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the ends of the bone.

Classification. These fractures should be described using the Salter -Harris classification (Fig. 28 -3).

Types. All types of growth plate fractures may be associated with growth arrest, and the parents should be advised of this.

Types 3 and 4 frequently require open reduction and fixation because they are, by definition, intra -articular fractures. These injuries cross the growth cartilage with communication of bone on both sides of the growth plate and are therefore at greatest risk of causing growth arrest.

Types 1 and 2 frequently do well with closed reduction and cast immobilization; however, some types that are very unstable may require a pin or screw fixation. Growth arrest is an unlikely sequel to these injuries.

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FIGURE 28-3 Salter-Harris classifications of epiphyseal fractures. (Redrawn with permission from

Salter RB, Harris WR. Injuries involving the epiphyseal plate. J Bone Joint Surg. 1963;45A:587.

)

Buckle (or torus) fractures (Fig. 28 -2) are incomplete fractures that occur in the metaphysis of bones adjacent to (but not involving) the growth plate.

A common site is the distal radius.

Treatment. Frequently, these fractures require only cast immobilization to prevent further angulation. Occasionally, a gentle closed reduction and a well-molded cast are required for more severely angulated fractures.

Greenstick fractures (Fig. 28 -2)

Site. Because of the flexibility and plasticity of a child's bones, some shaft fractures extend through only one side or one aspect of the cortex.

Treatment. Because of the potential for recurrent angulation despite an initial excellent closed

reduction, the remaining cortex of the fractured bone should be disrupted so that the alignment of the bone can be easily obtained and maintained.

Spiral fractures are unusual in children; the occurrence of a spiral fracture should always raise the question of child abuse.

A careful history obtained from the child's parents, caregiver, and siblings, as well as a complete physical examination, is important when differentiating fractures caused by accidents from those caused by child abuse.

A radiograph skeletal survey should be performed when child abuse is suspected. This usually includes anteroposterior projection of the trunk and extremities, plus anterior, posterior, and lateral views of the skull. Radiographs of the hands and feet can be requested if indicated.

Multiple fractures of varying age and stage of healing is diagnostic of child abuse. If any suspicion of abuse is present, social service/child protective consultation is mandatory.

Supracondylar fractures of the humerus

Displaced fractures require urgent attention.

The potential for compression or entrapment of the brachial artery can lead to limb ischemia and compartment syndrome.

The potential exists for entrapment of the radial and median nerves.

A careful neurovascular examination should be done before and after any attempts at reduction are made.

Treatment. For displaced fractures, a closed (occasionally open) reduction with pin stabilization and long-arm casting is frequently the treatment of choice. If swelling is thought to be too severe, then a brief period of lateral traction followed by pinning may be indicated.

Fractures of both forearm bones

In children, these fractures are usually managed with closed reduction and plaster immobilization. The casts must be carefully molded, and the patient must be closely observed acutely for possible compartment syndrome and to ensure that the interosseous space is preserved so that forearm rotation is maintained after healing.

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In adolescents , an open reduction with internal fixation may be necessary if reduction is not satisfactory. Remodeling of the diaphysis is minimal after 10 years of age.

Distal radius fractures

The distal radial metaphysis is a frequent site for buckle fractures.

The distal radial epiphyseal plate is a frequent site for growth plate fractures. The growth plate fracture, if displaced, should have a closed reduction under anesthesia with cast immobilization.

Femur fractures

In children between the ages of 2 and 10 years, femur fractures can most often be managed with closed reduction and plaster spica cast immobilization.

It is desirable to have 1–1.5 cm of overlap to allow for the postfracture overgrowth that frequently occurs.

If overlap exceeds this amount, then a period of traction is indicated to restore length and allow early callus formation. This is followed by spica casting.

In children 11 years and older with an isolated femur fracture, treatment with an intramedullary rod, open plating, or external fixation is typically preferable to prolonged traction and spica casting. The physician should discuss with the parents the risks and potential benefits of all treatment options.

Regardless of the age, children who have multiple trauma or head injuries, in which prolonged traction would interfere with nursing care or could be potentially harmful because of the child flailing in bed, should be considered as candidates for operative fracture stabilization.

