arrest. Infants and toddlers with a femoral neck fracture can usually be treated with isolated spica cast immobilization (no internal fixation). Older children and adolescents with a proximal femur fracture will frequently require cannulated or pediatric hip compression screw fixation through the physis to stabilize the fracture.

Figure 4. Same 17-year-old female patient's status post internal fixation with three cannulated screws.

Proximal femur fractures in the pediatric population are associated with a relatively high rate of complication. Owing to the significant vascular vulnerability in this area, osteonecrosis (AVN) of the femoral head continues to be the most frequent and serious complication after hip fractures in children. Providers should inform patients and their families of the significant risk for osteonecrosis at the time of injury and at each follow-up appointment. The overall incidence of AVN following femoral neck fractures is estimated between 20 and 50% (Cheng & Tang, 1999). Most researchers agree that the best predictors for developing AVN are the age of the child and the amount of displacement of the fracture at the time of injury (Moon & Mehlman, 2006; Cheng & Tang). In general, older children with type I and II femoral neck fractures that are significantly displaced are at the highest risk for developing osteonecrosis. There is growing evidence that early and more aggressive operative management including core decompression or hip aspiration followed by internal fixation reduces this risk (Cheng & Tang; Ng & Cole, 1996). There is no clearly effective treatment for posttraumatic AVN in children, and older children/adolescents will often have persistent pain and stiffness. When AVN is detected, the internal fixation (screws) can be removed to prevent hardware penetration into the joint once the fracture has healed (see Figure 5A and B). Treatment for the posttraumatic AVN is otherwise focused on maintaining motion and containment of the femoral head. Unfortunately, the long-term results of posttraumatic AVN are poor in more than 60% of patients (Davison & Weinstein, 1992). Additional complications that are associated with this fracture include nonunion, coxa vara, premature physeal closure, and infection.

Figure 5. A. CT scan of left hip showing AVN of femoral head with collapse and hardware close to joint space. B. AP x-ray of the pelvis status post hardware removal [Note flattening/deformity of femoral head from AVN].

Femoral Shaft Fractures

Femoral shaft (diaphysis) fractures constitute 62% of all pediatric femur fractures, are one of the most common fractures in children (Rewers et al., 2005), and are the most common cause of fractures requiring hospitalization (Wright, Wang, Owen, Stephens, et al., 2005) (see Figure 6A and B). They are the most common, major pediatric injury treated by orthopaedic surgeons. Care of these fractures involves achieving fracture union with acceptable amount of angulation and limb length discrepancy while minimizing hospitalization and impact on the patient's family (Wright, 2000). The treatment modalities for femur fractures depend upon the fracture location as well as the age and weight of the child. In general, younger, smaller children are treated with closed reduction and spica casting or Pavlik harness, and older children/adolescents are treated with flexible/rigid intramedullary nailing (Brock, 2001; Anglen & Choi, 2005). The choice of treatment also depends upon the mechanism of injury, whether the fracture is open or closed, presence of neurovascular injury, head injury, multiple trauma, pathologic fractures, and the child's social environment. Nurses caring for children with this type of fracture should provide the children's families with the knowledge and support they need to care for a child with limitations in mobility and self-care.

Figure 6. A. 3-month-old male with right midshaft femur fracture [Patient has underlying connective tissue/bone disorder]. B. 10-year-old male with left midshaft femur fracture. C. 13-year-old female with markedly displaced right supracondylar femur fracture (Salter Harris IV fracture).

Etiology

The mechanism of injury for femur fractures in children can vary from a simple playground accident to a high-energy injury such as a motor vehicle crash (Gray, 2002). Causes of femoral shaft fractures are often reported as age dependent; children between the age of 1 and 6 years most commonly sustain this fracture due to falls, children between 6 and 9 years sustain fractures due to motor vehicle-pedestrian accidents, and adolescents are often injured by motor vehicle accidents (Hinton, Lincoln, Crocket, Sponseller, & Smith, 1999). Many studies have shown the leading cause of femur fracture for child-ren under 1 year of age, or children not yet walking, is nonaccidental (NAT) and this concern remains significant throughout the toddler years (Scherl et al., 2000).

Nonaccidental Trauma

Rewers et al. (2005) recently reported an extensive review of 1139 cases of pediatric femur fractures (occurring at infancy through adolescence) and discovered that 48 of those cases were found to be nonaccidental. This study found that NAT femur fractures in children under the age of 4 were more common in boys, the injury occurred most often at home, and 60% were classified as diaphyseal (midshaft) fractures (Rewers et al.). Gross and Stranger (1983) reported a higher incidence of abuse in their population, finding that 80% of children who sustain a femur fracture below walking age (12-14 months) were victims of child abuse. Yet, conversely, Schwend, Werth, and Johnston (2000) demonstrated that there did not appear to be a correlation between preambulatory status and NAT femur fractures. Although the Gross and Stranger study on pediatric fractures was specific to the preambulatory population and the Rewers et al. study was inclusive of all children, both represent significant knowledge for practitioners to guide their awareness of NAT. Assessment of the possibility of NAT, or child abuse, remains a real concern for practitioners caring for any young child presenting with a femur fracture, especially one not walking or lacking significant explanation of the circumstances of a fall or trauma (see Figure 7A and B).

