Pediatric Orthopedic Surgical Emergencies

Pediatric Orthopedic Surgical Emergencies
Joshua M. Abzug ●
Martin J. Herman
Editors
Pediatric Orthopedic Surgical

Emergencies
Editors
Joshua M. Abzug Martin J. Herman
Department of Orthopedics Orthopedic Center for Children
University of Maryland School of Medicine St. Christopher’s Hospital for Children
Timonium, MD, USA Philadelphia, PA, USA
ISBN 978-1-4419-8004-5 ISBN 978-1-4419-8005-2 (eBook)

DOI 10.1007/978-1-4419-8005-2
Springer New York Heidelberg Dordrecht London
Library of Congress Control Number: 2012936120
© Springer Science+Business Media New York 2012

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This book is dedicated to the pediatric
patients we take care of. The information
provided is meant to aid those caring for
children in an acute setting and to serve as a
practical resource. We hope that the care of
injured children will be improved with the
helpful strategies suggested for dealing with
orthopedic emergencies.
I would like to thank my wife, Laura, and
children, Noah and Benjamin, for their love
and understanding. They have sacrificed
their time with me and permitted me to help
with this project. I would also like to thank
my parents, Ed and Tobie, and my Aunt Renee,
who have been by my side since the beginning
when I decided to become a physician. I cannot
conclude without thanking my co-editor, Marty
Herman, and Beth Schad, developmental
editor, for their patience and guidance.
Joshua M. Abzug
This book is dedicated to Gabrielle, Ann,

Lizzie, Katherine, and Patrick. Because of
their constant love and support, I have been
able to pursue my passion for caring for
others and educating others about children
with orthopedic conditions and injuries.
Martin J. Herman
Foreword
It is my great pleasure to introduce the first edition of Pediatric Orthopedic Surgical

Emergencies. The primary purpose of this textbook is to assist the orthopedic sur-
geon whose on-call responsibilities require him or her to treat pediatric orthopedic
surgical emergencies.
For the general orthopedic surgeon, and even the pediatric orthopedic surgeon,
nighttime calls can present urgent questions or concerns. Often we do not have the
time to research the problem or to triage these patients to other surgeons. This text-
book is a single source designed to provide updated information on the current
treatments and best practices needed to care for patients with pediatric orthopedic
surgical emergencies.
Drs. Herman and Abzug have a great deal of personal experience in treating
children at a level 1 trauma center. They have also invited an outstanding group of
surgeons to author this textbook, many of whom have written papers or have pre-
sented lectures on the topics included. The textbook is consistent and uniform. The
information is easy to identify and very practical in nature. This is a wonderful book
to have on your shelf in a prominent location, ready to use on those nights when you
take calls and have urgent questions.
I congratulate Drs. Herman and Abzug for their wonderful work.
Cincinnati, OH, USA James J. McCarthy
vii
Contents
Part I Trauma Overview
1 Polytrauma in the Pediatric Patient ..................................................... 3

Joshua M. Abzug and Martin J. Herman
2 The Mangled Extremity in Children .................................................... 17
Sapan D. Gandhi, Joshua M. Abzug, and Martin J. Herman
3 Compartment Syndrome ....................................................................... 29
Baxter Willis
Part II Spine
4 Cervical Spine Injuries in Children ..................................................... 43

Steven W. Hwang, Per D. Trobisch, Andrew Jea,
and Amer F. Samdani
5 Thoracic and Lumbar Spine Injuries .................................................. 67
Hitesh Garg, Joshua Pahys, and Patrick J. Cahill
Part III Upper Extremity
6 Supracondylar Humerus Fractures ..................................................... 89

Joshua M. Abzug, Dan A. Zlotolow, and Scott H. Kozin
7 Upper Extremity Replantation in Children......................................... 111
Part IV Lower Extremity
8 Pediatric Hip Fractures and Dislocations ............................................ 127

James J. McCarthy, Kenneth J. Noonan, and Sapan D. Gandhi
ix
x Contents
9 Pediatric Proximal Tibial Fractures

with Vascular Compromise ................................................................... 141
William Hennrikus and Tamara Pylawka
10 Open Tibia Fractures in Children and Adolescents ........................... 157
Joseph Rosenblatt and Shannon D. Safier
Part V Infection
11 Septic Hip................................................................................................ 175

Peter D. Pizzutillo and Megan Gresh
12 Necrotizing Fasciitis ............................................................................... 187
Kevin J. Little and Joshua M. Abzug
Part VI Other
13 Slipped Capital Femoral Epiphysis ...................................................... 203

Panagiotis Peter Glavas and B. David Horn
Index ................................................................................................................ 233

Contributors
Joshua M. Abzug Department of Orthopedics, University of Maryland School of

Medicine, Timonium, MD, USA
Patrick J. Cahill Shriners Hospital for Children, Philadelphia, PA, USA
Sapan D. Gandhi Drexel University College of Medicine, Philadelphia, PA, USA
Hitesh Garg Department of Spine Surgery, Artemis Health Institute, Gurgaon,
Haryana, India
Panagiotis Peter Glavas Sainte-Justine University Hospital Cente, Montreal,
QC, Canada
Megan Gresh Department of Orthopedic Surgery, St. Christopher’s Hospital for
Children, Philadelphia, PA, USA
William Hennrikus Department of Orthopedics and Pediatrics, Penn State
College of Medicine, Hershey, PA, USA
Martin J. Herman Orthopedic Center for Children, St. Christopher’s Hospital
for Children, Philadelphia, PA, USA
B. David Horn Department of Orthopedic Surgery, The Children’s Hospital of
Philadelphia, Philadelphia, PA, USA
Steven W. Hwang Department of Neurosurgery and Orthopaedic Surgery,
Tufts Medical Center, Boston, MA, USA
Andrew Jea Department of Neurosurgery, Texas Children’s Hospital,
Baylor College of Medicine, Houston, TX, USA
Scott H. Kozin Department of Orthopedic Surgery, Shriners Hospital for Children,
Philadelphia, PA, USA
Kevin J. Little Division of Pediatric Orthopedic Surgery, Cincinnati Children’s
Hospital Medical Center, Cincinnati, OH, USA
xi
xii Contributors
James J. McCarthy Department of Orthopedic Surgery, Cincinnati Children’s

Hospital Medical Center, Cincinnati, OH, USA
Kenneth J. Noonan Department of Pediatric Orthopedics, U.W. School of Medicine
and Public Health, 1985 Highland Avenue, Madison, WI, USA
Joshua Pahys Shriners Hospital for Children, Philadelphia, PA, USA
Peter D. Pizzutillo Department of Pediatric Orthopedic Surgery, St. Christopher’s
Hospital for Children, Philadelphia, PA, USA
Tamara Pylawka Department of Orthopedic Surgery, Penn State College of
Medicine, Hershey, PA, USA
Joseph Rosenblatt Clinical Instructor of Pediatric Orthopedic Surgery,
Department of Orthopedics, St. Christopher’s Hospital for Children, Philadelphia,
PA, USA
Shannon D. Safier Assistant Professor of Pediatric Orthopedic Surgery,
Department of Orthopedics, St. Christopher’s Hospital for Children, Philadelphia,
PA, USA
Amer F. Samdani Department of Neurosurgery and Orthopaedic Surgery,
Tufts Medical Center, Boston, MA, USA
Per D. Trobisch Department of Orthopaedic Surgery, Shriners Hospitals for
Children—Philadelphia, Philadelphia, PA, USA
Baxter Willis Division of Pediatric Orthopedics, Children’s Hospital of Eastern
Ontario, Department of Surgery, Ottawa, ON, Canada
Dan A. Zlotolow Department of Orthopedics, Shriners Hospital for Children,
Part I
Trauma Overview
Chapter 1
Polytrauma in the Pediatric Patient
Joshua M. Abzug and Martin J. Herman
Abstract This chapter focuses on the polytraumatized pediatric patient. The most
common mechanisms of injury are discussed as well as prevention strategies to
avoid these devastating injuries. A significant discussion regarding the physiologic
differences between the adult and child is presented to allow a thorough understand-
ing of why these children can appear stable one minute and be critically ill the next.
The initial methods of evaluating and stabilizing these children are also provided.
Keywords Polytrauma • Pediatric polytrauma • Multiply injured child • Pediatric

fractures • Pediatric trauma
Introduction
Unintentional injury is the leading cause of death in children between the ages of 1
and 14 years [1]. In the USA, approximately 15,000 deaths annually are directly
attributable to traumatic injuries, many of which are preventable [1]. Furthermore,
traumatic injuries account for 50% of all deaths in children compared to only 10%
of deaths in the overall population of the USA [1].
J.M. Abzug, MD (*)

Department of Orthopedics, University of Maryland School of Medicine,
1 Texas Station Court, Suite 300, Timonium, MD 21093, USA
e-mail: jabzug@umoa.umm.edu
M.J. Herman
Orthopedic Center for Children, St. Christopher’s Hospital for Children,
3601 A Street, Ste 133-1, Philadelphia, PA 19134, USA
e-mail: martin1.herman@tenethealth.com
J.M. Abzug and M.J. Herman (eds.), Pediatric Orthopedic Surgical Emergencies, 3
DOI 10.1007/978-1-4419-8005-2_1, © Springer Science+Business Media New York 2012
4 J.M. Abzug and M.J. Herman
Nonfatal injury is the leading cause of emergency department visits for children
and adolescents, necessitating as many as 11 million visits per year. Motor vehicle
crashes, pedestrian and bicycle-riding injuries, falls, violence, and sports activities
are among the leading causes of these injuries, many of which are isolated extremity
fractures, sprains, and contusions.
Approximately 10% of children and adolescents who are the victims of trauma
sustain injury to more than one organ system, multiple long-bone fractures, or limb-
or life-threatening injuries. Often referred to as a “polytrauma patient” or the
“multiply-injured child,” these children and adolescents present unique challenges
to the orthopedic surgeon charged with their care. Musculoskeletal injuries are
second only to head injuries as causes of long-term morbidity from pediatric trauma
[2]. This chapter will focus on concepts of polytrauma management for the pediatric
patient with orthopedic injuries. Important anatomic and physiological differences
between pediatric and adult patients will be highlighted. Trauma team cooperation,
management strategies for damage control and definitive treatment, and the impor-
tance of injury prevention will be discussed.
Differences Between the Child and Adult
Anatomic Considerations
The skeleton of the child responds differently to traumatic injury compared to an

adult primarily because it is comprised of a combination of bone and cartilage that
is changing constantly until skeletal maturity. In general, a child’s bone is more
porous and less dense than adult bone. Because of this, plastic deformation may
occur before bone failure and less energy is required to cause fracture. The perios-
teum in children is also thicker and stronger compared to adults, limiting fracture
displacement and the extent of soft tissue damage due to fracture. The child’s perios-
teum is also more vascular, contributing to larger callous formation and more rapid
healing of fractures.
Children’s long bones have physes, or cartilage growth plates, toward their prox-
imal and distal ends. These structures are biomechanically weaker than the sur-
rounding ligaments or metaphyseal bone. Therefore, children more commonly
sustain fractures that involve the physes or the adjacent metaphyses (Salter–Harris
1 and 2 fractures), not ligamentous injuries. The presence of complex cartilage
anlages at the ends of growing bone, especially in younger children, contributes to
a decreased incidence of periarticular fractures compared to adults. Articular inju-
ries in children typically involve the physis (Salter–Harris 3 and 4 fractures) and
rarely occur in isolation. Damage to the physes from traumatic injury may result in
angular deformities and limb-length discrepancies due to growth disturbance, a
complication unique to children.
The difference in body proportions between a child and adult also leads to differ-
ent injury patterns. The ratio of a child’s head to their torso is proportionally larger
1 Polytrauma in the Pediatric Patient 5
Fig. 1.1 “Waddell’s Triad.” One simple explanation for the constellation of injuries seen in the
multiply-injured child is the reconstruction of the injury scene proposed by Wadell [4]: Children
struck by motor vehicles are first contacted by the bumper at the level of the femur, then by the body
or hood of the vehicle, injuring the thorax or abdomen. As the vehicle comes to a stop, the child is
finally abruptly hurled to the ground, sustaining a head injury (Courtesy of Dan Zlotolow, MD)
compared to an adult, with the largest disproportion noted in younger children. This
increased ratio makes the head more vulnerable to injury because it is relatively
heavier, resulting in the head striking the ground first during a fall, especially in
younger children [3]. The large head to small torso disproportion coupled with
increased ligament laxity and smaller paracervical muscle mass all contribute to an
increased incidence of upper cervical fractures in younger children compared to
adolescents and adults.
The child’s short stature and lower overall weight compared to adults also
influences injury patterns. An example is the injury constellation seen when a pedes-
trian is struck by an automobile. In an adult, the automobile’s bumper makes contact
with the tibia or knee, whereas in a child it contacts the femur or pelvis. Additionally,
the child, lighter than the adult, is more likely to become a projectile when struck,
sustaining injury not just from direct contact with the automobile but also with the
ground. One common combination of injuries in the polytraumatized child, termed
“Waddell’s triad,” consists of a femur fracture from the bumper strike, a thoracoab-
dominal injury from contact with the car hood, and a head injury from striking the
ground [4] (Fig. 1.1).
Physiologic Considerations
The physiologic response secondary to the stress of trauma is different in children

compared to adults. The child’s body surface to weight ratio is larger leading to the
development of hypothermia more rapidly. Children also have a smaller total blood
volume; therefore, blood loss volumes easily tolerated by adults may be catastrophic
for children. A 20–30% loss in blood volume can be tolerated in children before
their blood pressure decreases due to more effective physiologic compensatory

mechanisms compared with adults. [3] The surgeon must be aware that traumatic
shock may occur quite rapidly in children after significant or ongoing hemorrhage,
despite previously stable vital signs.
Trauma Scoring Systems
Trauma scoring systems generally are not used to make clinical decisions or alter
management. Assigning a trauma score or grade to each patient, however, provides
an objective measure of injury severity so that comparisons of specific treatment
protocols can be made between patients with similar severity profiles. Scoring sys-
tems are also useful for analysis of trauma care efficacy and efficiency, not only for
research purposes, but also to effect improvements in patient care. Many of the
commonly utilized systems are designed to assess the severity of the adult poly-
trauma patient and are not ideal for the multiply-injured child. The modified injury
severity scale (MISS) [5] and pediatric trauma score (PTS) [6] have been specifically
developed for pediatric trauma patients. These trauma scoring systems, along with
the Glasgow coma score (GCS) modified for pediatric patients [7], are commonly
used at many pediatric trauma centers.
The MISS is calculated by assessing neurologic status, the face and neck, chest,
abdomen, and extremities and pelvic girdle. Each area is graded from 1 to 5 with 1
being minor injury and 5 being critical, survival uncertain. For example, a minor
injury (1 point) involving the extremities and pelvic girdle, is a sprain or simple
fracture/dislocation. A moderate injury (2 points) would be open fractures of the
digits or nondisplaced long-bone or pelvic fractures. A severe, non-life-threatening
injury (3 points) would be given for displaced long bone or multiple hand or foot
fractures, an open long-bone fracture, displaced pelvic fractures, and laceration of
major nerves or vessels. Severe, life-threatening injuries (4 points) include multiple
closed long-bone fractures or amputation of a limb. Lastly, critical, uncertain sur-
vival injuries (5 points) include multiple open long-bone fractures. Similar grading
occurs for the aforementioned remaining 4 body areas [5].
The PTS is composed of six subcategories including weight, airway, systolic
blood pressure, central nervous system, fractures, and wounds. Each subcategory
can receive 2 points, 1 point, or −1 point. Examples include 2 points for no frac-
tures, 1 point for a closed or suspected fracture, and minus −1 for multiple closed or
open fractures. For wounds, 2 points are given if no wounds are present, 1 point for
minor wounds, and −1 point for major penetrating wounds or burns [6].
The pediatric GCS is very similar to the adult GCS with patients greater than two
years of age having identical scoring to that of the adult scoring system. Children
less than or equal to two years of age have identical scoring for the eye-opening
category with minor changes made for the verbal response and motor response cat-
egories. Regarding the verbal response category, 5 points are given if the child coos
or babbles, 4 points if the child is irritable or cries, 3 points if the child cries to pain,
2 points if the child moans in response to pain, and 1 point if there is no verbal
response. The motor response category gives 6 points to children with normal,
spontaneous movement, 5 points if the child withdraws to touch, 4 points if the child
withdraws to pain, 3 points if abnormal flexion is present, 2 points if abnormal
extension is present, and 1 point if there is no motor response [7].
The usefulness of trauma scoring systems for aiding in management decision-
making and predicting outcomes, especially for the polytraumatized child, has been
questioned by some researchers. [8, 9] Ott and colleagues applied 11 different
trauma scoring systems to 261 pediatric and adolescent trauma patients. The authors
calculated the prognostic ability of each scoring system to determine survival, length
of stay in the intensive care unit, length of stay in the hospital, and overall long-term
outcome. The trauma injury and severity score-scan (Triss-Scan) was found to have
the highest correlation with duration of treatment and overall long-term outcome.
Neither the MISS nor PTS were found to be significantly better than the adult trauma
scoring systems for predicting outcomes in children [8]. Yian and colleagues
assessed 91 pediatric polytrauma patients utilizing 6 different trauma scoring sys-
tems to evaluate them for correlation with orthopedic injuries. The authors found
that the TRISS-b, another adult scoring system, had the strongest correlation for
length of stay in the intensive care unit and number of total complications, and that
the trauma score (TS) was a strong predictor of the hospital course. No significant
advantage of the PTS compared with the adult scoring systems was identified [9].
Because of the controversy as to which scoring system is best, no single scoring
system is universally applied for the pediatric trauma patient.
Patient Evaluation and Management
Primary Survey and Resuscitation
Evaluation and treatment of the pediatric trauma patient begins at the scene of the
injury. Early resuscitation and proper stabilization require specialized equipment
designed for the pediatric patient. Examples include backboards modified to accom-
modate the relatively large head (Fig. 1.2), small cervical collars, small diameter
endotracheal tubes, small-bore intravenous needles, and needles capable of estab-
lishing intraosseous access. It is essential that the patient is properly immobilized
prior to transport to prevent any further injury, especially when spinal injury or
extremity fractures are present.
Upon arrival at a pediatric trauma center, the principles of diagnosing and treat-
ing life-threatening injuries are followed. This begins by performing a primary sur-
vey and initial resuscitation simultaneously. The primary survey focuses on the
airway, breathing, and circulation (The ABCs), as well as a brief neurologic exam
and complete exposure of the patient. Establishment and maintenance of the airway
is the primary focus of all trauma patients. This must occur with neck stabilization
to prevent worsening any potential cervical spine injuries that may be present.
Fig. 1.2 Backboards utilized for pediatric patients. (a) Adult backboard that does not accommo-
date for the relatively large pediatric head causes the cervical spine to go into flexion. (b) Pediatric
backboard with cutout to accommodate the relatively large pediatric head allows the cervical spine
to go into slight extension. (c) Alternative method of utilizing an additional board under the body
to allow the pediatric cervical spine to go into slight extension (Courtesy of Dan Zlotolow, MD)
Once the airway is established, the breathing status of the child should be
assessed. Any injury that compromises diaphragm excursion restricts ventilation in
children [3]. Diaphragmatic rupture and intra-abdominal injuries, pneumothorax,
pulmonary injury with hemothorax and flail chest must be considered in a child who
is having difficulty with ventilation. Endotracheal intubation and mechanical venti-
lation are done emergently if airway compromise or difficulty maintaining oxygen
saturation is identified.
When assessing the circulatory status, it is important to remember the child’s
improved ability to maintain perfusion in the face of hypovolemia. Initially after
injury, the child may maintain blood pressure in the normal range by peripheral
vasoconstriction and increasing the heart rate. The earliest signs of shock in the
pediatric polytrauma patient include tachycardia, tachypnea, cold extremities, and
decreasing urine output. Because rapid decompensation can occur in children after
initial signs of cardiovascular stability, aggressive resuscitation must be initiated at
the earliest warnings of impending shock. The first step in the resuscitation process
is to establish two large bore peripheral intravenous lines and to begin infusion of
isotonic crystalloid solution. Fluid boluses should be utilized until the child’s heart
rate normalizes and urine output is adequate. If no response is seen after a fluid chal-
lenge, blood transfusion should be considered. From the scene of injury through
emergency evaluation and resuscitation the child’s body is exposed, frequently

leading to hypothermia in the pediatric polytrauma patient. Because of the detri-
mental effects of low-core temperature on physiologic function, maintaining the
child’s temperature by infusing warm fluids, covering the child with warm blankets,
and increasing the room temperature are critical steps in the resuscitation that
improve outcomes.
Secondary Survey
After the primary survey is completed and the resuscitation process is begun, the
next step in diagnosis and management of the pediatric trauma patient is to perform
a secondary survey. This involves completing the history and performing a thorough
head-to-toe physical examination done by the trauma team including the pediatric
surgeon and the orthopedic surgeon, among others, based on the types of injury
encountered. Ideally, the neurologic status of the child is determined prior to admin-
istration of medications or intubation. This is especially critical if a traumatic brain
injury or spinal cord injury is suspected.
The orthopedic surgeon is a critical member of the trauma team and should be
involved in the assessment of any patient with a suspected spinal or extremity injury.
The spine and pelvis are typically assessed first. The collar is removed temporarily
and the head is held steady while the cervical spine is palpated for tenderness, defor-
mity, or gross step-offs. After replacement of the collar, the patient is logrolled into
the lateral decubitus position. The entire thoracolumbar and sacral spine, as well as
the posterior pelvis and perineum, are inspected for signs of injury such as bullet
holes, abrasions, lacerations, or ecchymoses. Subsequently, palpation of the entire
spine, sacroiliac joints, and posterior pelvis is performed to identify step-offs or
other abnormalities. A rectal exam to assess sphincter tone, evidence of blood or
bone fragments, or a high-riding prostate that may indicate an injury to the urethra
must be performed. After log-rolling the patient back to the supine position, the
anterior pelvis is assessed for soft tissue injuries and deformity. The iliac wings are
gently compressed and rocked for evidence of tenderness or gross motion. A pelvic
binder is applied if gross deformity or instability is noted at the time of initial evalu-
ation, especially if the patient is exhibiting signs of hemodynamic instability
(Fig. 1.3).
The examination then proceeds to the extremities. Beginning at the medial bor-
der of the clavicle, the entire upper extremity is palpated for any tenderness or crepi-
tus and each joint is assessed for swelling, tenderness, or limited motion. A careful
motor and sensory exam and assessment of vascular status by documentation of
pulses and distal perfusion complete the upper extremity assessment. The lower
extremities are evaluated in a similar thorough and systematic fashion.
Soft tissue abrasions, lacerations, crush injury, and areas of tissue degloving are
noted throughout the extremities. Soft-tissue damage or swelling may be the only
indicator of an underlying skeletal injury or may be an early sign of a limb at risk
Fig. 1.3 (a) AP pelvis of a multiply-injured child with hemodynaic instability who sustained a
traumatic head injury and a displaced pelvic ring fracture among other fractures. The order in
which measures are applied when managing a pediatric patient with a pelvic fracture that is poten-
tially the source of uncontrolled hemorrhage is similar to that for adults: (1) Application of pelvic
binder (2) Angiography and embolization (3) Surgical fixation. This patient’s hemodynamic status
stabilized after application of the pelvic binder and subsequently underwent definitive fixation
8 days after injury (b)
for compartment syndrome. Prior to imaging, extremities with gross deformity

should be grossly realigned by gentle longitudinal traction and splinted. Large
wounds or abrasions and open fractures, especially those with obvious contamina-
tion or debris, should be cleaned and covered with a sterile dressing. Intravenous
antibiotics are administered in the emergency department to patients with open frac-
tures and tetanus status is confirmed in all patients.
Imaging
Standard trauma imaging typically includes anteroposterior (AP) radiographs of the

chest and pelvis and some method to clear the cervical spine. At many trauma cen-
ters, computed tomography (CT) scanning of the cervical spine has replaced radio-
graphs, especially for children with a suspected head injury. CT scans of the head,
chest, abdomen, and pelvis are performed if the mechanism of injury or physical
examination suggests injuries to those areas may be present. Magnetic resonance
imaging (MRI) is rarely used in the setting of acute evaluation of the trauma patient
except for patients exhibiting evidence of spinal cord injury. High-quality orthogo-
nal radiographic views of the extremities should be performed to identify fractures
at all areas of deformity, tenderness, crepitus, or soft tissue injury.
Table 1.1 Components of a Pediatric Trauma Team

Pediatric surgeon
Pediatric emergency room physician
Pediatric orthopedic surgeon
Pediatric neurosurgeon
Pediatric anesthesiologist
Pediatric intensive care physician
Pediatric physical medicine and rehabilitation physician
Pediatric trauma-trained nursing personnel
Trauma Team
Management of the polytraumatized child is best accomplished through a multi-

disciplinary team approach headed by the pediatric trauma surgeon (Table 1.1).
Resuscitation to preserve the life of the child and complete diagnosis of all injuries
are the primary tasks of the team in the critical first 12–24 hours after injury.
Emergency limb-preserving surgery is performed by the orthopedic surgeon if the
child’s condition permits and includes management of the dysvascular limb, open
fractures with severe soft tissue injury, the mangled extremity, and those limbs
with an impending compartment syndrome. In the critically ill child, all emer-
gency surgery should be limited in scope to minimize blood loss and anesthesia
exposure.
Fracture Management
Damage Control
The concept of “damage control orthopedics,” introduced by adult orthopedic

trauma surgeons, advocates for temporary stabilization of fractures with external
fixation until more definitive treatment can be done after the patient’ s condition has
improved. It is hypothesized that early definitive surgery is a second major physio-
logic stressor (“second hit”) that may be detrimental to an already critically ill
patient effected by a significant injury (“first hit”) [10] (Fig. 1.4). Delay of definitive
treatment allows for some recovery, reducing the risk of serious postoperative com-
plications such as acute respiratory distress syndrome (ARDS) and multiorgan sys-
tem failure after prolonged orthopedic surgery.
Damage control orthopedics has not been studied in children. For practical
purposes, the concept of delaying prolonged definitive surgery for critically ill chil-
dren applies in few instances. For the majority of pediatric orthopedic injuries,
splinting and temporizing traction can be safely used in place of external fixation.
Limited limb-saving surgery for the dysvascular limb, severe open fractures, and
Fig. 1.4 Schematic demonstrating the “two-hit hypothesis”. ARDS—Acute respiratory distress
syndrome
compartment syndrome, however, is sometimes necessary. At our institutions, a

“damage control” approach is used for children with:
1. Persistent hemodynamic instability despite resuscitation efforts;
2. The “triad of death,” that is, hypothermia, coagulopathy, and acidosis;
3. A traumatic brain injury with intracranial pressure measuring > 30 mm Hg despite
medical management.
Definitive Fracture Stabilization
The timing of definitive fracture stabilization for the multiply injured child has not
been extensively studied in published series. Loder et al. in a review of 78 pediatric
trauma patients with musculoskeletal injuries and at least one other major injury
found that early fracture stabilization within the first 3 days after injury shortened
the length of stay in the intensive care unit, the length of stay in the hospital, and
length of time ventilator support was required [11]. Letts and colleagues, studying
a similar patient cohort, determined that pediatric polytrauma patients whose frac-
tures were stabilized early in their hospital course also experienced fewer complica-
tions compared with those who were treated in a delayed fashion [12].
Based on these reports and our experience, it is our practice to perform definitive
fracture surgery within 24–48 hours of injury, or as soon as the patient’s condition
permits. Clearance for the operating room is a decision made with input from the
trauma team, including the anesthesiologist who will care for the child in the operat-
ing room. To ensure that the safest decision for the child is made, the orthopedic
surgeon must make a careful and thorough preoperative plan, and communicate
directly with the trauma team about critical aspects of the surgery, including the
anticipated length of the procedure, the extent of surgery, and the estimated blood
loss. Each injury is treated ideally with techniques that permit early mobilization
and provide the best chance for the child to make a complete recovery from his/her
orthopedic injuries.
Outcomes
Providing specialized pediatric care from the prehospital environment to the emer-
gency room to the floor or intensive care unit is mandatory in order to obtain the best
possible outcome without causing unnecessary additional injury. Therefore, pediat-
ric trauma centers have evolved to optimize the care of injured children. Multiple
studies have demonstrated improved overall survival of children treated at pediatric
trauma centers compared to adult trauma centers [13–15]. Additionally, Potoka
et al. noted that survival was significantly improved at pediatric trauma centers
compared to adult trauma centers, with or without added pediatric qualifications, in
children with head, spleen, or liver injuries. Children who sustained moderate or
severe head injuries were more likely to undergo a neurosurgical intervention and
subsequently have a better outcome when they were treated at a pediatric trauma
center. In addition, a significantly higher number of children with spleen and liver
injuries underwent surgical exploration, with or without splenectomy, at adult
trauma centers yet outcomes were higher at the pediatric trauma centers [15]. Based
on this data, we feel children sustaining a traumatic injury should ideally be treated
at a pediatric trauma center whenever possible.
Injury Prevention
Preventing unintentional injury in children is the responsibility of the global com-

munity. Targeted education programs, safe product design, and governmental safety
legislation, such as the mandatory use of car seats and the introduction of helmet
rules for bicyclists, are some important injury prevention strategies that have made
a difference for children (Fig. 1.5). Healthcare providers, and orthopedic surgeons,
in particular, are in a unique position to educate parents and patients about injury
prevention. The American Academy of Orthopedic Surgeons’ campaign to educate
the public about the dangers of all—terrain vehicles is one example of this educa-
tion effort on a national scale (www.aaos.org).
Community-based efforts are, perhaps, the most important strategies for success-
ful injury prevention. Safe Kids USA (www.safekids.org) and Injury Free Coalition
for Kids (www.injuryfree.org) are some the organizations that promote parental and
child education to prevent unintentional injury, provide safety devices, and advocate
for improved safety legislation. The goal of injury prevention is to identify faulty or
dangerous products as well as unsafe environments, and to teach those responsible
for the care of children how to avoid or diminish the risk of unintentional injury.
Fig. 1.5 The introduction of federally mandated child safety seat requirements and the increased
use of helmets are injury prevention initiatives that contributed to a decline in the number of fatal
traumatic injuries during this time period
Conclusion
Despite improved preventive measures, pediatric trauma continues to occur on a

daily basis with a significant mortality rate. When these inevitable injuries occur,
children receive the best potential outcome when they are treated at a specialized
pediatric trauma center that is capable of performing the necessary procedures to
stabilize and resuscitate the child. By following established protocols and having
personnel available who are specially trained as pediatric patients, survival can be
improved. The orthopedic surgeon who understands the anatomic and physiologic
differences associated with children compared with adults is able to provide the
optimal treatment leading to the best outcomes.
References
1. Ramenofsky ML. Pediatric abdominal trauma. Pediatr Ann. 1987;16:318–26.

