Most studies have shown a male predominance for fractures, particularly in adolescence. Boys sustain fractures at 2.7 times the rate of girls. However, as girls are increasingly involved in more athletic events, this margin will likely narrow.

The most common fracture-related operations are performed on the elbow (23%), tibia (12%), femur (9.8%), forearm (5.5%), and the distal aspect of the radius (5%). However, pediatric fractures treated in the emergency department (ED) typically involve the forearm, hand, or wrist, are treated with simple closed reduction, and do not require admission Fracture location varies with chronologic age, a finding that is probably due to a combination of the anatomic maturation of the child and the age-specific activities of childhood.

Fractures are much more common during the summer, with children out of school and more likely to be outside playing with more intense physical activity. A positive correlation has been identified between the hours of sunshine per month and the rate of fractures requiring admission to the hospital. The fracture rate was 2.5 times higher in the summer compared to the winter. ^{, ,} There is also a strong association between sunshine and fractures, and a negative association between rain and fractures. It has also been shown that peak fracture rate occurs when children are most active during the day. The afternoon is the most frequent time for fractures to occur, correlating with the time of peak activity for children. ^, A study performed in Sweden showed a peak fracture rate around 2:00 to 3:00 p.m. Another study from Texas demonstrated a bell curve fracture rate with the peak occurring at 6:00 p.m. ^,

Fractures can occur in the home or school environment. Most school-related fractures are due to sport activities. Injuries in the home during the late afternoon and evening account for more than 83% of all injuries to children. Fractures in the home environment do not correlate with the physical attributes of or poor precautions in place in the house; rather disruption of the family structure is a more significant risk factor. The overall incidence of fractures occurring at home increases with the age of the child. ^, In a Swedish study, fracture incidence was correlated with the degree of social disabilities such as welfare or alcoholism in the family.

Fractures are commonly found in children as a result of maltreatment. The incidence of physical abuse to children is estimated to be 4.9 per 1000. Of those abused, 1 of every 1000 will ultimately die as a result. Early recognition and reporting is essential because children who return home after hospitalization with unrecognized abuse have a 25% risk of serious future injury and a 5% risk of death. Children at highest risk for abuse are first-born children, premature infants, stepchildren, and handicapped children. Most cases of child abuse involve children younger than 3 years of age. Any young child presenting with an injury mechanism that does not fit the injury pattern, bruising or other associated injuries, or fractures in different stages of healing should be viewed with circumspection as to cause ( Table 17.1 ). ^, Diagnostic radiographic plain imaging with a skeletal survey is necessary for the child who is under the age of 2 years with an unexplained or suspicious fracture.

In the immature skeleton, longitudinal and appositional growth takes place through the physes (growth plates) located at the ends of the long bones, in the endplates of the vertebral bodies, or at the periphery of the round bones in the feet and hands. The physis is essential for normal skeletal growth, but it is also the weakest portion of the bone in children. Approximately 30% of fractures of the long bones include an injury to the physis. Most fractures that involve the growth plates heal without consequence. However, some injuries can result in permanent damage with significant sequelae such as angular deformity or complete cessation of growth.

The ends of every long bone consist of an epiphysis (near the joint), physis, and metaphysis (area of newly formed bone). At the time of skeletal maturity, the physis closes, which means there is no more longitudinal growth. Fracture healing in children is rapid and the potential for remodeling is great due to the growth potential of the immature skeleton. These characteristics allow for nonoperative management of some fractures in children that would receive operative treatment in the adult. Remodeling of fractures predictably occurs in the plane of primary motion of the adjacent joint (usually flexion/extension) and, to a lesser degree, in the coronal plane (varus and valgus deformities). Remodeling is not predictable in the transverse plane of fractures, with rotational malalignment.