Figure 7. A. 14-month-old male with right radius/ulna fracture in advanced stage of healing. B. Same patient also found to have left midshaft femur fracture.

Physical Examination/Assessment

Most patients with a femur fracture are unable to walk and are in extreme pain with obvious fracture. However, the diagnosis might be more difficult in obtunded patients with head injury or multitrauma. Multidisciplinary trauma service evaluation is recommended for children sustaining injury in motor vehicle collisions at speeds of more than 30 mph, involved in a vehicle versus pedestrian accident, sustaining a fall greater than 20 feet, or whenever nonaccidental injury or abuse is a possibility (Dowd, McAneney, Lacher, & Ruddy, 2000), as using trauma service can decrease treatment time and improve survival rates in children (Dowd et al.; Vernon, 1999). An anterior-posterior and lateral radiograph including the hip and knee should be obtained. Clearance of the child's cervical spine as well as assessment of all systems is also necessary, as trauma to other systems is assumed to be present until ruled out (Wilbur, 1998). Waddell's triad of femoral fracture, intraabdominal or intrathoracic trauma, and head injury are associated with high-velocity automobile injuries (Kasser & Beaty, 2005). It is important to note isolated closed fractures of the femur should not cause an acute drop in the patients hematocrit. Providers must search for other sources of blood loss when there are declining levels or if it is less than 30% (Ciarallo & Fleisher, 1996).

Treatment

Treatment of femoral shaft fractures varies greatly and ranges from lengthy hospitalizations involving traction and spica casting to immediate operative fixation using internal or external devices (Beaty & Kasser, 2005). Current treatment methods in children include the application of a Pavlik harness (newborns and infants less than 6-9 months), application of spica cast (6 months to 5-8 years), traction followed by application of a spica cast, external fixation, flexible intramedullary nails (6-12 years), interlocking rigid nails (skeletally mature/closed physes), and compression plate fixation (Gray, 2002).

Spica Casting and Pavlik Harness

Newborns and infants (up to 6 months of age) with a femur fracture can often be treated successfully in a Pavlik harness (see Figure 8). The harness is preferred to spica casting, as the risks of skin breakdown are avoided while adequate union and acceptable limits of deformity can often be achieved (Beaty & Kasser, 2005). The Pavlik harness is easily adjusted and is generally well tolerated in infants, providing adequate outcomes as compared with spica casting (Podeszwa, Mooney, Cramer, & Mendelow, 2004). Children between the age of approximately 6 months and 5-8 years (under 80 lbs) are usually treated with spica cast immobilization (see Figure 9). Closed reduction and spica casting usually provide adequate union, acceptable amounts of limb length discrepancy, and angulation deformity (Ferguson & Nicol, 2000; Infante, Albert, Jennings, & Lehner, 2000). Spica casting has been shown to provide simple, safe, and effective care for femoral shaft fractures in the younger population (Anglen & Choi, 2005); there are no requirements for specialized tools or implants with spica casting, although it does cause minimum anesthetic risk to the patient. It also requires knowledge of placement and maintenance of spica cast, as well as education of cast care for the child's caregivers. There are conditions that make a spica cast for the younger population a disadvantage. Patients with multiple trauma will have restricted access and there will be issues with difficulties in evaluating soft tissues as well as mobilization and positioning. Children who are large for their age or obese may present challenges in achieving acceptable alignment. For these reasons, evaluation during the first 3 weeks is recommended, as the most common complication of spica casting is excessive femoral shortening of greater than 20 mm (Anglen & Choi).

Figure 8. 1-month-old female in Pavlik harness.

Figure 9. 2-year-old male with right femur fracture in spica cast.

Effects of Casting

All children are affected by the prolonged casting and possible hospitalization while being treated in a spica cast (Newman, 2005), with older children and adolescents being more affected by the prolonged immobil-ity and loss of independence (Hughes et al., 1994). Family members are affected by the significantly increased caregiver burden for these children. For these children and their families, issues such as decreased autonomy and independence, social isolation of the child and the parent, missed school, lost work, and altered self-image are all reasonable to anticipate further children and families (Newman). Education and anticipatory guidance with frequent assessment of the ability of the family to provide adequate care for their children as well as themselves are hallmarks of quality pediatric orthopaedic care. Teams organized by nurses that include social workers and therapists can assess the family for adequate knowledge, services, and equipment necessary to adapt their home and school environments and allow a rapid return to the child's normal routine.