2. Marcus RE, Mills M, Thompson GH. Multiple injury in children. J Bone Joint Surg Am.
1983;65:1290–4.
3. Wilber JH, Thompson GH, Son-Hing J. The multiply injured child. In: Green NE, Swiontkowski
MF, editors. Skeletal trauma in children. 4th ed. Philadelphia, PA: Saunders Elsevier; 2009.
p. 57–83.
4. Waddell JP, Drucker WR. Occult injuries in pedestrian accidents. J Trauma. 1971;11:844–51.
5. Mayer T, Matlak ME, Johnson DG, et al. The modified injury severity scale in pediatric mul-
tiple trauma patients. J Pediatr Surg. 1980;15:719–26.
6. Tepas JJ, Mollit DL, Talbert JL, et al. The pediatric trauma score as a predictor of injury sever-
ity in the injured child. J Pediatr Surg. 1987;22:14–8.
7. James HE. Neurologic evaluation and support in the child with an acute brain insult. Pediatric
Ann. 1986;15:16–22.
8. Ott R, Kramer R, Martas P, et al. Prognostic value of trauma scores in pediatric patients with
multiple injuries. J Trauma. 2000;49:729–36.
9. Yian EH, Gullahorn LJ, Loder RT. Scoring of pediatric orthopaedic polytrauma: correlation of
different injury scoring systems and prognosis for hospital course. J Pediatr Orthop.
2000;20:203–9.
10. Pape HC, Giannoudis P, Krettek C. The timing of fracture treatment in polytrauma patients:
relevance of damage control orthopedic surgery. Am J Surg. 2002;183:622–9.
11. Loder RT. Pediatric polytrauma: orthopaedic care and hospital course. J Orthop Trauma.
1987;1:48–54.
12. Letts M, Davison D, Lapmer P. Multiple trauma in children: predicting outcome and long-term
results. Can J Surg. 2002;45:126–31.
13. Hall JR, Reyes HM, Meller JL, et al. The outcome for children with blunt trauma is best at a
pediatric trauma center. J Pediatr Surg. 1996;31:72–7.
14. Nakayama DK, Copes WS, Sacco W. Differences in trauma care among pediatric and nonpe-
diatric trauma centers. J Pediatr Surg. 1992;27:427–31.
15. Potoka DA, Schall LC, Gardner MJ, et al. Impact of pediatric trauma centers on mortality in a
statewide system. J Trauma. 2000;49:237–45.
Chapter 2
The Mangled Extremity in Children
Sapan D. Gandhi, Joshua M. Abzug, and Martin J. Herman
Abstract A mangled extremity is an extremity that has sustained severe traumatic

injury to at least three of the systems of a limb (soft tissue, bone, nerves, and
vasculature). Management of mangled extremities in children poses a difficult
challenge to the treating surgeon, as decisions must be made quickly to ensure the
best possible outcome for the patient. The most difficult decision is whether limb
salvage should be attempted or amputation should be performed. This chapter
reviews the presentation, evaluation, treatment, and outcomes of mangled extremi-
ties in children.
Keywords Mangled extremity • Mangled limb • Traumatic amputation • Acquired

limb deficiency • Limb salvage • Lawnmower injury • Farm machinery injury
Introduction
A mangled extremity is defined as severe traumatic injury to at least 3 out of 4 systems

of a limb (soft tissue, bone, nerves, and vasculature) [1]. It is often referred to as a
traumatic amputation or acquired limb deficiency because the overwhelming majority
S.D. Gandhi (*)

Drexel University College of Medicine, 2900 W. Queen Ln, Philadelphia, PA 19129, USA
e-mail: sapandgandhi@gmail.com
J.M. Abzug, MD
M.J. Herman
Orthopedic Center for Children, St. Christopher’s Hospital for Children,
3601 A Street, Suite 133-1, Philadelphia, PA 19134, USA
e-mail: martin1.herman@tenethealth.com
18 S.D. Gandhi et al.
of these injuries present as an amputated or near-amputated limb. Although

significant strides in emergency care and reconstructive techniques have been made,
the mangled limb is typically associated with an extremely poor prognosis. Almost
every treatment option usually results in some decline in functionality.
In North America, injuries to children are a pressing public health concern, as more
than 70% of catastrophic injuries resulting in significant morbidity to children are
preventable [2]. The primary mechanism of injury is power lawn mower injuries, caus-
ing 42% of all amputations in children less than 10 years of age [3]. In many cases, the
child is riding on the lawn mower with a parent or grandparent and subsequently falls
off the resulting in severe injury. Alternatively, the child may be playing in the yard and
the parent or grandparent reverses the power lawn mower without realizing the child is
there. In both cases, the resulting injury is devastating to the child physically and
psychologically and to the family psychologically and financially.
Farm machinery, motor vehicle accidents, and railroad injuries are other causes
of mangled extremities in children [2, 4] (Fig. 2.1). Explosions from fireworks can
cause amputations of digits or the entire hand, In areas ravaged by war, children can
sustain more severe mangled extremities resulting from land-mine explosions or
gunshot wounds [5, 6].
Demographics
Demographical information for children sustaining severe trauma to the extremities is

limited, however, it is well established that ride-on lawn mowers and farm machinery
are a significant cause of morbidity in children [7, 8]. Additionally, multiple studies
have shown a twofold to threefold higher incidence of injuries in males [3, 4].
Time of year also has been shown to be significant with lawn mower and motor
vehicle accidents primarily taking place in the summer months (i.e., June and July,
respectively), and farm machinery trauma occurring in early fall (i.e., September).
Emergency Room Considerations
Presentation
The child with a mangled extremity will often present with trauma to multiple parts
of the body including the head, neck, chest, or abdomen. Although severe trauma to
the limb can be distracting, the surgeon should refrain from giving the mangled
extremity attention until life-threatening injuries are cared for and stabilization of
the patient has been achieved.
In many cases, the child will present with complete or near complete traumatic
amputation of the affected limb. In other cases, the child may have sustained an
2 The Mangled Extremity in Children 19
Fig. 2.1 Thirteen year old female who had her foot run over by a train. (a) Appearance of the
dorsum of the foot. Note the skeletonized toes distally. (b) Plantar surface. Note the large lacera-
tion in addition to the degloving injury. (c) Lateral radiograph. Note the intact bony structure
with the obvious soft tissue degloving. This patient had her toe phalanges disarticulated, which
permitted coverage of the remainder of the foot with the available skin. (Courtesy of Joshua
Abzug, MD)
open fracture in conjunction with severe peripheral nerve damage and/or arterial
rupture. Proper evaluation and treatment of life-threatening injuries is critical to the
favorable outcome of pediatric patients.
Evaluation and Preparation for Surgery
It is mandatory that advanced trauma life support (ATLS) protocols are followed
starting with the ABCs (airway, breathing, circulation). Once the ABCs are com-
pleted, the remainder of the primary and secondary surveys should be performed.
During the secondary survey, the mangled extremity should be assessed by first
obtaining hemostasis. Usually direct pressure is sufficient to stop bleeding; how-
ever; occasionally it is necessary to utilize a tourniquet. As a last resort one can
clamp or clip a vessel to obtain hemostasis; however, these measures decrease the
ease and success of vasculature repair.
Once hemostasis has been obtained, the difficult decision regarding limb salvage
versus amputation must be considered. The mangled extremity severity score
(MESS) is a simple grading scale used to assist surgeons with this difficult decision-
making process and has been validated in studies examining outcomes in adults
with severe lower extremity injuries [9, 10]. It assigns scores to various clinical
findings associated with the mangled limb. If the skeletal or soft tissue injury is low
energy (stab, fracture, civilian gunshot wound) 1 point is assigned, if it is medium
energy (open or multiple fractures), 2 points are given, if it is high energy (shotgun
or military gunshot, crush injury), 3 points are given, and if it is very high energy
(high energy plus gross contamination), 4 points are given. If the limb has a reduced
or absent pulse but normal perfusion, 1 point is given, if there is a limb that is pulse-
less with diminished capillary refill, 2 points are given, and if there is a limb that is
cool, paralyzed, insensate, or numb, 3 points are given. If the patient’s systolic blood
pressure is always greater than 90 mmHG then 0 points are given, if the systolic
blood pressure is transiently less than 90 mmHG then 1 point is given, and if the
systolic blood pressure is persistently less than 90 mmHG then 2 points are given.
No points are added if the patient is less than 30 years of age, 1 point if the patient
is between 30 and 50 years old, and 2 points are added if the patient is over 50 years
of age [9]. If the sum of the scores is greater than or equal to 7, amputation is indi-
cated. If the score is less than 7, successful limb salvage may be indicated. Studies
have suggested that the MESS may be useful in the pediatric population [11]; how-
ever, no study has validated such usage. Therefore, while the MESS may be used as
a guideline for treating the afflicted child, much of the evaluation may depend on the
experience and judgment of the surgeon.
One may argue that an attempt to salvage every mangled extremity should be made,
and a revision amputation can be undertaken if there are complications with the sal-
vaged limb. However, the treating surgeon should be careful not to follow this logic.
A failed salvaged limb requiring secondary amputation has potentially devastat-
ing consequences for the patient, not only physically in terms of multiple hospital-
izations and procedures but also psychosocially in terms of bearing the brunt of the
psychological consequence of severe injury twice [1]. On the other hand, children
possess a superior healing potential compared to that of adults, which may encour-
age the surgeon to pursue limb salvage more aggressively than in adults (Fig. 2.2).
Thus, thorough evaluation must be undertaken and all attempts to identify injured
limbs that would benefit most from early amputation should be made.
Fig. 2.2 (a) Fourteen year old boy who fell while jumping onto a freight train. AP radiograph
shows fracture-dislocations of the right midfoot in association of an ankle fracture-dislocation,
which was reduced in the ER. He had near-amputation of the 5th ray and severe loss of lateral soft
tissue. AP (b) and lateral (c) radiographs of the foot after 10 procedures. He underwent triple
arthrodesis in his final procedure to realign the hindfoot. He is now independently weight-bearing
with an orthotic (Courtesy of Joshua Abzug, MD)
Early in the evaluation process, the orthopedic surgeon should work with other
surgical specialists such as plastic surgeons, hand surgeons, and vascular surgeons
to assess the damage of the limb and its recovery potential. Although there are few
definitive useful guidelines for immediate amputation, some signs may indicate that
amputation is best performed early. Considerations include the fracture pattern, the
extent of vascular injury, and the integrity of perfusion to the extremity as well as
the presence of nerve injury [1, 12].
The mechanism of injury should also be considered when deciding whether to

pursue limb salvage or amputation. Extensive crush injuries may indicate amputa-
tion, while clean, sharp lacerations may have more potential for replantation. Injuries
from lawn mowers or farm machinery may be associated with extensive contamina-
tion that complicates the attempt at limb salvage, and therefore amputation may be
the best option.
Additionally, the time elapsed since injury should also play a role in the decision
process. Muscle undergos irreversible ischemic damage after losing perfusion for
more than 6 h when warm and 12 h when cold. Other soft tissue structures, such as
nerves, undergo irreversible damage after losing blood supply for 12–24 h.
Ischemic necrosis can have substantial implications in the reconstruction effort.
In the field, amputated parts should be wrapped in gauze, placed in a sealed plastic
bag and then placed on ice to minimize effects of ischemic damage. The parts should
never be placed directly on the ice. In the emergency room, parts of the limb that
have lost partial or complete perfusion should be wrapped in gauze, placing a plastic
bag with ice around them to cool the ischemic parts of the extremity [13]. Care
should be taken to lower the temperature of the limb, but not freeze any tissues as
that may cause more damage.
Lastly, overall assessment of the child’s health and social situation should be
considered when deciding between limb salvage and amputation. Co-morbidities
such as cardiac conditions or diabetes may affect the child’s ability to tolerate exten-
sive surgical reconstruction. Once limb salvage or amputation has been recom-
mended, and the parents are in agreement, the child should be immediately taken to
the operating room and prepared for surgery.
Surgical Treatment
Amputation
When amputation is pursued, it is important for the surgeon to consider the growth
potential of the limb as well as the usage of a prosthesis. In upper limb amputation,
the surgeon should maintain the maximum amount of bone length possible while
still excising the traumatized area of the limb. This will enable the limb to be uti-
lized as a “helper hand”. If the trauma is limited to the distal aspect of the limb, and
carpal/metacarpal bones can be saved, the child may be able to retain the ability to
pinch and pick up small objects.
In above-knee amputations, the surgeon should retain as much of the femur as
possible as a short femur could be lengthened in the future. It is important to ensure
that there is sufficient soft tissue coverage at the distal end of the above-knee ampu-
tation as direct weight-bearing on a prosthesis will occur here. If the child can retain
a long femur, his or her surface contact with the prosthesis will increase and provide
a more stable base for abductor function, minimizing abductor lurch.
In through-knee amputations (i.e., knee disarticulation), the child can retain good
functionality as bony overgrowth is limited and an excellent surface for prosthetic
contact and control is maintained [14]. To provide the patient with maximal hip
extension power, the surgeon should attach the hamstrings to the stumps of the
cruciate ligaments [15]. Because the femur of the amputated limb will grow at
nearly the same rate as the normal limb, the surgeon should perform a distal femoral
epiphysiodesis some years before the child reaches skeletal maturity so that the
femoral stump can be fitted with a prosthesis including a knee without creating a leg
length discrepancy.
With below-knee amputations, any viable part of the proximal tibia should be
preserved as lengthening of the proximal tibia will aid in permitting usage of pros-
thesis [16]. Although this procedure may be difficult for both the surgeon and the
patient, the child has the potential for significantly higher functional gains com-
pared to knee disarticulations and above-knee amputations. Among the benefits is
control of the knee joint, preservation of knee proprioception, and decreased energy
expenditure during walking and standing. The prosthetic devices used for below-
knee amputees are simpler, easier to fit, and more comfortable. To achieve maximal
results, the surgeon should aim to have at least 6 cm below the knee joint by the time
the child reaches skeletal maturity [2].
Limb Salvage
Limb salvage requires a multidisciplinary surgical approach, including contribu-

tions from orthopedic surgeons, plastic surgeons, upper extremity surgeons, and
vascular surgeons. After anesthesia and administration of prophylactic antibiotics,
the mangled extremity should be briefly irrigated and gross debris removed.
A detailed exam evaluating injuries to nerves, vascular structures, bone, and soft
tissue structures should be performed next. If vascular compromise is present, it
should be addressed immediately so that extensive and thorough excision of con-
taminated tissue can take place without worry of prolonging ischemia time.
The most important goal in early treatment of the mangled extremity is perform-
ing a thorough debridement of wound to prevent contamination and limit the chances
of subsequent infection. An open, compromised wound with high levels of contami-
nation can result in invasive infections to the child in as little as 6 h after injury [13].
It has been shown that thorough debridement and flap coverage within the first 72 h
leads to a decreased infection rate, fewer secondary amputations, and a lower non-
union rate [17, 18].
Open fractures should be treated as an emergency with surgical intervention
ideally occurring within 4–8 h after the injury [19, 20]. Excision of nonviable muscle
and contaminated or avascular bone fragments should be undertaken during the
debridement as these are niduses for infection. Jagged bone edges can be smoothed
utilizing a rasps or a saw to make the bone ends more amenable to subsequent bone
graft procedures that may be required in the future. Once adequate vascularity is
Fig. 2.3 Sixteen year old male who sustained a Type IIIB open tibia fracture. The fracture was
stabilized with an external fixation system, enabling access to the skin wound created by the open
fracture for later flap coverage (Courtesy of Joshua Abzug, MD)
present and the debridement has been performed, attention should be turned to
stabilizing the bony elements. Typically, we utilize external fixation devices are they
are readily available, easy to apply, and permit access to the soft tissue structures
that may require multiple procedures in the ensuing days (Fig. 2.3). Alternative
options include application of internal fixation; however, it is important to ensure
that the hardware is not exposed.
Complications and Outcomes
Bony Overgrowth After Amputation
Bony overgrowth after amputation can be a significant problem, especially due to

the need for children to obtain multiple prostheses as they grow. Usually, a painful
bursa develops indicating friction between the bone and the prosthesis. If this is
not addressed promptly, wound breakdown can occur leading to the bone protrud-
ing through the skin. Treatment is elimination of prosthetic usage followed by
revision amputation [21]. Such procedures may be required every 2–3 years until
skeletal maturity is reached.
One can attempt to limit bony overgrowth by having a cartilaginous surface at
the end of the distal limb to help minimize overgrowth. Cases of disarticulation
provide a cartilaginous surface. Alternatively, one can create a cartilaginous cap
utilizing cartilage from the amputated segment or a piece of iliac crest.
Phantom Pain
Although children with congenital limb loss or very young children with acquired
limb loss rarely have phantom pain, older children who undergo limb amputation
may experience phantom pain [2]. Usually, this pain is not debilitating; however,
severe cases do exist that may require physical therapy or medications to manage
the symptoms. Intraoperatively, nerves should undergo sharp laceration with place-
ment of the distal stump into muscle in an effort to minimize painful neuroma
formation.
Psychosocial Consequences of Limb Loss
Usually, very young children do not differ much than children of congenital limb
deficiencies in terms of psychosocial consequences. Their sense of loss and adjust-
ment period is minimal. However, older children may go through a grieving process
with damage to their self-esteem and self-image occurring. Encouragement and
positive reinforcement is often necessary to bring children with acquired limb
deficiencies back to a “normal” psychosocial state. Trained mental health providers
should be involved early in the care of patients with mangled extremities.
Limb Salvage Failure
Unfortunately, limb salvage is not always successful and secondary amputation may
become necessary due to lack of perfusion, infection, or chronic pain. Careful initial
assessment of the limb may aid in determining if limb salvage should be attempted
or primary amputation should be performed. Secondary amputation after attempted
limb salvage has devastating psychosocial and financial impact on the patient and
their family.
Limited studies are present discussing the advantages and disadvantages of
amputation and limb salvage in children. However, a number of studies focusing on
adults have provided a number of conclusions that are applicable to the pediatric
population.
In a Swiss study by Hertel et al. [22], patients with severe lower extremity injuries
underwent primary amputation or limb salvage. While patients with limb salvage
required more surgical procedures than amputation (8 versus 3.5, respectively), they
had greater functionality, less pain after complete recovery, and sustained fewer
lifestyle changes compared to patients with similar injuries who underwent amputa-
tion [22]. However, Georgiadis et al. showed that amputated patients had fewer
complications compared to limb salvage patients, shorter hospitalizations, less
procedures, and faster recovery time [23].
These differences represent the fact that there is no right answer. Whether to
attempt limb salvage or perform a primary amputation is a complex decision that
occurs on a case by case basis depending on the mechanism of injury, the extent of
injury, and the patient/surgeon’s preferences.
References
1. Wolinsky PR, Webb LX, Harvey EJ, Tejwani NC. The mangled limb: salvage versus amputa-
tion. Instr Course Lect. 2011;60:27–34.
2. Limb deficiencies. In: Herring JA, editor. Tachdjian’s pediatric orthopaedics. 4th ed.
Philadelphia: Saunders Elsevier; 2007.
3. Letts M, Davidson D. Epidemiology and prevention of traumatic amputations in children. In:
Herring J, Birch J, editors. The child with a limb deficiency. Rosemont, Illinois: American
Academy of Orthopaedic Surgeons; 1998. p. 235.
4. Loder RT. Demographics of traumatic amputations in children. Implications for prevention
strategies. J Bone Joint Surg Am. 2004;86-A:923–8.
5. Can M, Yildirimcan H, Ozkalipci O, et al. Landmine associated injuries in children in Turkey.
J Forensic Leg Med. 2009;16:464–8.
6. Stover E, Keller AS, Cobey J, Sopheap S. The medical and social consequences of land mines
in Cambodia. JAMA. 1994;272:331–6.
7. Lubicky JP, Feinberg JR. Fractures and amputations in children and adolescents requiring
hospitalization after farm equipment injuries. J Pediatr Orthop. 2009;29:435–8.
8. Costilla V, Bishai DM. Lawnmower injuries in the United States: 1996 to 2004. Ann Emerg
Med. 2006;47:567–73.
9. Johansen K, Daines M, Howey T, Helfet D, Hansen Jr ST. Objective criteria accurately predict
amputation following lower extremity trauma. J Trauma. 1990;30:568–72 (Discussion 72–3).
10. Helfet DL, Howey T, Sanders R, Johansen K. Limb salvage versus amputation. Preliminary
results of the Mangled Extremity Severity Score. Clin Orthop Relat Res. 1990;256:80–6.
11. Fagelman MF, Epps HR, Rang M. Mangled extremity severity score in children. J Pediatr
Orthop. 2002;22:182–4.
12. Lange RH. Limb reconstruction versus amputation decision making in massive lower extrem-
ity trauma. Clin Orthop Relat Res. 1989;243:92–9.
13. Bernstein ML, Chung KC. Early management of the mangled upper extremity. Injury. 2007;38
Suppl 5:S3–7.
14. Loder RT, Herring JA. Disarticulation of the knee in children. A functional assessment. J Bone
Joint Surg Am. 1987;69:1155–60.
15. Rab G. Principles of amputation in children. In: Chapman M, editor. Operative orthopaedics.
Philadelphia: JB Lippincott; 1993. p. 2469.
16. Younge D, Dafniotis O. A composite bone flap to lengthen a below-knee amputation stump.
J Bone Joint Surg Br. 1993;75:330–1.
17. Byrd HS, Cierny 3rd G, Tebbetts JB. The management of open tibial fractures with associated
soft-tissue loss: external pin fixation with early flap coverage. Plast Reconstr Surg.
1981;68:73–82.
18. Byrd HS, Spicer TE, Cierney 3rd G. Management of open tibial fractures. Plast Reconstr Surg.
1985;76:719–30.
19. Oakes R, Urban A, Levy PD. The mangled extremity. J Emerg Med. 2008;35:437–44.
20. Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture wounds. Clin Orthop
Relat Res. 1989;243:36–40.
21. Abraham E, Pellicore RJ, Hamilton RC, Hallman BW, Ghosh L. Stump overgrowth in juvenile
amputees. J Pediatr Orthop. 1986;6:66–71.
22. Hertel R, Strebel N, Ganz R. Amputation versus reconstruction in traumatic defects of the leg:
outcome and costs. J Orthop Trauma. 1996;10:223–9.
23. Georgiadis GM, Behrens FF, Joyce MJ, Earle AS, Simmons AL. Open tibial fractures with
severe soft-tissue loss. Limb salvage compared with below-the-knee amputation. J Bone Joint
Surg Am. 1993;75:1431–41.
Chapter 3
Compartment Syndrome
Baxter Willis
Abstract Early recognition and prompt treatment of compartment syndrome in

children is essential to prevent long-term disability. Warning signs of a compart-
ment syndrome in a child include pain out of proportion to the injury, increasing
analgesic requirement, and anxiety and agitation in an otherwise healthy child.
These symptoms demand careful examination of the child and prompt treatment by
appropriate fasciotomy of the compartment(s) involved if there is sufficient evi-
dence of compartment syndrome.
Keywords Compartment syndrome • Pain • Anxiety • Agitation • Increasing

analgesia • Fasciotomy
Introduction
Compartment syndrome is a constellation of symptoms caused by elevated pressure

of tissue fluid in an enclosed osseofascial compartment which interferes with cir-
culation to the muscles and nerves of that compartment [1] (Fig. 3.1). Ischemia of
the nerves within the involved compartment first causes sensory changes, such as
paresthesias followed by muscle weakness. As the venous congestion and edema
progress, and perfusion diminishes, muscle pain and weakness worsen. Permanent
muscle and nerve injury may develop as early as 6–8 h after critical compartmental
pressures have been achieved. The end product of prolonged ischemia is loss of
nerve function and muscle replacement with fibrosis in the involved compartment.
Emergent fasciotomy of the involved compartment decompresses the fixed space,
B. Willis (*)
Division of Pediatric Orthopedics, Children’s Hospital of Eastern Ontario,
Department of Surgery, 401 Smyth Road, Ottawa, ON, Canada, K1H 8L1
e-mail: bwillis@cheo.on.ca
30 B. Willis
Injury
Arterial or arteriolar lesion Hemorrhage
Ischemia Swelling Edema
Impaired venous flow Increased tension
Resolution
Compartment syndrome
Fasciotomy
Fig. 3.1 Pathophysiology of compartment syndrome
permitting venous outflow and increasing tissue perfusion. In children, excellent

results are expected when the diagnosis is made in a timely fashion and adequate
release is performed [2].
Compartment syndrome is relatively uncommon in children. Its clinical manifes-
tations are similar to adults; however, compartment syndrome in children has some
unique features. Common causes in children include fractures and crush injuries to
either the upper or lower extremity, postoperative swelling after elective osteoto-
mies and other musculoskeletal procedures, constrictive splints or casts, burns,
extravasation of fluid from intravenous fluid administration, infections, and insect
or snake bites. A vascular injury requiring repair combined with a fracture has a
high incidence of compartment syndrome in children [3]. The most common sites
are the leg and forearm in association with tibial fractures of the leg, supracondylar
fractures of the humerus, and displaced fractures of both bones of the forearm [2].
Patient Assessment
The classic findings of compartment syndrome in adults are the so-called 5 P’s
which include “pain”, “pallor”, “parasthesias”, “paralysis”, and “pulselessness”
(see Table 3.1). Pain is the classic symptom and is usually severe, unrelenting, and
3 Compartment Syndrome 31
Table 3.1 The compartment syndrome in adults

Traditional adult signs of Pediatric signs of compartment
compartment syndrome (The P’s) syndrome (The A’s)
Pain Anxiety
Pallor Agitation
Parasthesias Analgesia requirement increasing
Paralysis
Pulselessness
out of proportion to the original injury [1–4]. In children, the classic signs and
symptoms of compartment syndrome may not be readily detectible. Rather, the
treating physician should be aware of the three A’s in the diagnosis of compartment
syndrome in children which include “anxiety”, “agitation”, and “analgesia” require-
ment increasing [3, 4]. Review of the nursing record for narcotic administration that
demonstrates an increasing need for analgesia is the most valuable evidence of com-
partment syndrome [2]. Older children are more likely to exhibit pain as the primary
symptom whereas younger children may have difficulty communicating that they
are in considerable pain. As a consequence, children who demonstrate anxiety, agi-
tation, or lack of cooperation and an increasing analgesia requirement after appro-
priate treatment and splinting of the injury or fracture require careful examination
to rule out compartment syndrome.
Physical Examination
Concern over the possible diagnosis of compartment syndrome requires the

removal of any circumferential dressing, splint, or cast. The extremity should be
examined for swelling or skin changes, and the compartments palpated for tender-
ness and tenseness of the soft tissues. Passive stretch of the muscles within the
involved compartment may elicit or increase the child’s pain. However, if the
patient has sustained a sensory or combined motor and sensory neurologic injury
at the time of the fracture, the diagnosis will be made more difficult to establish.
Median nerve injury at the time of a supracondylar fracture of the humerus is a
common example [2, 4, 5].
Decreased sensation and weak or absent motor function in the limb may be late
signs of a compartment syndrome. Typically children younger than eight years or
those with cognitive impairment are unable to cooperate with the examination or
verbalize responses to questions about sensation or movement. The surgeon, how-
ever, must make every attempt to fully evaluate motor and sensory function in all
patients. Patient observation of the child’s function while being asked to perform a
task (e.g., grasp a pen), repetition of the examination over time, and involving fam-
ily members in the examination are some ways to improve the chances of detecting
changes in sensory and/or motor function in young or uncooperative children.
32 B. Willis
SUSPECTED CLINICAL FINDINGS
Unconscious Patient
Inconclusive Clinical Findings
Conclusive Compartment Pressure

Clinical Measurement
Findings
>30 mmHg
<30 mmHG
Continuous Compartment
Pressure Monitoring
Repeated Clinical Exam
<30 mmHg
Positive Clinical >30 mm Hg

Diagnosis
FASCIOTOMY
Fig. 3.2 Algorithm used in diagnosing and treating acute compartment syndrome (from [16] with
permission)
The preservation of a distal pulse or distal perfusion is the norm in patients with
compartment syndrome [6]. The absence of a pulse is a very late manifestation of a
patient with compartment syndrome [1–5, 7]. If a pulse is not palpable, use of
modalities such as Doppler ultrasound, and arteriography may be useful to confirm
vascular status, especially if the suspected compartment syndrome is associated
with a potential vascular injury. Loss of distal perfusion is a poor prognostic sign for
the patient with a compartment syndrome.
Compartment Pressure Measurement
In those patients in whom a diagnosis of compartment syndrome is suspected, mea-

surement of compartment pressures may be useful to confirm the diagnosis [6, 8]
(Fig. 3.2 and Table 3.2). Clinical situations which may warrant the use of a pressure
monitoring device include the unconscious patient who has sustained a significant
extremity injury, an uncooperative patient with a suspected compartment syndrome
Table 3.2 Indications for compartment pressure measurement

Unconscious patient with significant extremity injury
Uncooperative patient with a suspected compartment syndrome in whom an adequate physical
examination is not possible
Patient with a significant extremity injury (fracture or soft-tissue injury) who has a concomitant
sensory nerve or combined motor and sensory nerve deficit
in whom an adequate physical examination is not possible or a patient with a

significant extremity injury (fracture or soft-tissue injury) who has a concomitant
sensory nerve or combined motor and sensory nerve deficit [1, 3, 5]. Because com-
partment pressure measurement assessment is painful and anxiety-provoking, espe-
cially for younger patients, use of local anesthetics, conscious sedation, or, in some
cases, general anesthesia are recommended based on the clinical scenario.
There are a number of commercially available compartment pressure monitoring
devices which employ a side bore needle that is inserted into the involved compart-
ment and a fluid-filled syringe attached to a pressure-sensitive monitor. The compart-
ment pressures may also be obtained with devices assembled from arterial line
equipment and other components available in the hospital [8]. A pressure reading of
greater than 30 mmHg is an absolute indicator of a compartment syndrome as well as
a compartment pressure within 30 mmHg of the diastolic blood pressure [6, 8, 9].
The unreliable nature of the physical examination, the difficulty in obtaining
adequate compartment measurements, and the potential errors in the tools utilized
to obtain pressure measures make the diagnosis, at times, extremely difficult to
make in children. The surgeon must keep in mind, however, that the diagnosis of
compartment syndrome is a clinical one (see Table 3.3). If a compartment syndrome
is clinically suspected, fasciotomy must be considered.
Treatment
Once diagnosed, a compartment syndrome is treated by appropriate fasciotomies.