Physeal fractures are classified to predict outcome and guide treatment. Most orthopedic surgeons use the Salter Harris classification ( Fig. 17.1 ). Classic teaching states that types I and II injuries heal without growth abnormalities if reduced appropriately. However, some reports dispute this. Types III and IV injuries usually occur in older children and frequently require anatomic realignment via open reduction to restore congruity of the joint to minimize the risk of arthritis and restore continuity of the physis to decrease the risk of growth disturbance. Type V injuries are higher energy crush injuries that are not usually recognized at the time of the injury but have a high risk of growth arrest.

Salter Harris classification of physeal injuries with Rang modification.

Adapted from Rang ML, ed. The Growth Plate and its Disorders . E&S Livingstone; 1969:139.

Children sustain injuries that are different from those in adults due to their size and activities. A common example is a pedestrian struck by a car. An adult will frequently sustain an injury to the tibia or knee from the car’s bumper. However, the same mechanism will result in a fracture of the femur or pelvis in conjunction with a chest or head injury in a small child. Motor vehicle crashes (MVCs) are the most common cause of multiple injuries to children, both as occupants and pedestrians.

Open fractures are orthopedic injuries that should be taken care of in an emergent, or at minimum urgent, fashion in children. ^, These fractures can result from high-energy mechanisms and are often seen in the setting of other injuries as well. Open fractures in children and adults are classified according to the Gustilo–Anderson system ( Table 17.2 ). The four goals of treatment of open fractures are prevention of infection, bony union, prevention of malunion, and return to function of limb and patient. ^, To attain these goals, the child’s tetanus status should be ascertained and open fractures treated by early irrigation and debridement along with broad-spectrum antibiotics. One study found that early treatment of tibial shaft fractures in children resulted in fewer cases of osteomyelitis when compared with those treated later. However, another study found no difference in infection or nonunion rates with delayed debridement in 390 open fractures of the lower extremities in adults. Additionally, in a study of 554 pediatric open fractures, there was no difference in infection rates when debridement was within 6 hours of injury compared with 7–24 hours. There is no consensus on the effect of delayed operative treatment of open fractures with regard to rates of infection and need for secondary surgical procedures to promote bone healing. ^, Our practice is to debride open fractures within 24 hours of presentation and more urgently if there is severe contamination or an injury in a high-risk environment, such as a farm.

Pediatric traumatic amputations are unique injuries, typically caused by machinery, power lawnmowers ( Fig. 17.2 ), farm equipment ( Fig. 17.3 ), and MVCs. MVCs are the most common cause of an amputation in adolescents. Push and riding lawnmowers produce complex wounds with open fractures that resemble contaminated blast injuries, and have an annual incidence of approximately 11 per 100,000. These injuries frequently require serial debridement, internal or external fixation, and reconstruction of soft tissue defects. Wounds should not be surgically closed until the tissues are clean. Unfortunately, amputation is often needed.

(A) A 4-year-old girl fell off the riding lawnmower her grandfather was operating with her in his lap. (B) This radiograph shows multiple open comminuted hand fractures including the forearm. She required multiple surgical irrigation and debridement procedures before local flap closure was possible. Power mower injuries are the most frequent cause of traumatic major limb amputations in a young child.

(A) A 6-year-old boy was riding on a tractor with his father, fell off, and was run over by the brush hog that was being pulled behind, resulting in a contaminated open lower extremity amputation. (B) This radiograph shows comminuted, open fractures. (C) After multiple surgical procedures, including irrigation, debridements, delayed closure, and revision amputation, he was fitted with a low-tech temporary prosthesis made from PVC pipe.