External Fixation

External fixation is often thought of as a form of "portable traction" for a pediatric femoral shaft fracture. External fixation offers a valuable solution for several difficult problems: open fractures or fractures associated with severe soft-tissue injury, children with multiple trauma or head injury, or fracture patterns that are not amenable to flexible intramedullary nailing (see Figure 10) (Flynn et al., 2002). Most pediatric orthopaedic surgeons use a stable unilateral external fixator along the lateral aspect of the femur in children. External fixation can be applied quickly with minimal anesthesia time allowing access to wounds and soft tissue as well as early mobilization of the patient (Krettek, Hass, Walker, & Tscherne, 1991) although there are significant disadvantages such as pin tract infections, knee stiffness, and higher refracture rate (Blasier, Aronson, & Tursky, 1997; Skaggs et al., 1999) as well as an increased caregiver burden for the family.

Figure 10. 6-year-old male with extensive bilateral lower extremity trauma [Note external fixation of femur and tibia].

Pin site care with half-strength hydrogen peroxide is usually started on the second postoperative day. Showering is allowed once the wound is stable and there is no communication between the pin and the fracture hematoma. Numerous studies have shown the high rates of infection following application of pins associated with external fixation. Miner and Carroll (2000) reported on outcomes of external fixation in pediatric femur fractures and found a 72.6% incidence of at least one documented pin tract infection. The patients or their parents must be taught pin care and how to identify early symptoms of infection (drainage, redness, increased pain). External fixation has been used much less frequently in the treatment of pediatric femur fractures because of the recent advances of flexible intramedullary nailing.

Intramedullary Nailing

Intramedullary nails are placed to provide internal support through the intramedullary canal during fracture healing. Two types of nails are available for use: rigid and flexible. Flexible nails are less likely to cause AVN but due to their lack of fixation on the bone they have less stability than rigid locking nails (Beaty & Kasser, 2005). Flexible nails are placed either antegrade (from the hip) or retrograde (from the knee). Children between 6 and 12 years of age (more than 60-80 pounds) with a femur fracture are usually candidates for flexible intramedullary nailing procedures (see Figure 11). Flexible nailing procedures usually eliminate the need for casting and immobilization and also decreases the length of hospitalization (Anglen & Choi, 2005). Most patients are placed in a simple knee immobilizer postoperatively to reduce knee pain and quadriceps spasm. Touch-down weight bearing is usually allowed as soon as the patient is comfortable. The rods are usually removed approximately 9-12 months after injury when the fracture line is no longer visible on radiograph.

Figure 11. 10-year-old male with left diaphyseal femur fracture status post flexible intramedullary nailing.

Rigid intramedullary fixation is an option for fixation of femur fractures in children older than 12 years of age and often eliminates problems with angular malalignment and shortening. These rigid nails are stronger and provide rigid fixation, thereby providing more internal support for a child or adolescent (Beaty & Kasser, 2005) (see Figure 12A and B). Reamed nailing with rigid nails is not recommended for children under the age of 12 years because of the smaller size of the femur as well as the increased risk for proximal femoral growth arrest and AVN of the femoral head (Mileski, Garvin, & Huurman, 1995). Studies continue to evaluate unacceptable limb length discrepancy, angulation deformities, and rates of complications, as well as the impact on family care and healthcare costs with these difficult treatments.

Figure 12. A. 14-year-old male with left subtrochanteric femur fracture (Note previous SCFE with screw). B. Same patient status post fixation with rigid interlocking nail.

Developmental Issues Related to Immobilization and Treatment

Children are significantly affected by immobilization, pain, fear, and lack of independence brought on during the care and healing of a femur fracture. This type of fracture can require long periods of immobility until sufficient callus formation has occurred to allow for ambulation with or without assistive devices. Assessing the effects that these restrictions have upon the development of independence and self-care of a child or young adult is a specialized skill for pediatric orthopaedic nurses and nurse practitioners. The child's home environment needs to be thoroughly assessed to optimize recovery and ensure safety. Can the child safely move about his or her home and use safety restraints in the car, use the toilet, and bath? Does the family have the knowledge to provide safe and accessible care for their child? Are there community or home-based services available if needed? These questions are ideally addressed prior to sending a child home or very soon after going home to assist the family in the problem-solving process. The child's school or preschool environment should also be assessed. Keeping a child in school is vital for his or her school success and also promotes emotional healing, as normal schedules and routines are reestablished. School accommodation should be focused on providing the least restrictive, the most safe, and also the most reasonable accommodation available. School staff such as the school nurse, teacher, disability counselor, occupational or physical therapists should be available for consultation to assist in keeping a child in school as much as possible.