Emergency surgical release of all compartments of the involved extremity should be
done in all cases of a suspected compartment syndrome regardless of intracompart-
ment pressure measurements. The only exception exists in the forearm, where the
volar compartments are the only ones those require fasciotomy. However, compart-
ment syndromes associated with severe crush injuries, circumferential burns, or a
vascular injury should have the entire forearm compartments released. An extensile
volar Henry approach [2, 3, 10] (Figs. 3.3 and 3.4) extending from the antecubital
fossa to the palm is required to adequately perform a volar fasciotomy. The surgeon
must ensure that both the superficial and deep compartments are entered, taking
care to identify and release the individual muscles of these compartments. At the
level of the wrist, the median nerve must be carefully identified to permit safe and
complete release of the carpal tunnel. If a complete forearm fasciotomy is necessary,
the dorsal compartment and “mobile wad” are easily released through a separate
extensile dorsal incision.
34 B. Willis
Table 3.3 Diagnosis of compartment syndrome

Clinical examination Absolute pressure reading greater than 30 mmHg
Pressure reading within 30 mmHg of the diastolic blood pressure
Fig. 3.3 Henry approach to the volar aspects of the forearm (courtesy of Dan A. Zlotolow, MD)
Fig. 3.4 Henry approach to superficial and deep compartments of the forearm (courtesy of Dan A.
Zlotolow, MD)
In the leg with a compartment syndrome, all four compartments require

fasciotomy. This is best accomplished with a two-incision approach [3–6, 11, 12].
The medial incision is made behind the palpable posterior edge of the tibia and a
fasciotomy of the superficial posterior compartment is performed. Next, the soleus
muscle must be taken down from the posterior edge of the tibial shaft in its distal
third allowing exposure of the fascia overlying the deep posterior compartment. In
similar fashion, the deep posterior compartment is decompressed along its entire
length (Fig. 3.5). Because the periositeum is thick and adherent to the fascia along
Fig. 3.5 (a) Double incision technique for performing fasciotomies of the four compartments of the
lower extremity. (b) Lateral incision. (c) Medial incision. (d) Cross section of lower extremity showing
position of anterolateral and posteromedial incisions that allows access to the anterior and lateral
compartments and superficial + and deep posterior compartments (courtesy of Dan A. Zlotolow, MD)
36 B. Willis
the posterior edge of the tibia here, subperiosteal dissection of the compartment
from the posterior tibia is adequate to achieve release and care must be taken to
ensure that the muscle fascia has been divided.
A second anterolateral longitudinal incision placed along the posterior third of
the anterior compartment is used to release the anterior and lateral compartments.
Care must be taken to avoid injury to the superficial peroneal nerve by identifying
and avoiding the nerve as the release proceeds from proximal to distal. After com-
plete release of the anterior compartment fascia, through the same skin incision, the
lateral compartment is identified posterior to the intermuscular septum and decom-
pressed in a similar fashion.
If the compartment syndrome is associated with a fracture, the fracture is best
managed with fixation in most cases. Internal fixation options, including K-wires
intramedullary nails or plate-screw constructs are preferred to facilitate fas-
ciotomy wound management. External fixation of fractures is also an option but
the surgeon must consider pin placement carefully so not to interfere with soft-
tissue management.
Wound Management
The compartments are left open at the time of release and closed on a delayed
primary basis by any number of techniques. In the lower extremity, typically one
incision may be closed after 48–72 h; however, it may be difficult to close the sec-
ond incision at this same setting. One method of wound closure for the remaining
incision is to utilize a combination of skin staples placed on the wound edges and
small vascular loops placed through the skin staples. The vascular loops are threaded
through the staples in a fashion similar to shoe laces placed through eyelets. The
loops can be pulled taut everyday until the skin edges approximate each other.
Another commonly used method is to place a vacuum-assisted closure (VAC) sys-
tem on the wounds after release. This allows for reduction of soft-tissue edema
while covering the wound, protecting against contamination and eliminating drain-
age on external bandages or splints. The VAC system also helps to prepare the
wound bed for skin grafting in the event that delayed primary closure cannot be
accomplished after several days of vacuum-assisted wound management.
Care After Fasciotomies
After surgery, the limb should be carefully splinted for comfort and to diminish the
risk of contractures. As soon as the wounds have healed or skin grafting has taken
to an adequate degree, physical therapy is instituted to prevent soft-tissue stiffness
and to increase muscle function. However, the type of associated fracture or other
Table 3.4 High-risk circumstances for compartment syndrome

Floating elbow
Supracondylar humerus fracture with concominant median nerve palsy
High-energy tibia fracture treated in a circumferential cast
Tibial osteotomy
Child placed in a sitting spica cast
Excessive manipulation of a forearm fracture
injuries will often determine the rehabilitation regimen. Full recovery from a limb
fasciotomy in children may take 6–12 months.
Complications
The worst complication of a compartment syndrome is failure to recognize the diag-

nosis. Prompt recognition and early fasciotomy give the best possible results [1–3,
5, 6, 8, 11, 13]. Release of compartments within 12–24 hours of injury or even later
may be beneficial if the symptom onset has been gradual. Compartment syndrome
release performed 5–7 days or later after diagnosis is not beneficial and may increase
the risk of infection. Contracture releases, tendon lengthening, tendon transfers, and
other reconstructive procedures may be required to treat the sequelae of ischemic
contractures when compartment syndromes are missed.
Special Situations
The majority of compartment syndromes occur in the forearm after fractures and in
the tibia after fractures or elective procedures in children. Fractures at particularly
high risk for compartment syndrome include supracondylar humerus fractures,
especially those that occur in association with ipsilateral forearm fractures, the
“floating elbow” (see Table 3.4). The diagnosis is especially difficult to make if
median nerve palsy occurs simultaneously with a supracondylar humerus fracture
because the sensory and motor changes that develop early in an evolving compart-
ment syndrome of the forearm cannot be detected if median nerve function is dimin-
ished or absent. While compartment syndromes are uncommon after most both
bone forearm fractures, prolonged manipulation in the operating room during
intramedullary nailing poses an increased risk for developing the condition [7, 14].
Tibia fractures, especially those that occur in children from high-energy mecha-
nisms, are at an increased risk for compartment syndrome. Regardless of the frac-
ture pattern, fracture location, or whether it is an open or closed injury compartment
syndrome may develop. Proximal tibia fractures, tibia–fibula fractures that occur at
the same level, and those that result from a crush injury are especially at high risk.
38 B. Willis
It is our practice to perform closed reduction and cast placement in the emergency
department for closed displaced tibia fractures. The cast is then bivalved and the
child is admitted for frequent neurovascular and pain assessments, taking care to
provide enough analgesia for pain control but not so much that sedation interferes
with an adequate examination. A similar protocol is followed when performing
elective osteotomies of the tibia.
In young children with femur fractures, lower leg compartment syndrome has
been reported as a complication of treatment. In the past, most femur fractures,
especially in younger children, were treated with skin traction prior to spica cast
application. Tight wrapping, excessive traction that compromised arterial flow, and
compression of arterial flow at the ankle due to improper foot plate usage at the end
of the skin traction wrapping are some of the etiologies of this complication. More
recently, compartment syndrome of the leg has been reported after immediate spica
cast placement for femur fractures [15]. It is hypothesized that application of trac-
tion through the lower leg while applying the cast and utilizing a “sitting” spica
position with the hip and knee flexed to 90° creates excessive pressure on the poste-
rior calf muscles after emergence from anesthesia [11]. Any child who is placed in
an immediate spica cast must be assessed after surgery for signs of a compartment
syndrome in the lower leg.
Summary
Compartment syndrome is an uncommon but potentially devastating condition that

occurs most commonly in association with fractures of the upper extremity and tibia
in children. Its diagnosis is best made by assessing children for the three A’s: wors-
ening “anxiety”, “agitation” despite attempts to comfort, and increasing “analgesia”
needs. The classic P’s of compartment syndrome are less reliable in children. Careful
clinical assessment, sometimes coupled with measurement of intracompartmental
pressures, establishes the diagnosis. Emergency fasciotomy yields excellent results
in children as long as it is performed within 24 h after evolution of the condition.
References
1. Willis RB, Rorabeck CH. Treatment of compartment syndrome in children. Orthop Clin North
Am. 1990;21(2):401–12.
2. Gorczyga JT, Roberts CS, Prigh KJ, Ring D. Review of treatment and diagnosis of acute
compartment syndrome of the calf: current evidence and best practices. Instr Course Lect.
2011;60:35–42.
3. Flynn JM, Bashyal RK, Yeger-McKeever M, Garner MR, Launay F, Sponseller PD. Acute
traumatic compartment syndrome in children: diagnosis and outcome. JBJS Am.
2011;93(10):937–41.
4. Herman MJ, McCarthy J, Willis RB, Pizzutillo PD. Top 10 pediatric orthopaedic surgical emer-
gencies: a case-based approach for the surgeon on call. Instr Course Lect. 2011;60:373–95.
5. Bae DS, Kadiyala RK, Waters PM. Acute compartment syndrome in children: contemporary
diagnosis, treatment and outcome. JPO. 2001;21(5):680–8.
6. McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk?
JBJS (Br). 2008;82:200–3.
7. Mubarak SJ, Owen CA, Hargens AR, et al. Acute compartment syndromes: diagnosis and
treatment with the aid of the Wick catheter. JBJS (Am). 1978;60:1091–95.
8. Mubarak SJ, Carroll NC. Volkmann’s contracture in children: aetiology and prevention. JBJS
(Br). 1979;61:285–93.
9. Prasun ML, Ouellette EA. Acute compartment syndrome of the upper extremity. J Am Acad
Orthop Surg. 2011;19(1):49–58.
10. Matsen FA, Veith RG. Compartment Syndrome in Children. JPO. 1981;1:33–41.
11. Whitesides TE, Heckman MM. Acute compartment syndrome: update of diagnosis and treat-
ment. J Am Acad Orthop Surg. 1996;4:209–18.
12. Matava MJ, Whitesides TE, Seiter JG, et al. Determination of the compartment pressure
threshold of muscle ischemia in a canine model. J Trauma. 1994;37:50–8.
13. Sheridan GW, Matsen FA. Fasciotomy in the treatment of the acute compartment syndrome.
JBJS (Am). 1976;58:112–5.
14. Yuan PS, Pring ME, Gaynor TP, Mubarak SJ, Newton PO. Compartment syndrome following
intramedullary fixation of pediatric forearm fractures. J Pediatr Orthop. 2004;24:370–5.
15. Large TM, Frick SL. Compartment syndrome of the leg after treatment of a femoral fracture
with an early sitting spica cast. A report of two cases. J Bone Joint Surg Am. 2003;85A:
2207–10.
16. Bourne RB, Rorabeck CH. Compartment syndromes of the lower leg. Clin Orthop Rel Res.
1989;240:97–104.
Part II
Spine
Chapter 4
Cervical Spine Injuries in Children
Steven W. Hwang, Per D. Trobisch, Andrew Jea, and Amer F. Samdani
Abstract Pediatric cervical spine injuries are not commonly encountered; however,
early diagnosis and proper management are critical to optimize outcomes. The pedi-
atric spine differs significantly from the adult spine leading to differing injury pat-
terns. In this paper, we review the required diagnostic studies, the most common
injury patterns, and treatment options for pediatric patients with a cervical injury.
Keywords Cervical spine clearance • Cervical spine trauma • Halo vest • Odontoid
fractures • SCIWORA
Introduction
Traumatic cervical spine injury (CSI) is not particularly common among adults and
is quite rare in children. From a large national registry of over 1.3 million patients,
only 4.5% of traumas involved the cervical spine, and 13.1% of those required surgical
intervention (1). CSIs in children are even more infrequent and are diagnosed in only
1–9% of all children requiring hospital admission for traumatic injuries (2–4). In a
series of 95,654 trauma patients less than 3 years of age, only 1.59% had any associ-
ated cervical spinal cord or spinal column injury (5). Several trauma centers have
S.W. Hwang • A.F. Samdani (*)

Department of Neurosurgery and Orthopaedic Surgery, Tufts Medical Center,
Boston, MA, USA
P.D. Trobisch
Department of Orthopaedic Surgery, Shriners Hospitals for Children—Philadelphia,
A. Jea
Department of Neurosurgery, Texas Children’s Hospital, Baylor College of Medicine,
Houston, TX, USA
44 S.W. Hwang et al.
reported pediatric CSIs to represent only 2–5% of all spinal trauma encountered over
a decade or more of practice (6–8). However, due to the devastating impact these inju-
ries can have on a patient’s life, early diagnosis and proper management are crucial.
Epidemiology
The majority of CSIs have been classified and managed based on adult experience,
as there is a paucity of pediatric literature. However, pediatric CSI is markedly dif-
ferent from adult pathology. Depending on the age, the pediatric spine has significant
growth potential, a greater propensity to heal, and differing anatomic, physiologic,
and biomechanical considerations. Thirty to forty percent of spinal trauma in adults
occurs at the cervical spine, whereas 60–80% of pediatric spinal injury is localized
to the cervical region (9). Several factors are thought to explain the higher percent-
age of CSI in pediatrics: younger children have (1) a large head sitting on a high
fulcrum, (2) underdeveloped neck musculature, (3) relative ligamentous laxity, (4)
more horizontal facet angulation, (5) wedging of the vertebrae, (6) a greater amount
of cartilaginous bone, (7) unfused ossification centers, and (8) underdeveloped
uncinate processes (10–12). Furthermore, the fulcrum of movement in the cervical
spine is centered at C2–3 in children less than 8 years of age and at C5–6 in adults
(13). Generally, the biomechanical development of the cervical spine is distinct
until the age of approximately 8 years, at which time its properties become more
analogous to those of the adult spine.
The bimodal age distribution of CSI in children reflects these differences in spi-
nal characteristics and pathophysiology. The average age of children having a CSI
is 10–11 years, but a bimodal age distribution can be observed with the main peak
incidence around 14–16 years and the minor peak incidence around 3–5 years of
age (2, 14). The younger group has a higher incidence of upper CSI with C2 most
commonly involved (15–17). From a series of 84 pediatric spinal injuries, Birney
and Hanley (10) found the mean age of upper cervical injuries at 6.2 years as
opposed to a mean age of 13.6 years among patients with lower spine injuries (10).
Approximately 60% of patients with CSI are boys, with a ratio of 1.6 : 1 (M : F) (2).
This is largely due to their increased participation in sports, represented by a 3.5 : 1
male-to-female ratio in sports-related CSIs (2).
Motor vehicle-related accidents account for approximately 50–60% of cervical
spinal injuries, sport injuries for approximately 25%, falls for 15% and child abuse
for 3% (2, 14).While motor vehicle-related accidents are overrepresented in younger
children, sports-related injuries are typically seen in children older than 8 years of
age (2). The greater representation of motor vehicle accidents in young patients
likely accounts for the higher percentage of neurological injury and even death in
this group (2, 18). More than one-third of the children with injury to the cervical
spine have signs of spinal cord injury, and mortality rates as high as 18% have been
associated with CSIs (2, 4). However, most of the lethal traumas have associated
injuries, with the majority of these being closed head injuries (1, 2).
4 Cervical Spine Injuries in Children 45
Diagnostics
Children with suspected CSI should be immobilized immediately in the field before
further diagnostic tests are attempted. Either one or a combination of a rigid cervical
collar, a backboard, head and neck blocks, and tape may be required depending on
the age of the patient. When taping the chest, care must be taken not to inhibit chest
expansion, thereby decreasing inspiratory capacity. For young children with a rela-
tive large head/chest ratio, a double mattress to lift up the chest or a backboard
recess for the occiput may prevent additional injury due to neck flexion. If a double
mattress is applied in children younger than 8 years, the chest should be elevated at
least 2.5 cm (19–21). The external auditory meatus should be aligned with the
shoulders, and more than 2.5 cm of elevation may be required in younger children.
Upon arrival to the Emergency department, a complete physical evaluation and
trauma work-up should be undertaken. With regard to the cervical spine, particular
attention should be paid to assessment of associated head injury, facial trauma, or
neurological impairment, as all have a higher incidence with CSI (1, 22). Any neu-
rological impairment should be recorded using the American Spinal Injury
Association score (23). Depending on the age of presentation, motor strength may
vary and sensory examination may be limited. Diagnostic imaging of the cervical
spine may then be completed once the patient is deemed hemodynamically stable.
No guidelines have defined optimal criteria for cervical spine clearance in the
pediatric population. A few series have applied criteria validated in large adult
cohorts to children and have shown good sensitivity, but conclusions regarding
younger children are limited given the paucity of cases. Children may be prone to
display signs of distress (i.e., crying) given the psychological trauma and fear of the
hospital, and children less than 2 cannot adequately communicate verbally. Viccellio
et al. (24) applied NEXUS (National Emergency X-Radiography Utilization Study)
criteria to 3,065 children less than 18 years of age as follows: (1) lack of posterior
midline tenderness, (2) lack of neurological deficit, (3) normal level of alertness, (4)
no evidence of intoxication, (5) lack of distracting injury. They divided children into
three categories by age: 0–2 years based on their inability to verbally communicate
(n = 88); 2–8 years based on the immaturity of their spine (n = 817); and 9–17 based
on their more developmentally mature spines (n = 2,160). Thirty (0.98%) sustained
an injury, but only 4 were younger than 9 years, and there was no evidence of spinal
cord injury without radiographic evidence (SCIWORA). They reported 100% sen-
sitivity and 100% negative predictive value, although a wide confidence interval
was observed given the small sample size (24). They concluded that NEXUS crite-
ria could reduce the use of radiographs by 20% in children and that it was an effec-
tive tool in older children, but cautioned against its application in young toddlers.
A multicenter study pooled data from 22 centers totaling 12, 537 patients under
the age of 3 years and identified 0.66% who had CSI. Using a negative predictive
value of 99.93% for scores under 2 using points assigned to 4 variables (Glasgow
Coma Score < 14, GCSEYE = 1, motor vehicle accident, and age 2 years or older),
they did not miss any CSI diagnosis (25).
Other authors have also proposed variations on the NEXUS criteria. Jaffe et al.
(26) suggested imaging in the presence of neck pain or tenderness, reduced range of
motion, history of neck trauma, abnormal neurological exam, or change in mental
status (26). Lee et al. (27) proposed imaging when NEXUS criteria were present,
but expanded indications to include a history of neck trauma, significant mecha-
nism, inconsolable exam, trauma to the head or face, or transient neurological
deficits (27). In general, it is safer to err on the side of caution and obtain imaging if
there is significant concern for spinal trauma. Regardless, if the physician is unable
to clinically clear the cervical spine, negative CT or radiographs alone are insufficient
to adequately exclude the risk of ligamentous injury. Therefore, we often will leave
a rigid collar in place and attempt to clinically remove it once the child is calmer and
surrounded by familiar people. Alternatively, we wait until dynamic radiographs or
MRI with STIR images are available to indicate that it is appropriate to do so.
While a full radiographic evaluation in an adult with CSI consists of an antero-
posterior (AP), a lateral, and an open mouth odontoid view, the latter is rarely fea-
sible in younger children due to limited understanding and cooperation. In one
retrospective series, only 1 in 51 odontoid views was felt to be helpful with a diag-
nosis, and it was deemed unnecessary in children less than 9 years of age (28). The
sensitivity to identify osseous injury with an AP and lateral view spanning the
occiput to C7 lies in the high 90% range. However, up to 30% of radiographs are
occasionally misinterpreted and may lead to an inappropriate delay in management
in 20% of children; therefore, a meticulous and systemic radiographic reading is
required (26, 29–32).
When evaluating radiographs, the examiner should review soft-tissue elements
as well as the osseous components. Typically, in children less than 15 years of age,
the retrotracheal space measures approximately 3.5 mm whereas the retropharyn-
geal tissue averages 7–9 mm (7). The prevertebral soft tissue should measure less
than two-thirds the width of the vertebral body at any cervical level (33). The lateral
radiograph should also be reviewed for alignment by ensuring smooth, contiguous
lines along: (A) supraspinous line, (B) spinolaminar line, (C) facet line, (D) poste-
rior vertebral line, (E) anterior vertebral line. Furthermore, specific ratios and mea-
sures have been described to screen for certain pathologic injuries. These lines are
originally described for roentgenograms but can also be helpful in reading CT or
MRI scans.
• The Wackenheim clivus line is drawn as an extension of the clivus. In a normal
individual it lies tangential to the posterior aspect or transecting the posterior
one-third of the dens. An abnormal Wackenheim clivus line typically denotes
basilar invagination with the dens more rostral, but can be associated to atlanto-
occipital dislocation (AOD) or atlantoaxial dislocation with the dens at a greater
distance from the line (Fig. 4.1a).
• The basion–dens interval (Harris ratio) is a line drawn from the basion to the tip
of the dens and is increased (normal −4 mm to 12 mm) in AOD. Therefore,
greater than 12 mm is considered abnormal (Fig. 4.1b) (34).
Fig. 4.1 Lateral cervical radiograph illustrating established diagnostic measures: (a) Wackenheim’s
line, (b) Harris’s basion–dens distance, (c) Powers’ ratio (bp/oa), and (d) atlanto-dental interval
• The Powers ratio describes the distance from the basion to the posterior arch of
the atlas over the opisthion and the anterior arch of the atlas. Ratios greater than
1 are considered abnormal (Fig. 4.1c) (35).
• The condylar gap (primarily measured on CT) measures the distance between
the occipital condyle and the lateral mass of C1. Values of >5 mm should raise
concern for longitudinal distraction.
• The atlanto-dental-interval (ADI) describes the distance between the posterior
surface of the anterior arch of C1 and the anterior surface of the dens. The ADI
is pathologically increased if it measures >5 mm in children younger than 8 years
of age and >3 mm in children older than 8 years of age. Increase in the ADI can
be found in atlantoaxial instability including atlantoaxial rotatory subluxation
(Fig. 4.1d) (36).
• The Swischuk line is drawn between the laminae of C1 and C3 on a lateral roent-
genogram. This line helps to differentiate C2/3 pseudosubluxation from a patho-
logic subluxation. Pseudosubluxation is present if the lamina of C2 does not fall
more than 2 mm anterior to the Swischuk line on the extension view (37).
• The ratio of interspinous process distance between C1–C2 and C2–C3 should
not exceed 2.5 (38).
Flexion–extension views are not recommended for initial evaluation but can be
helpful when there is a questionable finding on static roentgenograms or to evaluate
persisting pain in the mid- to long-term. However, physiologic phenomena that can
be seen in younger children should not be misinterpreted as CSI. The most common
is a pseudosubluxation, usually at C2–3, which can be seen in one-fifth to one-third
of normal cervical spine roentgenograms in children younger than 8 years of age;
40% occur at C2–3 and 10% at C3–4 (Fig. 4.2). The use of the Swischuk line can
help distinguish the two using the spinolaminar line (37). Other normal physiologic
phenomena that may be misinterpreted as fractures include secondary ossification
centers (the tip of dens ossifies by 7–8 years of age and the neurocentral synchon-
drosis typically calcifies by 12 years of age) or vertebral body wedging. The sub-
dental synchondrosis may be misinterpreted as a dens fracture but is present in all
3-year-old children and in 50% of 5-year-olds; often it persists until 12 years of age
(39–44). Vertebral wedging is common in pediatric vertebral columns secondary to
the greater component of cartilaginous bone and may be present in up to 7% of
pediatric spines (37, 45).
Although plain radiographs are the favored initial evaluation, increasingly more
CT scans of the cervical spine are being obtained (46). Adult studies have suggested
increasing sensitivity with the use of CT imaging over plain radiographs alone when
evaluating for cervical spine trauma, but similar evidence has not been reported in
children (47, 48). A review of 600 pediatric cases noted that CT imaging alone did
not identify any abnormalities that were not already apparent on plain radiographs
or from clinical findings (49). Furthermore, the yield of CT imaging may be lower
in children given the ossification centers and decreased calcification (3, 50, 51).
Given the significant association between head injury and cervical spine trauma, it
is conceivable to obtain a rapid image of the cervical spine concurrently (1, 52).
Fig. 4.2 Lateral flexion and extension radiographs displaying pseudo-subluxation of C2 on C3
There is currently no consensus for use of CT imaging in assessing the pediatric

cervical spine. We recommend obtaining one if the quality of radiographs is poor,
when symptoms persist despite normal radiographs, when increasing anatomic
detail is desired of an identified abnormality (such as for presurgical planning), or
when radiographs fail to demonstrate a source of soft-tissue swelling. It should also
be considered in cases of severe trauma with a limited examination.
In the adult literature, MRI scans have been shown to carry greater sensitivity
than dynamic flexion–extension radiographs to clear the cervical spine (53). They
are routinely obtained to assess for ligamentous injury among obtunded or
sedated patients and can detect ligamentous disruption, dural disruption, disc
herniations, hematomas, or cord contusions (54–56). Furthermore, MRI findings
have been correlated with prognosis in the presence of hemorrhagic cord contu-
sion and cord infarction (57). However, their use has not been validated in the
pediatric cervical spine.
MRI use in the pediatric cervical spine has largely been extrapolated from adult
experience, although a recent study reviewed 231 pediatric cases and required MRI
scans to establish a diagnosis or clear the cervical spine in 31% of cases secondary
to failure of plain radiographs or clinical examination (58). Frank et al. (59)
described their protocol for MRI use in children and noted a shortened hospital ICU
stay, lower costs, and faster clearance of the cervical spine after implementation of
their protocol (59). Their protocol involved obtaining MRI scans on patients who
(1) were obtunded or nonverbal with a likely mechanism, (2) equivocal plain films,
(3) neurological symptoms without radiographic findings, and (4) inability to clini-
cally or radiographically clear the cervical spine within 72 hours of admission (59).
Although MRI may allow clearance of the cervical spine, sedation may be required
in noncompliant, younger children to obtain adequate quality imaging. Therefore,

clinical assessment must balance the risks and benefits of obtaining imaging with
sedation against the potential risk of delaying a diagnosis or cervical spine clear-
ance. An MRI should be ordered in the presence of any neurological deficit or if
there is significant concern for ligamentous injury. It may also be considered when
the clinical presentation does not coincide with available imaging findings or in
obtunded patients with significant concern for CSI.
Specific Injury Patterns
Osseous Injury
Classification and management of cervical spine trauma has largely been based on
adult literature given the paucity of pediatric series. Therefore, condylar fractures,
C1 ring fractures (Jefferson fractures), Hangman’s fractures of C2 or odontoid frac-
tures, subaxial ligamentous injury, vertebral column injury, and varying combina-
tions of posterior element injuries have all been based on adult experience with the
caveat that pediatric osseous structures have a greater propensity to heal. However,
pediatric CSI does have several distinct traumatic pathologic entities that are uncom-
mon in adults. We will address some of the more unique pediatric injuries such as
pediatric dens/synchondrosis fractures, atlantoaxial rotatory fixation, atlanto-occip-
ital dissociation, and SCIWORA in more detail.
Up to 80% of patients with injury to the cervical spine have signs of osseous
injury, of which two-thirds are fractures and one-third are dislocations (2, 10, 14).
Upper CSIs also occur nearly twice as often as lower CSIs. Birney and Hanley (10)
described their series of 84 pediatric patients with CSI and categorized injuries
into five types. The most common pathology was atlantoaxial rotatory fixation
(AARF) (27%), followed by osseous fractures at the atlas and axis (24%), combined
osseous and ligamentous injury (23%), SCIWORA in 21% and atlanto-occipital
dissociation (5%) (10). Brown, Brunn, and Garcia (2) reviewed 105 injuries in 103
patients and noted that SCIWORA occurred in 39% of patients, fractures alone in
26%, fracture dislocations in 17%, fracture with spinal cord injury in 11%, and
multiple fractures in 7% (2). A summary of common osseous injury patterns is
shown in Table 4.1.
Atlanto-Occipital Dislocation
AOD (also called occipito-atlanto-axial dislocation, or occipito-atlanto dislocation),

although rare, most commonly occurs in young children involved in trauma with
significant mechanisms of injury. Typically these are severe motor vehicle accidents
Table 4.1 Key features of common pediatric CSI