While fractures of the pelvis and proximal femur are rare in the pediatric population, they usually involve high levels of energy and should be treated urgently. Fractures of the pelvis require a comprehensive workup for concomitant injuries to the central nervous system, abdominal viscera and genitourinary systems. Approximately 67% of pediatric patients with pelvic fractures have associated injuries and about one-third have long term comorbidities. ^, Pediatric pelvic ring injuries differ significantly from adult pelvic trauma in terms of injury patterns, treatment options, and outcomes. The pediatric pelvis is more elastic due to increased cartilage and thickened periosteum. The sacroiliac (SI) and pubic symphyseal joints are also wider and capable of absorbing more force than the adult pelvis. Thus, a higher level of injury is needed to fracture the pediatric pelvis. The epiphyseal and apophyseal portions also predispose pediatric patients to avulsion injuries at the anterior iliac crest, ischial tuberosity, anterior superior iliac spine, and anterior inferior iliac spine. The Pediatric Advanced Life Support (PALS) protocol states that every patient should have an AP pelvis radiograph upon presentation. Pelvic fractures rank second to head injuries in terms of complications, including life-threatening visceral injuries. The mortality rate of pelvic fractures is 9%–18%. Children with multiple injuries should be checked carefully to exclude fractures of the pelvis.

Some common findings of pelvic fractures are the presence of a hematoma beneath the inguinal ligament ( Destot sign ); decreased distance between the greater trochanter and anterior superior iliac spine on the affected side in lateral compression injuries ( Roux sign ); and the presence of a bony prominence or hematoma on rectal examination ( Earl sign ). An anteroposterior pelvis radiograph is usually sufficient as the initial screening study, although increasingly these injuries are diagnosed by computed tomography (CT) as part of the initial trauma evaluation. Most pediatric pelvic fractures, even those in which the pelvic ring is disrupted, can be treated nonoperatively with good outcomes. However, pelvic fractures that are associated with shock, open pelvic fractures, or vertical shear injuries may require operative fixation. ^,

Femoral neck fractures are rare injuries also usually due to high-energy trauma and associated with other comorbid injuries. Femoral neck fractures involve the proximal femoral epiphysis, femoral neck, and intertrochanteric regions of the femur. Fractures of the femoral neck are serious injuries that typically require operative treatment. Patients present with an inability to bear weight to the injured extremity and usually have a shortened and externally rotated extremity. High suspicion for other injuries of the central nervous system, abdomen, and genitourinary systems should be raised. Avascular necrosis caused by disruption of the blood supply to the femoral epiphysis is a dreaded complication of this fracture, occurring in up to 75% of children after this injury. ^, The risk of developing osteonecrosis correlates with a more proximal anatomic location of the fracture in the femoral neck, the extent of displacement, and any delay in reducing the fracture. The Delbet classification describes four different types of femoral neck fractures:

• Type I Transepiphyseal fractures

• Type II Transcervical fractures

• Type III Cervicotrochanteric fractures

• Type IV Intertrochanteric fractures

The risk of avascular necrosis decreases from Type I to Type IV (e.g., transepiphyseal with the highest risk). These patients are also at increased risk of delayed union, nonunion, and premature physeal closure. ^{, , ,} Accordingly, fractures and dislocations of the proximal femur are orthopedic emergencies that require immediate anatomic reduction, which can be achieved with internal fixation using closed or open techniques ( Fig. 17.4 ). ^{, , , ,} Traumatic hip dislocation is exceedingly rare in pediatric patients; however, they are also injuries that need to be tended to urgently. Prompt reduction within 6 hours decreases the risk of avascular necrosis. Posterior hip dislocations are much more common than anterior dislocations, and there should be a high suspicion that the reduction is not perfect, with advanced imaging being performed after reduction. Reduction of hip dislocations should be performed in a controlled environment with fluoroscopy to ensure there is not physeal separation during the reduction attempt. Intracapsular pressures have been found to be high (48 mmHg) in unstable slipped capital femoral epiphysis, similar to levels found in compartment syndrome. ^, Open decompression of the capsule will decrease the intracapsular pressure and, at least in theory, the resulting risk of osteonecrosis.

(A) Anteroposterior radiograph of the pelvis of a 12-year-old girl injured from a fall showing a displaced transcervical fracture of the left femoral neck ( arrow ). The fracture was treated emergently by closed reduction and internal fixation with two cannulated screws. (B, C) Radiographs 1 year later show healing of the fracture and no evidence of osteonecrosis.