Tibial Eminence Fractures

Tibial eminence fractures are the anterior cruciate ligament (ACL) tear equivalent injury in skeletally immature children. They are relatively rare injuries in children and usually occur following a fall from a bicycle or during athletic activities. Isolated ligamentous injuries of the knee are a somewhat rare occurrence in children under the age of 14 years with open physes. The incompletely ossified tibial eminence in a child usually fails before the ACL. There is, however, some overlap between ACL ruptures and tibial eminence fractures, and injuries to the ACL are now recognized more frequently in children and preadolescents (Flynn et al., 2002). Tibial eminence fractures occur most commonly in boys who are 10-14 years old. The most common mechanism of injury is planter flexion (axial loading) with hyperextension of the knee. A blow to the front of a slightly flexed knee may drive the femur posteriorly onto the fixed tibia, causing an avulsion fracture at the tibial eminence (Wiley & Baxter, 1990). This is very similar to ACL injuries in older adolescents and adults.

The classification system described by Meyers and McKeever (1970) is a very simple way to group these fractures based on the amount of displacement. Type I fractures are nondisplaced, type II fractures are partially displaced (avulsed fragment remains hinged on posterior border), and type III fractures are completely displaced with complete separation of the avulsed fragment from the epiphysis (see Figure 13A). Anteroposterior and lateral radiographs should be obtained if this injury is suspected. The lateral radiograph is most important as it shows the fracture fragment in the best manner (Herring, 2002). A computerized tomography (CT) scan can also be used to image the fracture and determine the degree of displacement. Physical examination usually reveals a large hemarthrosis, pain and difficulty or inability bearing weight on the affected leg. The knee will usually be held flexed and passive extension will be quite painful, often limited by muscle spasm. Although it is usually quite difficult to assess ligamentous stability following an acute injury, there frequently will be laxity of the ACL on examination with a positive anterior drawer and Lachman test.

Figure 13. A. CT scan of 14-year-old female with left type III (displaced) tibial eminence fracture. B. Same patient status post open reduction and internal fixation of left tibial eminence fracture.

Nondisplaced (type I) tibial eminence fractures are usually treated conservatively with closed reduction and long-leg casting. There is some controversy between placing the knee in slight extension versus flexion. If tolerated, most pediatric orthopaedic surgeons prefer to treat nondisplaced tibial eminence fractures in slight extension. If there is a tense hemarthrosis, aspiration of the knee can assist in achieving extension (Herring, 2002). Local anesthesia can be instilled at the time of needle aspiration to provide additional pain relief. Most type II and III tibial eminence fractures require open or arthroscopic reduction and internal fixation of the fracture fragment (see Figure 13B). Although mild, asymptomatic laxity of the ACL is quite common following this injury. Postoperative stiffness of the knee is common with this injury, and early range of motion and physical therapy are often instituted.

Tibia Fractures

Tibia fractures are a common injury in children. They are the third most common type of fracture (representing 15% of the total fractures) in children and can be seen following significant or relatively minor trauma (Heinrich, 2001; Herring, 2002). Displaced, open, or comminuted fractures of the tibia can be seen in children, following a motor vehicle crash or a significant trauma, whereas a toddler's fracture of the tibia is often seen with a simple trip over a toy. A general principle to remember is that a more significant trauma is necessary to fracture the tibia and/or fibula in older children and adolescents. The treatment will vary greatly depending on the age of the child, the type and location of the fracture, and the amount of angulation that is present. In general, closed fractures of both the tibia and the fibula in children have much fewer complications, heal faster, and have less morbidity than those in adults (Buckley, 2002). Most pediatric tibia fractures can be managed nonoperatively with reduction and immobilization techniques (see Figure 14). However, there are several types of tibia fractures that are notorious for causing complications and long-term sequela.

Figure 14. 6-year-old girl with left tibia fracture in long leg cast.

Open fractures of the tibia are often the result of a motor vehicle crash or pedestrians being struck by a vehicle, and account for approximately 7-8% of all tibia fractures (Kreder & Armstrong, 1995). As with any case of open fracture, providers should urgently refer these patients for operative treatment. Complications can often be minimized with prompt initiation of treatment, including the administration of parenteral antibiotics (intravenous) as well as irrigation and debridement along with the fixation of the fracture (Buckley, 2002). It is also important to note that the tibia is the second most commonly fractured bone in children who are abused and providers must always assess for this possibility. Approximately 26% of abused children with a fracture are found to have an injured tibia (King, Defendorf, Apthort, et al., 1988).

Closed fractures of the tibia that do not involve the physis (growth plate) are often classified by their anatomic location (proximal metaphyseal, diaphyseal, and distal metaphyseal fractures). The diaphyseal fractures are then subdivided into proximal, middle, and distal third. Approximately, 50% of the pediatric tibia fractures occur in the distal third (at the ankle) and 39% occur in the midshaft region (Heinrich, 2001). Seventy percent of pediatric tibia fractures occur as an isolated injury, and 30% are seen with fibula fractures. Tibia fractures can be caused by a direct (impact) or an indirect trauma (rotational stress), and the fracture pattern often varies with the age of the child. The most common causes of tibia fractures in children are falls, pedestrians being struck by a car, motor vehicle crashes, and sporting injuries (especially skiing and football injuries).

