This is a powerpoint developed by the consultants from the mater children's hospital brisbane emergency department (which has now amalgamated with the royal children's hospital to create the brand new Lady Cilento Children's Hospital LCCH) This is ideal for medical students/ residents to use to learn paediatrics orthopaedics. Easy and fun to go through.

1. Paediatric Orthopaedics
A Self-directed Learning
Package
Mater Children’s Emergency
Department
Brady / Reilly updated 2011

2. Fractures in Children
• Children’s fractures are unique due to their immature
skeleton.
• This module will take you through some common and
important fractures, helping you to recognise and
describe them.
• You will also learn about fractures and conditions that
are less common, but very important not to miss.

3. Common Fractures
The sites of the most common fractures
vary with each age group.
[Pictures from Thornton, Gill
“Children’s Fractures”
Saunders 1999]

4. Parts of a Long Bone
You will need to know these for describing fractures in children.
Epiphysis
Epiphyseal plate (Physis)
Metaphysis
Diaphysis

5. Salter-Harris Classification

6. Describing Fractures
When describing a fracture, follow the following formula:
1. open or closed
2. bone/s involved
3 .part of bone involved – midshaft/distal third/metaphysis/epiphysis
4. type of fracture –bowing
-buckle
-greenstick (with or w/o cortical or periosteal breach)
-transverse
-oblique
-spiral
-comminuted
5. displacement – direction of displacement of distal fragment relative
to proximal fragment eg palmar or volar/dorsal, anterior/posterior
6. angulation – the angle the distal fragment makes with the main axis
of the bone eg ‘distal fragment angulated 20 degrees posteriorly’
7. Presence or absence of associated dislocation
8. Presence or absence of associated neurovascular injury

7. For example…
This is a closed greenstick-type fracture of the distal radius with minimal
displacement and 10 degrees of dorsal angulation of the distal fragment.
10

8. Example 2
30 This is a closed transverse fracture of
the distal third of the radius and ulna.
The distal fragment of the ulnar fracture
is displaced dorsally and both distal
fragments are angulated to
approximately 30 degrees.
Remember that displacement and
angulation are different – displacement
means that there is lateral translation or
distraction or shortening of the two
fracture fragments relative to one
another, angulation means they are bent!

9. Example 3
Dislocations without fractures are
described in a similar way, but instead
of the bone, it is the involved joint that
is described.
This is a closed dislocation of the
metacarpophalangeal joint of the
thumb with dorsal displacement of the
distal fragment/proximal phalanx.

10. Upper Limb Fractures
We will now work through the most important
upper limb fractures:
• Supracondylar fracture
• Dislocated elbow
• Medial epicondyle fracture
• Fractured radius and ulna
• Distal radial fracture
• Fractured metacarpals
• Fractured scaphoid
• Monteggia fracture-dislocation

11. Supracondylar Fracture
• Unique to children under 10, rare in adults
• Most common elbow fracture in children
• Caused by a fall on the outstretched hand, with
hyperextension of the elbow
• The fracture is at the lower end of the humerus,
above the medial and lateral epicondyles
• May be radiologically subtle
• Missed fractures may result in permanent
neurovascular injuries or elbow deformity

12. Supracondylar fractures
• Supracondylar fractures are important because of the
associated high incidence of nerve and vessel injury
• The brachial artery and the median, radial and ulnar
nerves can all be kinked or torn by the fracture fragment
as they run in front of and behind the elbow joint
• All must be clinically evaluated and documented in every
patient
• Brachial artery injury may manifest as delayed capillary
refill, a cold pale hand or absent pulses at the wrist
• Median nerve injury (most common) may manifest as
inability to flex the interphalangeal joint of the thumb or
sensory loss
• To diagnose a supracondylar fracture it is important to
know the Elbow Rules

13. Cubital fossa nerves and artery
Radial N S: dorsal forearm
M: Finger gun gesture
Median N S: radial palm
M: OK gesture
Ulnar N S: ulnar forearm
M: Cross fingers
Brachial A: radial and ulnar
pulses and hand
perfusion

14. Elbow Rule #1
A line drawn through the radial head always intersects the
capitellum in both AP and lateral views
Radial head
capitellum

15. Every time you see an elbow xray, just think to yourself:
radial headcapitellum, radial headcapitellum.
capitellum
Radial head

16. Elbow Rule #2
A line drawn along the anterior aspect of the humerus (the
Anterior Humeral Line) should intersect the middle third of the
capitellum.
Capitellum

17. Elbow Rule #3
A posterior fat pad (a black lucency posterior to the distal
humerus), if visible in a true lateral film, indicates a fracture.
No fat pad Posterior fat pad
Normal elbow Supracondylar fracture

18. Radiographic Findings
In most supracondylar fractures, the
anterior humeral line does not pass
through the middle third of the
capitellum, but anterior to it.
In addition, there is a visible
posterior fat pad
The radial head and the capitellum
are usually still aligned, because the
fracture is above this level
In this fracture there is posterior
angulation and displacement of the
distal fragment

19. Supracondylar Fracture
This xray shows a suprandylar fracture with posterior displacement, angulation
and rotation of the distal fragment.
Anterior humeral line

20. Dislocated Elbow
Generally, this is not a tricky diagnosis clinically or radiologically. The xray
shows a dislocation of the right elbow joint with posterior displacement of the
radius and ulna.

