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Book Reading
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Outline
Fracture of the tibia tubercle
 Fracture of the proximal tibial epiphysis
 Fracture of the shaft of the tibia and fibula
 Fracture of the ankle
 Injury of the foot
 Traumatic amputation

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Fracture of the tibia tubercle


Tibia tubercle: patella tendon insertion, most
anterior and distal portion of the proximal tibia
epiphysis
Result from jumping or a rapid quadriceps
contraction against a flexed knee
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Osgood-schlatter disease



Active children over the age of 8
Pain in tibia tubercle
Superficial microfracture of the cartilage at the
insertion of the tendon
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Evaluation


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Pain, swelling, tenderness
Limited displacement: may not be an effusion,
capable of limited active extension
Displaced frx: active knee extension is
impossible, effusion,
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Classification
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Treatment


Non-displaced type I: long leg cast in extension
for 4~6 wks
Others: ORIF with screws and washers, post-op
immobilization for 4~6 wks
Complication:
 Genu recurvatum
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Fracture of the proximal tibial epiphysis


Uncommon, 3% of epiphyseal injuries of lower
extremity
Proximal tibial epiphysis:
 55%
of the length of the tibia
 25% of the entire length of the limb
 0.6 cm per year

Popliteal artery: lies close to the epiphysis in the
popliteal fossa, at risk of injury with displaced
fracture
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Evaluation
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Pain, swelling, decreased ROM of knee
Neurovascular assessment
Vascular injury is suspected  arteriogram
Classification:
 Salter-Harris classification
Associated injury:
 Popliteal artery and peroneal nerve injury
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Treatment

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Salter-Harris type I, II: close reduction +
immobilization 4~6 weeks
Salter-Harris type III, IV: CRIF with
percutaneous pins or cannulated screws
Displaced frx with vascular injury: urgent
reduction and vascular status reassess
 Irreducible


or vascular injury present: open reduction
After reduction, splint in 10 ~20 degree flexion
Cast when risk of compartment has decreased
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Fracture of the shaft of the tibia and fibula
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The third most common long bone fracture
Low-energy fall in a young child or high-energy
trauma
10% are open
Risk of acute compartment syndrome
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Evaluation

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Pain, swelling, deformity is less common
because the fibula is frequently uninjured
Young child: stop walking, point tenderness
Assess skin condition and neurovascular status
May be invisible in toddlers and infant  bone
scan
Classification: no formal classification system
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Treatment -- Proximal metaphyseal frx

Potentially troublesome because of complication
of late valgus alignment
 Valgus
alignment: within 6 months, largest 2 years
after injury

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Any valgus angulation should be corrected
before casting
Long leg cast in varus for 4~6 weeks
Follow alignment weekly for the first few weeks;
any loss of reduction should be reduction
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Treatment – Closed diaphyseal frx
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Always nonoperaive
Correct angular and rotational deformity; apply
long leg cast
Radiography: obtain weekly for the first few
weeks, cast is wedged is necessary
Acceptable alignment:
>
50% fragment apposition
 <10 degree angulation on AP and lateral view
 <20 degree of rotation
 <1 cm shortening

Fail close reduction  OP
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Treatment – Open frx
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Stable low-energy injury: windowed cast
More extensive soft tissue damage: external
fixation, smooth pin, or limited internal fixation
Soft tissue coverage should be accomplished
within 7 days
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Treatment -- Distal metaphyseal frx

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Frequently malalign in recurvatum as a result of
impaction of the anterior cortex
Close reduction, long leg cast with the foot in
plantar flexion
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Complication -- compartment
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Potential devastating complication
Poorly controlled pain is the earliest sign
Discomfort during passive stretch of the muscle
Partial fibulectomy: lead to valgus deformity in
child, should not be performed
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Complication – Delay union or nonunion
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Fail to heal within 6 months
Unusual
Mean healing time
 10 weeks in close frx
 5 months in open frx
Iliac crest bone grafting: usually successful in
healing the nonunion
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Complication – Angular deformity

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Result from poor alignment or over-growth
Valgus deformity from frx of proximal tibia
metaphyseal
 Frequently
correct spontaneously over several years
 Observation is recommended
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Complication – Rotational deformity
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Result from inadequate reduction
Does not spontaneously correct
>20 degree  rotational osteotomy
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Complication – Proximal tibial physeal
closure
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Rare complication
Cause a genu recurvatum deformity
Corrected with an opening wedge osteotomy
Complication – Leg length discrepancy
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Overgrowth is usually the cause
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Child abuse
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Fracture of the ankle
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10% ~ 25% of all physeal frx
Usually result from indirect force
Physeal closure:
 central portion  medial potion  lateral
portion
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Evaluation