Most children with tibia fractures present with a history of a traumatic event. The child will usually have an acute pain and will demonstrate an unwillingness to bear weight on the affected limb. On physical examination, frequently there is an extensive swelling, ecchymosis, and deformity with this injury (Setter & Palomino, 2006). Toddlers and very young children with nondisplaced tibia fractures (Toddler's fracture) may present with guarding and a limp or an inability to bear weight but will often lack the extensive swelling and noticeable deformity seen with displaced fractures. It is important to determine whether the mechanism of injury was a direct or an indirect force. Fractures that result from a direct trauma (such as being run over or hit by a motor vehicle) require very careful examination of the soft tissues. Any evidence of skin penetration at the fracture site is an indication that the fracture is open and contaminated. Damage to the soft tissues surrounding the tibia is often much greater than that initially apparent on examination. Although acute compartment syndrome following tibia fractures in children is relatively rare, providers must assess for pain with passive dorsiflexion of the toes, complete a thorough neurovascular assessment including motor and sensory examination, and measure compartment pressure if necessary (Herring, 2002). Any child suspected of having a tibia fracture should have anteroposterior and lateral radiographs of the tibia and fibula. Radiographs should include both the knee and the ankle.

Proximal Tibia Fractures

Although proximal tibia fractures are much less common than midshaft and distal tibia fractures, they are often the most problematic fractures (see Figure 15). This type of fracture is most common in children aged between 3 and 6 years. The medial cortex of the proximal tibia fails in tension, often resulting in an incomplete or greenstick fracture. The fibula is generally not affected although plastic deformation may occur and can also contribute to the posttraumatic valgus deformity seen with this fracture. This fracture is usually treated with closed reduction and long-leg casting with the knee flexed approximately 5-10[degrees] and a varus mold placed at the fracture site (Setter & Palomino, 2006). The cast is usually left for 4-6 weeks depending on the age of the child (older children need a slightly longer immobilization). Although these fractures may appear to be innocuous, they can result in a late progressive valgus deformity. Parents should be advised that this specific type of tibia fracture can result in a late angulation, and the child will need a follow-up for approximately 1-2 years following injury (Skak, Jensen, & Poulson, 1987).

Figure 15. 7-year-old male with right Salter Harris II proximal tibia fracture.

The valgus deformity is believed to result from an asymmetric growth of the physis of the proximal tibia. Spontaneous correction of this angular deformity occurs in most young children, and recent literature suggests that tibia valgus following proximal tibia fractures should not be surgically corrected until late adolescence. Because of the high percentage of both the spontaneous resolution and the recurrence, surgical correction should be postponed until the end of the growth. Parents should be instructed regarding the importance of follow-up visits and should also be informed about the likelihood of spontaneous correction if a valgus deformity occurs.

Diaphyseal Tibia Fractures

Tibial shaft fractures are a common injury in children and are often seen in conjunction with fractures of the fibula. Most diaphyseal tibia fractures in children under 5-6 years of age are nondisplaced or minimally displaced spiral or oblique fractures. The so-called "toddler fractures" fit into this category (see Figure 16). Dunbar, Owen, and Hogrady (1964) originally described the toddler's fracture as a spiral, oblique fracture of the distal tibial shaft in children less than 3 years of age. The mechanism of injury in children of this age group is often due to a simple fall or twist. Often, there is no known cause for the injury, and the toddler will simply start limping or refuse to weight bear on the affected limb. Providers must always assess the possibility of infection (fever, redness, etc.) rheumatological disorders, as well as neoplasm in the differential diagnosis of any limping child. Anteroposterior and lateral radiographs of the tibia/fibula should be obtained to assess a fracture. Toddler fractures typically occur in children under the age of 3-4 years, and the physical examination and radiographic findings can be quite subtle. The patient with a toddler fracture will often present with normal radiographs.

Figure 16. 2-year-old male with toddler's fracture of right tibia.

Oudjhane, Newman, Oh, Young, & Girday (1988) analyzed the radiographs of 500 acutely limping toddlers and identified 100 toddlers in whom a toddler fracture was the cause of the gait abnormality. The most common site of fracture was the distal metaphysis of the tibia. An infant or young child with a known or suspected toddler fracture should be treated with a short- or long-leg walking cast for 3-4 weeks. Once in the cast, the toddler or the young child can bear weight on the cast as tolerated. Sometimes a wee-walker pediatric air cast boot can be used for a toddler fracture (see Figure 17). Similar to buckle/torus fractures, toddler fractures of the tibia are stable, and casting is done mainly for patient comfort. To avoid delay in the treatment of toddler's fracture, many institutions presumptively recommend casting toddlers and young children with a history of acute injury, limping gait or inability to walk, no constitutional signs, and negative radiographs (Halsey et al., 2001). Complications following a toddler fracture of the tibia are exceedingly rare.