Important characteristics
Atlanto-occipital dislocation Usually seen with high energy trauma, 48%
mortality rate
Atlantoaxial rotary subluxation Frequently seen after minor trauma or upper
(syn.: dislocation, fixation) respiratory tract infection. Patients clinically
present with a torticollis (“Cock-Robin”
appearance)
Atlas burst fracture Usually seen in older children and teenagers.
(aka Jefferson fracture) Caused by axial trauma to the head
Axis fractures Usually odontoid fractures below synchondrosis.
Fractures to the body (e.g. Hangman’s fracture)
are rare in children. Physiologic synchondrosis
between odontoid and C1 body can be seen up
to age 11
Subaxial cervical injuries Uncommon in children. Usually associated with
high energy trauma
and, given the severity of injury, head trauma is commonly present as well (60). The
primary physioanatomic structures that counter vertical traction injuries are the tec-
torial membrane, the alar ligaments, and the paraspinal musculature (34, 61–63).
Therefore, disruption of these ligamentous structures can leave the spine unstable
and predispose to neurological injury (Fig. 4.3a–c). A high mortality is associated
with this pathology given the potential injury to the brain stem and associated lower
cranial nerves, but increasing numbers of patients are surviving and presenting with
spinal cord injury or cranial nerve problems, or even without neurological impair-
ment (60, 64). Neurological injury, particularly cranial 6th nerve palsies, may be
present from traction secondary to instability.
The improved mortality rate associated with this pathology may be secondary to
increasing early intervention in the field, awareness of the diagnosis, and early sur-
gical stabilization (60, 64–66). However, traction should be avoided in these patients,
as the disruption of ligamentous stability may be aggravated by added weight and
contribute to greater vertical distraction causing further injury to the spinal cord or
brain stem (67). The diagnosis is often delayed or missed because no osseous injury
is associated with the trauma, and radiologic findings may be subtle in the presence
of significant concurrent comorbid injuries. Gregg, Korbeek, and du Plessis (64)
reported that 11% of patients presented intact but had permanent neurological
decline secondary to delays in diagnosis and that 43% of patients presented with
some degree of neurological deficit (64). Retropharyngeal space wider than 7 mm is
often an indirect sign of upper cervical injury but does not have great sensitivity.
Distances of greater than 5 mm between the occipital condyle and the lateral mass
of C1 have also been used to infer the presence of AOD (68). The Powers ratio and
the Harris basion–dental distance of 12 mm can also be used to increase overall
sensitivity at detecting AOD, but the Powers ratio may not identify pathology if the
distraction is primarily vertical, as the ratio is still preserved (69). Wholey, Bruwer,
and Baker (70) determined that the average basion–dental distance should not
Fig. 4.3 Six-year-old girl in motor vehicle accident (MVA) intubated at the scene. (a) Sagittal CT
reconstruction showing widened C1–2 gap posteriorly. (b) MRI STIR image showing significant
edema and fluid in C1–2 articulation and across attachment of alar ligamentl. (c) postoperative
lateral radiograph illustrating occiput to C2 fusion
exceed 5 mm in adults and 10 mm in children (70). Hosalkar et al. (16) reported that
5 of 16 patients with AOD in their series survived and one remained ventilator
dependent (16). Gregg, Korbeek, and du Plessis (64) performed a review of the lit-
erature and noted a 65% survival at 1 month for patients arriving at the hospital,
although they speculated that many patients likely died at the scene of injury. Of the
Fig. 4.4 Axial CT with lines displaying the coronal axis and the fixed rotation between C1 and C2
patients presenting with deficits, 37% returned to normal function and 57% had
incomplete recovery. A quarter of patients died within 24 hours. Patients presenting
with tetraplegia had the worst prognosis, with 47% having no recovery and 38%
deceased by 30 days (64). Early stabilization, with definitive management being
internal fixation, is recommended.
Atlantoaxial Rotatory Fixation
AARF represents a pathologic adhesion and rotation of the atlas on the axis beyond
physiologic norms (Fig. 4.4). Typically, it develops after minor trauma, postpha-
ryngeal infection, or after head and neck surgery. Patients present with their head
in a classic “cock-robin” posture with limited range of motion and occasionally
have pain, but rarely neurological compromise. Chronic AARF should be distin-
guished from torticollis based on the fact that torticollis is correctable with passive
range of motion which may require muscle relaxants, is typically not associated
with intense pain (jaw and neck), and can be differentiated by dynamic CT imaging
(71). Fielding and Hawkins (72) proposed a four-tier classification of AARF: type
I: intact transverse ligament with unilateral rotation; type II: disrupted transverse
ligament with 2–5 mm of anterior displacement of C1 on C2; type III: disrupted
transverse ligament and alar ligaments with C1 displaced more than 5 mm anteriorly;
and type IV: posterior displacement of C1 on C2, only arising with a hypoplastic
dens (72). Pang and Li (73) defined use of dynamic CT to make the diagnosis and
established normal ranges of motion of C1 on C2. They established their own
classification using dynamic CT and determined that no movement between C1 and
C2 occurs in type I pathology; the angle decreases but never reaches 0 in type II;
the difference in angle between the atlas and axis reduces to 0 if the head passes 20
degrees of rotation contralaterally with type III; and type IV is a spectrum between
type III and normal (74). Normal biomechanics were established as C1 moving
independently of C2 over the first 23 degrees, then both moving in conjunction up
to 65 degrees of rotation, after which they are fixed at an angle of 43 degrees (73).
However, this system does not consider translational subluxation that may be seen
in acute trauma in the higher grades of Fielding and Hawkins system (71).
Typically, acute AARF is reducible, with traction if necessary, and can be treated
conservatively with a halo vest or alternate external orthotic for three months. Some
authors have suggested using osseous remodeling of the C2 facet as a landmark to
discontinue halo wear and convert to a rigid collar (75). Treatment of AARF should
be started at the time of diagnosis, as chronic AARF or delays in treatment have
been associated with greater chance of recurrence, increasing duration of therapy,
and greater need for surgical intervention (76). Typically, traction with halo or
Gardner–Wells tongs are applied using adjuvant muscle relaxants and analgesics. If
reduction is obtained, the patients can be converted to an immobilizing vest. Some
have described use of a halo vest for three months, whereas Pang et al. favor a
Guilford brace (G.A. Guilford and Sons Orthotic Laboratory, Cleveland, Ohio).
Pang et al. report converting to a halo vest at the third attempt, but others have advo-
cated earlier fusion after prior failure. However, if the subluxation is irreducible, or
repeated conservative therapy has failed, surgical intervention is warranted. Pang
et al. reported the ability to reduce all acute AARF cases with very few requiring
surgical intervention, although type I and II cases were more likely to require sev-
eral attempts at closed reduction. Chronic AARF had a worse prognosis, with
patients requiring greater than 2 weeks of traction and 50% being nonreducible and
50% requiring surgical intervention. Of those who avoided a fusion, most will likely
have reduction of motion at C1–2 regardless (71).
Odontoid Fractures: Os Odontoideum
Os odontoideum represents a well-corticated ossicle that replaces the dens without

an osseous connection to the remaining axis. Five ossification centers develop in the
axis, and the tip of the dens where the ossicle lies typically calcifies by 7 years of
age. Although the etiology remains unclear, traumatic or congenital causes currently
predominate theories. Associated congenital anomalies of the occipitocervical region
as common, such are Klippel–Feil, occipitalization of C1, basilar invagination, and
hypertrophy of the C1 arch (77). Two subtypes have been described: orthotopic,
where the ossicle moves in conjunction with C1, and dystopic, where the os remains
attached to the basion. Patients may present with neck pain, myelopathy, verte-
brobasilar injury, and typically have an increased ADI. In a series of 16 patients
treated surgically, Sankar et al. (78) reported a mean ADI of 8.3 mm even among
asymptomatic, incidentally identified patients (78). However, several authors rec-
ommend surgical intervention, even in asymptomatic patients, suggesting that the
risk of surgical complication is relatively low compared to the risk of symptomatic
progression of the pathology (78, 79). Controversy exists regarding management, as
some have shown long-term stability (over 7 years) in the absence of symptoms
even with radiographic instability (80).
Guidelines published in 2002 from the American Association of Neurological
Surgeons (AANS) suggested that insufficient data were available to draw any con-
clusions but proposed that asymptomatic patients with or without radiographic
instability could be managed with conservative measures given the limited and vari-
able clinical course of the disease (81).
Cartilaginous/Synchondrosis Fractures
Odontoid fractures in children younger than 7 years of age usually are distinct and
represent an avulsion of the synchondrosis as opposed to a true osseous interruption
(Fig. 4.5a, b). Other fractures of the dens that involve osseous structures, or after the
synchondrosis is closed, should be treated based on adult literature with the under-
standing that children will have a higher rate of fusion with external orthoses.
In young children, the axis is divided by synchondroses between the body, odon-
toid process, and neural arches. These cartilaginous plates do not ossify until
approximately 5 to 7 years of age and are a potential source of biomechanical weak-
ness (15, 43, 82, 83). Odontoid synchondrosis fractures can occur with severe or
relatively minor trauma, and patients rarely have a neurological injury, instead pre-
senting with neck pain or torticollis (84). Synchondrosis fractures generally do not
involve actual osseous disruption, as they are caused by a shearing force that causes
a “slip” in the cartilaginous material rather than an actual interruption of bone (11).
Hosalkar et al. (16) reviewed their experience of 17 patients with an odontoid
synchondrosis fracture and pooled data from existing published cases to formulate
a classification system describing these fractures based on the extent of displace-
ment of the odontoid process from the vertebral body (16). Type I injuries were
defined as fractures through the odontoid synchondrosis and were further subdi-
vided into type A (0–10% displacement), B (10–100% displacement), and C
(>100% displacement). Type II fractures were above the level of the synchondro-
sis. Based on this classification system, they recommended halo immobilization
for type IA, closed reduction and halo fixation for type IB, and surgical stabiliza-
tion for type IC (16). Most authors advocate that initial treatment for odontoid
synchondrosis fractures should be closed reduction and external stabilization, with
Fig. 4.5 Two-year-old girl, neurologically intact following MVA, presenting with an odontoid
fracture above the synchondrosis (type II) with angulation and slight displacement. (a) Sagittal CT
reconstruction highlighting the fracture and (b) postoperative lateral radiograph showing occipito-
cervical fusion to C2. We opted to perform a fusion given associated disruption and edema of the
transverse, alar, and tectorial ligaments as well as her young age and associated risk from halo vest
placement
close radiographic follow-up (11, 15, 17, 84). There is a high rate of fusion with
external orthosis; a meta-analysis reported a fusion rate of 93% with a treatment
duration of 3–6 months (15).
Spinal Cord Injury
Many children with CSI will have concurrent spinal cord injury, of which the majority
are incomplete. Most patients with neurologic deficits will recover significantly over
time. However, only 4–14% of SCI occur in children less than 15 years of age (4, 85).
In the CSI cohort reported by Birney and Hanley (10), 44% had associated spinal cord
injury and 24% had complete injuries (10). Etiologies for spinal cord injury in the
pediatric age group parallel adult injuries with motor vehicle accidents being most
common, followed by diving accidents, sports-related injuries, gunshot injuries, falls,
transverse myelitis, and tumors. The significantly improved clinical outcomes among
children with spinal cord injury may partially be attributed to an overrepresentation of
SCIWORA injuries in younger patients. The prognosis for SCIWORA is more favor-
able and many patients will have significant recovery over time.
Spinal Cord Injury Without Radiographic Abnormality
Up to 50% of children with spinal cord injury do not have an abnormal radiographic
finding, which is known as SCIWORA (18, 57, 86, 87). The term SCIWORA ini-
tially described objective signs of myelopathy as a result of trauma in the absence
of abnormal findings on roentgenograms and tomography. However, with the advent
of and widespread use of MRI, the incidence of SCIWORA seems to have decreased
substantially now that we can diagnose contusions, edema, or hematomas. Cirak
et al. (86) identified 24 patients (6%) from their cohort with the diagnosis of
SCIWORA, but after reviewing available MRI scans, the incidence decreased to 1%
(86). Brown et al. (2) reported a higher incidence of 39% without the use of MRI
and noted its occurrence in older children with sports-related injuries and in all child
abuse cases (2). A meta-analysis identified that 90% occur in the pediatric popula-
tion and only 10% in adults (87). The high incidence in the pediatric population may
reflect the physiologic ligamentous laxity in a child’s spine; in cadaveric studies, the
pediatric spinal column is reported to tolerate 2 inches of stretching, whereas the
spinal cord can only sustain ¼ inch prior to injury (88). Launay, Leet, and Sponseller
(87) reported that 74% occurred in the cervical spine and 26% in the thoracic region,
with the onset of symptoms observed as late as four days post injury. SCIWORA
may also present with a wide range of symptomatology including incomplete cord,
complete cord, central cord, Brown–Sequard, or anterior cord syndromes, and
17.1% may actually have recurrent SCIWORA with re-expression of their symp-
toms up to several weeks later (87). In the meta-analysis, they reported that 33% had
a complete recovery, 15% a partial improvement, 49% no improvement, and 4%
died (87). The only predictor of clinical outcomes after SCIWORA is the initial
presentation; milder presentations have a better prognosis (89).
Treatment
Any CSI should be managed through a trauma protocol. Given the potential risk of
associated injury and correlation with severe mechanisms of injury, proper trauma
evaluation should be routine. As discussed above, all patients should be immobi-
lized in the field and transported to the hospital in the appropriate stretcher with
cut-outs or additional thoracic elevation if necessary. Upon arrival at the hospital,
well-established trauma algorithms should be followed focusing on cardiorespira-
tory stabilization. Immobilization of the cervical spine should be maintained during
this process to minimize secondary insults to the spinal cord if injury does exist
Particular care should be taken to monitor the mean arterial pressure and avoid
hypotension or hypovolemia, especially in the setting of spinal cord injury and
spinal shock.
If neurological impairment is present, emergent imaging (including MRI) is war-
ranted to determine if surgical decompression would be of benefit. Classically, the
poor outcome associated with complete injuries obviated the need for emergent
surgical management, but incomplete injuries with mass lesions (hematoma, bony
fracture, fracture dislocation) do require emergent decompression and stabilization.
The necessity and timing of surgical decompression in children with spinal cord
injury is matter of ongoing discussion. The mainstay of treatment in children with
SCIWORA is immobilization to avoid secondary displacement of potentially undi-
agnosed instabilities. Hard collar immobilization for 12 weeks with an additional
12 weeks of activity restriction is the preferred method and has not been associated
with recurrent injury. The absence of ligamentous injury on MRI will lead many
doctors to decrease the periods of immobilization and activity restriction.
Rigid cervical collars provide some support but are limited by patient compli-
ance, the need for tailored collars in young infants, and the lack of upper cervical
immobilization. Specific collars such as SOMI or Minerva braces may provide
additional stability, but the standard therapy for unstable cervical spine fracture of
the upper cervical spine remains halo-vest immobilization (90, 91). Rigid cervical
collars are useful in older children who are more likely compliant and for mid- to
lower-cervical injuries. Noninvasive halo immobilization is also available, but
current experience with such external orthoses is limited.
Halo placement in young children requires general anesthesia to maintain a con-
trolled environment, and a head board can be used to position the patient in neutral
alignment. If closed reduction is being attempted, fluoroscopic imaging should be
used to ensure proper alignment. Four to 8 pediatric pins are recommended with 2
to 8 inch-pounds of torque depending on age. Typically, children under the age of 2
should not have pins placed given the risk of skull fracture. The head circumference
should be measured and an appropriately sized halo ring should be selected. Then
the pin sites are swabbed with sterile prep and local infiltration if desired. Pins are
positioned approximately 1 cm above the eyebrow and lateral to the mid-pupillary
line to avoid inadvertent skull fractures into the frontal sinus and to avoid the
supraorbital nerve and vascular supply. The halo ring should rest approximately
1 cm above the top of the ear, and the eyes should be closed during screw placement
to avoid lid retraction and forced eye opening. Opposing pins should be tightened
simultaneously to the desired tension and verified using a calibrated torque. The
bolts should then be tightened to minimize loosening of the screws, but screw ten-
sion should be verified at least once 24 hours postprocedure by loosening the bolt
and tightening the screw to the desired torque. We typically wash our pin sites twice
daily using a mixture of 1 : 1 sterile saline and hydrogen peroxide. Patients should
return frequently in clinic to minimize development of complications. Once the halo
is positioned appropriately, the vest can be placed and adjusted to the desired align-
ment per the manufacturer’s instructions with radiographs obtained to confirm
desired alignment.
The halo can be employed without the vest for purposes of traction as well.
Similarly, chin straps may also provide distraction and allow for reduction of
specific cervical injuries. Usually, 5 or 10 pounds of weight are used initially, but
the starting weight should not exceed 10% of the total body mass. In adults, approx-
imately 5 pounds per segment are used as an estimate for the targeted weight with
gradual increases; however, given the ligamentous laxity in children, we favor using
2 or 3 pound increments depending on age and injury type. Muscle relaxants may
be needed to provide tension relief and loosen the musculature. Radiographs should
be obtained with the addition of any weight, and the weight should be reduced
immediately if any neurological decline develops.
The role of methylprednisolone in acute spinal cord injury remains controver-
sial. A few randomized, prospective studies have sought to address the value of
administering steroids to patients with acute spinal cord injury. However, young
children were usually excluded from these studies. Therefore, administration of
steroids in children with spinal cord injury has never been addressed. In adults, the
benefit is increasingly questioned, since improved outcomes were marginal and
were only observed in post hoc subgroup analysis, whereas increased rates of
complications were well documented and significant (NASCIS [North American
Spinal Cord Injury Study] I, II, III) (92, 93). However, 15% of the cohort studied
were adolescents aged 13–19 years; no children less than 13 were enrolled in the
study. Therefore, steroid therapy for spinal cord injury in children is not currently
recommended.
There is no widely accepted standard defining appropriate management of cervi-
cal spine and spinal cord injuries in children. In general, most children with CSIs
can be treated nonoperatively with closed reduction, if required, followed by a rigid
cervical collar or a halo vest for 12 weeks. However, some children will need surgi-
cal stabilization; ligamentous injuries with instability are more likely to require sur-
gical stabilization than osseous injuries. Brown et al. (2) reported that 18% of their
cohort required surgery (although halo placement was considered a surgical inter-
vention), whereas Orenstein et al. (14) stated that 62% of younger children and 36%
of older patients had unstable injuries (2, 14). High complication rates with halo
vest placement, although mostly minor in nature, further support increasing use of
surgical intervention (94).
Instrumented fusion of the cervical spine in pediatric patients is increasingly
more common. Likely advances in technology and instrumentation tailored for the
pediatric population have sufficiently improved the safety and efficacy allowing
acceptable outcomes to be achieved. However, assessment of fusion rates in the
pediatric literature is obscured by the variability of fusion constructs and the paucity
of data.
We reviewed the literature for pediatric cervical instrumentation and limited
series to those involving trauma with documentation of construct type and outcomes
(complication or fusion rates). When including only series with >80% trauma, only
5 cohorts were identified (Table 4.2). With the addition of 10 patients from our own
series, we pooled 96 patients and had a mean age of 11.9 years. The majority of
patients had autograft employed and postoperative orthoses as well. The mean fol-
low-up was 111.6 months with a reported fusion rate of 82%. Successful fusion
was determined based on three criteria: (1) CT-confirmed osseous bridging, (2)
dynamic flexion–extension at 3 months, and (3) plain radiographs with osseous
growth at 3 months. The majority of pseudarthroses developed in the earlier series.
Complications developed in 36 patients, again mostly localized to the earlier series
Table 4.2 Summary of pediatric cervical instrumentation in traumatic CSI
Gender Mean Post-op Follow-up Fusion # Patients with
Author Year N (F : M) age (yrs) Levels fused Construct details Graft orthosis (months) rate Complications complications
Stabler et al. 1985 7 4 : 03 11 O–C1 (1) Posterior wiring, Auto Halo (3); 37 0/7 Graft resorption; 7
(95) C4-T1 (1) Gallie’s collar (4) wire breakage,
C1–2 (5) fusion pseudarthrosis
McGrory 1994 42 14 : 28 12.7 Posterior (39); Wiring Auto Halo (13); 210 24/31 Undesired 26
Anterior (3) (interspinous, collar (29) extension of
sublaminar); fusion, hip
sublaminar graft pain,
sutures pseudarthrosis,
infection at
donor site,
adjacent level
instability
Brockmeyer 1995 2 1 : 01 15 C2 Odontoid screw; None n/a 28.5 2/2 None 0
et al. (96) Haid plates
13 5 : 08 15 C3–5 (1) Anterior plating; Auto (9); Halo (3) 32.9 13/13 Graft settling 1
C3–6 (1) lateral Haid allo (4) requiring
C4–6 (2) plates reoperation
C5–6 (2)
C6 (1)
C6–T1 (2)
C5–7 (2)
C6–7 (1)
C7–T1 (1)
8 5 : 03 11.8 C1–2 Lateral mass Auto Halo (2) 14.5 8/8 Superficial wound 1
screws infection
Gender Mean Post-op Follow-up Fusion # Patients with
Author Year N (F : M) age (yrs) Levels fused Construct details Graft orthosis (months) rate Complications complications
Meyer et al. 2001 4 2 : 02 8.3 C1–2 Brook’s; Auto Halo (2); 26.3 4/4 Neurological 1
(97) Gallie’s; collar (2) decline
Halifax
clamps
3 1 : 02 13 C1–2 Transarticular Auto Collar 17.3 3/3 None 0
screw with
wiring
1 1 : 00 16 C2 Odontoid screws None Collar 16 1/1 None 0
Duhem et al. 2008 1 n/a 10.6 O-C2 Wiring Auto n/a n/a 1/1 n/a n/a
(98)
4 n/a 7.5 C1–2 Wiring Auto (3); n/a n/a 4/4 n/a n/a
none (1)
1 n/a 10 C2–3 C2–3 ACDF Auto n/a n/a 1/1 n/a n/a
Highlighted blocks represent subgroups of patients from respective series
Levels fused: O—occiput; value in parentheses represents number of patients having those levels fused; if no number is listed all patients had those levels fused
Graft: auto—autologous bone; allo—allograft
Post-op orthosis: number in parentheses represents number of patients being placed in that type of orthotic
Fusion rate: reported number of patients with successful fusions by CT, X-ray or dynamic imaging at 3 months of follow-up
and included graft resorption, instrumentation failure, pseudarthrosis, unplanned

extension of fusion, iliac graft pain, infection, adjacent instability, neurological
decline, graft settling, and reoperation (Table 4.2). Overall, more recent series have
reported greater successful fusions and lower complication rates.
Given that most series combined congenital and traumatic etiologies, we also
reviewed any pediatric series that included at least 5 trauma patients and identified
13 series with 342 patients and a mean age of 9.9 years. The reported fusion rate
was 94%, with 75/336 having reported complications.
Most pediatric series have reported excellent rates of fusion and moderate risk of
associated complications. The majority used autologous bone and some type of
external orthosis as well, typically halo immobilization. However, with improved
biologic agents and instrumentation, there has been decreased use of postoperative
orthosis with similarly successful outcomes. Current literature is too varied and
sparse to draw any significant conclusions regarding orthotics use and the role for
biologic agents in the pediatric population.
Conclusion
Although pediatric CSI is infrequently encountered, its impact on the quality of life
of patients and caregivers is tremendous. A high index of suspicion should be main-
tained in trauma patients and when the clinical presentation is discordant from the
history to minimize delay or missed diagnoses. The paucity of cases restricts our
ability to make significant conclusions regarding diagnosis and management, but
physicians should err on being overly cautious given the potential ramifications of
the pathology. With improving technology, surgical intervention is becoming more
efficacious and safer, but little improvement has been made in managing acute SCI
and SCIWORA. Further clinical advances may be best achieved by pooling out-
comes into large multicenter databases.
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Chapter 5
Thoracic and Lumbar Spine Injuries
Hitesh Garg, Joshua Pahys, and Patrick J. Cahill
Abstract Uniqueness of pediatric thoracolumbar spine injuries demands special

attention despite their low prevalence. The different activity profiles of children
along with different biomechanical characteristics of pediatric spine result in specific
injury patterns. Spinal cord injuries without radiological abnormalities and carti-
laginous fractures with or without neural compression are unique to pediatric spine
trauma. Different surgical techniques may be required to deal with small anatomy
and future growth. Also the rehabilitation and follow-up of patients with pediatric
spine injury present unique challenges such as development of spinal deformity
with growth. In this chapter, we have tried to throw light on primary emergency
room management, different injury mechanisms, accepted treatment protocols, and
follow-up of children with injuries to the thoracolumbar spine.
Keywords Pediatric spine • Thoracolumbar • Trauma • SCIWORA
H. Garg (*)
Department of Spine Surgery, Artemis Health Institute,
Sector 51, Gurgaon, Haryana 122001, India
e-mail: spinedoc.hitesh@gmail.com
J. Pahys
Shriners Hospital for Children,
3551 North Broad Street, Philadelphia, PA 19140, USA
e-mail: jpahys@hotmail.com
P.J. Cahill
Shriners Hospital for Children,
e-mail: pcahill@shrinenet.org
68 H. Garg et al.
Introduction
Trauma to the thoracolumbar spine is relatively rare in children but it merits special
consideration because of certain features which differentiate it from adult trauma.
Particular care must be taken at the time of initial treatment and during follow-up in
children with thoracolumbar fractures to minimize the potential complications of
late deformity, instability, and neurologic injury secondary to remaining growth.
Throughout the developmental period and into early adolescence, the pediatric
spine has greater mobility compared to adults. This phenomenon is a result of rela-
tive ligamentous laxity, shallow angulation of the facet joints, immature develop-
ment of the surrounding musculature, and incomplete ossification of the vertebrae.
Fractures in the region of the endplate also warrant additional attention in the
pediatric population. A fracture of the cartilaginous end plate alone will not
affect longitudinal growth, whereas, fractures near the disc space involving the
bony endplate can affect the growth zone of the physis, resulting in premature
epiphyseal fusion and increasing the potential for abnormal growth and progres-
sive deformity.
Lastly, the possibility of an apophyseal herniation is a unique occurrence in
pediatric thoracolumbar spine trauma. In a manner analogous to adult interverte-
bral disc herniation, the apophysis can herniate into the spinal canal in children.
This may present as low back pain and radicular neurologic findings similar to disc
protrusion.
Epidemiology
Injuries of the thoracic and lumbar spine are relatively rare in children.
Occipitocervical and cervical spine injuries are much more common due to the
relatively large head size, underdeveloped neck musculature, ligamentous laxity,
shallow angulations of the facet joints, and incomplete ossification of the verte-
bral bodies (1, 2). Children account for 2% to 5% of all spinal injuries (3), while
only 0.6% to 0.9% of all spine trauma cases are in the pediatric thoracic and lum-
bar spine (4). The most common causes of pediatric thoracolumbar spinal injuries
are motor vehicle accidents (MVAs), sports and recreational injuries, and falls
from height (5).
Thoracolumbar injuries are much more common in adolescents compared to
younger children. In one series of 89 patients of thoracolumbar and sacral injuries,
92% of the patients were above the age of 10 years (5). MVAs (57%) were the most
common cause of injury in this series followed by sports-related injuries (21%).
Associated injuries included head and facial trauma (28%), multisystem trauma
(11.2%), other orthopaedic injuries (13.4%), and cervical spinal injuries (4.7%) (5).
Mechanism of injury also varies according to age. In another series of spinal
fractures (6), motor vehicle accidents were the leading cause of injury in infants
(71%), while falls were the leading cause of spinal trauma in toddler and school-age
5 Thoracic and Lumbar Spine Injuries 69
children, 48% and 34%, respectively. The leading mechanisms of injury in the ado-
lescent group were sports-related injuries (29%) followed by MVAs (24%).
Adolescents accounted for all gunshot wounds, demonstrating the exposure risk of
this age group (6).
Motor vehicle sports, particularly all-terrain vehicles (ATVs) and all-terrain
cycles (ATCs), are increasingly recognized as risk factors for trauma, including
spinal cord injury (SCI). Children are at particular risk because those under the age
of 16 may not be strong enough, or do not have fully developed motor and judgment
skills to properly operate an ATV. ATVs account for significant morbidity and mor-
tality, with death rates remaining unchanged since 1987. One-third of ATV-related
injuries are in children under the age of 15. The American Academy of Pediatrics
(AAP) and the American Academy of Orthopaedic Surgeons (AAOS) have both
issued position statements stating that persons under the age of 16 should not oper-
ate ATVs, passengers should not be permitted at any time, ATVs should only be
used off-road, and ATVs should only be operated during daylight hours, among
other recommendations (7).
Clinical Presentation and Examination
A considerable amount of force is usually required to cause thoracolumbar frac-

tures, and this force is typically dissipated throughout the entire body. Therefore,
patients with thoracolumbar fractures often have multiple concomitant injuries
involving the head, chest, abdomen, pelvis, extremities, and other parts of the spine.
Some of the common injuries associated with thoracolumbar fractures are cardiac
contusion, pneumothorax, hemothorax, aortic injury, abdominal visceral ruptures,
and renal and bladder injuries.
After the initial hemodynamic stabilization and primary survey, a detailed second-
ary survey and spine survey is mandatory. Additionally, a detailed history should be
performed to identify the mechanism of injury, as this will shed light on the energy
involved in trauma. High-energy injuries such as motor vehicle accidents are usually
associated with much more damage than low-energy injuries such as a fall from a
height. If the mechanism of injury does not correlate with physical examination or the
radiographs, child abuse should be strongly suspected and appropriate steps should be
taken. Other persons involved in the accident, witnesses, and/or paramedics should also
be interviewed, as a child may not be able to articulate sufficient details of the accident.
Lastly, even though the patient may be moving all of his/her extremities, it is important
to elicit the history of transient neurological deficit, as there may be occult instability
which may need to be excluded before clearing the spine.
The importance of physical examination cannot be overemphasized in a pediatric
patient. Any patient with significant trauma should be assumed to have a spine
injury unless proven otherwise. A high index of suspicion should be maintained in
all patients with head injury, any loss of consciousness or high energy trauma with
multiple injuries.
70 H. Garg et al.
In a conscious and communicative patient, any area of pain should be evaluated