Femoral shaft fractures are common injuries in children and were the most common pediatric fracture requiring hospitalization in one study. The incidence and mechanism of these fractures varies with patient age and gender.

Child abuse accounts for up to two-thirds of femur fractures in children younger than 1 year, but only 11% of fractures in children between ages 1 and 2 years. ^, Any fracture pattern can occur as a result of abuse. However, in an infant too young to walk with a transverse fracture pattern, abuse is likely.

Falls are the leading cause of femur fractures in children ages 2–3 years, frequent enough to be labeled as a “toddler fracture” of the femur. ^, MVCs are the most common cause in older children. Although internal bleeding following a femur fracture can be fairly extensive, transfusion in isolated, closed injuries is rarely needed. Other causes of blood loss must be investigated if there is hemodynamic instability or a falling hemoglobin value at 24 hours after injury in a patient with a femur fracture, especially in the setting of multiple injuries.

Treatment of femur fractures also varies with age ( Fig. 17.5 ). Younger children (under 4–5 years of age) are usually treated nonoperatively by closed reduction and immediate spica cast immobilization. Older children (4–10 years) are managed with flexible nails or plates. Adolescents (over 10 years of age or greater than 100 pounds) may be treated as adults with solid, reamed femoral nails. These should be introduced through the tip of the greater trochanter, rather than through the piriformis fossa, to avoid injury to the vascular supply to the femoral head. A review of rigid nails for older children and adolescents noted no cases of osteonecrosis with nail entry via the lateral aspect of the greater trochanter. In contrast to adults, the timing of femur fracture stabilization in children, even in the setting of multiple injuries, does not appear to have an effect on the development of pulmonary complications. The implications are that surgical treatment can be deferred until the child’s general medical condition permits, with the caveat that expeditious stabilization of the femur, as well as other long-bone fractures, will facilitate mobilization and nursing care in the overall management of the child.

Four methods for treatment of femoral shaft fractures in children and adolescents are shown. (A) Spica cast in a 24-month-old child; (B) flexible intramedullary nails in a 7-year-old child; (C) submuscular plating in an 8-year-old child with severe head injury; and (D) rigid locked intramedullary nail in an 11-year-old child.

Knee injuries in children differ from those in adults. In children, the cartilage of the physes, apophyses, menisci, and articular surface are weaker than the knee ligaments and are thus more prone to injury. Therefore, fractures about the knee occur more commonly than ligamentous injuries in skeletally immature individuals. The distal femoral physis is the largest and fastest growing physis. It is often injured because of a direct blow and is common in sports injuries. Most fractures are Salter Harris types I or II injuries. These fractures usually can be treated by closed reduction and percutaneous, cross-pin stabilization. Fractures extending into the articular surface (types III and IV injuries) require open reduction and internal fixation if displacement of the articular surface is greater than 2 mm. Because of the surface area of this growth plate, its complex undulating anatomy, and the forces required for displacement, fractures of the distal femoral physis, even types I and II injuries, may result in permanent growth disturbance in up to 50% of cases. All of these fractures should be followed for a minimum of 1 year, with serial radiographs, to evaluate for sequelae of growth arrest.

Traumatic knee dislocations are rare injuries, with fractures of the distal femur or proximal tibia physes being more common. Knee dislocations are true orthopedic emergencies due to risk of neurovascular injury. Knee dislocations can occur from high- or low-energy mechanisms with a high incidence of morbidity. The reported incidence of associated vascular injury ranges from 15%–65%. These are due to popliteal artery injuries, often from tethering between the adductor hiatus and the gastrocnemius-soleus complex. Emergent reduction should be performed with a thorough neurovascular exam following reduction. An ankle-brachial index (ABI) is essential, regardless of the pulse examination. A CT-angiogram is indicated for an ABI less than 0.9, with vascular surgery consultation as necessary. The Schenck Anatomic Classification describes knee dislocations as follows: 1) knee dislocation with ACL (anterior collateral ligament) rupture; 2) knee dislocation with ACL and PCL (posterior collateral ligament) ruptures; 3) knee dislocation with ACL, PCL, and one collateral ligament disrupted; 4) knee dislocation with ACL, PCL, and both collateral ligaments disrupted; and 5) knee dislocation with associated periarticular fracture.