Figure 17. 16-month-old male with left tibia toddler's fracture in pediatric wee-walker boot.

Most pediatric diaphyseal tibia fractures are caused by a torsional force (twisting) when the body rotates with the foot in a fixed position (Heinrich, 2001). Pediatric tibial and fibular shaft fractures are usually uncomplicated and can be treated with simple closed reduction/manipulation and cast application. Indications for operative treatment include open fracture, fractures that have failed casting, the multiple injured child, and irreducible fractures (Setter & Palomino, 2006). Displaced fractures are often reduced in the operating room under conscious sedation/general anesthesia. Although age-dependent, the generalized limits of acceptable positioning following a reduction are less than 10 mm shortening, less than 10 degrees of varus, valgus, or recurvatum, and no malrotation (Heinrich, 2001).

Unstable fractures of the tibia and fibula may require operative reduction and surgical stabilization. Common methods of fixation include percutaneous pins, flexible nails, external fixation, and plates/screws. Standard operative treatment for skeletally mature adolescents and adults with a tibia fracture is an intramedullary locking nail (see Figure 18). This type of fixation secondary to potential damage to open physes is usually avoided in younger children secondary to potential damage to open physes (Setter & Palomino, 2006). Recently, there has been an increase in the use of flexible nailing of tibia fractures (see Figure 19). Kubiak, Egol, Scher, Wassermann, Feldman, Koval(2005) compared the use of external fixation with flexible nailing in tibia fractures and found that the flexible nails provided faster healing, decreased scarring, decreased infection rate, and decreased refracture rate. Many fractures of the tibia initially require a long-leg cast following closed or open treatment. Postoperative evaluations must include careful neurovascular assessments to rule out acute compartment syndrome. Nurses must check the circulation, sensation, and movement of the toes in all children with a tibia and/or fibular fracture. The treatment of a child exhibiting severe pain after a tibia fracture initially involves splitting any cast or padding. Compartment releases or fasciotomy should be considered if the intracompartmental pressure is above 30 mmHg in any of the four leg compartments (Grottkau, Epps, & DiScala, 2005). When recognized early and treated appropriately, outcomes in children with compartment syndrome are usually favorable (Bae, Kadiyala, & Waters, 2001).

Figure 18. 14-year-old male with left tibia/fibula fracture status post rigid intramedullary nailing of tibia.

Figure 19. 10-year-old male with left tibia/fibula fracture status post flexible intramedullary nailing of tibia.

Similar to other fractures, the length of the treatment depends on the age of the child and the type of fracture and ranges from 3 to 4 weeks in a toddler fracture to approximately 3 months in an adolescent with a tibia and fibula fracture. Older children and adolescents with tibia fractures can usually be changed from a long-leg cast to a short-leg cast after 4 weeks and then into an aircast walking boot after another 4-6 weeks. Physical therapy to assist in gait training, quadricep strengthening, hamstring stretching, and knee/ankle range of motion is often required following tibia fractures in older children and adolescents.

Ankle Fractures

Foot and ankle fractures are also quite common in young children and adolescents. Similar to adults, most fractures of the tibia and fibula occur in the distal third (medial/lateral malleolus) in children (Herring, 2002). Injuries to the ankle in children usually result from twisting, falls, and direct blows. Pain, swelling, deformity, and difficulty/inability bearing weight are common symptoms seen on physical examination. Anteroposterior, lateral, and mortise radiographs of the ankle should be obtained to assess a possible fracture. Radiographs of the tibia/fibula and foot may also be needed to assess the associated fractures. Distal fibula physeal injuries are the second most common growth plate fracture and are the most common injuries in the pediatric ankle. Similar to many other pediatric injuries, a distal fibula physeal fracture is more common than a ligamentous injury or sprain in a child. Because a Salter Harris (SH) I fracture often cannot be seen radiographically, it must be presumed in a growing child with tenderness over the region of the physis (growth plate). Fractures of the distal tibia and fibula are most common in children between 10 and 15 years of age and are more common in boys than in girls (Herring, 2002). Salter Harris I and II fractures account for 15 and 40% of ankle fractures, respectively (distal tibia/fibula) (Kay & Tang, 2001). These fractures can almost always be treated with closed reduction with or without manipulation and casting except in the rare instance in which soft-tissue interposition prevents reduction (Flynn et al., 2002).

Most fractures of the distal tibia/fibula require immobilization for 6-8 weeks. Unlike SH types I and II, types III and IV are much more likely to require open reduction and surgical stabilization. Salter Harris types III and IV fractures of the ankle involve both the physis and the articular surface of the joint and often require more aggressive treatment. Although less common, these types of physeal ankle injuries include the juvenile Tilleaux fracture (SH type III) and triplane fracture (SH type IV) that will be discussed in a separate section. The overall prognosis following fractures of the distal tibia/fibula in children is dependent on the skeletal maturity of the patient, the fracture type, the severity of the injury, the degree of comminution and displacement of the fracture, and the adequacy of reduction (Mashru, Herman, & Pizzutillo, 1996). With proper treatment, however, most children with distal tibia and fibula fractures do well.