Plate or external fixation is preferable in children between the ages of 2 and 10 years.

Flexible intramedullary rods may be considered in children 11 years of age and older.

Supracondylar femur fractures and fractures of the proximal tibia can be easily confused with a ligamentous knee injury during the physical examination.

It is important to remember that skeletally immature individuals uncommonly have injuries to the ligaments. Rather, they frequently fracture the growth areas of the distal femur or proximal tibia, owing to the relative weakness of the junction of the growth plate with the adjacent ossifying cartilage.

When a child's knee is unstable on physical examination, one should assume a periarticular growth plate injury until proven otherwise. In the setting of normal plain x-rays, stress radiographs of the knee may be helpful to ascertain the exact cause and location of the motion.

Fractures of the tibia may be open because of the subcutaneous position of the bones.

These fractures can also be associated with a relatively high incidence of compartment syndromes.

Examination. All patients with tibia fractures should be examined for any skin disruption, and the neurovascular status of the leg should be evaluated and documented.

Treatment. These fractures in children are well managed with plaster immobilization. If larger open wounds are present, external fixation should be employed to allow access for wound care.

E Fractures in adults

Fractures of the spine, hip, the proximal humerus, and the distal radius at the wrist are all quite common in elderly persons with osteoporosis.

In general, distal radius fractures can be managed with closed reduction and cast immobilization. If unstable and maintenance of satisfactory reduction is unsuccessful, internal or external fixation of the fracture may be necessary.

Proximal humerus fractures may simply require collar and cuff immobilization. More severe fractures may require open reduction and internal fixation or prosthetic replacement. Early motion

after callus development is essential to decrease shoulder stiffness.

Because of the associated morbidity of bedrest and recumbency and the weight-bearing function of the hip, operative repair of the fracture or hemiarthroplasty is actually the conservative management and is associated with better long-term function and survival of the patient.

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Simple osteopenic compression fractures can frequently be managed with bracing for 3–4 months. Metastatic disease should be ruled out as a cause.

Humeral shaft fractures may have an associated radial nerve palsy.

Generally, the palsy recovers spontaneously with immobilization. Careful attention must be paid to the hand to prevent stiffness and contractures until the radial nerve recovers.

If the palsy develops after closed reduction, then exploration is typically indicated to ensure that the nerve is not entrapped within the fracture site. Frequently, plate stabilization is performed at the same time.

The fracture, when isolated , may be treated with a sling and humeral fracture brace. Early range-of - motion exercises of the shoulder and elbow and isometric exercises for the biceps and triceps are indicated as well.

The fracture in conjunction with multiple trauma , other lower extremity fractures, or ipsilateral forearm and hand injuries frequently require intramedullary rod or plate fixation to allow use of a crutch or hand and upper extremity rehabilitation.

Fractures of both forearm bones

Because of the conjoined two bone system and precise functional requirements of the forearm, these fractures require open reduction and internal fixation for optimal functional results.

The consideration of compartment syndrome is important, especially in crushing injuries.

Distal radius fractures

If the distal radius fracture is extra-articular and results from a relatively low -energy injury, then it can frequently be treated by closed reduction and immobilization in a well-molded, long-arm cast.

If the fracture is intra -articular and results from a relatively high-energy injury (e.g., motor vehicle accident, fall from a height), then it frequently requires more aggressive treatment. Closed reduction with percutaneous pinning, external fixation, or open reduction and internal fixation may be used to obtain and maintain a satisfactory reduction.

If a distal radioulnar joint injury is suspected, then the forearm should be immobilized in full supination.

Scaphoid fractures

Wrist pain, especially in the anatomic snuff -box after a fall on an outstretched wrist, should arouse suspicion of this carpal bone injury. Healing is often delayed owing to a precarious blood supply to the bone, which is largely covered with articular cartilage.

Nondisplaced fractures are treated with thumb -spica casting, whereas displaced fractures require surgical open reduction and internal fixation.

Phalangeal fractures

Because of the precise, fine function of the extensor mechanism in the fingers and the problem of stiffness resulting from adherence of the tendons to the adjacent skeleton, early range-of -motion exercise of the fingers has a high priority.