further. A cursory neurological examination should be performed at this stage by
asking the child to lift his legs and arms from the bed and move his/her fingers,
wrist, toes, and feet. If the child can do this and sensation to touch and pinprick is
found to be intact in all of the extremities, a certain degree of baseline neurological
status has been established. A detailed neurological examination can then be per-
formed after the patient has been sufficiently stabilized.
The neck should be examined first, as it is readily accessible given that the child
is usually lying supine, thus making the back not readily accessible for examination.
An assistant should be asked to hold the head and neck steady and the examiner
should proceed to palpate the neck posteriorly, anteriorly, and from the sides. If
there are no areas of tenderness, no distracting injuries, and no obvious neurological
injury, the child should be asked to raise the neck from the bed and move it from
side to side. However, if there is a high index of suspicion for the presence of a
cervical spine injury, cervical spine radiographs and/or a computed tomography
(CT) scan should be obtained prior to having the child move his/her neck. After
examination of the neck, the child may then be logrolled using standard three person
technique. This includes having one person stabilize the cervical spine in a neutral
position, while two assistants logroll the patient maintaining spinal precautions at
all times. The examining physician then carefully but efficiently examines the back
and remainder of the spine. The skin should be carefully inspected for any skin
breakdown, redness, ecchymosis, or swelling. All the spinous processes should be
gently palpated to look for any areas of tenderness or step-off. Crepitus may be
appreciated in the setting of spinous process fractures, while widening of spinous
processes or deformity indicates the likely presence of a fracture. A brief rectal
exam (outlined below) should be performed while the patient is turned to assess for
rectal tone and sensation if there is a concern for any neurologic injury. In an uncon-
scious or uncooperative child, a full set of spine radiographs should be obtained
before moving the patient.
After the primary survey and brief spinal exam are performed, a more thorough
neurological examination can be obtained. Despite the neurological exam poten-
tially being extremely challenging in a very young patient, every attempt should be
made to obtain as much information as possible early in the presentation. The motor
strength of all the major muscle groups, as well as sensation and reflexes, should be
assessed. It must be noted that a child can have a mass flexion withdrawal even in
the presence of complete tetraplegia. Therefore, it is very important to establish the
presence of voluntary motor control to rule out neurological injury. Any patient who
is comatose, unconscious, uncooperative, or unable to communicate should be
assumed to have a spine injury, and all spine precautions should be continued until
further examination can be performed.
In patients with SCI, the bulbocavernosus reflex should be assessed to rule out
spinal shock. Assessment is performed by checking for anal sphincter contraction in
response to squeezing the glans penis in males or tugging on the Foley catheter in
females. This spinal cord-mediated reflex involves the S2, S3, and S4 nerve roots.
Absence of a bulbocavernosus reflex indicates that either the patient is in spinal
shock or there is an injury to either the conus medullaris or cauda equina. Spinal
shock usually persists for 24 to 72 hours. Complete absence of distal motor/sensory
function or perirectal motor/sensation, despite the presence of the bulbocavernosus
reflex, indicates a complete SCI.
As part of a thorough neurological evaluation, a complete rectal examination
should be performed. The presence of perianal sensation, rectal motor function, or
great toe flexion, i.e., sacral sparing, in the presence of an SCI indicates an incom-
plete injury. This carries a significantly better prognosis for potential neurologic
recovery than a complete SCI. Sacral sparing is an evidence of the physiologic con-
tinuity of spinal cord long-tract fibers, with the sacral fibers located more at the
periphery of the cord. All of the aforementioned examinations should be repeated
after spinal shock has subsided to provide a more complete delineation of the
patient’s true neurologic status and level of injury.
Imaging of Spine
Imaging algorithms for suspected injuries of the thoracolumbar spine have under-
gone significant change due to the availability of rapid, multislice CT and magnetic
resonance imaging (MRI). A high suspicion for thoracolumbar fractures should be
maintained in all patients with high energy trauma, an altered level of conscious-
ness, tenderness, or palpable step-off in the thoracic or lumbar spine on exam, and/
or the presence of neurological deficits or radiculopathy. Any of the aforementioned
findings warrants at least plain radiographs of the thoracolumbar spine (8). Thorough
reviews of the radiographs by experienced physicians are extremely important to
prevent missed or delayed diagnosis (8).
When evaluating imaging studies of thoracolumbar trauma, it is critical to dif-
ferentiate compression fractures from burst fractures as their management is entirely
different and burst fractures have a higher propensity for the development of neuro-
logic deficits. Burst fractures disrupt the anterior and middle columns of the spine,
whereas compression fractures involve only the anterior column. Any changes in
the middle column such as loss of posterior height, discontinuity in the posterior
vertebral body cortex, or increase in interpedicular distance should be followed up
with a CT scan of the thoracolumbar spine. Modern CT scans offer the advantages
of increased speed and accuracy with the ability to do the scan simultaneously with
head, thoracic, or abdominal scans. Further, three-dimensional imaging provided by
CT scans is quite beneficial for potential surgical planning. Due to these advantages,
many centers have now shifted to using CT scans as the initial imaging modality of
choice in patients with acute blunt spine trauma (9).
MRI is utilized to evaluate for apophyseal and posterior ligamentous injuries in
the pediatric spine, which can be missed on CT scans. More importantly, all patients
with suspected SCI should undergo MRI of the spine, once the patient is medically
stable. Very young patients may need anesthesia for MRI examination. Clinical
indications for MR imaging include signs of myelopathy, radiculopathy, progressive
72 H. Garg et al.
Table 5.1 Indications for obtaining an MRI

Signs of myelopathy
Signs of radiculopathy
Progressive neurologic deficit
Spinal cord injury
An unexpected level of neurologic findings above the level of the radiographically seen injury
neurologic deficit, SCI, and/or an unexpected level of neurologic findings above the
level of the radiographically seen injury (9). Kulkarni et al. have described three
patterns of injury in the spinal cord and found them to be valid and reliable in adults
(10). Pattern 1 depicts an area of low intensity on T2-weighted images and represents
acute cord hemorrhage. Pattern 2 depicts an area of high signal intensity on
T2-weighted images and represents cord edema. Pattern 3 is a mixed pattern, depicting
an area of low signal intensity surrounded by an area of high signal intensity, and
represents central hemorrhage surrounded by an area of edema (10). Patients with
pattern 2 have the highest probability of recovery. Resolution of spinal cord edema
as demonstrated on follow-up MRI often will correlate with neurologic improve-
ment. Sledge et al. have found these patterns to be valid even in the pediatric thora-
columbar spine (11). However, the age of the patient, pattern of injury, level of
injury, and other characteristics of the immature pediatric spine should be taken into
account while evaluating, treating, and predicting outcomes in pediatric spinal
trauma (Table 5.1).
Classification of Pediatric Thoracolumbar Fractures

and Their Management
Multiple classification systems have been applied to thoracolumbar fractures in

adults but none of them have ever been studied or validated in children. Watson-
Jones (12) was the first to describe three fracture types in 1938, including simple
wedge fractures, comminuted fractures, and fracture dislocations. Kelly and
Whitesides (13) initially described a two column concept of the spine for defining
spinal stability in fractures, which was later modified by Denis (14) into a three
column concept. The anterior column comprises the anterior longitudinal ligament
and anterior two thirds of the vertebral body and disc, while the middle column
comprises the posterior third of the vertebral body and disc and the posterior longi-
tudinal ligament. The posterior column encompasses the posterior elements of the
spine along with the posterior ligaments. Based on this three column concept,
thoracolumbar fractures can be classified as shown in Table 5.2.
None of these anatomic classification systems account for the patient’s neuro-
logic status, address the importance of the posterior ligamentous structures, provide
prognostic information, or guide clinical decision making. Holdsworth (15) was
Table 5.2 Denis Classification system for spine fractures

Type of fracture Axis of rotation Force
Compression Middle column Anterior compression force
Burst Posterior column Anterior compression force
Flexion distraction Anterior column Posterior distraction force
Fracture dislocation Variable Distraction or shear plus rotation
Table 5.3 TLICS grading scale

Category Points
Injury morphology
Compression 1
Burst +1
Translational/rotational 3
Distraction 4
Neurological status
Intact 0
Nerve root 2
Cord, conus medullaris
Incomplete 3
Complete 2
Cauda equina 3
PLC
Intact 0
Injury suspected/indeterminate 2
Injured 3
TLICS classification system. Modified from (18)
the first to stress the importance of the posterior ligamentous complex in his mecha-
nistic classification. Subsequently, the AO/Magerl classification (16) described
three major injury mechanisms, including compression (Type A), distraction (Type B),
and torsion (Type C). Each type is subsequently divided into three groups (A1, A2,
A3, etc.) and each group is then further divided into three subgroups, thus making
this classification system too comprehensive to be used in routine clinical practice.
The most recent classification system presented has been from Vaccaro et al.
(17, 18) and is known as the thoracolumbar injury classification and severity score
(TLICS). The TLICS defines injury based on three clinical characteristics: injury
morphology, integrity of the posterior ligamentous complex, and neurologic status
of the patient. This severity score offers prognostic information and is helpful in
medical decision making. Initial application of the TLICS has shown good to excel-
lent reliability and validity in adults; however, it has not been tested nor validated
for the pediatric population. A score >4 suggests the need for surgical treatment
because of significant instability, whereas a score <4 suggests nonsurgical treat-
ment. A patient with a score of 4 may be treated either surgically or nonsurgically.
In the setting of multiple fractures, management is determined based on the injury
with the greatest TLICS severity score (18) (Table 5.3).
74 H. Garg et al.
Compression Fractures (Fig. 5.1)
Compression fractures involve injury to the anterior column of spine and are the
most common injury pattern seen in the pediatric thoracic spine due to the natu-
ral kyphosis in the thoracic spine and wedge shape of the immature vertebral
body. Axial loading of the spine as occurs during diving injuries, falls, or foot-
ball injuries is the common mechanism of injury for these fractures. The end
plates may be involved in the fractures, with the superior end plate sustaining an
injury twice as often as the inferior end plate. Compression fractures are typically
stable with no need for surgery. They can be managed in a thoracolumbosacral
orthosis (TLSO) for 8–12 weeks (5, 19). If the compression is mild (less than 20
degrees), the patient can be treated symptomatically, with or without external
support.
If the anterior column wedging is less than 30 degrees and the vertebral physes
remain active, restoration of vertebral body height typically occurs. However, if the
amount of wedging is more than 30 degrees or the end plate is damaged, there is a
risk of progressive deformity (20). A CT scan is usually indicated in compression
fractures with more than 30% loss of anterior vertebral body height or any loss of
posterior vertebral body height to rule out a burst fracture with middle column insta-
bility. When there is more than 50% loss of anterior height or there are multiple
compression fractures leading to an increased kyphosis, posterior instrumentation
may be necessary which should encompass the entire kyphotic deformity (21, 22).
Nonetheless, most of the compression fractures have a good prognosis with great
remodeling potential, especially in younger patients (23).
Fig. 5.1 (a and b) Compression fracture. The axis of rotation is on the middle column. CT scan
demonstrating fracture of the anterior column with preservation of middle and posterior column
integrity. (Courtesy of Shriners Hospital for Children, Philadelphia, PA)
Burst Fractures (Fig. 5.2)
Burst fractures are caused by axial (vertical) loading of the thoracolumbar spine,
driving the nucleus of the disc into the vertebral body which ultimately fractures.
These fractures are defined by involvement of both the anterior and middle col-
umns. Radiographically, an increased interpedicular distance is seen on the antero-
posterior (AP) view, retropulsion of the bony fragment into the spinal canal is
visualized on the lateral view (Fig. 5.3), and/or an associated complete or greenstick
fracture of the lamina is present. Burst fractures are considered potentially unstable
if there is focal kyphosis greater than 20 degrees, greater than 50% canal compro-
mise, involvement of the posterior column, and/or a neurological deficit.
Stable burst fractures (Fig. 5.4) can be managed conservatively in a TLSO or
hyperextension brace for 6–8 weeks.
Unstable burst fractures and stable burst fractures with severe communition or
with associated injuries are better managed surgically (Fig. 5.5). Contouring the
rods and achieving three-point fixation help to reduce the deformity and restore the
spinal alignment. The classical teaching has been to fuse the spine from two levels
above to two levels below the fractured region. Some surgeons believe that with the
use of modern pedicle screw systems, instrumentation levels can be shortened,
extending from one level above to one level below the fractured vertebra especially
in the lumbar spine (22). Additionally, it may be possible to use one pedicle screw
at the fracture level, which will aid in the strength of the construct. After reduction,
if loss of anterior body height is greater than 60%, anterior grafting may be required
(22). Recently, minimally invasive methods for management of these fractures are
gaining popularity; these include percutaneous pedicle screw fixation of the fracture
followed by removal of instrumentation after fracture healing. This helps in earlier
Fig. 5.2 Burst fracture. The axis of

rotation is over the posterior column.
(Courtesy of Shriners Hospital for
Children, Philadelphia, PA)
76 H. Garg et al.
Fig. 5.3 (a and b) L5 burst fracture demonstrating retropulsion of the bony fragment into the
spinal canal. (Courtesy of Shriners Hospital for Children, Philadelphia, PA)
mobilization and may also potentially preserve mobility after instrumentation

removal (24). If the burst fracture involves the end plate, progressive deformity can
occur and therefore these patients should be followed very closely.
Flexion Distraction Injuries (Seat Belt Fractures, Chance

Fractures) (Fig. 5.6)
In the initial description of these fractures by Chance, the flexion moment was theo-
rized to travel through the neural arch and exit through the anterior vertebral body
(25). It is now accepted that a combination of flexion and distraction is causative,
such that the anterior column fails in flexion and posterior column fails in distrac-
tion (26, 27).
Gumley and colleagues (28) suggested a classification based on the location of the
fracture in the posterior elements of the vertebra. Type I fractures extend through the
spinous process and travel symmetrically forward through all the posterior bony ele-
ments to emerge in a variable position within the vertebral body. Type II fractures are
identical, except that the fracture line traverses the posterior elements between the
spinous processes. Type III fractures are asymmetric, involving the posterior elements
more on one side than the other, which is possibly associated with a rotational force
occurring around a seat-belt strap. Children are particularly susceptible to seat-belt
injuries for several reasons. These include a large head relative to their body length, a
higher center of gravity compared with that of adults, poor protection of thoracic and
abdominal organs by the chest and abdominal wall, and underdevelopment of the
anterior iliac crests, which serve to anchor the body to the seat belt (29).
Fig. 5.4 (a–d) Stable burst fracture involving the anterior and middle columns with minimal
kyphosis and no canal compromise. A stable fracture such as this can be managed conservatively.
(Courtesy of Shriners Hospital for Children, Philadelphia, PA)
78 H. Garg et al.
Fig. 5.5 (a) AP x-ray demonstrating intrapedicular widening at fractured level. (b) lateral x-ray
demonstrating focal kyphosis. (c) axial CT scan demonstrating canal compromise. (d) post-
operative PA x-ray and (e) post-operative lateral x-ray demonstrating restoration of alignment
Fig. 5.5 (continued)
Fig. 5.6 Flexion distraction injury

(Chance fracture). The axis of rotation
falls on the anterior column with
posterior distraction force. (Courtesy
of Shriners Hospital for Children,
Philadelphia, PA)
80 H. Garg et al.
Bony chance fractures can be managed conservatively if acceptable alignment

can be obtained in a cast or TLSO as bone-on-bone contact of the fractured ends
will have a higher propensity to heal as opposed to a purely ligamentous injury.
If proper alignment is unable to be obtained, or the injury extends through the
disc and not the vertebral body, surgical stabilization with posterior instrumenta-
tion is recommended. Surgical stabilization can also be performed in bony chance
fractures because of advantages of early mobilization and avoiding all problems
of prolonged recumbency (Fig. 5.7). Instrumentation is usually extended one
level above and one level below the level of injury using pedicle screws or hooks.
A posterior compression force is usually required for reduction of the fracture
(22, 30).
Fig. 5.7 (a, b, and c) Flexion distraction injury in a 17-year-old girl managed with a posterior
instrumented fusion. (Courtesy of Shriners Hospital for Children, Philadelphia, PA)
Fracture Dislocation Injuries for the Thoracic/Lumbar

Spine (Fig. 5.8)
These injuries, typically located at the thoracolumbar junction, are very rare and are
the result of high-energy trauma. An associated neurological deficit is common.
Fig. 5.8 (a–f) T6–T7 fracture dislocation in a 13-year-old boy due to a fall from a height with
complete cord transection and paraplegia below the level of injury. He underwent a T3 to pelvis
fusion with two level corpectomy for correction of the deformity and to prevent progressive neu-
romuscular scoliosis in the future. (Courtesy of Shriners Hospital for Children, Philadelphia, PA)
82 H. Garg et al.
A fracture/dislocation is an unstable injury and thus will always require urgent sur-
gical intervention with long rigid fixation and multiple anchors starting close to the
fracture level. Anterior stabilization may be required, in addition to posterior instru-
mentation, depending on the injury pattern and severity.
Minor Fractures
Minor fractures of the transverse processes or spinous processes in the thoracolum-

bar spine may occur due to blunt trauma to the spine. They may indicate associated
pleural cavity injuries in the thoracic spine, renal injuries in the thoracolumbar
region, and unstable pelvic fractures in the lower lumbar spine. These associated
injuries must be carefully ruled out in these patients. Isolated transverse or spinous
process fractures themselves do not typically require any intervention.
Vertebral Apophyseal Injuries
Vertebral apophyseal injuries are unique to the developing spine and typically occur
in children younger than ten years of age from a significant traumatic event. The
injury is due to a complete separation of the vertebral apophysis from the primary
spongiosa of the vertebral body without failure of the intervertebral disc or annulus
fibrosis with the actual fracture traversing through the hypertrophic zone of the growth
plate. The inferior growth plate is involved twice as often as the superior growth plate.
This type of fracture may spontaneously reduce and may not be seen on initial plain
radiographs, but may be subsequently diagnosed on MRI or CT scans. These fractures
usually heal readily with reduction and cast or brace immobilization.
SCIWORA
Spinal cord injury without radiographic abnormality (SCIWORA) was first described
by Pang and Wilberger in 1982, when MRI was not yet used routinely (31). The
definition of SCIWORA has since become somewhat confusing after the advent and
widespread use of MRI as patients with SCIWORA on plain radiographs are found
to have cord injury on MRI. The incidence of SCIWORA in pediatric SCI ranges
widely in reported series from 5% to 67%. This wide range observed is largely
because of differences in defining criteria, the differential availability of diagnostic
tools in various medical centers, and awareness of the syndrome (3). Most clinicians
now agree that SCIWORA is spinal cord injury in the absence of bony radiographic
abnormalities. Utilizing this definition, the incidence of SCIWORA in pediatric SCI
is 34.8% (3, 32).
The incidence of SCIWORA is higher in children compared to adults as the ver-

tebral column is much more elastic and pliable in children. In very young children,
the vertebral column can stretch as much as 2 inches without dislocation whereas the
spinal cord can stretch by only 0.25 inch without tearing. Another possible mecha-
nism for SCIWORA in pediatric populations is physeal end plate fracture with no
detectable evidence on plain radiographs. The incidence of SCIWORA is much
higher in the cervical spine as compared to the thoracic spine, with only 13% of
SCIWORA cases involving the thoracic spine. The upper thoracic cord seems more
likely to be injured severely, possibly because of the presence of a watershed vascular
supply zone and the distribution of the exiting nerve roots and dentate ligaments.
SCIWORA should potentially be considered an unstable injury even though there are
no recognizable radiographic signs of extensive bony destruction or ligamentous tear.
Delayed neurological deficit and recurrent SCIWORA have been shown to occur after
the initial traumatic event. This potentially unstable injury can result in recurrent trauma
to the spinal cord even from seemingly innocuous movements after the initial injury.
Delayed neurological deficit can even result in complete paralysis from 30 minutes to
4 days after injury, with recurrent SCIWORA occurring in 17% of patients (33).
Patients with SCIWORA at the thoracic level should be put on complete bed rest
with log roll precautions until other associated injuries have been excluded and a
rigid brace is fabricated. Typically, patients are treated with a TLSO with an added
cervical component for upper thoracic lesions for a total of 12 weeks.
The management of patients without any abnormality on the MRI is controversial.
According to Pang (32), patients with persistent neurological deficit after 24 hours
should be immobilized in a brace for 12 weeks whereas patients with transient neuro-
logical deficits should be immobilized in a brace for 7–10 days and then reevaluated.
The outcome of patients with SCIWORA depends on the age of the patient and
the initial neurological examination. Pang (32) reported that 75% of children
younger than 8 years of age with SCIWORA had complete (Frankel grade A) or
severe (Frankel grade B and C) injuries, compared with only 15% of patients older
than 8 years of age. Importantly, up to 50% of children who sustain these injuries
have subsequent neurologic deterioration.
Management of Patients with Spinal Cord Injury
Nearly all patients in whom SCI occurs before the adolescent growth spurt develop
progressive scoliosis (34, 35) (Fig. 5.9). Therefore, young children with SCI should
be monitored very closely for development of spinal deformity. Orthotic treatment
should be started as soon as the spinal deformity is identified. Although there is no
strong literature support for the use of bracing in patients with SCI, in the authors’
experience, if bracing is started in curves less than 10 degrees, potential fusion can
be avoided and if bracing is started after 20 degrees, some slowing of curve progres-
sion can occur (36, 37). Bracing can impair daily activities and independence, but
the potential benefits clearly outweigh the risks and complications.
84 H. Garg et al.
Fig. 5.9 (a–d): A 9-year-old patient with progressive neuromuscular scoliosis secondary to SCI
at the age of 4 years. She was treated with a posterior instrumented fusion from T2 to the pelvis.
The potential causative factors for the development of progressive spinal

deformity in pediatric SCI are: residual fracture deformities after the initial injury,
truncal muscle imbalance, development of spasticity secondary to incomplete SCI,
progressive cord apoptosis, and development of syringomyelia. Progressive defor-
mity and poor sitting balance in the wheelchair are some of the indications for
surgical intervention. Spinal deformities should be treated in a similar manner as
neuromuscular scoliosis with modern corrective surgical techniques when bracing
fails to prevent progression.
Surgical correction and fusion in this population have a high complication rate
(38, 39). The incidence of pseudarthrosis requiring revision surgery may be as high
as 29% (38), and infection rates are also elevated compared to other causes of sco-
liosis with our data indicating an infection rate of 16% (39). Potential reasons for
the high complication rate include poor wound healing due to the lack of protective
sensation, incontinence resulting in wound contamination, and confinement to bed
or a wheelchair which predisposes the child to pressure ulcers. Management of
spinal deformity related to SCI is fraught with complications, and revision surgery
is common.
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Part III
Upper Extremity
Chapter 6
Supracondylar Humerus Fractures
Abstract Supracondylar humerus fractures are the most common pediatric

elbow fractures. This chapter will provide the information necessary to under-
stand the relevant anatomy, etiology, and incidence of these common injuries.
The technique to treat the fracture will be discussed in detail as well as the
potential complications.
Keywords Supracondylar fracture • Pediatric elbow fractures • Elbow trauma

• Humerus fracture • Upper extremity fractures
Introduction
Supracondylar fractures are the most common pediatric elbow fracture accounting
for 3.3% of all pediatric fractures [1, 2]. Treatment of these fractures has substan-
tially changed over the past decade, including decreased rates of malunion and
compartment syndrome utilizing modern techniques [3]. However, some aspects of
treatment remain controversial. This chapter will provide our current treatment
recommendations based on the medical literature published to date.
J.M. Abzug, MD (*)

D.A. Zlotolow
Department of Orthopaedics, Shriners Hospital for Children, 3551 North Broad Street,
Philadelphia, PA 19140, USA
e-mail: dzlotolow@shrinenet.org
S.H. Kozin
Department of Orthopaedic Surgery, Shriners Hospital for Children,
e-mail: skozin@shrinenet.org
90 J.M. Abzug et al.
Fig. 6.1 Drawing

depicting the thin region
of bone (supracondylar
region) between the
olecranon fossa posteriorly
and the coronoid fossa
anteriorly (Courtesy of
Dan A. Zlotolow, MD)
Supracondylar fractures comprise two-thirds of pediatric hospitalizations for

elbow injuries [4]. These fractures are most common in children between five and
seven years of age [3], with current data suggesting a nearly equal incidence between
girls and boys [3, 5, 6]. The vast majority of injuries occur in the nondominant
extremity; therefore, the left side is more commonly cited [5, 6].
The supracondylar region of the distal humerus is formed by a thin piece of bone,
between the olecranon fossa posteriorly and the coronoid fossa anteriorly, which
connects the medial and lateral columns of the distal humerus (Fig. 6.1). When the
elbow is forcefully extended, such as occurs upon impact with an outstretched hand
during a fall, the olecranon engages the olecranon fossa and acts as a fulcrum.
Simultaneously, the anterior aspect of the elbow capsule places a tension force on
the distal part of the humerus just proximal to its insertion [3]. The end result of
these combined forces is an extension-type supracondylar fracture, which accounts
for 97–99% of supracondylar fractures [5, 7].
6 Supracondylar Humerus Fractures 91
The remaining supracondylar fractures are flexion-type injuries and also occur
due to a fall [7]. It is thought that landing directly on the elbow, as opposed to an
outstretched hand, may be the mechanism for creating this injury pattern.
Physical Examination
Children who sustain supracondylar humerus fractures present with pain and swell-
ing about the elbow region. Motion may be limited based on the fracture severity
and the patient’s pain tolerance. Particular attention should be paid to the amount of
swelling present, any skin puckering, or any abrasions and/or breaks in the skin.
This first part of the examination should be performed by observation only.
The next step is to palpate the injured extremity to determine if there are other
areas of injury and the exact location of tenderness about the elbow. Palpation
should begin away from the obvious site of injury to gain trust from the child, begin-
ning either at the shoulder region or hand. It is important to observe the child’s face
for grimacing or signs of withdrawal as children may be anxious and have a difficult
time vocalizing their pain. When the elbow region is reached, particular areas should
be isolated to determine the location of maximal tenderness, including the radial
neck (palpation distal to the elbow joint on the lateral side), the lateral condyle (pal-
pation at the joint line itself on the lateral side), the olecranon (palpation distal to the
elbow joint on the medial side), and the supracondylar region (palpation proximal
to the elbow joint on the medial and/or lateral sides). While the former areas may
elicit some tenderness to palpation, more discomfort should be present when assess-
ing the supracondylar region. This careful examination will aid the examiner in
confirming the suspected diagnosis while avoiding missing a concomitant injury.
The most common ipsilateral fracture that occurs simultaneously with supracon-
dylar fractures is a distal radius fracture, thus constituting a floating elbow (Fig. 6.2)
[4]. Children who sustain a diaphyseal forearm fracture in addition to their supra-
condylar fracture are at increased risk for developing compartment syndrome of the
forearm [8].
The next step in the examination involves performing a thorough neurologic
exam. This assessment may be difficult based on anxiety, pain, or poor cooperation
from the child, especially in those children under 5 years of age. However, it is
imperative to be patient and persistent in order to obtain an accurate and thorough
examination. This is done by observing the child over a prolonged period of time or
performing repeat exams as necessary. Flexion of the interphalangeal (IP) joint of
the thumb indicates an intact anterior interosseous nerve (AIN), flexion of the proxi-
mal interphalangeal (PIP) joints of the digits indicates an intact median nerve,
flexion of the distal interphalangeal (DIP) joint of the small finger indicates an intact
ulnar nerve, and extension of the metacarpophalangeal (MP) joints of the fingers
indicates an intact radial nerve.
Nerve injuries are present in 11.3% of patients who sustain a supracondylar frac-
ture [9]. Specifically, extension-type supracondylar fractures are most commonly
Fig. 6.2 Radiograph

depicting a floating
elbow. Note the
supracondylar fracture in
the top half of the
radiograph and the distal
radius/ulna fracture at the
bottom of the radiograph
(Courtesy of Shriners
Hospital for Children,
Philadelphia, PA)
associated with injury of the AIN, followed by the median nerve, radial nerve, and
ulnar nerve in order of frequency [9]. Flexion-type supracondylar fractures are most
commonly associated with ulnar nerve injury [9]. Nerve injuries identified at the
time of injury usually resolve within 6–12 weeks. A change in the neurological
examination postoperatively is concerning and may indicate injury to the nerve
occurred during manipulation and pinning of the fracture, entrapment of the
nerve within the fracture site, or emerging compartment syndrome. Exploration of
the nerve or forearm fasciotomies may be necessary.
Lastly, the vascular status of the extremity needs to be assessed. This is first
accomplished by palpating the radial artery and utilizing Doppler ultrasound if
needed. The current terminology to describe the vascular status of the limb is based
on perfusion of the hand since children have abundant collateral flow to the forearm
and hand originating proximal to the fracture region. Therefore, the vascular status
of the injured extremity is described as normal, a pink, pulseless hand, or dysvascu-
lar (white, pulseless hand). Signs of a “pink” hand include normal capillary refill,
skin temperature, and color.
Differential Diagnosis
The differential diagnosis of a supracondylar fracture includes other fractures about

the elbow, specifically, radial neck/head, lateral condyle, medial epicondyle, olecra-
non, and distal humerus coronal shear fractures. Transphyseal separations are most
likely to occur in children below 3 years of age and can be assessed utilizing an
elbow arthrogram. Additionally, an elbow dislocation or ligamentous injury must be
ruled out. In younger children, a nursemaid’s elbow is a potential ligamentous cause
of limited motion about the elbow. Lastly, infection must be ruled out in the pres-
ence of a swollen, painful elbow without antecedent trauma.
Imaging
Radiographic imaging should begin with an anteroposterior (AP) view of the distal
humerus rather than of the elbow, and a true lateral view of the elbow. Radiographs
should be examined for fracture displacement, angulation, comminution, and/or intra-
articular extension. Rotational or translational malalignment should also be noted. If
one is unsure about the presence of a fracture line versus a physeal line, comparison
radiographs of the contralateral elbow can be helpful. In order to rule out any concomi-
tant injuries, orthogonal views of the entire upper extremity should be obtained.
The initial AP radiograph may appear normal and therefore it is imperative to
examine the lateral radiograph for displacement or presence of a posterior fat pad
sign, which is a radiographic lucency along the posterior distal humerus and olecra-
non fossa caused by an elbow effusion displacing fat from the olecranon fossa.
Skaggs and colleagues demonstrated that 76% of children who initially had radio-
graphs with a posterior fat pad sign without evidence of a fracture line ultimately
had an occult fracture of the distal humerus, proximal radius, or olecranon based on
repeat radiographs demonstrating periosteal fracture healing. Of this subgroup, 53%
had a supracondylar fracture of the humerus [10]. In contrast, the anterior fat pad
can be seen on a lateral radiograph of an uninjured flexed elbow and is an unreliable
indicator for occult fracture.
Posterior displacement of the distal fragment can be assessed by determining
where the anterior humeral line (a line drawn along the anterior cortex of the
humerus and extended distally) intersects the capittelum (Fig. 6.3). This line should
intersect the middle third of the capittelum in children older than four years of age
but may lie in the anterior third of the capittelum in children under four years of
age [11]. If the line does not intersect the capittelum at all, posterior displacement
is present indicating an extension-type supracondylar fracture (Fig. 6.4).
The Baumann angle, or humeral capitellar angle, is assessed on the AP radio-
graph to evaluate for varus angulation of the fracture. This angle is measured by
determining the angle between the long axis of the humeral shaft and the physeal
line of the lateral condyle. The normal range is from 9° to 26°, with a decrease indi-
cating varus angulation.
Fig. 6.3 Normal lateral radiograph of a pediatric elbow with the anterior humeral line drawn on
it. Note the anterior humeral line intersecting the middle third of the capittelum (Courtesy of
Shriners Hospital for Children, Philadelphia, PA)
Fig. 6.4 Anterior humeral line that does not intersect the capittelum at all; thus, posterior
displacement is present indicating an extension-type supracondylar fracture (Courtesy of Shriners
Hospital for Children, Philadelphia, PA)
Classification
Supracondylar fractures are initially described based on displacement of the distal

fragment into either flexion or extension. The modified Gartland classification
system is the most commonly utilized system for describing extension type supra-
condylar humerus fractures.
Type I fractures are non-displaced and are only diagnosed by the presence of a
posterior fat pad sign. Gartland Type II supracondylar fractures have an intact poste-
rior hinge. Wilkins expanded this type into A and B subtypes with Type IIA fractures
being extended without rotational abnormality or fragment translation and Type IIB
fractures having rotational displacement or translation present in addition to the
extension [12] (Fig. 6.5a, b). Type III fractures have complete displacement with no
cortical contact (Fig. 6.6). A Gartland Type IV supracondylar fracture has been pro-
posed by Leitch and colleagues to indicate multidirectional instability due to com-
plete loss of a periosteal hinge. The authors propose that these fractures may occur
due to the initial injury itself or result from repeated attempts at reduction [13].
Treatment by Fracture Type
Type I Fractures
These non-displaced fractures are treated in a well-padded long arm cast or a poste-
rior splint with the elbow in 70–90° of flexion for approximately 3 weeks. Casts
should never be placed in hyperflexion as this position decreases perfusion to the
Fig. 6.5 (a) Radiograph of a Type IIA supracondylar fracture. Note the posterior displacement
without a rotational component. (b) Radiograph of a Type IIB supracondylar fracture (Courtesy of
Shriners Hospital for Children, Philadelphia, PA)
Fig. 6.6 Fluoroscopic image of a Type III supracondylar fracture (Courtesy of Shriners Hospital
for Children, Philadelphia, PA)
forearm and hand and may result in compartment syndrome. Repeat radiographs
should be performed at 1 week to ensure no fracture displacement has occurred.
Type II Fractures
Treatment of Type II fractures is controversial with some authors recommending

closed reduction and pinning of all Type II fractures [3], others recommending closed
reduction and pinning of only Type IIB fractures [14], and others recommending
closed reduction and casting of all Type II fractures [15].
The rationale for some authors recommending operative intervention is that the
distal part of the humerus contributes only 20% of arm growth and has little
remodeling potential. Thus, a near anatomic reduction is necessary to prevent
malunion. Additionally, these fractures can be unstable leading to further dis-
placement over time. Operative fixation obviates the need for repeat radiographs
on a weekly basis, which is especially important in potentially noncompliant
patients. O’Hara and colleagues showed that all of their Type IIB and III fractures
treated with pinning healed without malunion and none required repeat operation.
In contrast, one-third of the Type IIA fractures initially treated nonoperatively
required surgery and some developed cubitus varus [14].
Table 6.1 Reasons for urgent surgical intervention