Avulsion fractures from either the lateral malleolus or the fifth metatarsal are also commonly seen in children with inversion sprain type injuries to the ankle (see Figure 20). The fractures often persist radiographically despite immobilization in a cast. It can be difficult to determine if the fragment or ossicle represents a fracture or a normal ossification center. If asymptomatic, no treatment is required for the ossicle or avulsed fragment. However, if there is persistent pain or instability in the ankle after immobilization, simple excision may be recommended (Kay & Matthys, 2001)

Figure 20. 15-year-old female with avulsion fracture of right distal fibula (lateral malleolus).

Triplane/Juvenile Tillaux Fractures

Triplane and juvenile Tillaux fractures of the distal tibia are known as "transitional fractures" because they occur only during the transition period that occurs from a skeletally immature ankle (open physes) to a skeletally mature ankle (closed physes). The physis (growth plate) in the distal tibia begins to close centrally, and then over a period of 18 months to 2 years the closure progresses medially, posteriorly, and laterally (Rab & Grottkau, 2001). The last portion to close is the anterolateral corner. When the central part of the physis closes (usually around the age of 12-14 years), a triplane fracture becomes common. This complex fracture may consist of two, three, or occasionally more fragments, and there may also be an associated fracture of the fibula. The fracture is seen in three different planes (sagittal, coronal, and transverse) on radiographs. There is usually extensive swelling on physical examination of the ankle, and the patient is often unable to bear weight on the affected leg.

After obtaining radiographs, a CT is usually needed to fully determine the fracture pattern and the degree of displacement (see Figure 21A and B). Because it is a SH type IV pattern, the fracture occurs at the distal tibia through the metaphysis, into the physis, and out through the epiphysis. It involves the articular surface of the ankle joint, and any step-off greater than 2-3 mm warrants open reduction and internal fixation. If there is no displacement, the fracture can usually be treated with immobilization in a long-leg cast. However, weekly follow-up visits for 2-3 weeks are needed to ensure that there is no displacement. A long-leg cast is often needed initially for 4 weeks and then a short-leg cast for an additional 2-3 weeks. Closed reduction is always attempted initially, but this type of fracture often requires open reduction and screw fixation. To avoid issues with skin breakdown and an increased risk for compartment syndrome, surgery is usually done after the acute swelling in the ankle has decreased. Failure to obtain an anatomic reduction can result in articular incongruity and posttraumatic arthritis several years later. Because the physis is in the process of closing, late angular deformities and/or leg length discrepancies are uncommon following fixation of this fracture. Therefore, screw fixation should be done to maximize stability and joint congruity. Following operative reduction of this fracture, a short-leg cast is normally needed for 4-6 weeks.

Figure 21. A. CT scan with 3D reconstructed views of left triplane ankle fracture. B. CT scan with 3D reconstructed views of left triplane ankle fracture.

The juvenile Tillaux fracture is a SH type III fracture of the distal tibia. It is also known as an adolescent "transitional" fracture and occurs when the distal tibia physis starts to close/fuse. The anteroinferior tibiofibular ligament avulses a fragment of the bone corresponding to the portion of the distal tibial physis that is still open. The fracture occurs through the epiphysis and exits out through the physis (growth plate) that is still open. On physical examination, there is often local tenderness at the anterior lateral joint line, which can help to differentiate this injury from an ankle sprain where the tenderness is often below the level of the ankle joint. However, there may only be a slight swelling with this injury, and providers must evaluate all adolescents during the "transitional period" of physeal closure for this fracture. Anteroposterior/lateral/and mortise views of the ankle should be obtained, and a CT scan is also often needed to evaluate the displacement (see Figure 22). Similar to the triplane fractures of the tibia, tillaux fractures must be reduced if more than 2 mm of displacement is found(Cummings, 2002). Closed reduction is attempted; however, open reduction with cannulated screw fixation of the fracture fragment is often necessary (see Figure 23). Immobilization is usually needed for 6-8 weeks, the time when weight bearing is permitted and a physical therapy course is initiated.

Figure 22. CT scan of right ankle with displaced juvenile Tillaux fracture of distal tibia.

Figure 23. Same patient 1 year s/p open reduction internal fixation of right distal tibia Tillaux fracture.

