Lower Extremity Fractures in

Lower Extremity Fracture Children

Management
Anatomic and physiologic
variations between adults
and children
Brian Brighton, MD, MPH

Closed management
Levine Children’
Children’s Hospital
Carolinas Medical Center with casting results in
Charlotte, NC good outcomes

Important to know how
Oscar Miller Day
and when to intervene
October 16, 2009
with surgical
management

Lower Extremity Fractures Fractures of the Hip

Pediatric Hip
Relatively uncommon
Fractures

Less than 1% of all fractures in children and

Pediatric Diaphyseal
less than 1% of all hip fractures
Femur Fractures

Fractures around the
Majority are the result of high energy
Knee trauma

Tibial Shaft Fractures

Transitional Ankle
Fractures

Blood Supply of the Proximal Femur Vascular Anatomy

< 4 months 4 months-3years

Trueta, JBJS,
39-B, 1957

4-7 years Pre-adolescent

1
 Delbet Fracture Classification Hip Fractures

Type I – Transepiphyseal

Transphyseal fractures

Occur more often in
younger children

May be caused by child
abuse

50% associated with

Type I-
I- Transepiphyseal dislocation
Risk of AVN high, especially

Type II-
II- Transcervical

with dislocation

Type III-
III- Cervicotrochanteric
Malunion,
Malunion, Premature
physeal closure

Type IV-
IV- Intertrochanteric

Hip Fractures Hip Fractures

Type II-
II-
Type III-
III-
Transcervical Cervicotrochanteric

AVN related to both

Most common fracture severity and

45-
45-50% amount of initial
displacement

Risk of AVN related
AVN rate 20%
to initial
Complications include
displacement (up to coxa vara,
vara, premature
43%) physeal closure,

Treat with ORIF nonunion

Hip Fractures

Type IV-
IV-
Intertochanteric
Pediatric Diaphyseal Femur

11-
11-17% of hip Fractures
fractures

Far fewer complications
than femoral neck
fractures

Treatment method
variable, ranging from
spica cast, traction, to
ORIF

2

Decision Making

Age

Mechanism of injury

Fracture pattern and location

Associated Injuries

Surgeon preference
AAOS Clinical Practice Guideline
on the Treatment of Pediatric
Diaphyseal Femur Fractures
(PDFF)
June 2009
AAOS CPG for PDFF

Treatment with a
Pavlik Harness or a
spica cast are options
for infants 6 months
and younger with a
diaphyseal femur
fracture (C)
Pediatric Diaphyseal Femur
Fracture Options
Flynn JM, Schwend RM. JAAOS 2004
AAOS CPG for PDFF

Recommend that
children younger than
36 months with a
diaphyseal femur
fracture be evaluated
for child abuse (A)
AAOS CPG for PDFF

Suggest early spica
casting or traction for
children age 6 months
to 5 years with a
diaphyseal femur
fracture with less than
2 cm of shortening
(B)
3
 Early sitting spica – 3 part, 90-
90-90 AAOS CPG for PDFF

It is an option for
physicians to use
flexible intramedullary
nailing to treat
children age 5 to 11
years diagnosed with
diaphyseal femur
fractures (C)

This technique, recommended in textbooks and articles, may

increase risk of developing compartment syndrome

AAOS CPG for PDFF Piriformis Fossa Entry Site

Rigid trochanteric entry nailing,

submuscular plating, and flexible
intramedullary nailing are treatment
options for children age 11 to skeletal
maturity diagnosed with diaphyseal femur
Thometz J, JBJS 1995.
fractures, but piriformis or near
pirformis entry rigid nailing are not
treatment options (C)
Astion D, JBJS 1995

Raney E. JPO, 1993.

9 yo male with left femoral shaft 13 yo male with right femoral shaft
fracture fracture

4
Distal Femoral Physeal Fractures Distal Femoral Physeal Separation

Classified by the Salter-

Salter-Harris Classification

Often occur with high energy injuries or sports related
activities in older children

SH I and II fractures may be treated with closed
reduction and percutaneous fixation

SH III and IV may require ORIF

Complications include growth disturbance with limb
length inequality or angular deformity

Salter Harris II Distal Femur Fracture

Distal Femoral Physeal Separation

Salter Harris II Distal Femur Fracture Salter Harris II Distal Femur Fracture

5
 Tibial Spine Fracture

“Pediatric ACL injury”
injury”

Anatomy

ACL attaches to
intercondylar eminence

Mechanism of Injury

sports

bicycle
Tibial Spine Fracture

Signs & Symptoms

hemarthrosis

lack extension (bony block)

anterior laxity

Imaging

lateral knee x-
x-ray

Classification

Meyers & McKeever (JBJS 1959)

Type I minimal displacement

Type II hinged

Type III completely displaced

Tibial Spine Fracture Tibial Tubercle Fracture

Recommendations
Avulsion fracture of the

Type I Fractures:
tibial tubercle

long-
long-leg cast: extension
Fractures occur in boys

Type II & III Fractures:
ages 13-
13-16

Occurs during athletic

Aspiration & Reduction
jumping activites

Nonreducible: ARIF

Eccentric quadriceps

Fixation Options contraction

Cannulated 3.5 mm
Epiphyseal Screws

Suture

I
Tibial Tubercle Fracture II

Evaluation

Check for active knee
extension and

Displacement of tubercle
on lateral radiographs

Classification

Ogden modification of
Watson-
Watson-Jones classification III IV
based on location of
fracture line and
comminution

6
 Tibial Tubercle Fracture Tibial Shaft Fractures

Common fracture among children and

Beware of risk of adolescents
compartment syndrome
Mainstay of treatment in closed
• Branches of the anterior reduction and immobilization in a long
tibial recurrent artery that leg cast
may retract laterally and
Acceptable alignment
distally
<8 (10°
(10° coronal or sagittal plane, < 1cm
• Result in hematoma shortening, complete translation ok)
formation and increase the
Older children (<5°
(<5° of varus/valgus or
risk of developing sagittal deformity, < 5 mm of shortening,
compartment syndrome 50% translation

Operative treatment for irreducible or
Pape et al. CORR, 1993
unstable fractures, open fractures,
polytrauma

Tibial Shaft Fractures Tibial Shaft Fractures

Tibial Shaft Fractures Tibial Shaft Fractures

7
 Ankle Fractures Ankle Fractures

Transitional Ankle Fractures

During the transition time of physeal closure

Physeal Closure

Timing: begins to close…
close…

Girls 12 years

Boys 13 years

Pattern of closure

Central, then Medial, then Lateral

Tillaux Ankle Fractures

SH III

Caused by external rotation

CT scan often helpful

Acceptable articular
reduction of <2mm for
closed treatment

If surgery is required

Closed reduction and
percutaneous medial
transepiphyseal or lateral
transphyseal screws

Open reduction via anterior
arthrotomy with screw
fixation
13 yo girl with ankle injury

Tilleaux Fracture
Triplane Ankle Fractures

Multiplanar,
Multiplanar, SH IV

SH III on AP, SH II on lat

CT scan often helpful

Acceptable articular
reduction of <2mm for
closed treatment

If surgery is required

Open reduction performed
through anterior approach
with a transepiphyseal
screw then screws in the
metaphyseal fragment
13 yo girl with ankle injury
S/P ORIF

8
 Triplane Ankle Fracture
Triplane Ankle Fractures

Three part triplane fracture

Two part triplane fracture