Proximal tibial physeal injuries are uncommon due to the reinforcement provided by the knee joint capsular attachments and collateral ligaments. Vascular compromise of the lower leg due to popliteal artery injury is also possible in this scenario, particularly with extension-type injuries in which the proximal portion of the tibial metaphysis is displaced posteriorly. Such injuries tent the popliteal artery at the level of the physis and proximal to the trifurcation, where it is relatively tethered by the peroneal branch as it courses through the fascia entering the anterior compartment of the leg ( Fig. 17.6 ). Careful vascular examination of the lower extremity is critical following injuries to the proximal tibia. Intraarticular knee injuries typically manifest with a hemarthrosis and include patellar fractures or dislocations, tibial spine/plateau fractures, osteochondral fractures, and ligamentous/meniscal injuries. These injuries are not emergencies and can be splinted with delayed definitive treatment. Tibial tubercle fractures are common and have a heightened risk of compartment syndrome due to injury to the anterior tibial recurrent artery. The tibial tubercle is a secondary ossification center of the proximal tibia. Tibial tubercle fractures tend to occur in adolescent males near the end of their growth. The Ogden classification describes tibial tubercle fractures as follows:

• Type I Fracture of the secondary ossification center near the insertion of the patellar tendon.

• Type II Fracture propagates proximal between the primary and secondary ossification centers.

• Type III Coronal fractures extending posteriorly to cross the primary ossification center.

• Type IV Fracture through the entire proximal tibial physis.

• Type V Periosteal sleeve avulsion of the extensor mechanism from the secondary ossification center.

(A) Anteroposterior and lateral radiographs of a 13-year-old boy showing a Salter Harris type I fracture of the proximal tibial physis with posterior displacement of the distal fragment following an extension-type injury. (B) Distal pulses were diminished before and after closed reduction and stabilization of the fracture. (C) Arteriogram shows occlusion of the popliteal artery ( arrow ) at the level of the fracture. Vascular repair with an interposition graft was performed successfully. (D) Drawing shows the relationship of the popliteal artery to the proximal tibial physis and mechanism of vascular injury ( arrow ) in this fracture.

D, Adapted from Zionts LE. Fractures and dislocations about the knee. In: Green NE, Swiontkowski MF, eds. Skeletal Trauma in Children . 3rd ed. Saunders; 2003:460.

Type I injuries can usually be treated nonoperatively in a long leg cast in extension; however, types II through V usually require open reduction and fixation with soft tissue repair.

Patellar injuries are also very common in the pediatric population. Patellar fractures are often caused by a direct blow to the knee and are treated similarly to adult patellar fractures. Patellar sleeve fractures are more common in children between the ages of 8–16 years old. Many of these patients have anatomic features that predispose them to patellofemoral instability. Acute patellar dislocations are usually due to a noncontact injury mechanism, usually from a valgus load to the knee with internal rotation of the femur on a dorsiflexed foot. First-time patellar dislocations should be reduced and treated nonoperatively with appropriate bracing and physical therapy. Patients with multiple patellar dislocations may require a stabilization procedure along with possible realignment osteotomies of the tibia or femur.

Nonphyseal fractures of the tibia and fibula are among the most common injuries involving the lower extremity in children. ^, Fortunately, most of these injuries occur from low-energy mechanisms and can be treated nonoperatively. However, one must always be vigilant about the possibility of compartment syndrome following closed or open fractures of the tibial shaft. As a general principle, the child who has a tibia fracture after being struck by a motor vehicle should be assumed to have a compartment syndrome until proven otherwise. Indications for operative treatment of tibial shaft fractures include open fractures, neurovascular injury, impending compartment syndrome, unacceptable alignment after closed reduction, and fractures occurring in the setting of multiple traumas.