AP, lateral and mortise view
CT scanning: complex pattern and intraarticular
frx

Classification
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 Anatomic
pattern: Salter-Harris classification
 Mechanism of injury: Tachdjian-Dias classification
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Treatment
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2 mm intraarticular displacement is acceptable
Salter-Harris type I distal tibia frx:
 Nondisplaced:
short leg walking cast for 4~6 weeks
 Displaced: long leg cast for 3 weeks  short leg
walking cast

Salter-Harris type II distal tibia frx:
 Most
common, associated with fibular frx
 Close reduction to < 5 degree varus or valgus
angulation
 Long leg cast for 2 weeks short leg walking cast
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
Salter-Harris type III and IV distal tibia frx
 Undisplaced:
close reduction
 Irreducible: ORIF

Salter-Harris type V distal tibia frx: rare
 No

formal recommendation
Tillaux fracture
 Slater-Harris
type III caused by external
rotation
 Close reduction by internal rotation and
confirmed by CT scan, long leg cast for
3 weeks  short leg cast for 3 weeks
 Irreducible : ORIF
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
Triplane fracture
 Slater-Harris
type IV
 CT scan to assess displacement and surgical plan
 Goal: less then 2 mm of displacement by close or
open mean
1. Anteriolateral physis
2. Remaining physis
3. Tibia metaphysis

Salter-Harris type I distal fibular frx
 50%
displacement is acceptable
 Short leg walking cast for 4 weeks
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Complication
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Malunion: if inadequate reduction
Growth arrest: common in Salter-Harris type III
and IV
Arthritis
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Injury of the foot

In young children, the bone are primarily
cartilaginous and pliable; less susceptible to frx

Talus frx
Calcaneus frx
Navicular frx
Injury of the tarsometatarsal joint
Metatarsal frx
Phalangeal frx
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Talus fracture
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Forced dorsiflexion combined with inversion or
eversion
Rare in child
Pain, swelling tenderness and difficulty bearing
weight
Hawkins classification
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Treatment

Nondisplaced: nonweightbearing cast for 6~8
weeks  weightbearing cast for 2 weeks
Displaced:
 Close reduction
 > 5 mm displacement after close reduction 
ORIF
Monitor with periodic radiography to r/o AVN
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Lateral and medial talar process fracture:
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 Tenderness
beneath malleoli
 Immobilization with avoid weightbearing
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Complication
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AVN: occur during the first 6 months after injury
Hawkin’s sign: subchondral lucency on plain flim
 Evidence
of revascularization of talar body; indicator
of talar viability
 Absence does not indicated AVN in child
MRI to screen AVN
 Tx: nonweightbearing in
patellar tendon-bearing
articulated orthosis until
revascularization
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Calcaneal fracture
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Clinical course is benign particularly in young
child
History of fall is common
Tenderness area is difficult to locate
Radiography is often normal
Intraarticular injury  CT scan
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Treatment
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
Majority: casting
Significantly displaced intraarticular fracture
 Reduced
percutaneously or open
 Avoid weightbearing for 6 weeks
Associated injury
 L-spine injury, particularly after falls from height
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Navicular injury
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Dorsal chip fracture: cast immobilization
Stress fracture: nonweightbearing cast for 6~8
weeks
Injury of the tarsometatarsal joints
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Impact while on tiptoe, heel-to-toe compression,
or a fall backward while the foot is fixed
Classification: as with adult
Nondisplaced: short leg cast
Displaced: close or open reduction and fixed
with threaded pins or screws
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Metatarsal fracture
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Direct or indirect trauma
Most frequent at metatarsal neck
Pain, swelling, tenderness, difficulty bearing
weight
No specific classification
Lateral angulation or translation does not affect
outcome
Volar displacement may cause metatarsalgia
Possibility of compartment syndrome
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Avulsion fracture of the base of the fifth
metatarsal
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Pull of the peroneus brevis or the abductor digiti
minimi
Short leg walking cast for 3~6 weeks
Jones fracture
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Fracture at the metaphyseal-diaphyseal junction
of the fifth metatarsal
Intramedullary screw fixation or open bone
grafting
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Phalangeal fracture
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Direct trauma
Proximal phalanx is most frequent
Most heal without complication
Nondisplaced: buddy taping and hard-sole shoe
Displaced: reduce with traction and buddy taping
Displaced Salter-Harris fracture: often nail bed is
disrupted, fracture is open
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Thanks for your attention!
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