Percutaneous pin or plate fixation to maintain the anatomical length of the skeleton, or closed treatment by splinting with “buddy” taping of stable fractures, are acceptable methods, assuming the goal of early motion can be obtained to avoid finger contracture and dysfunction.

Spinal fractures are associated with high-energy mechanisms of injury. Automobile accidents, motorcycle accidents, and falls from heights are frequent mechanisms in spinal fractures. Associated neurologic injury must always be considered and ruled out.

General initial treatment

All unconscious patients involved in motor vehicle or motorcycle accidents should be assumed to have a spinal injury until proved otherwise. Complete spinal radiographs are indicated to rule out these fractures.

All patients suspected of having a spinal injury should be immobilized on a long spine board with a cervical collar and head blocks.

A careful neurologic examination should be performed (including rectal examination, bulbocavernous reflex, and perirectal sensation) to distinguish between an

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incomplete (i.e., some neurologic function present below the level of injury) and a complete (i.e., no function below the level of injury) neurologic injury to the spinal cord.

Cervical spine fractures are frequently associated with quadriplegia.

If one level of injury is found, there is an increased incidence of another level of injury in the cervical spine.

Cervical radiographs must include the C7 -T1 junction, because as a transition zone from a mobile (cervical) to a relatively immobile (thoracic) region, it is frequently a site of injury.

Thoracic spine fractures

When thoracic spine fractures are associated with paraplegia , a high-energy injury is usually implicated because of the relative stability provided in this region by the rib cage.

Simple compression fractures may occur in elderly osteopenic patients secondary to minimal trauma (e.g., coughing).

Metastatic disease can be present in patients with thoracic spine compression fractures.

Injuries between T1 and T10 with neurologic deficit frequently indicate a cord -level injury. Injuries from T11-T12 may include a mixed neurologic injury consisting of conus medullaris

(central) and spinal nerve roots (peripheral).

Lumbar spine fractures can present with a mixed neurologic injury from L1 -L2 with involvement of the conus medullaris (upper motor neuron) as well as the cauda equina (lower motor neuron or root lesion). Below L2, the injury typically involves only nerve roots.

Treatment

All patients with suspected neurologic injuries related to spinal cord injury should be started on a steroid protocol.

Methylprednisolone is given as a bolus dose of 30 mg/kg body weight, followed by an infusion of 5.4 mg/kg/hour.

In patients with acute spinal cord injury, this treatment protocol has been associated with improved neurologic recovery. Steroid therapy begun within the first 3 hours after an injury should continue for 23 hours. If steroids are started from 3–8 hours postinjury, they should be continued for 48 hours. If steroid therapy is not instituted in the first 8 hours, no neurologic benefit will occur.

Urgent decompression of neural elements in patients with incomplete or progressive neural deficits or injuries at the level of the cauda equina is the optimal approach.

Spinal stabilization with instrumentation to prevent the development or worsening of a neural deficit, and to facilitate early rehabilitation, should be performed.

Patients with complete quadriplegia or paraplegia should also be considered as candidates for spinal stabilization with instrumentation on a less urgent basis to allow early rehabilitation.

Pelvic fractures (see II C 2)

Femoral shaft fractures. Early stabilization of femoral fractures has been shown to decrease pulmonary complications and to shorten intensive care unit stays in the multiply injured patient.

The most universally accepted method of stabilization is placement of a statically interlocked intramedullary rod.

Traction is indicated on a short-term basis if the patient is considered to be too critically ill for surgery (e.g., severe coagulopathy, marked elevation of intracranial pressure). Formal stabilization should be performed as soon as the patient's condition is stable.

Intramedullary stabilization is the treatment of choice for isolated femoral shaft fractures. This is due to a relatively low complication rate and superior functional outcome when compared with traction followed by cast bracing.

Tibial fractures frequently may be open and can be associated with compartment syndromes. These two associated problems must be anticipated and managed appropriately.

Isolated fractures of the tibia are generally best managed with plaster immobilization and early weight bearing. Early return to function may be facilitated by intramedullary nailing of the tibial shaft fracture.