Ankle fractures are typically caused by indirect, torsional forces. Injuries to the distal tibial and fibular physes account for 25%–40% of all children’s physeal injuries. ^, Sports injuries are the cause of up to 60% of physeal fractures about the ankle. Nonoperative management has historically been the preferred approach, except for intraarticular fractures or when the fracture cannot be reduced by closed techniques. Occasionally, when a distal tibia fracture cannot adequately be reduced by closed reduction, open reduction is needed. CT is very useful in defining the pathoanatomy of fractures with intraarticular involvement or unusual patterns and is useful for preoperative indications and technique planning. Foot fractures are uncommon, and most can be treated nonoperatively with immobilization and restricted weight-bearing. More complex injuries that receive operative intervention include displaced fractures of the talar neck, displaced intraarticular fractures of the calcaneus, fractures or dislocations of the tarsometatarsal (Lisfranc) joint, open fractures, lawnmower injuries, and the unfortunately increasingly common firearm injuries ( Fig. 17.7 ).

(A) A 16-year-old boy sustained a rifle gunshot wound to his foot at close range. The entry wound was through the dorsum of the foot with skin loss and tendon damage. (B) This radiograph shows the midfoot fractures and bullet fragments. (C) After irrigation and debridement, an external fixator was applied. (D) A rotational sural artery flap provided innervated coverage to the dorsum of the foot. The arrow shows the branch of the sural artery providing the vascularity for the flap. (E) Six months postoperatively, the foot is functioning well, and he has sensation to the dorsum of the flap.

Injuries to the upper extremity are very common in children and can range from isolated buckle fractures to limb-threatening dislocations with neurovascular compromise. Fractures of the clavicle are frequent pediatric injuries. Clavicle shaft fractures in children are usually uncomplicated and require little, if any, treatment other than sling immobilization for comfort. Enthusiasm for internal fixation of clavicle fractures in adults has increased due to studies that have documented greater rates of nonunion, symptomatic malunion, and residual shoulder disability with nonoperative management. In a prospective randomized trial of 132 patients with clavicle fractures aged 16–60 years, internal fixation produced better outcome scores, earlier union, reduced rate of nonunion, and no malunion in comparison to nonoperative management. Internal fixation of adolescent clavicle fractures remains controversial, and accepted indications include open fractures and skin compromise. Relative indications in older adolescents include multiple injuries, floating shoulder injuries, comminuted fractures, and shortened fractures. Distal clavicular fractures in the immature child may mimic acromioclavicular separation. The periosteal sleeve of the distal clavicle remains intact with the coracoclavicular ligaments attached. ^, This fracture heals rapidly and requires no treatment other than sling immobilization for comfort unless displaced enough to compromise the skin.

Sternoclavicular dislocations are infrequent injuries that occur at the junction of the superior manubrium and medial clavicle. Most dislocations are due to high-energy mechanisms like MVCs or sports trauma. Anterior medial clavicle physeal fractures/dislocations occur more frequently than in the posterior direction. Patients with a posterior fracture/dislocation are at increased risk of abutment/injury to surrounding important structures. Careful examination should be performed to evaluate for dysphagia, dyspnea, respiratory compromise, neck venous engorgement, ipsilateral upper extremity diminished pulses, and neurological compromise. Anterior dislocations can often be treated with closed reduction with high success rates and good functional outcomes. Posterior dislocations should be treated urgently in the operating room. The clavicle injury may exert a tamponade effect on an injured vessel that is revealed suddenly after reduction, so it is critical for a thoracic or vascular surgeon to be aware and on standby. The physis of the medial clavicle is the last to close, which may not occur until after 21 years of age. The so-called dislocation of the sternoclavicular joint is usually a type I physeal fracture in children and adolescents, from direct or indirect trauma to the shoulder. Pain and swelling are localized to the sternoclavicular joint, and the shoulder is usually held forward. Although uncommon, compression of the mediastinal structures is the most serious complication of this injury and can manifest with dyspnea, dysphagia, or hoarseness. Without treatment, the most frequent problem associated with persistent posterior displacement is dysphagia.