21. Medial Epicondyle Injuries
•The medial epicondyle is the third ossification centre in the
elbow, becoming visible at around 6 years of age.
•Injuries usually occur when the elbow is forcibly abducted, and
the medial epicondyle is pulled away from the lower end of the
humerus by the ulnar collateral ligament.
•On AP view, the medial epicondyle should lie within 3mm of the
distal humerus. If it is further away than this, it is likely to have
been avulsed.
•On lateral view the medial epicondyle should not be visible, as it
is obscured by the capitellum. If you can see it in a true lateral,
it’s not in the right place.
•If in doubt, xray the opposite side to compare

22. Medial epicondyle fracture
Medial epicondyle

23. Medial Epicondyle Fracture
Extensive soft tissue
swelling Gap >3mm
Avulsed medial epicondyle
Normal elbow
Gap less than 3mm

24. Fractured Radius and Ulna
These fractures may be very obvious clinically and radiologically. This
xray shows fractures of the mid-shaft of the radius and ulna with
dorsal angulation of 80 degrees with minimal displacement of the
distal fragments because the dorsal cortex and periosteum of the
bones are still intact.
80

25. These fractures can also be very subtle – shown here is a greenstick fracture
of the distal radius with ulnar bowing – a fracture type unique to children.
Radial greenstick fracture
Ulnar bowing
Radial greenstick fracture

26. Distal Radial Fracture
Again, these fractures may be very obvious, as shown at left, or
just a subtle buckle (torus) fracture

27. Fractured Fifth Metacarpal
Epiphyseal plate
Fracture

28. Fractured Scaphoid
Scaphoid fractures are uncommon in
children
When they do occur, it is in the more
skeletally mature child (usually greater
than 10 years)
Fracture across waist of scaphoid

29. Monteggia Fracture-dislocation
In its most common variant, this is a fracture of the distal ulna associated with a
dislocation of the radial head at the elbow. This is an uncommon injury, but the
radial head dislocation is often missed, making it important to know what to
look for.
Generally, the ulnar fracture is obvious. Due to the close relationship between
radius and ulna, the resultant shortening should prompt a search for a balancing
radial defect.
The radial head dislocation becomes apparent if you follow the ‘radial
headcapitellum’ rule.
This particular fracture-dislocation is usually treated with closed reduction
under general anaesthesia. Other variations of disruption/dislocation occur.

30. Monteggia Fracture-dislocation
Radial head
Capitellum
Ulnar fracture

31. Lower Limb Fractures
• Fractured femur
• Fractured tibial spine
• Fractured tibia
• Ankle fractures
• Slipped upper femoral epiphysis (SUFE)

32. Fractured Femur
This is usually an unequivocal diagnosis. This xray shows a transverse fracture
of the midshaft of the left femur with lateral displacement of the distal fragment,
but with minimal angulation. That is, the distal fragment has moved sideways
from the fracture site but has not angled away from the long axis of the bone.

33. Fractured Tibial Spine
This fracture is the paediatric equivalent of the anterior cruciate ligament tears seen in
adults. Because ligaments have maximal tensile strength in childhood, the bone at the
site of insertion fractures (or avulses) first. Because these fractures are subtle on AP
view, they can be missed. However, as with all joints, an effusion after trauma in the
paediatric population usually indicates significant, often bony disruption and should
always be referred to the orthopaedic team.
Fracture line just
visible on AP view
Fracture line more
apparent on lateral

34. Fractured Tibia
Spiral fractures of the tibia are relatively
common in toddlers as they are learning to
walk. As the child gets older, however,
considerably more force is required to
fracture the tibia.
Note that the fracture is quite difficult to
see on the lateral film. Remember all
fractures require a minimum of two views,
and the joints above and below need to be
visualised.

35. Ankle Fractures
With all ankle fractures, remember
that the tibia and fibula often fracture
together (like the radius and ulna) and
a fracture in one should prompt a
thorough search for a fracture in the
other.
The fibula in particular may fracture at
a site distant from the site of the tibial
fracture. The entire length of the fibula
needs to be xrayed so as not to miss
this.
This fracture is described on the next
slide.

36. Ankle Fractures
This fracture looks difficult to
describe, but if you follow the formula
it makes it easier.
This is a closed fracture of the distal
Tibial fracture
line
left tibia and fibula. The tibial fracture
extends through the epiphyseal plate
Fibular fracture and into the metaphysis of the tibia
sites
(Salter Harris type II fracture). The
distal fragment is displaced laterally
and is angulated to 30 degrees.
30
30 The fibula shows two greenstick
fractures of the distal shaft. The
fractures are not displaced but are
angulated to 30 degrees.

