1

What is the Salter-Harris fracture classification?

This classification deals with pediatric fractures and their relationship to the growth plate. The classification has five levels (I–V), and each level relates to both the acute treatment recommended and overall prognosis. Higher level (III–V) Salter-Harris fractures are representative of progressively more serious injuries and greater growth disturbances and require close orthopedic follow-up.

2

Sort the fractures in Fig. 28.1 through 28.5 according to the Salter-Harris classification (I–V) ( Fig. 28.6 )

Fractures are type III, IV, I, II, and V, respectively.

Descriptions are embedded in the answer to question 2.

From Yamamoto LG, Chung SMK, Inaba AS: Salter-Harris. Radiology Cases in Pediatric Emergency Medicine 1 [case 18], University of Hawaii John A. Burns School of Medicine.

Diagram of the Salter-Harris classification. Abbreviations: M, metaphyseal involvement; E, epiphyseal involvement.

From Yamamoto LG, Chung SMK, Inaba AS: Salter-Harris. Radiology Cases in Pediatric Emergency Medicine 1 [case 18]. University of Hawaii John A. Burns School of Medicine.

Salter I: Fracture is confined within the growth plate and often not visible on radiographs. A widening of the physis or evidence of epiphyseal displacement may sometimes be seen. Fig. 28.3 shows displacement of radial epiphysis.

Salter II: Fracture involves the metaphysis and the physis.

Salter III: Fracture extends through the growth plate and epiphysis. Lowest classification of intraarticular fractures.

Salter IV: Also an intraarticular fracture that involves metaphysis, growth plate, and epiphysis.

Salter V: A crush/compression-type fracture that damages the physis. Often not seen on initial radiographs and retrospectively diagnosed once growth arrest has occurred. Fig. 28.5 shows a follow-up x-ray in a child with an axial load mechanism to the ankle and subsequent growth arrest.

3

Describe clinical and historical clues that suggest a young child has a nursemaid’s elbow needing reduction rather than an elbow fracture necessitating radiographs

A nursemaid’s elbow, an anatomic entrapment of the annular ligament between the radial head and capitellum, results from axial traction on the distal aspect of a child’s extremity (classic mechanism is lifting up on the wrist to pull the child up or back to prevent stumbling). Most elbow fractures in contrast involve blunt trauma to the elbow or a fall on an outstretched hand mechanism. Children with nursemaid’s usually present with the arm held closely to the side, pronated, and partially flexed. While these children refuse to move the elbow, in contrast to children with fractures there is usually no swelling or ecchymosis and no pinpoint bony tenderness to the distal humerus or proximal radius and ulna.

4

What pediatric extremity fractures are suspicious for nonaccidental trauma?

Any extremity fracture may be the result of abuse, particularly if associated with other injuries concerning for abuse or if the fracture and the history/mechanism are discordant (mechanism not plausible based on child’s developmental age and abilities, for example). The following extremity fracture patterns have the greatest specificity for abuse and should always arouse a high index of suspicion:

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  Femur fractures in preambulatory children

  
  
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  Spiral extremity fractures in preambulatory children

  
  
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  Multiple fractures in various stages of healing

  
  
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  Chip fractures of the metaphysis

  
  
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  Metaphyseal corner (aka “bucket handle”) fractures

5

Explain compartment syndrome and describe injury mechanisms or fractures that place a patient at risk for its development

Compartment syndrome describes a situation where an elevated pressure within an extremity’s fascial compartment prevents adequate perfusion. Resultant ischemia to the muscles, nerves, and vessels can ensue, leading to devastating extremity injury. Extremity injuries as a result of crushing forces, proximal tibiofibular fractures, displaced supracondylar fractures, midshaft radius and ulna fractures, and elbow dislocations are all high-risk fractures. Additionally, constrictive dressings and casts placed soon after injury and not “bivalved” to allow space for ongoing swelling are associated with compartment syndrome.

6

What signs and symptoms are concerning for possible compartment syndrome?

It cannot be emphasized enough that compartment syndrome is mainly a clinical diagnosis. Swollen and taught soft tissue in the traumatized region and pain out of proportion to the injury are usually the first (and sometimes only) clues to this diagnosis. The five Ps of compartment syndrome, in addition to pain, sometimes include paresthesia, pallor, paralysis, and pulselessness. Pain out of proportion should never be ignored, particularly if the pain is made worse with passive extension of the muscles in the compartment.

7

What are “plastic fractures”?

Torus, greenstick, and bowing fractures are often collectively referred to as “plastic fractures” and are unique to children as a result of the pliability of the pediatric skeleton. Torus (aka “buckle”) fractures are common, result from cortex bulging of a long bone without a visible fracture, and generally heal well with simple immobilization. Greenstick fractures, which consist of a visible fracture on one side and a bend on the other side, are usually treated with removable splint/cast immobilization and sometimes closed reduction depending on the fracture. Bowing fractures are uncommon and when seen are usually in the forearm in children between the ages of 2 and 5. These injuries will often require reduction to prevent permanent bone angulation.

8

Describe the location of injury and treatment of a “toddler’s fracture.”

A toddler’s fracture is a subtle radiographic fracture and involves the distal third of the tibia in ambulatory preschool children. This is a nondisplaced fracture, and as the fracture line is often spiral or oblique, it can be difficult to see on radiographic series without an oblique view. Young children with toddler’s fractures will often present with refusal to bear weight or walk, and the injury usually results from fairly minor trauma such as a low height fall.