Diagnosis of this injury requires awareness and a CT or MRI to confirm the diagnosis. Radiographs may show the posterior dislocation, but it is most clearly seen on CT images ( Fig. 17.12 ). Closed reduction can be attempted under general anesthesia, but recurrent displacement is common. Open reduction is more reliable than closed reduction, securing the fragments with large suture through the thick periosteal sleeve of the epiphysis and through several drill holes through the end of the shaft. Traditionally, open reduction is performed in conjunction with a general, vascular, or thoracic surgeon assisting or available in the event of unrecognized or iatrogenic injury to the great vessels.

A 16-year-old boy injured his right clavicle when he was checked into the board while playing hockey. He complained of difficulty swallowing. Anteroposterior radiograph of the right clavicle appeared normal. CT scan with thin cuts through the sternoclavicular joint shows posterior displacement (arrow) of the medial end of the clavicle.

Fractures about the proximal humerus can usually be treated nonoperatively. In all age groups the tremendous arc of motion in the shoulder joint allows a fairly large margin for fracture alignment. In the younger child, the rapid growth of the proximal humeral physis, which accounts for about 80% of the length of the bone, contributes to rapid and predictable remodeling of all but the most angulated fractures. In these children, no treatment other than immobilization for comfort is usually necessary. ^, Markedly displaced fractures in the teenager, however, may not remodel because there is not sufficient remaining growth. ^, Most injuries in this age group are unstable, displaced, and angulated Salter Harris type II fractures. These fractures frequently are closed reduced and then fixed with percutaneous Steinmann pins. ^,

Humeral shaft fractures occur in a bimodal distribution and usually occur in patients under 3 years or above 12 years old. Multiple different anatomic locations, fracture patterns, angulation, and displacement exist to classify these fractures. There is a heightened risk of radial nerve injuries in humeral shaft fractures with increased risk in the distal humeral shaft. Most humeral shaft fractures can be treated nonoperatively due to robust remodeling potential. Nonoperative treatment should be employed for fractures with less than 20-degree angulation in the coronal and sagittal plane, less than 15 degrees of rotation, and up to 2 cm of shortening.

Fractures about the elbow can be difficult to diagnose because the anatomy of the immature elbow is confusing due to the presence of numerous centers of ossification. Knowledge of the sequence of appearance and maturation of the secondary ossification centers allows proper differentiation of the fracture from normal age-specific anatomy. A comparison radiograph of the contralateral elbow may help correctly identify the nature of the injury. The capitellum ossifies at 1 year old and fuses between 12–14 years, the radial head ossifies at 3 years and fuses between 14–16 years, the medial epicondyle ossifies at 5 years and fuses between 16–18 years, the trochlea ossifies at 7 years and fuses between 12–14 years, the olecranon ossifies at 9 years and fuses between 15–17 years, and the lateral epicondyle ossifies at 11 years and fuses between 12–14 years of age.

The most common fracture about the distal humerus in the child is a supracondylar fracture. These fractures are classified according to the amount of displacement. The Gartland classification describes supracondylar humerus fractures as follows:

• Type 1 Nondisplaced.

• Type II Extension type with angulation with intact posterior hinge.

• Type III Extension type with complete displacement without bony hinge.

• Type IV Controversial fracture type that is unstable with flexion and extension.

