Courtesy: Amr Abdelgawad, Maimonaides Medical Centre, NY, USA

Apophyseal and Avulsion Injuries

Apophysis

• Secondary ossification center located outside the joint where tendons attach.

Common apophyseal attachments

• Calcaneus: Achilles tendon.
• Tibial tubercle: Patellar tendon.
• Anterior inferior iliac spine (AIIS): Rectus femoris.
• Anterior superior iliac spine (ASIS): Sartorius.
• Ischial tuberosity: Hamstrings.
• Iliac crest: Abdominal muscles.

Treatment

• Rest.
• Activity restriction.
• Most injuries are managed nonoperatively.

Pediatric Hip Dislocation

Features

• Usually posterior dislocation.
• Limb is adducted and internally rotated.

Management

• Gentle reduction under anesthesia.
• Avoid physeal separation.
• Open reduction for irreducible or nonconcentric reductions.

Proximal Femur Fractures

Delbet Classification

Type I: Transphyseal

• Highest risk of avascular necrosis.

Type II: Transcervical

• High risk of avascular necrosis.

Type III: Cervicotrochanteric

• Moderate risk of avascular necrosis.

Type IV: Intertrochanteric

• Lowest risk of avascular necrosis.

Complications

• Avascular necrosis.
• Nonunion.
• Varus collapse.

Treatment

• Emergency fixation.
• Capsulotomy or aspiration to reduce intracapsular pressure.
• Fixation with screws, pins with hip spica, or pediatric hip plates.

Femoral Shaft Fractures

Age based treatment

Less than 6 months

• Pavlik harness.

6 months to 5 years

• Immediate hip spica cast.

5 to 12 years

• Transverse fractures: Flexible intramedullary nails.
• Comminuted fractures: Submuscular plating.

More than 12 years or weight more than 45 kg

• Rigid intramedullary nail using a lateral entry point.

Flexible Intramedullary Nails

Best indications

• Midshaft fracture.
• Transverse pattern.
• Noncomminuted fracture.
• Weight less than 45 kg.

Key point

• Correct nail diameter is essential.

Most common complication

• Knee irritation.

Rigid Intramedullary Nailing

Important principle

• Use lateral trochanteric entry.
• Avoid piriformis entry because of the risk of avascular necrosis.

External Fixation

Indications

• Open fractures.
• Polytrauma.

Complication

• Refracture after removal.

Submuscular Plating

Indications

• Comminuted fractures.
• Proximal or distal femoral shaft fractures.

Advantages

• Preserves alignment.
• Maintains limb length.

Nonaccidental Trauma

Clinical clues

• Femur fracture in a nonambulatory child.
• Multiple fractures.
• Delayed presentation.
• Inconsistent history.

Important point

• Spiral fracture alone does not indicate child abuse.

Management

• Notify child protection services when abuse is suspected.

Distal Femoral Physeal Injuries

Features

• Highest risk of growth arrest.
• Mammillary interdigitation contributes to physeal injury.

Complications

• Limb length discrepancy.
• Angular deformity.

Management

• Urgent reduction.
• Screw fixation for large metaphyseal fragments.
• Kirschner wires for smaller fragments.

Patellar Sleeve Fracture

Features

• Small bony fragment with a large cartilaginous component.
• Disruption of the extensor mechanism.

Treatment

• Open reduction and internal fixation.

Tibial Spine (Eminence) Fracture

Equivalent injury

• Anterior cruciate ligament avulsion.

Classification

Type I

• Nondisplaced.

Type II

• Hinged displacement.

Type III

• Completely displaced.

Special point

• Irreducible Type III fractures often have entrapment of the anterior horn of the medial meniscus.

Treatment

• Type I: Cast immobilization.
• Type II: Closed reduction.
• Type III: Surgical fixation.

Tibial Tubercle Avulsion

Mechanism

• Common in adolescents during jumping activities.

Complication

• Compartment syndrome due to injury of the recurrent anterior tibial artery.

Treatment

• Open reduction and screw fixation.

Proximal Tibial Metaphyseal Fracture

Complication

• Cozen phenomenon causing progressive valgus deformity.

Treatment

• Observation.
• Guided growth if deformity persists.

Toddler Fracture

Features

• Spiral fracture of the tibial shaft.
• Usually occurs in children aged 2 to 3 years.
• Fibula remains intact.
• Initial radiographs may be normal.

Treatment

• Above knee cast.

Tibial Shaft Fracture

Treatment

• Usually managed conservatively.

Important consideration

• Monitor closely for compartment syndrome.

Distal Tibial Physeal Injuries

Complication

• Growth arrest in up to 50 percent of cases.

Management

• Salter Harris Type I and II: Closed reduction.
• Salter Harris Type III and IV: Open reduction and internal fixation.

Special Fractures

Tillaux Fracture

• Avulsion fracture of the anterolateral distal tibial epiphysis.
• Caused by the anterior inferior tibiofibular ligament.
• Treated with open reduction and internal fixation.

Triplane Fracture

• Fracture involving three anatomical planes.
• Requires anatomical articular reduction and open reduction with internal fixation.

Pediatric Foot Fractures

Most common fracture

• Base of the first metatarsal.

Exam Pearls

• Femur fracture in a nonambulatory child should raise suspicion of child abuse.
• Flexible intramedullary nails are best for transverse midshaft femoral fractures.
• The most common complication of flexible nails is knee irritation.
• Distal femoral physeal injuries carry the highest risk of growth arrest.
• Irreducible Type III tibial spine fractures are commonly associated with meniscal entrapment.
• Tibial tubercle avulsion fractures are associated with compartment syndrome.
• Proximal tibial metaphyseal fractures may lead to Cozen valgus deformity.