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Patients with multiple injuries, open tibial fractures , and some fracture patterns known to be associated with the development of unacceptable shortening or malalignment should be considered candidates for intramedullary rods or external fixation. Plate fixation with an open tibial fracture has limited indication because of the further stripping of crucial blood supply typically necessary to place the plate.

Ankle fractures may involve the distal fibula, lateral malleolus, or medial malleolus.

Distal fibula or lateral malleolus. When significant displacement of the distal fibula with widening of the mortise is found on the initial radiographs, open reduction and internal fixation is most commonly indicated to provide stability to the ankle mortise.

Fractures of the medial malleolus in association with fractures of the distal fibula may indicate ankle instability resulting from a more violent mechanism of injury. Large, displaced fragments of the medial malleolus are an indication for open reduction and internal fixation to prevent the development of nonunion and to restore the articular surface.

Spiral fractures of the proximal fibula require a clinical and radiographic evaluation of the ankle joint. A Maisonneuve fracture implies disruption of the medial ankle (fracture or deltoid ligament tear), the intervening syndesmotic ligaments between the distal tibia and fibula, and proximal fibula fracture.

F Dislocations

Shoulder

Presentation. Dislocations of the glenohumeral joint are especially common in young adults. These dislocations frequently recur in patients under the age of 40. In first -time dislocations that occur after 40 years of age, a tear of the rotator cuff should be suspected.

Management. Shoulder dislocations are also associated with axillary nerve palsy. The neurologic examination should test for:

Sensation over the deltoid muscle

Active firing of the deltoid muscle

Hip

Presentation. Dislocations of the hip occur in high-velocity injuries, especially automobile accidents. They are associated with fractures of the ipsilateral femur and patella and with contralateral hip fractures or dislocations.

Management. Hip dislocations require prompt reduction to reduce the risk of avascular necrosis resulting from concomitant injury to the blood supply to the femoral head.

Knee

Presentation. A dislocation of the knee implies severe ligamentous injury around the knee.

Ligamentous knee injuries occur most commonly in sports-related activities.

Total ligamentous disruptions and dislocations are usually the result of violent injuries and may be associated with limb -threatening neurovascular injury.

Management. The most important consideration is the common occurrence of injuries to the popliteal artery and vein as well as to the peroneal nerve. The first step in management of a patient with a dislocated knee is to evaluate the neurovascular status of the lower extremity. Then, the ligaments and capsule around the knee are evaluated.

After a formal evaluation, a gentle closed reduction should be attempted.

All patients with knee dislocations deserve a formal angiographic evaluation of the femoral artery with runoff (one third will have vascular injury).

G Musculotendinous injuries

The musculotendinous unit is most commonly disrupted by overuse but may also be disrupted by forced lengthening of the muscle.

Tear of the rotator cuff

Presentation. Middle -aged and older patients with intermittent shoulder pain may have an episode of acute pain when the weakened tendon tears.

Management. Most tears are small and may be treated symptomatically. However, after acute symptoms resolve, if the shoulder demonstrates poor muscular function or continued pain despite nonoperative therapy (e.g., anti -inflammatory medication, physical therapy), operative repair should be considered.

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Quadriceps disruptions

Presentation. Middle -aged and older patients, especially those with diabetes mellitus or renal disease, may acutely disrupt the quadriceps mechanism proximal to the patella.

Physical examination shows minimal swelling and tenderness. The patient has weakness in the leg after hearing a “pop” and may be able to raise the leg if the knee is passively placed in a straight position. However, the patient is unable to initiate extension against gravity with the knee at 90 degrees of flexion.

Surgical repair is indicated.

Patellar tendon disruptions

Presentation. These injuries often occur in young to middle -aged athletic patients. Often, the “weekend warrior” type of athlete sustains this type of injury.

A physical examination similar to that for a quadriceps disruption shows an inability to fully extend the knee against gravity.

Surgical repair is indicated.

Achilles tendon disruptions

Presentation. The patient is usually young to middle aged. Again, these injuries typically occur in the “weekend warrior” as opposed to professional athletes.