Occult supracondylar humerus fractures exist and there should be a high index of suspicion when there is a history of trauma and pain in the supracondylar region with a radiographic posterior fat pad sign. Type III fractures are the most severe, with the distal fragment completely displaced. The injury typically occurs from a fall on the outstretched hand, with greater soft tissue injury the higher the fall. In children with lax ligaments, the elbow will hyperextend and shear off the distal portion of the humerus through the olecranon fossa. The major problems with this injury are swelling and nerve and/or vascular injury. One should think of these injuries as soft tissue injuries that happen to also have a fracture. This fracture does not need immediate operative reduction and stabilization unless there are other extenuating circumstances, such as vascular injury, compartment syndrome, or an open wound. Currently, general practice is to delay treatment until the next day. Initially, the elbow is splinted in less than 90 degrees of flexion with a loose bandage over a posterior splint. These fractures usually can be reduced by closed manipulation and stabilized by percutaneous pins ( Fig. 17.13 ).

A 6-year-old fell while horseback riding and landed on his outstretched left arm. (A) Anteroposterior and (B) lateral radiographs show a completely displaced (type III) supracondylar humerus fracture. Neurovascular status of the extremity was intact. (C, D) The child was treated with closed reduction and percutaneous fixation with smooth Steinmann pins.

There has been longstanding controversy as to the treatment of the pulseless (by Doppler imaging) extremity in patients who have sustained a supracondylar fracture. Absence of the pulse with this fracture is not uncommon. It is thought that the absence of the radial or ulnar pulse may be the result of vascular spasm and/or direct vascular injury. However, the collateral circulation about the elbow is so rich that the circulation to the forearm and hand usually remains normal. Treatment of the vascular injury has been debated for decades in the orthopedic and vascular surgery literature. The current practice is observation as long as circulation to the hand and forearm is clinically normal (<3 seconds capillary refill time). The only true indication for vascular exploration is the pulseless, ischemic extremity, which is a true surgical emergency. In this instance, the fracture should be reduced and stabilized with crossed pins, the fracture site explored if circulation does not recover, and immediate vascular repair if the limb remains ischemic.

Compartment syndrome is a feared complication that is uncommon in the modern era. Stabilizing the fracture with internal fixation avoids the need to immobilize the elbow in hyperflexion, which has been shown to increase the risk of vascular compression and forearm compartment swelling.

The signs of compartment syndrome are well known, but pain that is out of proportion to the fracture itself is most important. The 3 As of compartment syndrome to remember are A nxiety, A gitation, and A nalgesic requirements that are increasing because of pain. Once this fracture is stabilized, the child should be comfortable with minimal pain that is well relieved by medication. Passive extension of the fingers should be possible to a neutral position. If not, it suggests the need for investigation of a compartment syndrome by removal of the splint, palpation of the forearm compartment, and pressure measurements, if necessary. If the compartment pressures are elevated, fasciotomy should be urgently performed. Fasciotomy should not be delayed by obtaining compartment pressure measurements if a compartment syndrome is obvious clinically. In the prevention, diagnosis, and treatment of compartment syndrome, “time is tissue,” with increasing delay in diagnosis leading to worse outcome.

Salter Harris type I fractures of the distal humerus are less common than other injuries about the elbow and are frequently misdiagnosed. In very young children, this fracture often occurs as the result of NAT and should trigger investigation into the possibility of NAT. This fracture also may occur in newborns from birth trauma. As a result of difficult delivery, as well as with the older infant or child, the fracture may not be diagnosed until the healing callus is noted about a week after the injury, at which time manipulation of the fracture is either not possible or ill advised ( Fig. 17.14 ).

An 11-month-old infant, ultimately determined to have been the victim of abuse, presented with a swollen arm. (A) On the anteroposterior radiograph of the elbow, the capitellum, the proximal radius, and the ulna are displaced from their normal positions relative to the distal humerus ( arrows ), consistent with a fracture separation of the distal humeral epiphysis. In an elbow dislocation, the radius and ulna are displaced relative to the distal humerus but the capitellum is not displaced from its normal position in the distal humerus. (B) The lateral radiograph of the elbow shows a small metaphyseal fragment ( arrow ), also consistent with a fracture of the distal humeral physis and not with dislocation of the elbow. This fracture was treated with cast immobilization. (C, D) Note the exuberant fracture callus 3 weeks after the injury.

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