Open fractures
Abnormal neurovascular exam
Skin puckering
Floating elbow
Severe swelling
Impending compartment syndrome
Based on these findings, our current practice is to treat the vast majority of
Type II fractures with closed reduction and pinning. If a child is treated nonopera-
tively in a splint for a Type II fracture, repeat radiographs are performed within
5–7 days to evaluate for displacement. If the reduction is maintained in the splint,
conversion to a long arm cast once swelling subsides allows for better control of
the fracture fragments without the risk of compartment syndrome. Operative
fixation is undertaken if the reduction is not maintained. We have found that
closed reduction and pinning up to 7 days from the injury is no more difficult than
treating the fracture acutely.
Type III
These fractures are treated with closed reduction and percutaneous pinning. If
closed reduction is not possible, open reduction and internal fixation is performed.
Operative intervention should be performed urgently in the case of open fractures,
any neurovascular compromise, skin puckering, severe swelling, a floating elbow,
or an impending compartment syndrome. If none of these situations are present,
the child can be admitted and observed with operative intervention performed
within 12–18 h of injury. Multiple recent studies have shown that if the fracture
meets these requirements, there is not an increased risk for conversion to open
reduction, superficial pin tract infection, iatrogenic nerve injury, or compartment
syndrome when these fractures are treated from 8 to 21 h after injury [16–18]. The
arm should be placed in a long arm splint with the elbow flexed 20–40° prior to
surgery. Additionally, neurovascular checks should be performed every two hours
and pain medication limited to agents that will not sedate the child or mask signs
and symptoms of an impending compartment syndrome. We have found that non-
narcotic medication, such as acetaminophen, typically provides sufficient analge-
sia (see Table 6.1).
Type IV
Type IV fractures are treated with attempted closed reduction and pinning similar to
type III fractures. Leitch and colleagues recommend rotating the fluoroscopy unit or
using two simultaneous units, rather than rotating the arm to obtain orthogonal
Table 6.2 Algorithm for pink, pulseless hand

Emergent closed reduction and pinning in operating room (open reduction if necessary)
Reassess vascular status of limb and observe for 15–20 min
No improvement Immediate arterial exploration via anterior approach
views. Additionally, the authors recommend pre-placement of the Kirschner wires

into the distal fragment prior to reduction [13]. Open reduction and internal fixation
is performed if closed techniques are unsuccessful.
Treatment of the Pink, Pulseless Hand
The pink, pulseless hand in association with a supracondylar humerus fracture is a

situation without consensus regarding treatment algorithm. We feel that both the
dysvascular limb and pink, pulseless hand require emergent treatment in the operat-
ing room. Closed reduction (open reduction if needed) followed by pinning of the
fracture is performed. Subsequently, the vascular status of the limb is reassessed and
observed for 15–20 min. If the hand is well perfused, whether or not a palpable
radial pulse is present, the elbow is splinted in 40–60° of flexion and the child is
admitted to the intensive care unit for frequent neurovascular monitoring. If ade-
quate perfusion is not restored to the hand, immediate arterial exploration is under-
taken through an anterior approach as described below for open reduction. An
arteriogram is not indicated as the level of vascular injury is known and arteriogram
may delay repair or cause unnecessary spasm of the vessel (see Table 6.2).
Operative Techniques
Closed Reduction and Percutaneous Pinning
Our preferred technique is to perform closed reduction and pinning in the operating
room under general anesthesia. The child is positioned supine on the operating room
table and preoperative antibiotics are administered. The fluoroscopy machine is
inverted to utilize as a hand table. The patient must be brought to the edge of the
operating room table to ensure that the elbow can be placed in the center of the
fluoroscopy unit (Fig. 6.7).
Closed reduction is initiated by performing the “milking maneuver,” an attempt to
remove the brachialis and biceps muscles from the distal spike of the proximal frag-
ment by “milking” the muscle bellies in a proximal to distal direction. Next, by stabi-
lizing the proximal arm, longitudinal traction is applied to the forearm and the elbow
is gently flexed (Fig. 6.8a, b). Pronation or supination may be employed to aid in the
reduction. Gentle traction may need to be applied for a prolonged period of time in
Fig. 6.7 Setup for closed reduction and percutaneous pinning of a supracondylar fracture. The
fluoroscopy unit is inverted and the child is brought to the edge of the table (Courtesy of Shriners
Hospital for Children, Philadelphia, PA)
severely displaced fractures. Varus and valgus angulation is now corrected by the
surgeon moving the distal humerus fragment between the thumb and index finger.
After these maneuvers are performed, fluoroscopy is performed to assess the
reduction. With the elbow maintained in a flexed position, angulation is assessed
with a shoot through AP view. If the angulation is unacceptable, varus/valgus adjust-
ment is performed by the surgeon adjusting the distal fragment between their thumb
and index finger. Once adequate reduction is confirmed, the shoulder is externally
rotated, while maintaining control of the arm, elbow, and forearm. A lateral view is
obtained to assess flexion and extension. If the distal fragment remains extended,
repeat traction and elbow flexion is performed.
If a “rubbery” feeling is encountered during these maneuvers instead of the usual
crepitation felt with fracture reduction, concern for interposition of the median
nerve and/or brachial artery should be present. In this scenario, consideration for
open reduction should be performed.
Fig. 6.8 (a, b) Closed reduction of a supracondylar fracture is performed by stabilizing the proxi-
mal arm and subsequently applying longitudinal traction to the forearm. Next the elbow is gently
flexed and the reduction is assessed with fluoroscopy (Courtesy of Shriners Hospital for Children,
Philadelphia, PA)
Fig. 6.9 Technique of utilizing tape to hold the elbow in a flexed position, thus maintaining the
reduction, if no additional help is present (Courtesy of Shriners Hospital for Children,
Philadelphia, PA)
Once the reduction is adequate, the surgeon maintains the reduction if addi-
tional help is available. If no help is present, we tape or CobanTM (3M, Minneapolis,
MN, USA) the elbow in a flexed position to maintain reduction and free up the
surgeon’s hands (Fig. 6.9). Keep in mind that as soon as the arm is placed and
held in deep flexion, ischemia time begins. The elbow region is then prepped and
draped utilizing the semi-sterile technique. This technique places a half sheet on
the fluoroscopy unit followed by prepping the mid forearm to mid humerus after
the surgeon and assistant have donned sterile gloves. No other drapes or gowns
are utilized, thus decreasing operative time and cost. Iobst et al. reported on this
technique in 304 cases without any superficial pin tract or deep infections requir-
ing treatment [19].
Prior to pin placement, fluoroscopic imaging is performed to ensure no loss of
reduction occurred. Specifically, confirmation that the anterior humeral line inter-
sects the capitellum, Baumann’s angle is greater than 10°, and the medial and lat-
eral columns are intact should be performed. The elbow is now placed on a bump
of folded towels. If an assistant is available, the surgeon should maintain the reduc-
tion and allow the assistant to drive the Kirschner wires. If tape or Coban was used
to hold the reduction, no assistance is necessary and the surgeon drives the
Kirshcner wires.
The capitellum is palpated and a 0.062 Kirschner wire or 2.0 mm Steinman
pin is placed through the skin onto the bone. The wire is then driven across the
fracture with the goal of having enough space to maximally separate the pins at
the fracture site while engaging both the medial and lateral columns. Typically,
we place two Kirschner wires for Type II fractures and three Kirschner wires for
Type III fractures. The Kirschner wires should ideally be divergent in both the AP
and lateral planes (Fig. 6.10). Crossing the olecranon fossa does no harm and adds
two additional cortices, thus improving fixation.
Once the pins are placed and adequate reduction is confirmed, stability should
be assessed in varus and valgus as well as flexion and extension under live
fluoroscopy. If any instability is present, an additional lateral pin is placed.
If there is no room for an additional lateral pin or medial comminution is present,
a small incision is made over the medial epicondyle and blunt dissection is car-
ried down to bone. Under direct vision with the elbow extended, a medial pin is
placed engaging both cortices. The pins should not cross at the fracture site.
Flexion of the elbow should ensure that there is no tethering of the ulnar nerve
about the pin.
The vascular status of the limb is now assessed and if adequate the Kirschner
wires are bent and cut. A long arm splint with the elbow in approximately 90°
of flexion is applied and the child is admitted to the hospital overnight for obser-
vation and to receive antibiotics. Radiographs are taken at one week following
surgery to ensure there has been no loss of reduction. The Kirschner wires are
removed in the office 3 weeks postoperatively and the child begins to utilize the
elbow as tolerated.
Fig. 6.10 Drawing depicting ideal Kirschner wire placement. Note the diverging Kirschner wires
in both the anterior and lateral projections (Courtesy of Dan A. Zlotolow, MD)
Open Reduction and Internal Fixation
Open reduction and internal fixation is necessary in an irreducible fracture, an open

fracture, or a dysvascular limb following reduction. An anterior approach through
the elbow flexion crease provides adequate exposure of the fracture site, neurovas-
cular structures, and any potential interposing soft tissue. Once the skin incision is
made, blunt dissection can be performed down to the fracture site to remove any
interposing soft tissue or neurovascular structures. Reduction and pinning should be
performed as described above and then any neurovascular injury should be addressed.
The artery is often tethered and release restores circulation; however, transection or
thrombosis requires emergent repair or reconstruction.
Complications
Despite ideal treatment, complications are common following treatment of supra-

condylar humerus fractures. Bashyal and colleagues performed a retrospective
review of 622 patients treated for supracondylar fractures and found a 4.2% overall
rate of complications. The most common complication was pin migration, with
1.8% of patients requiring an unanticipated return to the operating room for pin
removal. One percent of patients had an infectious complication including five
superficial pin tract infections and one pin tract osteomyelitis and subsequent septic
elbow arthritis. Four patients required a return to the operating room for repeat
reduction and pinning. One patient had a postoperative ulnar nerve injury and one
patient was found to have a malunion. Compartment syndrome was present in 0.5%
of patients [20].
Sankhar and colleagues demonstrated that proper technique is vital to prevent
loss of reduction when utilizing lateral entry pins alone. In their review of 279 dis-
placed supracondylar fractures, the authors found eight (2.1%) that had lost reduc-
tion. Seven of these eight fractures were initially treated with only two lateral entry
pins. Critical evaluation of the radiographs led the authors to identify important
technical aspects that must be followed to prevent loss of reduction. First, bicortical
fixation must be achieved with at least two pins (Fig. 6.11). Second, both the proxi-
mal and distal fragments must be engaged with at least two pins (Fig. 6.12). Lastly,
there must be at least 2 mm of pin separation at the fracture site [21] (Fig. 6.13).
Cubitus varus is a well-recognized complication following treatment of supra-
condylar fractures with either casting or pinning techniques. Since this complica-
tion is usually painless and does not restrict elbow motion, it was historically
believed to be a cosmetic deformity only. However, O’Driscoll and colleagues
identified 22 adult patients with complaints of pain and signs and symptoms of
elbow instability 20–30 years after sustaining supracondylar humerus fractures as
children that healed with cubitus varus. The authors showed that tardy posterolat-
eral elbow instability occurred because the cubitus varus caused medial displace-
ment of the elbow’s mechanical axis, thus causing asymmetric triceps forces that
Fig. 6.11 Drawing depicting failure to obtain bicortical fixation (Courtesy of Dan A. Zlotolow, MD)
Fig. 6.12 Drawing depicting failure to engage both Kirschner wires in the proximal fragment
(Courtesy of Dan A. Zlotolow, MD)
lead to slow attenuation of the lateral collateral ligament. Valgus osteotomy and
ligament reconstruction were required to obtain satisfactory results [22].
Based on these findings, we feel that corrective osteotomy should be performed
for all children with considerable residual cubitus varus after supracondylar frac-
tures. Our preferred technique is a lateral closing wedge osteotomy with pin fixation
performed via either a lateral or posterior approach (Fig. 6.14a–f ). If a sagittal plane
Fig. 6.13 Drawing depicting failure to separate the Kirschner wires at least 2 mm apart at the
fracture site (Courtesy of Dan A. Zlotolow, MD)
or rotational deformity is present, we will utilize a step-cut or dome osteotomy to

obtain the necessary correction.
Compartment syndrome results in a devastating complication if it is not recog-
nized and treated emergently. Bae and colleagues reviewed 33 pediatric patients
diagnosed with compartment syndrome. The “5 P’s” (pain out of proportion, pallor,
paresthesias, paralysis, and pulselessness) taught regarding diagnosis of adult com-
partment syndrome were found to be much less accurate in the pediatric patients.
Specifically, 88% reported substantial pain, 61% reported paresthesias, 36% had
paralysis, 30% had pallor, and 18% had pulselessness. Immediate surgical decom-
pression was performed in 23 of the patients while the remaining 10 patients were
initially observed. It was noted that these 10 patients had an increased frequency of
analgesia requirement as well as increased dosage requirements. These increasing
analgesia requirements preceded any neurovascular changes by an average of 7.3 h.
The authors concluded that increasing analgesia requirements are an important indi-
cator of an impending compartment syndrome in the pediatric population [23].
Subsequently, the “3 A’s” have evolved to aid in the diagnosis of compartment syn-
drome in pediatric patients including increasing Analgesia, Agitation, and Anxiety.
Based on the devastating consequence of missing a compartment syndrome, our
recommendation is to observe children for 12–24 h after they undergo closed reduc-
tion and percutaneous pinning of supracondylar fractures. This allows for neurovas-
cular checks and monitoring for signs and symptoms of increasing pain. Additionally,
we utilize non-narcotic or low-dose narcotics to prevent any masking of subtle signs
and/or symptoms of an impending compartment syndrome.
If concern for compartment syndrome exists, some authors recommend returning
the patient to the operating room for measurement of their compartment pressures.
Fig. 6.14 (a) Clinical photograph depicting cubitus varus after a supracondylar fracture. (b, c) AP
and lateral radiographs of cubitus varus after a supracondylar fracture. (d, e) Intraoperative photo-
graphs of a closing wedge osteotomy to correct cubitus varus. (f) Radiograph of the healed closing-
wedge osteotomy demonstrating correction of the cubitus varus (Courtesy of Shriners Hospital for
Children, Philadelphia, PA)
We prefer to diagnose compartment syndrome on clinical findings and proceed

directly to fasciotomies. Emergent fasciotomy begins with a volar forearm fascio-
tomy performed through an extensile approach from the wrist to the elbow. After
release of the volar compartments, measurements are performed of the dorsal and
mobile wad compartments. These latter compartments usually do not need to be
decompressed once an adequate volar fasciotomy is performed. Utilizing this tech-
nique, excellent results have been reported in 90% of patients if decompression is
performed within a mean of 30.5 h after diagnosis [23]. One caveat, we generally do
not alter our treatment based on compartment pressures. If there is sufficient concern
to warrant a repeat visit to the operating room, the risks of missing a compartment
syndrome are far greater than those of a fasciotomy (see Table 6.3 and Fig. 6.15a–f).
Table 6.3 Complications

Pin tract infections
Pin migration
Loss of reduction
Nerve injury
Cubitus varus
Compartment syndrome
Fig. 6.15 (a, b) Complication of missed compartment syndrome. The fingers are unable to be
fully extended unless the wrist is flexed. (c, d) Intraoperative photographs of a flexor–pronator
slide to address the missed compartment syndrome. Note the exposure of the entire ulna shaft and
interosseus membrane in order to elevate the flexor–pronator mass and slide it distally. (e, f)
Intraoperative correction obtained demonstrating full extension of the fingers and thumb with the
wrist extended (Courtesy of Shriners Hospital for Children, Philadelphia, PA)
Fig. 6.15 (continued)
Conclusion
Supracondylar humerus fractures are the most common fracture about the pediatric
elbow. Prompt diagnosis and treatment is essential for a successful outcome. When
performing closed reduction and percutaneous pinning, strict adherence to technique
will minimize potential pitfalls; however, even with ideal treatment, complications
will arise. The child must be observed for signs and symptoms of complications,
especially compartment syndrome.
References
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incidence, etiology and secular changes in a Swedish urban population, 1950-1979. Acta
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2. Otsuka NY, Kasser JR. Supracondylar fractures of the humerus in children. J Am Acad Orthop
Surg. 1997;5:19–26.
3. Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. J Bone Joint Surg
Am. 2008;90:1121–32.
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tors. Rockwood and Green’s fractures in children. 6th ed. Philadelphia: Lippincott Williams
and Wilkins; 2006. p. 543–89.
5. Cheng JC, Lam TP, Maffulli N. Epidemiological features of supracondylar fractures of the
humerus in Chinese children. J Pediatr Orthop B. 2001;10:63–7.
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Orthop. 1998;18:38–42.
7. Mahan ST, May CD, Kocher MS. Operative management of displaced flexion supracondylar
humerus fractures in children. J Pediatr Orthop. 2007;27:551–6.
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drome in ipsilateral humerus and forearm fractures in children. Clin Orthop Rel Res.
2000;376:32–8.
9. Babal JC, Mehlman CT, Klein G. Nerve injuries associated with pediatric supracondylar
humeral fractures: a meta-analysis. J Pediatr Orthop. 2010;30:253–63.
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elbow in children. J Bone Joint Surg Am. 1999;81:1429–33.
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to the capitellar ossific nucleus: variability with age. J Bone Joint Surg Am.
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12. Wilkins KE. Fractures and dislocations of the elbow region. In: Rockwood CA, Wilkins KE,
King RE, editors. Fractures in children, vol. 3. Philadelphia: JB Lippincott Co; 1984.
p. 363–575.
13. Leitch KK, Kay RM, Femino JD, Tolo VT, Storer SK, Skaggs DL. Treatment of multidirec-
tionally unstable supracondylar humeral fractures in children: a modified Gartland type-IV
fracture. J Bone Joint Surg Am. 2006;88:980–85.
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children. J Bone Joint Surg Br. 2000;82-B:204–10.
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humerus fractures: do they all need pinning? J Pediatr Orthop. 2004;24:380–84.
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Chapter 7
Upper Extremity Replantation in Children
Abstract When a child sustains an amputated part it is a devastating injury for

the child, his/her family, and the healthcare providers involved in the child’s care.
This chapter will focus on recognizing the mechanisms of injury to aid in
prevention, handling of the amputated part, and indications for replantation.
A brief discussion of the operative technique, postoperative care, and outcomes
will also be provided.
Keywords Pediatric replantation • Upper limb replantation • Pediatric hand trauma

• Mutilating hand injuries • Pediatric amputation
Introduction
The loss of a body part is an emotionally charged situation for the child, the child’s
family, and the healthcare team. In order to minimize the stress level of all involved,
it is essential that healthcare providers be knowledgeable about the handling of
amputated parts and the indications for replantation in children. This chapter will
provide an overview of the usual mechanisms of injury, patient evaluation when an
J.M. Abzug, MD (*)

D.A. Zlotolow
Department of Orthopaedics, Shriners Hospital for Children,
e-mail: dzlotolow@shrinenet.org
S.H. Kozin
Department of Orthopaedic Surgery, Shriners Hospital for Children,
e-mail: skozin@shrinenet.org
amputation occurs, handling of the amputated parts, and indications for replantation.
A brief discussion of the operative procedure, postoperative care, and outcomes will
be provided. Because of the microsurgical training required to perform upper extrem-
ity replantation in children, a detailed discussion of the operative procedure is beyond
the scope of this chapter.
Anatomic Differences
The upper extremity of a child is anatomically and physiologically different from an

adult. In early childhood, the bones of the amputated part may not be completely
ossified, complicating radiographic interpretation. If open physes are present, these
should be preserved when possible to maintain growth of the part. One advantage of
replantation in the child is that bone healing is rapid due to their rich periosteal
blood supply.
Soft tissue structures also routinely heal faster and with less scar in children
compared to adults. The biggest advantage of replantation in children is both the
speed and recovery potential of nerve regeneration after repair. Additionally, the
shorter distances required for nerve regeneration after repair allow for better muscle
and sensory recovery in proximal injuries compared to adults. Tendon gliding and
joint motion are also more easily restored. All of these situations lead to docu-
mented favorable outcomes of replantation in children [1–4].
Mechanism and Etiology
The majority of traumatic amputations in children occur around the elbow, the mid-
palm, or at the digital level, and are more common in boys than girls [5]. The mech-
anism of injury often directly correlates with the level and type of amputation. For
example, many hand or digital amputations are caused by a saw or axe [3].
Alternatively, bicycle chains and door slams usually cause amputations associated
with crush injuries and avulsions (Fig. 7.1). Proximal limb amputations are usually
caused by motor vehicle collisions, train accidents, or power tool injuries [3].
A somewhat unique mechanism of injury seen in children is hand injury related
to home exercise equipment. While treadmill injuries usually lead to abrasions,
burns, or minor lacerations [6], exercycle injuries can lead to traumatic amputations
[7] (Fig. 7.2). Benson et al. retrospectively reviewed 19 children with 32 trauma-
tized digits secondary to exercyle injury. Thirteen digits were injured by the wheel
spokes including three amputations. Nineteen digits were injured by the chain or
sprocket including sixteen amputations through the DIP joint or proximal to it. Of
the 19 amputations, only three were able to be replanted. The authors concluded that
children between the ages of 18 months and 5 years should not be allowed near
exercycle equipment and manufacturers should design shielding for the wheel
spokes and enclose the entire chain axis and gear interface [7].
7 Upper Extremity Replantation in Children 113
Fig. 7.1 Avuslion-type amputation in a 7-year-old child secondary to a door slam. (a) Dorsal view
of thumb with exposed distal phalanx. (b) Volar view of thumb with exposed distal phalanx.
(c) Dorsal view of amputated part. (d) Volar view of amputated part with visible bruising indicat-
ing a crush component to the injury as well (Courtesy of Joshua M. Abzug, MD)
Specific types of amputations include guillotine or sharp amputations, crush

amputations, and avulsion amputations. The best candidates for replantation are
those who sustain guillotine amputations. These injuries usually occur in older
children and have the best outcomes [3]. Crushing and avulsion amputations are
most common amongst younger children with a peak incidence around 5 years of
age (Fig. 7.3). These mechanisms have a less predictable outcome than guillotine
amputations [3].
Patient Evaluation
The evaluation of a child who sustains an upper extremity amputation begins at the
scene of the accident. The first priority is always the child as a whole and secondary
priority should be given to the amputated part. Therefore, standard advance trauma
Fig. 7.2 Successful

replantation of the long and
ring fingers after an
exercycle injury. A revision
amputation was required
for the index finger due to
the severity of injury
caused by the wheel spokes
(Courtesy of Shriners
Hospital for Children,
Philadelphia, PA)
Fig. 7.3 Multiple digit crush amputation caused by a young child placing their fingers in a paper
shredder (Courtesy of Joshua Ratner, MD)
life support (ATLS) and pediatric advanced life support (PALS) protocols should be
followed. This involves the establishment of an airway, breathing, and circulation
(The ABC’s) as the main focus. Direct pressure should be applied to any areas of
bleeding in an effort to minimize blood loss. If the bleeding is unstoppable and the
child is hemodynamically unstable, a tourniquet should be applied to the involved
extremity to maintain adequate perfusion to the remainder of the child. The time
the tourniquet was applied should be noted and provided to the replantation team.
Fig. 7.4 Amputated part

wrapped in moist sterile
gauze and then placed in a
waterproof bag prior to
being placed on ice
A tourniquet should only be applied when direct pressure has failed to control the
bleeding. One should not apply a clamp/hemostat to the end of the vessel to
control bleeding as this may damage the vessel and inhibit the opportunity for
replantation.
Secondarily, attention should be turned to the amputated part where pre-hospital
personnel need to be trained in preservation of the amputated part for potential
replantation. This involves placing the part in moist sterile gauze and then inside a
waterproof bag (Fig. 7.4). The bag is subsequently placed in a bucket of ice while
transport to the facility occurs. It is imperative that the part is not placed directly on
ice, as this will cause freezing/frostbite of the tissues. Additionally, the part should
never be placed on dry ice.
Once the patient is stabilized at the scene of the injury, they are ideally trans-
ported to a center capable of performing a replantation in a child. A formal assess-
ment of the amputated part and patient will be performed by the replantation team
to assess feasibility of replantation. Therefore, we do not recommend telling the
patient or patient’s family that replantation will definitely occur. The replantation
team should be notified as early as possible so that the appropriate personnel and
resources are mobilized and ready when the patient arrives at the institution.
A thorough assessment of the amputated part and proximal stump will be
performed by the replantation team in the operating room. Therefore, pre-hospital
personnel, emergency room physicians, and the trauma team should avoid removing
dressings that are maintaining hemostasis of the proximal stump and avoid remov-
ing the amputated part from ice. These endeavors only delay the replantation team
and may disturb the hemostasis that has already occurred. However, the remainder
of the usual ATLS and PALS protocols should be followed including the primary
and secondary surveys.
Simultaneously, the patient should be resuscitated by establishment of two large
bore intravenous catheters, infusion of warm Lactated Ringers solution, and warm-
ing of the patient. Transfusion should be utilized liberally as blood loss is usually
underestimated at the scene of injury. Forty-one percent of children undergoing
replantation have been shown to require postoperative blood transfusions [8, 9]. The
patient should also receive dose appropriate antibiotic prophylaxis with a first gen-
eration cephalosporin. Penicillin should be added for injuries contaminated with
soil or farm matter. Additionally, tetanus prophylaxis should be initiated.
Indications
The vast majority of microsurgeons feel that an attempt should be made to replant
any extremity amputation in children. This is due to the aforementioned excellent
healing potential in children, their ability to regain motion and sensation, and an
improved psychological state. It has been shown that early correction of deficiencies
leads to enhanced functional and psychosocial adaptation [10]. However, replanta-
tion should not be pursued in patients who are hemodynamically unstable nor in
patients whose life would be endangered by a prolonged procedure.
Specific considerations should include replantation of all thumb, multiple digit,
and midpalm and proximal amputations (Fig. 7.5). Upper arm replantation should
be attempted as long as the child is not too sick, the ischemia time is not prolonged,
there are not significant injuries at multiple levels, and the brachial plexus has not
been avulsed.
Single digit replantation is typically contraindicated in adults; however, this
should be attempted in children with a clean amputation as functional sensation and
motion can typically be restored. At the most distal anatomic levels (distal to the
DIP joint), microvascular repair may be technically impossible due to the size of the
vessels. In these circumstances, one can attempt arterial repair alone [11] or place-
ment of a composite graft [9]. Composite graft placement works best in younger
patients, typically less than 3 years of age, and more distal amputations. However,
anastomosis of the vessels by microsurgical techniques yields better outcomes and
therefore is preferred over composite grafting when technically feasible.
Technique
The technique of replantation begins by adequate preparation including mobiliza-