37. Ankle Fractures
This is a Tillaux fracture of the
ankle –the adolescent
equivalent of an avulsion
fracture of the medial malleolus
in a child (again, as the
ligaments are so strong the bone
fractures first).
Fracture Without knowing the
line eponymous name for it though,
you could describe it as a closed
fracture of the medial distal left
tibial epiphysis with minimal
displacement and no angulation.
The fracture line extends from
the epiphyseal plate to the tibio-
epiphysis talar joint space.

38. Slipped Upper Femoral
Epiphysis = SUFE
Slipped upper femoral epiphysis is a condition where the there is
displacement of the femoral head relative to the femoral neck
through the epiphyseal plate. The underlying multi-factorial
vulnerability to shear stress may cause gradual cumulative
slippage, or the epiphysis may slip acutely. It is the most common
hip problem of adolescence.
This disorder is important because early diagnosis improves outcome.
Initial missed diagnosis is the rule, with the average time to
diagnosis of 6 to 10 months.
SUFE eventually occurs in the opposite hip in 60% of patients.
Obese adolescent boys are most at risk, but SUFE can occur in any
adolescent (8-15 years).
Clinically there will be hip, knee or groin pain with or without a history
of trauma. In some 50% of patients, hip pain never develops and
the primary symptom is isolated knee pain referred from the hip.

39. SUFE
The radiologic findings can be subtle but become more obvious when the correct views
are obtained. While the AP can appear normal, the head should “mushroom” out over
the neck. As you can see in this case the frog-leg lateral clearly shows the slippage of
the femoral head t the level of the epiphyseal plate.
AP view Frog-leg lateral view

40. Cervical Spine Injuries
You will learn about:
• How to assess xrays of the cervical spine
• Teardrop fracture
• Jefferson fracture

41. Cervical Spine - 7 bones
and 3 views
A minimum of three views showing all seven cervical vertebra is the minimum
requirement for an adequate assessment of the cervical spine. The three views are
AP, lateral down to C7/T1 junction, and an open mouth peg view.
1
2
3
4
5
6
7

42. Cervical Spine Imaging
Note that for optimal neutral positioning in the supine
position, children under 10 with suspected spinal
injury must have a foam thoracic elevation device
(TED) inserted as part of routine spinal
immobilisation [to counter-balance their large heads].
Without this, hyperflexion and false positive
radiological findings, such as increased prevertebral
soft tissue thickening and pseudo-subluxation, are
more common.
Pandie et al 2010 BMJ

43. Cervical Spine- the 4 lines
Start with the lateral. Trace the 4 lines below, looking for any part of the vertebrae
that are out of alignment. The lines become more curved as you go from anterior to
posterior.
Spino-laminar line Anterior vertebral line
Spinous process line
Posterior vertebral line

44. Cervical spine – the soft
tissues
Next look at the soft tissues.
The maximal allowable width of the pre-
vertebral soft tissue space is:
- one half the vertebral body width from C1
to C4
- one whole vertebral body width from C4
to C7
Increased width of the pre-vertebral space
of a properly positioned cervical spine
suggests swelling, eg from a fracture or
ligamentous injury.

45. Cervical Spine – vertebral
bodies
The next step is to trace around individual
vertebral bodies in turn, looking for
irregularities in the usual rectangular shape.
Look particularly for wedge or
compression fractures, with irregular loss
of height, or teardrop fractures of the
anterior inferior corner of the vertebral
body. These are important because
although small, they indicate significant
ligamentous injury and hence potential
instability.

46. Teardrop Fracture

47. The next thing to assess on a lateral film is the pre-dental space – that is, the space
between the anterior border of the peg, and the anterior arch of C1. Anything greater
than 5mm (child or adult) is abnormal and suggests instability of the transverse
ligament

48. Cervical spine - AP
Next assess the AP view.
The main things to look for in this
view are:
-that the spinous processes line up
-that the vertebral bodies are
symmetrical and have no obvious
fracture
-that the vertebrae are evenly spaced

49. Cervical Spine - peg
Lastly assess the peg view. Look for a well-centred film with the peg lining up
with the gap between the front incisors. This film is slightly rotated.
Next look at the space either side of the peg – this should be symmetrical.
Then look at the outside edge of the lateral masses of C1 – this should line up
with the outside edge of C2.
Lateral masses of C1
Body of C2 Odontoid
process

50. C1/C2 Fracture
Note that the anterior and posterior vertebral lines are abnormal, and
the soft tissue spaces very widened. The peg has fractured and has
tilted forward, as has the anterior arch of C1. This will cause
angulation and compression of the spinal cord at the level of C2.

51. Jefferson Fracture
A Jefferson fracture is a burst
fracture of C1. Think of C1 as
peppermint lifesaver – it is
impossible to break it in only one
place. The ring will always break
in at least 2 places. This fracture
occurs due to compression – a
fall from a height, or hitting the
head on the roof of the car in a
motor vehicle accident. This film
shows a widened pre-dental space
from an associated ligamentous
instability.

52. Jefferson Fracture
On the peg view, it is apparent that the space either side of the peg is
widened and asymmetrical. In addition, the lateral masses do not
align with the lateral borders of C2 – they have been laterally
displaced.

53. Well done! You’re finished.