Metatarsal/Phalanx Fracture

Fractures of the metatarsals are a relatively common injury in children. Foot fractures account for approximately 6% of all the fractures in children, and 50% of foot fractures occur at the metatarsals (Staheli, 2001) (see Figure 24). The mechanism of injury in young children is often a direct trauma from an object falling onto the foot. This fracture also occurs commonly following a fall from a low height (i.e., jumping off a bed or a chair). Physical examination findings often include swelling, bruising, antalgic gait/limp, and/or inability to weight bear. Overall, the fifth metatarsal fractures (which include the avulsion fractures from ankle inversion injury) are the most common in children, followed by first metatarsal fractures (Owen, Hickey, & Finlay, 1995). Anteroposterior/lateral and oblique radiographs of the foot should be obtained to assess for this fracture. Metatarsal fractures are usually treated with a short-leg walking cast with an extended toe plate for approximately 3-4 weeks. Most metatarsal fractures can be treated conservatively with simple immobilization. However, markedly displaced, multiple, comminuted, intraarticular, or open fractures will usually require operative treatment.

Figure 24. 3-year-old male with a healing left 2nd metatarsal fracture.

Fractures occurring at the base (metaphyseal-diaphyseal junction) of the fifth metatarsal are commonly referred to as Jones fractures (see Figure 25). This fracture is notorious for its relatively high incidence of nonunion especially in the adult population. This injury is typically seen in older children and adolescents between 15 and 21 years of age. Initially the treatment for a nondisplaced Jones fracture in children is usually conservative. Immobilization is done with a short-leg nonweight-bearing cast. The healing of this fracture however, is unpredictable and nonunion can occasionally occur even in children. Immobilization is often needed for 3-4 months with this fracture. There are few literature that supports early operative fixation for Jones fractures given the slow and often unpredictable rate of healing. Torg, Balduini, and Zelco (1984) believed that conservative treatment and prolonged immobilization were ineffective in treating this injury and surgical fixation was a better option. More recently, Portland, Kodros, and Kelikian (2000) demonstrated that the time to union was shorter after operative treatment, with earlier return to weight bearing and full activities.

Figure 25. 15-year-old male with a left proximal 5th metatarsal/Jones fracture.

Forefoot and toe injuries in children are usually caused by crushing or stubbing injuries. These are common injuries and can often be treated with a short course (3-4 weeks) of immobilization. The immobilization often varies with the age of the child, the type of injury, and provider preference. Short-leg casts, air cast boots, hard sole shoes, and simple buddy taping are examples of the treatment methods. Because most children tolerate casting well, it is often easiest to place young children in a short-leg-walking cast. Similar to finger fractures, physeal injuries to the toes or phalanges are quite common. SH II fractures are also the most common type of phalanx growth plate fractures in the toe (see Figure 26). Surgery is usually only needed for markedly displaced, intraarticular (involves the joint), comminuted, or open fractures of the phalanx.

Figure 26. Salter Harris II fracture of left great toe distal phalanx.

Effects of Fractures on the Child

A recent study by Ding, McCarthy, Houseknecht, et al. (2006) examined the health-related quality of life in children with an extremity fracture. Children hospitalized for an extremity fracture at four pediatric trauma centers were studied using the Pediatric Quality of Life Inventory, which was given to the parent/caregiver at the time of injury and at 3 and 12 months postinjury. The health-related quality of life is a multidimensional construct (questionnaire) that aims to assess physical, emotional, and social well-being. Postinjury scores were significantly poorer at 3 and 12 months in children with a lower extremity fracture compared to those with an upper extremity fracture. Even at 12 months postinjury, children with a tibia, fibula, and/or femur fracture continued to report significantly poorer overall physical functioning. A limitation of this study is the small sample size (100 children) and the fact that only children who required hospitalization at a level I Trauma Center were included in the group. Another limitation of this study is that it did not separately evaluate the impact of the various treatments on the health-related quality of life (i.e., flexible nailing vs. external fixation).

It is clear that these fractures have a large impact on the child and the family. In children, fractures involving the lower extremity often require longer periods of immobilization compared to fractures of the upper extremity. Lower extremity fractures also frequently require nonweight-bearing status (crutches, wheelchair, etc.), which has an obvious impact on children and their family. Parents of children with casts and/or assistive devices are also affected by the children's immobilization and dependence. Parents report less sleep, less social interaction, more stress, increased physical pain, and disrupted sexuality when their child is immobilized and is dependent on them for activities of daily living and self-care needs (Newman, 2005). Anticipating these problems, minimizing the effects of immobilization, and assessing the need for support and teaching is a valuable role for orthopaedic nurses and nurse practitioners.

Conclusion

Lower extremity fractures are quite common in the pediatric population, and orthopaedic nurses and nurse practitioners can have a key role in facilitating a positive outcome. Although most pediatric lower extremity fractures can be treated conservatively, this article also describes several injuries and fractures that require prompt referral and surgical management. Although rare, complications can arise during the treatment and must be recognized to ensure that proper care is instituted. By understanding the specific types of lower extremity fractures and their treatment, as well as the expected outcome, nurses are able to give better care to young orthopaedic patients.

References