tion of resources and personnel. Ideally, there should be two surgical teams, each
consisting of a microvascular surgeon with at least one operative assistant such as a
nurse or scrub technician. The operating room should be large enough to accom-
modate both operative teams and the microscope.
Fig. 7.5 Example of a thumb amputation in a child. All thumb, multiple digit, and midpalm
and proximal amputations should undergo an attempt at replantation. (a) Clinical Photograph
(b) Radiograph
Upon arrival of the patient and the amputated part, the patient should be evalu-
ated by the trauma team for any associated injuries as described previously. One
percent of patients referred for emergency microsurgery have been found to have an
unrecognized serious injury [12]. Simultaneously, the amputated part should be
brought to the operating room where one microsurgical team prepares the part for
possible replantation. This includes a thorough cleansing and irrigation as well as
dissection of the part to identify structures necessary for replantation. In the case
of digital replantation, midlateral incisions are utilized for exposure to raise volar
and dorsal skin flaps. This permits identification of the flexor and extensor tendons,
the digital nerves, the digital arteries, and the dorsal veins. The arteries and veins
can be tagged utilizing microclips with a standardized protocol such as one clip
placed at the end of each artery and two clips placed at the end of each vein. Heavy
clamps such as hemostats should be avoided to prevent vessel damage. Such
damage can be considerable, forcing the surgeon to shorten the vascular structures
and in some circumstances to shorten the limb/digit.
In the case of a more proximal amputation, in addition to identification of the

vascular structures, the tendons should be labeled by placing a horizontal mattress
suture and a sticker identifying the particular tendon. These sutures can later be tied
to sutures placed in the proximal part of the limb, thus expediting replantation.
Additionally, fasciotomies should be performed in the arm, forearm, or hand, where
appropriate, as these will be required once revascularization occurs. The carpal tun-
nel should also be released in proximal amputations.
Once the patient has been stabilized and deemed to be resuscitated adequately to
undergo replantation, the patient should be brought to the operating room. The sec-
ond microvascular surgery team likewise begins by irrigating and debriding the
proximal stump. Next, utilizing the aforementioned techniques for the distal ampu-
tated part, the proximal stump structures are identified and labeled. A tourniquet
should be utilized to prevent blind dissection in a bloody field, thus, expediting the
replantation while avoiding injury to vital structures. The arteries and veins may be
identified by looking for the presence of a small hematoma at the end of each of
these structures. Additionally, milking the proximal stump in a proximal to distal
direction may extrude a small amount of blood, making identification of these struc-
tures easier.
The typical sequence of performing a replantation begins with bone shortening
and fixation. Typically, digits are shortened 1–1.5 cm and more proximal amputa-
tions undergo 2–5 cm of shortening. Skeletal fixation is performed using Kirschner
wires for the digital, trans-metacarpal, and trans-carpal amputations. Plates and
screws are generally reserved for amputations of the arm and forearm. Ideally, the
physes should be preserved to enable future growth of the limb. If physeal preserva-
tion is not possible, lengthening procedures can be performed later in life. After
skeletal stabilization, extensor tendon repair is performed followed by repair of the
flexor tendons.
Subsequently, the microscope is brought in and arterial repair is performed. Vein
grafts should be utilized if needed to avoid tension at the anastomosis site. A lack of
tension at the repair site decreases the risk of arterial thrombosis and the need for
reoperation. Once the arterial repair is completed, nerve repair via epineurial suture
techniques should be performed. In the presence of a gap or tension of the repair, a
nerve conduit is placed. Venous repair is subsequently performed, ideally with anas-
tomosis of at least two veins per artery repaired. Repair of the artery prior to venous
repair results in engorgement of the veins, facilitating venous repair. If only one
vein is anastomosed, venous congestion is more likely and the replantation may fail
or require the use of leeches (Fig. 7.6).
Lastly, the skin is approximated as loosely as possible while still covering vital
structures. A tension-free closure is necessary to avoid skin necrosis and venous
congestion. The child is placed in a loose, bulky hand dressing with plaster splints
utilized for immobilization and the limb is elevated on several pillows to aid with
venous return (Fig. 7.7). This sequence is followed in parallel for multiple digit
amputations such that bony work is done first in all digits, followed by extensor
tendon repair in all digits, and so on. Immediately prior to arterial anastomosis, the
patient is given a heparin bolus and then a subtherapeutic heparin drip is continued
Fig. 7.6 Utilization of leeches in an attempt to salvage a replant with venous congestion (Courtesy
of Shriners Hospital for Children, Philadelphia, PA)
Fig. 7.7 Example of a bulky postoperative dressing in the child who underwent long and ring
finger replantation after an exercylce injury. Note the elevation of the limb to aid in venous return
for the next 5 days [13]. While there is no single accepted anticoagulation protocol,
we have found this sequence to be successful.
In proximal replantations, the first step should be establishment of arterial inflow,
via a shunt if needed, to minimize ischemia time to the muscles. The typical sequence
Table 7.1 Sequence of repair

1. Bone
2. Extensor tendons
3. Flexor tendons
4. Arteriesa
5. Nerve
6. Veins
7. Skin
a
In proximal amputations, the arteries should be repaired first to establish blood flow to muscle
Table 7.2 Postoperative Care

Initial observation in the intensive care unit
Maintain room temperature >80°F
Avoid vasoconstricting foods (caffeine, cheese, chocolate)
Heparin drip for 5 days
Anxiolitics and/or narcotics to prevent pain, fear, anxiety
of replantation is then resumed. Immediate establishment of arterial inflow is not as

much of a priority in the digits, as there is no musculature present and metabolic
demands are slight (see Table 7.1).
It is imperative to establish a close working relationship with the anesthesiologist
so that the replantation team is aware of the patient’s overall condition at all times.
If the patient becomes unstable, the replantation should be aborted. The child’s life
takes priority over the injured extremity.
If replantation is successful, the child should be brought to the intensive care unit
postoperatively. Close observation of the child’s vital signs is imperative. If the
child becomes hemodynamically unstable and is unable to be resuscitated in a
timely manner, a return to the operating room is undertaken for removal of the
replanted part. It cannot be overemphasized that the child’s life is the paramount
concern.
In the intensive care unit, a warm room (>80°F) should be available as this
prevents vasoconstriction. Additionally, the child should be kept NPO for approxi-
mately 24 h in case a return to the operating room is required due to hemodynamic
instability, venous congestion, or decreased inflow. Once the child is allowed to eat,
vasoconstricting foods such as caffeine, cheese, and chocolate should be avoided.
Antibiotics should be continued for at least 48 h postoperatively. Our typical proto-
col is to leave the child in the intensive care unit for 5 days following replantation
while they are receiving the heparin drip. Sedation with narcotics and/or anxiolitics
may be necessary to minimize pain, fear, and anxiety, since sympathetic activation
may induce vasospasm [14]. After this, the child is transferred to the regular pediat-
ric floor for additional two days of observation without the heparin drip but on oral
aspirin, while maintaining the above dietary restrictions and warm room. The child
is typically discharged home at 7 days postoperatively (see Table 7.2).
Table 7.3 Steps to address the failing replant

Ensure adequate volume resuscitation
Ensure adequate oxygenation
Remove dressings
Remove constricting skin sutures
Elevate limb if venous congestion is present
Lower limb if arterial insufficiency is noted
Return to operating room within 4–6 h following loss of adequate perfusion
Monitoring
While the patient is in the hospital the replant should be assessed for any signs of fail-
ure. This includes regular assessments of color, pulp turgor, capillary refill, and tem-
perature. Capillary refill is best assessed at the paronychial skin, as assessment of the
subungual skin can provide a sense of false reassurance. The capillary refill should be
less than 2 s. Very brisk capillary refill, however, is indicative of venous congestion.
For digital replants, the temperature can be monitored utilizing a digital ther-
mometer and skin surface probes. A reading below 30°C indicates inadequate
perfusion to the replanted part. Additional, more complex measures of monitoring
include transcutaneous oxygen measurements, laser Doppler flowmetry, and
fluoroscein perfusion [14].
Addressing the Failing Replant
Failure of replantation can be devastating for the patient, the family, and the replan-
tation team, especially in children. Close monitoring can identify a replant at risk,
which should in turn trigger emergency measures to save the part.
The first step is to ensure that the patient is adequately volume resuscitated while
maintaining adequate oxygen-carrying capacity. Dehydration and a low hematocrit
can both lead to vasospasm and decreased arterial inflow of the replanted part [14].
While the patient’s hemodynamics are being optimized, the dressing should be
removed and the skin sutures should be evaluated for any that may be causing constric-
tion. Often, dried blood on the bandages creates a stiff constrictive dressing. Simply
releasing the circumferential dressing may improve arterial inflow and/or venous
return. The limb can also be elevated in the case of venous congestion or lowered in the
case of arterial insufficiency. Observation of the replant for approximately 15 min after
performing these maneuvers is adequate time to assess for improvement.
If an attempt is going to be made to return the replanted part to the operating
room, this should occur within 4–6 h following loss of adequate perfusion.
Performing a reanastomosis of the arteries, removing a thrombus, or placing a vein
graft across the artery anastomosis is most effective when an abrupt cessation of
arterial inflow is recognized [14] (see Table 7.3).
Outcomes
Success rates for pediatric replantation have been reported to be as high as 97%
[15]. Cheng et al. performed a long-term functional analysis of digital replantation
with an average follow-up of 11 years. Their series documented 151° of active finger
motion, 120° of active thumb motion, normal two point discrimination in 88% of
patients, and average grip strength equal to 79% of the contralateral side [15].
Baker and Kleinert [8] evaluated factors of success for digital replantation in
children under 34 months of age. Favorable uncontrollable prognostic factors
included guillotine-like amputations and body weight greater than 11 kg. Favorable
controllable factors included repair of more than one vein, bone shortening,
intraosseous fixation, and vein grafting of arteries and veins. No correlation was
found between survival and total ischemia time or digit position.
Proximal replantation outcomes are not as favorable as those for digital replanta-
tion [16]. Beris et al. reported a success rate of 77% for complete amputations and
80% for revascularization-type procedures. The decreased success rate is most com-
monly attributed to myonecrosis leading to sepsis [16, 17]. Additionally, an average
of 2.8 additional procedures were necessary to attempt to improve function in these
children [16].
Conclusion
Amputations sustained by children create an emotional situation for the patient, the
family, and the healthcare team. It is important for those involved in the care of the
patient to be knowledgeable regarding the handling of the amputated parts and to
triage the patient to a replantation center prior to any attempt at replantation. Given
adequate resources and personnel, a successful replantation can occur in the major-
ity of patients.
References
1. Van Beek AL, Wavak PW, Zook EG. Microvascular surgery in young children. Plast Reconstr
Surg. 1979;63:457–62.
2. O’Brien BM, Franklin JD, Morrison WA, et al. Replantation and revascularization surgey in
children. Hand. 1980;12:12.
3. Jaeger SH, Tsai TM, Kleinert HE. Upper extremity replantation in children. Orthop Clin North
Am. 1981;12:897–907.
4. Berger A, Meissl G, Walzer L. Techniques and results in replantation surgery in children. Int J
Microsurg. 1981;3:9.
5. Galway HR, Hubbard S, Mowbray M. Traumatic amputations in children. In: Kostvik JP, edi-
tor. Amputation surgery and rehabilitation – The Toronto experience. Edinburgh: Churchill
Livingstone; 1981.
6. Carman C, Chang B. Treadmill injuries to the upper extremity in pediatric patients. Ann Plast
Surg. 2011;46:15–9.
7. Benson LS, Waters PM, Meier S, et al. Pediatric hand injuries due to home exercycles. J Ped
Orthop. 2000;20:34–9.
8. Boyer MI, Mih AD. Microvascular surgery in the reconstruction of congenital hand anomalies.
Hand Clin. 1998;14:135–42.
9. Baker GL, Kleinert JM. Digit replantation in infants and young children: determinants of sur-
vival. Plast Reconstr Surg. 1994;94:139–45.
10. Serafin D, Kutz JE, Kleinert HE. Replantation of a completely amputated distal thumb without
venous anastamosis. Plast Reconstr Surg. 1973;52:579–82.
11. Heisten JB, Cook PA. Factors affecting composite graft survival in digital tip amputations.
Ann Plast Surg. 2003;50:299–303.
12. Partington MT, Lineaweaver WC, O’Hara M, et al. Unrecognized injuries in patients referred
for emergency microsurgery. J Trauma. 1993;34:238–41.
13. Cheng GL, Pan DD, Zhang NP, et al. Digital replantation in children: a long-term follow-up
study. J Hand Surg Am. 1998;23:635–46.
14. Beris AE, Soucacos PN, Malizos KN, et al. Major limb replantation in children. Microsurgery.
1994;15:474–8.
15. Wang S, Young K, Wei J. Replantation of severed limbs – Clinical analysis of 91 cases. J Hand
Surg Am. 1981;6:311–8.
16. Goldner RD, Urbaniak JR. Replantation. In: Green DP, Hotchkiss RN, Pederson WC, Wolfe
SW, editors. Green’s operative hand surgery. 5th ed. Philadelphia: Elsevier Churchill
Livingstone; 2005. p. 1569–86.
17. Conrad MH, Adams Jr WP. Pharmacologic optimization of microsurgery in the new millen-
nium. Plast Reconstr Surg. 2001;108:2088–96.
Part IV
Lower Extremity
Chapter 8
Pediatric Hip Fractures and Dislocations
James J. McCarthy, Kenneth J. Noonan, and Sapan D. Gandhi
Abstract Although hip fractures and dislocations are rare injuries in children, they
are important entities to understand and manage effectively because of the potential
severe complications such as avascular necrosis (AVN), varus malunion, nonunion,
and growth abnormalities leading to length discrepancy or angular deformities. This
chapter reviews presentation, treatment, and potential complications of pediatric hip
fractures and dislocations.
Keywords Pediatric hip fracture • Pediatric hip dislocation • Pediatric femoral

neck fracture • Hip fracture children • Hip dislocation children • Femoral neck fracture
children
Fractures of the Hip
Hip fractures are common in adults, but relatively rare in children, accounting for
less than 1% of all pediatric fractures [1, 2]. Despite its low prevalence, pediatric
hip fractures are important entities to understand and manage effectively because
of the potential severe complications such as avascular necrosis (AVN), varus
malunion, nonunion, and growth abnormalities leading to length discrepancy or
J.J. McCarthy (*)

Department of Orthopaedic Surgery, Cincinnati Children’s Hospital Medical Center,
3333 Burnet Avenue, Cincinnati, OH 45229, USA
e-mail: james.mccarthy@cchmc.org
K.J. Noonan
Department of Pediatric Orthopedics, U.W. School of Medicine and Public Health,
1985 Highland Avenue, Madison, WI 53705, USA
S.D. Gandhi
Drexel University College of Medicine, 2900 West Queen Lane, Philadelphia, PA 19129, USA
128 J.J. McCarthy et al.
Table 8.1 Common underlying pathologies of pediatric hip fractures [5]

Disuse osteopenia
Fibrous dysplasia
Langerhans cell histiocytosis
Metabolic bone disease
Malignancy
Osteogenesis imperfecta
Osteomyelitis
Simple and aneurysmal bone cysts
angular deformities. Unlike adult hip fractures, pediatric hip fractures typically
occur as a result of high-energy trauma that can cause other extremity, visceral or
head injuries in 30% of patients [3, 4]. Common mechanisms of injury include falls
from heights and motor vehicle trauma. Occasionally, pediatric hip fractures
result from minor trauma superimposed upon bone that is weakened by pathology
(Table 8.1). Simple bone cysts, osteomyelitis, and fibrous dysplasia are the most
common diagnoses associated with pathologic hip fractures in children [5].
The child with a displaced hip fracture presents to the emergency room after a
traumatic injury unable to ambulate due to severe pain and lies with a shortened
and externally rotated limb. Those patients with an obvious hip fracture caused by
high-energy mechanisms must be thoroughly evaluated for multisystem injury by
the trauma team. Traumatic brain injuries, thoracoabdominal trauma, and fractures
of the pelvis and the extremities are other injuries that frequently occur in children
who sustain hip fractures from severe trauma.
Non-displaced or incomplete fractures, such as a cortical disruption through a
bone cyst, often present as hip or knee pain that is more chronic or insidious in
nature. The child with a non-displaced hip fracture typically has a painful limp but
is still able to partially bear weight. On examination, hip and knee range are limited
and extremes of hip motion, particularly internal rotation, are painful. Axial com-
pression on the heel or standing on the effected leg may elicit pain. The differential
diagnosis is based on the clinical presentation and examination, and can include
developmental hip conditions such as SCFE and LCPD, femoral neck stress frac-
tures, pathologic fractures from neoplasms, and infections including septic arthritis
and osteomyelitis.
The infant with painful and limited hip motion is particularly challenging to
diagnose with a hip fracture. Irritability or pain with diaper changes, fairly
nonspecific findings, may be the only sign of a problem. Because of incomplete
ossification of the proximal femur, radiographs of the hip are sometime difficult to
interpret. Birth trauma, infectious etiologies such as septic arthritis and osteomyelitis,
and child abuse are differential diagnoses that must be considered when evaluating
8 Pediatric Hip Fractures and Dislocations 129
an infant with a potential hip fracture. Infants with hip fractures without a plausible
cause for fracture must also be examined for other sign of non-accidental injury,
undergo a radiological skeletal survey, and be evaluated by child protective services.
Imaging
A high-quality anterioposterior (AP) pelvic x-ray and a cross-table lateral x-ray of

the effected hip are best for identifying hip fractures. Non-displaced fractures or
stress fractures may be difficult to detect on radiographs. Additional studies, such as
a CT scan or a three-phase technetium bone scan, may be required to diagnose
occult fractures. Magnetic resonance imaging (MRI) is also useful for evaluating
patients with a potential hip fracture. A fracture appears as a linear black line (low
signal) surrounded by a high-signal band of bone marrow edema and hemorrhage
[6]. MRI also provides detailed information about surrounding soft-tissue structures
of the hip and pelvis that may help identify other conditions that present with a
similar clinical picture. Ultrasound is useful for evaluating the infant with a sus-
pected hip fracture. Joint effusion and abnormalities of the cartilaginous proximal
femur can be easily identified. Additionally, ultrasound evaluation is cheaper than
MRI, can frequently be done without sedation or anesthesia, and can be used to
assist in hip aspiration if necessary.
Classification
Pediatric hip fractures have been described for decades by the classification of
Delbet5. This classification scheme has been shown to be both descriptive and
prognostic [7]. Type I or transphyseal fractures occur through the proximal
femoral physis and sometimes occur in association with a dislocation of the
epiphysis from the acetabulum imparting a high likelihood of AVN. Type II or
transcervical fractures occur at the level of the femoral neck just distal to the
physis. Type III or basicervical fractures are located at the base of the femoral
neck and may or may not be intracapsular. Type II and III fractures account for the
majority of hip fractures in children. Type IV injuries are intertrochanteric frac-
tures. This type accounts for only 6–15% of hip fractures, and is typically associ-
ated with the best outcomes [1, 8].
Surgical Treatment
Fracture treatment is based on the age of the child, presence of femoral head dislo-
cation, and fracture stability after reduction (Fig. 8.1). Instrumentation for fixation
of the femoral head after fracture is also dependent on the age of the child and type
Fig. 8.1 Radiograph showing. (a) Hip fracture prior to reduction. (b) Reduction and internal
fixation. (c) Healed fracture
of fracture (Table 8.2). All hip fractures in children should be treated urgently,
ideally within 6–12 h of injury, in an effort to avoid AVN.
Type I
Spica cast immobilization is acceptable for children under 5 years of age with stable
non-displaced or minimally displaced fractures. Displaced fractures should be
reduced closed by gentle traction, abduction, and internal rotation. If the fracture is
stable, fixation is not indicated. Unstable fractures are best treated with small diam-
eter (0.062 or 5/64th in.) smooth pins placed from the lateral cortex parallel and
within the femoral neck and across the physis, obtaining purchase in the epiphysis.
Critical fluoroscopic evaluation is necessary to assess the quality of reduction,
stability of fixation and, most importantly, that the hip joint has not been violated.
Internal fixation is recommended for older children, even if the fracture is non-
displaced or appears stable after closed reduction. Smooth pins are typically utilized
for patients younger than 10 years of age to lessen the possibility of iatrogenic injury
to the proximal femoral physis and the risk of growth disturbance. For children
older than 10 years of age, cannulated screws (4.5–7.3 mm) are the best choice for
fixation. The additional stability provided by screws compared to wires outweighs
the growth inhibition that may result from their use.
If the femoral head is dislocated outside of the acetabulum (type IB), a single
attempt at closed reduction is worthwhile. Immediate open reduction, however, is
necessary if closed reduction is unsuccessful. The surgical approach is dictated by
the direction of femoral epiphysis dislocation. For example, anterior dislocations
are best treated through an anterior approach, while posterior ones are reduced
posteriorly. Internal fixation is indicated for all type IB injuries regardless of age.
8
Table 8.2 Fixation of femoral head after pediatric hip fracture

Patient age Type I Type II Type III Type IV
0–3 years (Spica cast 0.062-mm or 5/64-inch 0.062-mm or 5/64-inch 0.062-mm or 5/64-inch Pediatric hip screw and side plate
supplementation smooth wires smooth wires smooth wires or plate and cortical screws
Pediatric Hip Fractures and Dislocations
suggested) (less than or equal 3.5-mm)

4–10 years (Spica cast 5/64-in. smooth wires, 4.5 5/64-in. smooth wires, 5/64-in. smooth wires, Intermediate-sized hip screw and
supplementation or 6.5 cannulated screws 4.5 or 6.5 cannulated 4.5 or 6.5 cannulated side plate
suggested) (stainless steel screws (stainless screws (stainless steel
suggested) steel suggested) suggested)
Over 10 years 6.5 or 7.3-mm cannulated 6.5 or 7.3-mm cannu- 6.5 or 7.3-mm cannulated Intermediate or adult-sized hip
screws lated screws screws or hip screw screw and side plate
and side plate
131
Type II and Type III
Spica cast immobilization is acceptable for children under 5 years of age with stable
non-displaced or minimally displaced fractures confirmed by fluoroscopic examina-
tion. Because of the high risk of displacement and varus malunion, patients treated
in this way must be carefully followed with weekly radiographs for 2–3 weeks after
casting [9, 10].
Displaced type II and III fractures, especially in younger children, can frequently
be reduced closed in the operating room by applying gentle traction while internally
rotating and abducting the leg. This reduction may be performed on a standard
radiolucent operating room table or on a fracture table under fluoroscopy. However,
if closed reduction cannot be achieved after 1–2 attempts, the best plan is to proceed
directly to open reduction. The Watson-Jones anterolateral approach to the hip is
most commonly utilized. Alternatively for older children, the fracture may be treated
via a surgical hip approach for surgeons experienced with this technique.
Most Type II and III fractures that undergo reduction are best managed with
internal fixation. As for type I fractures, smooth pins can be used in children younger
than 10 years of age while cannulated screws are the best option for older children.
Two to three screws should be placed and spaced as widely as possible [11]. Usually,
the small size of the child’s femoral neck will accommodate only two screws. The
starting point should remain proximal to the level of the lesser trochanter, and care
should be taken to minimize drill holes in the subtrochanteric region to avoid
the possibility of iatrogenic subtrochanteric fracture. An adolescent hip screw and
side plate, placed with an additional cannulated screw directed above the lag screw
to control rotation, is also an option for the older child whose fracture required open
reduction. Satisfactory fracture stability requires advancement of fixation across the
physis in most cases. Because of the risks of loss of reduction, varus malunion, and
nonunion with these fractures types, especially for type II injuries, fracture stability
is paramount to concerns about growth disturbance from violation of the physis by
wires or screws.
Type IV Fractures
Spica cast immobilization is acceptable for children under 4–6 years of age with
stable non-displaced or minimally displaced intertrochanteric fractures confirmed
by fluoroscopic examination. As opposed to the other fracture types, intertrochan-
teric fractures are extracapsular and metaphyseal. Because of these factors, some
degree of displacement is acceptable because the risk of nonunion is minimal and
remodeling of 10–15° in either plane reliably occurs in patients with at least
2 years of growth remaining. For unstable fractures, traction for 10 days to 3 weeks
followed by spica cast immobilization is also an option.
Most displaced Type IV fractures, however, are best treated with open reduction
and internal fixation. The fracture is approached through a lateral exposure and
open reduction is performed. A pediatric or adolescent hip screw or locking plate
provides rigid internal fixation for this purpose. The implant size is determined
by the size of the femur and the weight of the child. For most intertrochanteric
fractures a lag screw placed in the femoral head attached to a 3 hole side plate is
adequate fixation.
Postoperative Care
Postoperative spica cast immobilization must be considered for most children with
type I–III fractures, regardless of the method fixation, with the exception of the
most reliable adolescents who have large threaded screws crossing the physis [5].
For patients with type IV fractures, spica cast immobilization is used to supplement
fixation for severely comminuted fractures and for those children who cannot adhere
to postoperative restrictions. Most intertrochanteric hip fractures treated with
fixation, however, do not require spica cast immobilization because of the stability
of screw-side plate constructs and the consistent healing of intertrochanteric
fractures compared to other hip fracture types.
The cast is maintained for 6–8 weeks. Children and adolescents who are not
casted are permitted to mobilize with a walker or crutches without weight-bearing
for 4–6 weeks and then are advanced to progressive weight-bearing based on
pain and radiographic healing. Surveillance for growth disturbance and AVN with
exams and radiographs every 6–9 months is recommended for a minimum of 2 years
after injury and ideally until skeletal maturity.
Capsulotomy
Capsular decompression must be considered when treating hip fractures in children.

Intracapsular hematoma under pressure may develop after Type I–III fractures that
potentially compromise blood flow to the femoral head and increase the risk of
AVN. Large needle aspiration of the fracture hematoma or direct opening of the hip
capsule are options recommended in published studies with no clear advantage
established of one method versus the other.
Complications
In general, more significant rates of AVN and growth arrest are noted in Type I and
Type II injuries compared to Type III and Type IV injuries [7]. Conversely, the latter
two groups tend to have higher rates of varus malunion, especially when internal
fixation is not utilized [12].
Fig. 8.2 Avascular necrosis

even after prompt reduction
and fixation
Avascular Necrosis
AVN is the most serious and frequent complication of hip fractures in children and
is the primary cause of poor results after fractures of the hip in children (Fig. 8.2).
Its overall rate has been reported as anywhere from 10% to 42% [2, 7, 13–17]. In a
recent Meta-analysis, the incidence of AVN was noted to be higher with more
proximal fractures, especially type I with a dislocated femoral head, with greater
fracture displacement, and older age [7]. Several studies report lower rates of
AVN in their series of patients treated within 24 h of injury [18, 19]. Early reduction
and stabilization may decrease AVN by preventing further injury to the tenuous
blood supply. Open reduction or capsulotomy may improve outcomes by decreasing
intra-articular pressure caused by fracture hematoma [20]. The long-term results of
established AVN are likely related to age of the patient and extent and location of
the necrosis within the head [4]. There is no clearly effective treatment for estab-
lished posttraumatic AVN in children. Treatment of AVN is controversial and
includes the role of re-directional osteotomy distraction arthroplasty with external
fixation, core decompression, vascularized fibular grafting, and intravenous bispho-
sphonates [12, 21–24].
Coxa Vara
Coxa vara has been reported to occur in approximately 20–30% of patients, although
adequate internal fixation decreases this rate [10, 14, 15, 25]. Remodeling may
occur in young children with mild deformities but older patients may require valgus
osteotomy to heal nonunion and restore limb length [12].
Premature Physeal Closure
Premature physeal closure occurs in approximately 5–65% of fractures [5, 12]. The
capital femoral physis contributes only a small portion of the total growth of the
lower extremity and therefore shortening due to premature physeal closure is not
significant except in very young children [5, 26]. If femoral growth arrest is expected
due to the implant use or injury to the physis, the surgeon may consider concomitant
greater trochanteric epiphysiodesis to maintain a more normal articular trochanteric
relationship, but this is rarely necessary.
Nonunion
Nonunions are uncommon and typically only occur in Type II and III fractures. The
primary cause of nonunion is failure to obtain or maintain an anatomic reduction
and displacement into varus. Rigid internal fixation combined with subtrochanteric
valgus osteotomy converts shear stress to compression across the nonunion site to
enhance healing [15]. Open bone grafting or vascularized grafting is rarely neces-
sary in children and adolescents.
HIP Dislocations in Children
Although traumatic hip dislocations are uncommon injuries in children, the high
risk of associated complications makes them important to understand. While
younger children (typically younger than 6 years old) can sustain isolated hip dislo-
cations from a low-energy injury such as falls from a low height, older children and
adolescents usually require high-energy mechanisms, such as motor vehicle crashes
or sports collisions [27].
Typically the child with a hip dislocation is in pain and cannot ambulate. The hallmark
clinical sign of dislocation of the hip is abnormal positioning of the limb. Children
with posterior hip dislocations lie with the hip flexed and adducted while those with
anterior dislocations hold the effected hip extended and abducted. In rare cases, the
femoral head may dislocate directly inferiorly, a condition known as luxation
erecta femoris or infracotyloid dislocation. A thorough evaluation for associated
injuries is critical in the emergency room for those children with high-energy
mechanisms. Head injuries, extremity fractures, and ipsilateral knee injuries are
most common injuries seen in association with hip dislocations. A careful neurovas-
cular exam of the effected extremity completes the assessment. Sciatic nerve and
superior gluteal nerves are particularly vulnerable to injury in hip dislocations.
Although neurologic injury can be expected in as many as 5% of children with hip
dislocations, most are expected to recover from nerve injury [27].
Imaging
Radiographs of the pelvis and hip are best for assessing the child with a suspected
hip dislocation. CT scanning is useful for assessing the bony pelvis for evidence of
associated acetabular fractures, most commonly posterior wall fractures, or femoral
head fractures both prior to and after hip reduction. MRI is typically not used to
make the diagnosis when the exam is consistent with a hip dislocation. MRI, how-
ever, is the best diagnostic modality for localizing intra-articular bony fragments or
soft-tissue interposition after reduction. At our institution, live fluoroscopic exami-
nation of the proximal femur is utilized for patients with open physes prior to closed
reduction to confirm that an occult fracture of the proximal femoral physis did not
occur with the dislocation which may become separated with manipulation.
Classification
Hip dislocations in children are classified depending on where the femoral head lies
in relation to the pelvis, namely posterior, anterior superior, and anterior inferior or
infracotyloid. More than 90% of hip dislocations in children are posterior [28, 29]
(Fig. 8.3). Fractures of the acetabulum and proximal femur may occur with any type
of dislocation.
Treatment Closed Reduction
Because a delay of reduction may increase the risk of AVN of the femoral head, hip
dislocations are best treated as emergencies. Close reduction in the emergency
department under conscious sedation is the initial treatment option for most hip
dislocations. For the typical posterior dislocation, the child is placed supine on a
stretcher and the effected hip is gently flexed to 90° and positioned in neutral rota-
tion and slight abduction. Longitudinal traction is then applied by pulling upward
on the thigh and flexed knee while the hip is gently manipulated. An audible and
palpable clunk signals reduction. Reduction in the operating room is indicated for
Fig. 8.3 (a) AP radiograph

of the pelvis of a 15-year-old
football player who sustained
an injury while being tackled.
He has a right posterior hip
dislocation. He was taken
to the operating room and
underwent fluoroscopic
examination of the right hip
documenting no occult
fractures of the proximal
femur. He then underwent
a successful closed reduction
of the hip. (b) Coronal CT
imaging reveals medial joint
space widening on the right
compared to left side. (c) CT
axial imaging reveals
osteoarticular fracture
fragment. He underwent right
hip arthroscopy for excision
of the fragment
any patient who fails closed reduction in the emergency room and for those with
evidence of physeal widening or other signs of an occult ipsilateral proximal
femur fracture to prevent displacement with reduction [30, 31]. After reduction,
the neurovascular status of the patient is carefully re-evaluated and additional
imaging is performed. Nerve exploration should be undertaken for patients with an
abnormal exam after reduction but had normal nerve function prior to reduction
[24, 32]. Plain radiographs and CT or MR are mandatory after reduction to docu-
ment concentric reduction without intra-articular osteochondral fragments or soft-
tissue interposition.
Open Reduction
Open reduction is primarily indicated for hip dislocations that cannot be reduced
by closed manipulation and for those dislocations associated with fractures of the
proximal femur. The hip is approached in the same direction that the hip dislocation
occurred. Hips that undergo closed reduction with evidence of intra-articular osteo-
chondral fragments or soft-tissue interposition on post-reduction imaging are also
best treated by open exploration of the joint or, in some cases, by arthroscopic surgi-
cal techniques [32]. Associated posterior wall fractures require open reduction and
fixation in most cases.
Care Post-reduction
Most hip dislocations are stable after reduction. For older children and adolescents,
a short period of protected weight bearing on crutches should be suggested until
soft-tissue recovery. Once pain has diminished and restoration of hip motion and
strength occurs, patients can resume normal activity. Spica cast immobilization or
bracing is used for those children who have evidence of instability or those who
cannot reliably adhere to protected weight-bearing instructions. Instability after
reduction is rare and typically spica cast immobilization is not needed. Clinical and
radiographic follow-up for a minimum of 2 years is recommended to allow for
detection of complications.
Complications
Long-term outcomes are generally good for most hip dislocations that occur in chil-
dren who undergo prompt and complete reduction. Incidence of AVN varies, but has
been reported to occur in about 12% of hip dislocations in children and is related to
the severity of initial trauma [28]. Urgent relocation may decrease the incidence of
this complication [28, 33, 34]. Hip instability after dislocation is rare in children,
and is seen most frequently after posterior dislocation in patients less than 8 years
of age or in patients with known ligamentous laxity such as those with Down syn-
drome or Ehlers–Danlos disease [35–38]. Chondrolysis and significant heterotopic
ossification are other complications of hip dislocations in children [28].
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B:528–42.
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18. Cheng JC, Tang N. Decompression and stable internal fixation of femoral neck fractures in
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children with fractures of the neck of the femur. Injury. 1996;27(6):419–21.
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Orthopedics. 1989;12(3):375–8.
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35. Banskota AK, Spiegel DA, Shrestha S, Shrestha OP, Rajbhandary T. Open reduction for
neglected traumatic hip dislocation in children and adolescents. J Pediatr Orthop. 2007;27(2):
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1003–6.
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1973;90:107–9.
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Chapter 9
Pediatric Proximal Tibial Fractures with
Vascular Compromise
William Hennrikus and Tamara Pylawka
Abstract Proximal tibia injuries in children range from benign green stick injuries
to limb-threatening fracture dislocations. The unique anatomy of the pediatric
physis guides the pattern of deformity with the force of the injury dictating the
severity of the trauma. Goals of the treating physician include not only immediate
fracture care but also an understanding of the long-term sequelae of this injury and
how to manage subsequent limb deformity. Vascular injury, physeal injury, and
nonorthopedic injuries all should be considered when treating pediatric proximal
tibia fractures.
Keywords Proximal tibia • Physeal fracture • Vascular injury • Pediatric • Tibia

fracture
Introduction
Participation in childhood sporting activities has increased, with the knee being the
most common site of injury [1, 2]. Fractures through the proximal tibia typically
occur in the 8–15 year age group. These injuries are rare; however, they can be
devastating. Mann and Rajmaira reviewed 2,650 long bone fractures in children
and found that 4% (12 fractures) involved the proximal tibia [3]. Peterson et al.
W. Hennrikus (*)
Department of Orthopaedics and Pediatrics, Penn State College of Medicine,
30 Hope Drive, Hershey, PA 17033, USA
e-mail: Whennrikus@hmc.psu.edu
T. Pylawka
Department of Orthopaedic Surgery, Penn State College of Medicine,
30 Hope Drive, Hershey, PA 17033, USA
142 W. Hennrikus and T. Pylawka
completed an epidemiologic study of proximal tibia fractures in Minnesota and

also found an incidence of 4% (8 fractures) [4]. The rarity of fractures at this
location is explained by the stability afforded by the anatomical design of the proxi-
mal tibial epiphysis and adjacent ring of soft tissue restraints. Large forces are
required to fracture this physis. The purpose of this chapter is to provide a compre-
hensive overview of the etiology, diagnosis and management of pediatric proximal
tibial fractures with special attention to fractures with vascular compromise.
Anatomical Considerations
Bony Anatomy
The proximal tibial epiphysis is the second largest epiphysis in the child’s skeleton,
second only to the distal femoral epiphysis [5, 6]. Anteriorly on the proximal
tibia, the secondary ossification center of the tibial tubercle appears between 9
and 14 years of age [7]. At approximately 15 years of age, the proximal tibial
epiphysis begins to unite with the tibial tubercle to complete the ossification
process.
The distal surface of the epiphysis is concave in shape to compliment the convex
proximal surface of the metaphysis [7]. In the midline, the physis extends down
underneath the tubercle adding extra stability at this point. Ossification of the physis
occurs in an uneven pattern with posterior physeal fusion occurring prior to anterior
fusion in the proximal tibia [7, 8].
Soft Tissue Anatomy
The capsule and synovium of the knee joint insert well above the physis with the
capsular ligaments acting to anchor the menisci to the tibial epiphysis both laterally
and medially. On the lateral side, the lateral collateral ligament (LCL) inserts onto
the fibula [9] and medially the medial collateral ligament (MCL) inserts beyond the
physis onto the metaphysis of the tibia [10]. The major portion of the MCL attaches
to the periosteum of the metaphysis and a minor portion attaches to the proximal
tibial epiphyseal perichondrium. Laterally, the LCL attaches primarily to the proxi-
mal fibular epiphysis with fibers spreading out over the lateral side of the tibial
epiphysis and metaphysis. Anteriorly, the patella ligament inserts onto the second-
ary ossification center of the tibial tubercle, with a few fibers extending beyond the
physis to attach on the upper tibial diaphysis [11]. This ring of protective anatomic
structures makes separation of the proximal tibial epiphysis extremely difficult and
rare. When fracture and/or separation at this site occurs vascular injury to the
popliteal artery has been reported [11–13].
9 Pediatric Proximal Tibial Fractures with Vascular Compromise 143
Fig. 9.1 Lateral

illustration emphasizing
arterial injury secondary to
posterior displacement of
proximal tibial
Vascular Anatomy
Popliteal artery injury is the major concern with injuries of the proximal tibial physis
[11–13]. As the popliteal artery travels distally it is firmly connected to the posterior
knee capsule via dense connective tissue and gives off three branches: the peroneal
artery, and the anterior and posterior tibial arteries. The trifurcation occurs just
distally to the physis and shortly after the trifurcation the anterior tibial artery
perforates the interosseous membrane further tethering the vascular structures. This
constrained nature of the vascular anatomy leads to injury when displacement of the
bony structures occurs (Fig. 9.1).
Signs and Symptoms
In a child with an injury to the proximal tibia, a meticulous physical examination

of the patient and the entire lower extremity should be completed. History given
by the patient or bystanders might aid in discerning the mechanism of injury. The
physical examination should include a detailed vascular, motor, and sensory exam.
If the injury is part of a trauma (i.e., MVC) the entire patient should be examined
and one should not be distracted by an obvious injury. Anteroposterior (AP) and
lateral radiographs of the injured tibia and knee help to define the injury. However,
in a few cases, radiographic exams may underestimate the extent of injury. For
example, radiographs may illustrate minimal displacement of a proximal tibia
fracture; however, the initial fracture may have been much more displaced and
spontaneously reduced (Fig. 9.2). Therefore, all proximal tibia fractures should be
Fig. 9.2 (a) Initial films illustrating injury. (b) Injury after knee extension and spontaneous
reduction. Compartment syndrome and vascular injury did occur
treated with caution because every fracture at this location can become a potential
limb-threatening injury. A computed tomography (CT) scan can be helpful for
complex, high-energy injuries.
Vascular examination should include assessment of bilateral dorsalis pedis and
posterior tibial pulses as well as the ankle-brachial index (ABI). A prompt vascular
surgery consultation is prudent in any injury suspicious for popliteal artery injury.
Compartment status should also be assessed by palpation, assessment for pain with
passive range of motion of the ankle, and compartment pressure measurements as
needed on a case by case basis.
Gross examination of the knee may exhibit an effusion or one may see the patient
holding the knee in a flexed position secondary to a hemarthrosis. Tendernes to
palpation may be 1–2 cm below the joint line as this is the anatomic location of the
physis. Angular deformities may be present if spontaneous reduction of the fracture
has not occurred.
Tibial Tubercle Fractures
Mechanism of Injury
The tibial tubercle is the insertion point of the extensor mechanism and fracture or
avulsion occurs during forced flexion as the quadriceps is actively extending
(Fig. 9.3). This fracture pattern is classically seen stemming from sporting activities
involving jumping such as basketball and is most common in males approximately
15 years of age, who are nearing the end of skeletal growth [14–16].
Fig. 9.3 Displaced tibial

tubercle from pull of
extensor mechanism
Classification
Several classifications of tibial tubercle fractures exist and are based on the size,
displacement, and comminution of the fracture fragments. Ogden’s classification
which was a modification of the original Watson-Jones classification is the most
commonly used.
Watson-Jones described three types of tibial tubercle avulsion fractures [14].
• Type I: Small fragment of distal tuberosity avulsed and displaced upward.
• Type II: Fracture through the secondary ossification center with the resulting
anterior tibial epiphysis displaced upward on the remaining hinge of
periosteum.
• Type III: Fracture extends into the proximal tibial epiphysis with the entire
tuberosity fractured at its base.
Ogden et al. modified the Watson-Jones classification in 1980 such that a greater
emphasis was placed on the intra-articular extension of the fracture (Fig. 9.4) [15].
• Type I: Separation through the distal portion of the physis under the tubercle with
the fracture progressing proximally at the secondary ossification center.
• Type IA: Incomplete separation of the fragment from the metaphysis.
• Type IB: Complete separation of the fragment from the metaphysis.
Fig. 9.4 Ogden classification of tibial tubercle fractures
• Type II: Separation extends anteriorly through the ossification centers of the
tibial tubercle and the proximal epiphysis.
• Type IIA: Fracture occurring without comminution.
• Type IIB: Fracture occurring with comminution.
• Type III: Separation occurs beneath the tubercle and propagates through the
proximal tibial epiphysis.
• Type IIIA: No comminution present.
• Type IIIB: Comminution present.
Treatment
Treatment of tibial tuberosity fractures is aimed at restoring the extensor mecha-

nism and joint surface, if it is disrupted. Type I fractures are the most common and
can generally be treated in a long leg cylinder cast as long as the fracture has less
than or equal to 2 mm of displacement. Fractures with greater than 2 mm of dis-
placement require open reduction and internal fixation (ORIF) [14–19]. ORIF can
involve tension band wiring, screw and washer fixation and/or suture repair of the
periosteum [16] (Fig. 9.5). Type II and III fractures are best treated with ORIF. It is
imperative to reduce and stabilize any articular incongruity as well as treat any addi-
tional knee internal derangement (i.e., meniscal tear). Arthroscopic or open joint
visualization should be performed to ensure adequate reduction of the joint surface.
Prophylactic anterior compartment fasciotomy is suggested at the time of ORIF.
Following ORIF, the extremity is immobilized in a cylinder cast for 4–6 weeks with
protected activity for additional 4–6 months [14–18].
Complications/Associated Injuries
Complications include compartment syndrome secondary to an injury to the recurrent

anterior tibial artery, quadriceps tendon avulsions, patellar tendon avulsions, collateral
Fig. 9.5 ORIF of tibial tubercle fracture
ligament injury and neurovascular injury. Additionally, long-term complications

include arthrofibrosis, premature epiphyseodesis leading to a recurvatum deformity,
weakness, residual pain and the potential for RSD, and re-fracture [16–19].
Proximal Tibial Physeal Fractures
Mechanism of Injury
Proximal tibial physeal injures are very rare with rates reported in the literature of
less than 1% of all physeal injuries [1, 6, 20]. These fractures are generally caused
by shearing, splitting, and avulsing trauma often resulting from a severe valgus
force [1]. Less commonly, these injuries result from a flexion force that can lead to
closure of the posterior physis and procurvatum deformity [18]. The most worri-
some mechanism is a hyperextension injury to the knee which causes the metaphy-
seal fragment of the proximal tibia to displace into the neurovascular structures
posteriorly [20] (Fig. 9.6). A displaced proximal tibial physeal fracture is the pedi-
atric equivalent of an adult knee dislocation.
Classification
Unlike fractures of the distal tibia, fractures of the proximal tibia are lacking a
descriptive and comprehensive classification system [21, 22]. The most utilized
classification is the Salter–Harris physeal injury (Fig. 9.7) system; however, some
Fig. 9.6 Proximal tibial

physis fracture with
metaphyseal fragment
displaced posteriorly and
disruption of popliteal
artery
Fig. 9.7 Salter–Harris physeal injury classification system
patterns that involve the lateral and anteroposterior planes are not accounted for by
the simple Salter–Harris scheme [23]. Mubarak et al. have proposed a more specific
classification system that reflects the direction of force and fracture pattern [22].
This newer classification system grouped fractures according to direction of force:
extension, flexion–avulsion, valgus, or varus (Fig. 9.8).
Treatment Options
A careful neurovascular examination is mandatory. If no vascular injury is suspected,

the fracture can be managed definitively by closed or open methods. However, a high
index of suspicion should be maintained for compartment syndrome and faciotomies
Fig. 9.8 Classification scheme of proximal tibial fractures based on mechanism [22]
should be performed as needed. In situations in which a vascular injury is suspected,

an arteriogram and a vascular surgery consultation are required. When a vascular
injury is present, definitive fixation of the fracture may occur in collaboration with
the management of the vascular injury.
Fractures through the proximal tibial physis are usually Salter–Harris I or II frac-
tures; however, occasionally a Salter–Harris type IV fracture does occur. These
fractures often have a crush component to the physis; thus, there is a significant
potential for a growth arrest to occur. Parents should be counseled about these
potential growth issues at the time of injury.
The goals of the treating surgeon are to reduce and stabilize the fracture without
causing secondary injury. Closed reduction can be attempted but should be gentle
and no more than two attempts should be made as multiple attempts at reduction
may risk additional injury to the physis. Open reduction may be required, as inter-
posed periosteum can prevent a closed reduction from being possible. Compartments
should be monitored carefully and if compartment syndrome is present emergent
fasciotomies should be performed.
Fixation of the fracture can be accomplished percutaneous pinning techniques or
by a formal ORIF with screw placement (Fig. 9.9). Following fixation, a noncircum-
ferential splint should be utilized until the swelling has subsided and the risk of com-
partment syndrome abates. Subsequently, a cylinder cast can be applied for 4–6 weeks.
The patient should have a total of 4–6 months of protected activity with careful radio-
graphic follow-up for 1 year to ensure proper healing without a growth arrest.
Complications/Associated Injuries
Complications include compartment syndrome due to injury to the anterior tibial

recurrent artery injury, popliteal artery injury (Fig. 9.10), quadriceps tendon avul-
sions, patella tendon avulsions, collateral ligament injury, and neurologic injury.
Fig. 9.9 ORIF of proximal tibial physeal fracture
Fig. 9.10 Popliteal artery

injury after proximal tibial
fracture
Fig. 9.11 Metaphyseal fracture “Cozen fracture”
Additionally, long-term complications can include arthrofibrosis, premature

epiphyseodesis leading to deformity, weakness, residual pain and the potential for
RSD, malunion, nonunion, and re-fracture [18–23].
Proximal Tibial Metaphyseal Fractures “Cozen Fracture”
Mechanism of Injury
Metaphyseal fractures are rare and usually occur between the ages of 3 and 6 years
of age (Fig. 9.11). Most of these fractures are torus or greenstick fractures that result
from twisting mechanisms and are associated with low energy trauma [24–27]. The
exception is blunt trauma that causes a displaced fracture (Fig. 9.12) as displaced
fractures in this location risk vascular compromise.
Classifications
Proximal tibial metaphyseal fractures are divided into two groups: non-displaced
(greenstick) and displaced.
Fig. 9.12 A displaced

proximal metaphyseal
fracture
Treatment Options
Acutely a fracture of the proximal tibial metaphysis should undergo a closed

reduction if necessary, and subsequently the limb should be splinted and moni-
tored for compartment syndrome. Once the swelling has subsided, the leg can be
casted with the knee in extension and a varus mold applied to the cast, with the
cast being maintained for approximately 6 weeks [21, 24, 27]. If one is unable to
reduce a displaced fracture in a closed manner due to soft tissue interposition,
then open reduction with exploration of the fracture site is indicated. A spanning
external fixation device may be utilized with release of the leg compartments if
needed [20, 21, 24–27]. Once the soft tissue envelope has decreased in swelling
definitive fixation and/or casting can be performed.
Algorithm for Management of a Pulseless Limb
In a patient with a suspected arterial injury stemming from a proximal tibia frac-
ture, the ankle brachial index (ABI) can be utilized as an initial screening test for
vascular injury [28]. The ABI is the ratio of the blood pressure in the lower leg
compared to the upper arm. In general, in the setting of a proximal tibia fracture, a
lower pressure in the leg suggests injury to the popliteal artery. The ABI is measured
using a doppler probe and a blood pressure cuff. The blood pressure cuff is placed
at the proximal arm and the distal leg. The Doppler probe is placed distal to the
cuff over the brachial artery in the arm and over the dorsalis pedis artery and then
the posterior tibial artery in the leg. While listening to the Doppler, the cuff is
inflated until the signal is lost. The cuff is slowly deflated and the pressure at which
the pulse is re-detected is noted as the systolic pressure of that artery [29].
In general, the higher reading of the right or left brachial artery is used and the
higher reading of the posterior tibial or dorsalis pedis arteries is used for the ABI
calculation. The formula is ABI (leg) = P (leg)/P (arm). An ABI of less than 0.9
indicates possible vascular injury [29].
If a patient has an obvious dysvascular limb, or if the ABI is less than 0.9, an
immediate vascular surgery consult is recommended. The decision to perform an
arteriogram, CT angiography [30], or MRA is best done in collaboration with the
vascular surgeon. In cases of a pulseless, cold, dysvascular limb, emergent explor-
atory surgery of the popliteal artery without a vascular study is indicated [29, 31]
similar to the recommended management of a vascular injury with a displaced
supracondylar humerus fracture [32].
At the time of arterial exploration, via a posterior or posterior–medial approach
to the knee, the vascular surgeon will repair or perform a vein bypass of the injured
popliteal artery prior to the orthopedic surgeon fixing the fracture. Subsequently, the
orthopedic surgeon will perform fasciotomies of the four compartments of the lower
leg and fracture fixation.
Complications
Displaced fractures have the potential to injure the anterior tibial artery thus
potentially leading to a compartment syndrome. Additionally, peroneal nerve
damage may be encountered from a crush injury or stretch injury during the initial
traumatic event. Medial tibial overgrowth following non-displaced fractures can
result in a valgus deformity of the tibia [20, 22, 24–27] (Fig. 9.13). Typically,
spontaneous correction of the valgus deformity occurs [26], however, if spontane-
ous correction has not occurred by 12 years of age, correction can be achieved
with a hemiephyseiodesis.
Summary
Pediatric proximal tibial fractures with vascular compromise are fortunately rare
injuries. The challenges in the management of these fractures center on recognizing
the possibility of vascular injury, obtaining an anatomic reduction, the liberal use of
fasciotomies, and urgent consultation with a vascular surgeon in cases of injury to
the popliteal artery.
Fig. 9.13 Genu Valgum: A late complication of a valgus deformity after a proximal metaphyseal
fracture
References
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fractures in children aged 0-16 years. J Pediatr Ortho. 1994;14:423–30.
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County, Minnesota, 1979-1988. J Pediatr Orthop. 1990;10:713–6.
5. Riseborough EJ, Barrett IR, Shapiro F. Growth disturbances following distal femoral physeal
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Fractures and dislocations of the knee, vol. 3. Philadelphia: JB Lippincott; 1984. p. 891–946.
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1982;64:536–41.
10. LaPrade RF, et al. The anatomy of the medial part of the leg. JBJS Am. 2007;89:2000–10.
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vascular compromise and compartment syndrome: a case report. J Ortho Surg Res. 2009;4:23.
12. Yeap JS, Harwant S, et al. Compartment syndrome of the calf and foot following a displaced
Salter-Harris type fracture of the distal tibial: a review of the literature and case report. Med
J Malaysia. 2001;56:66–9.
13. Tjoumakaris FP, Wells L. Popliteal artery transaction complicating a non-displaced proximal
tibial epiphysis fracture. Orthopedics. 2007;30(10):876–7.
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2008;2:469–74.
18. Bolesta MJ, Fitch RD. Tibial tubercle avulsions. J Pediatr Orthop. 1986;6:186–92.
19. McKoy BE, Stanitski CL. Acute tibial tubercle avulsion fractures. Orthop Clin North Am.
2003;34:397–403.
20. Edward PH, Grana WA. Physeal fractures about the knee. JAAOS. 1995;3:63–9.
21. Blanks RH, Lester DK, Shaw BA. Flexion-type salter II fracture of the proximal tibia. Clin
Ortho Relat Res. 1994;301:256–9.
22. Mubarak SJ, et al. Classification of proximal tibial fractures in children. J Child Orthop.
2009;3:191–7.
23. Patari SK, et al. Coronal split fracture of the proximal tibia epiphysis through a partially closed
physis: a new fracture patter. J Ped Orthop. 2001;21:451–5.
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Chapter 10
Open Tibia Fractures in Children
and Adolescents
Joseph Rosenblatt and Shannon D. Safier
Abstract Open tibia fractures in children comprise only 2–3% of all fractures yet
they account for one-third of open fractures that occur in this age group. Basic
management principles are similar to those used to care for adults with open tibia
fractures. Careful assessment of the child to rule out associated injuries, determina-
tion of soft tissue and neurovascular status of the fractured limb, administration of
antibiotics in the Emergency room, and thorough irrigation and debridement in the
operating room are keys to achieving good outcomes. While cast immobilization is
an option for some open fractures, fixation is utilized for many open fractures.
Flexible intramedullary nails, external fixation, percutaneous wire fixation, and
plate-screw constructs are all effective in stabilizing these fractures and are selected
based on age and the size of the child and the specifics of the injury.
Keywords Open tibia fracture • Irrigation and debridement • Flexible intramedul-

lary nails • External fixation • Compartment syndrome
Introduction
Tibial shaft fractures are a common injury in children with the majority being
closed injuries [1]. Typically, tibial shaft fractures result from low energy mecha-
nisms, such as sports injuries or falls from low-heights, and are best managed by
J. Rosenblatt, DO
Clinical Instructor of Pediatric Orthopedic Surgery, Department of Orthopedics,
St. Christopher’s Hospital for Children, 3601 A Street, Philadelphia, PA 19134, USA
S.D. Safier, MD (*)
Assistant Professor of Pediatric Orthopedic Surgery, Department of Orthopedics,
St. Christopher’s Hospital for Children, Erie Avenue at Front Street, Philadelphia, PA 19134, USA
e-mail: safiersd@yahoo.com
158 J. Rosenblatt and S.D. Safier
fracture reduction and cast immobilization. Open tibia fractures in children are rare
[2], comprising only 2–3% of all tibia fractures. However, open tibia fractures
account for approximately one-third of all open fractures in children [3]. When
they occur, these fractures are usually caused by violent traffic accidents and other
high-energy mechanisms, such as falls from heights. The reported demographics
and injury mechanisms vary widely from center to center [4].
Treatment principles regarding open tibia fractures in children do not
significantly differ from those for adults. Management is based on the following
principles: assessment of the patient, classification of the injury, antibiotic ther-
apy, débridement and wound management, fracture stabilization, and supplemen-
tal procedures to achieve healing. While outcomes of severe open tibia fractures
in children are generally better than those for adult injuries, serious complications
do occur and must be managed appropriately to insure healing and recovery of
function [5].
Associated Injuries
The prevalence of associated injuries in children with open tibia fractures has
varied between 15% and 74% in recent studies [1, 2, 6–10]. These include
moderate to severe head injuries (27%), other lower limb fractures (21%),
thoraco-abdominal and axial skeleton injuries (17%), and upper limb fractures
(13%) [6]. Fatality in children who sustain open tibia fractures has also been
reported in 1–7% of cases, although the true occurrence of death may be
underestimated due to deaths occurring at the scene of injury with undocumented
associated injuries [1, 6, 11].
Child Versus Adult
The goals of treatment of open tibia fractures in children are the same as for adults:
(1) preventing wound sepsis, (2) ensuring healing of soft tissues, (3) achieving bone
union, and (4) returning the patient to optimal function. However, open fractures in
children do differ from open fractures in adults in important ways. Thicker and
more active periosteom provides greater fracture stability and leads to more rapid
and reliable fracture healing in young children compared with that in older children
and adults [12]. Young children also have a greater potential for periosteal bone
formation [13]. Additionally, overall time to healing is faster and more reliable in
children than it is in adults with similar injuries, and children can even have the
ability to reconstitute bone in the face of bone loss [14]. Lastly, infection rates in
children with open fractures have been reported to be lower than those in adults with
similar fractures [15].
10 Open Tibia Fractures in Children and Adolescents 159
Emergency Department Evaluation
Examination
In the emergency department, all children with open fractures require assessment
of the ABCs (airway, breathing, and circulation) and control of the cervical spine
[16, 17]. A rolled towel or pad is typically placed under the shoulders of young
children to avoid neck flexion, as the proportionately large head of a child leads to
neck flexion and risk of neurologic injury when an adult board is used. The pediat-
ric advanced life support (PALS) [18] and advanced trauma life support (ATLS)
[19] manuals provide helpful guidelines for the evaluation and care of children
who have sustained traumatic injuries. Patients with a high-energy mechanism of
injury or multiple injuries should be evaluated by the trauma team. Intravenous
access is obtained, fluid resuscitation is begun, and intravenous antibiotics are
given promptly. If intravenous access is not readily obtainable, intraosseous infu-
sion can be performed with a large bone-marrow needle with a stylet placed in the
proximal part of the uninjured tibia, approximately 1 cm distal to the tibial tubercle
to avoid physeal injury [20]. Intraosseous infusion has been reported to be safe and
effective in children [21, 22]. Tetanus toxoid is given to patients who have not had
tetanus immunization within 5 years or if their status is unknown.
Once cardiopulmonary assessment and hemodynamic stabilization are
achieved, the neurovascular status of the fractured limb is determined. Neurologic
evaluation of all of the major nerves or muscle groups is performed in both the
injured and uninvolved extremities. If the patient is not able to cooperate with a
full neurologic examination because of age, mentation, or trauma, he or she is
observed for spontaneous motion, and any apparent deficit is noted. This may
require some patience when an injured and frightened child is being examined.
Young children may not answer questions regarding sensation but will often react
to sensory stimuli. The vascular evaluation should include assessment of capillary
refill as well as the color of the skin and digits, palpation of distal pulses and,
when the injury is severe or pulses are questionable, assessment of distal arteries
for Doppler pulses. Compartments should be palpated to ensure that they are sup-
ple. If compartments are tense or there is disproportionate pain with passive
stretch of the toes, compartment syndrome should be suspected. It is imperative to
recognize that the presence of an open fracture wound does not exclude the devel-
opment of compartment syndrome [23].
The open wound is inspected for bleeding, muscle, nerve, or tendon lacerations
or defects, bone exposure, and gross contamination. Traumatic wounds near a
joint must be investigated for communication with that joint by performing either
a saline load test [24] or probing the wound with a sterile cotton-tip applicator.
After wound assessment, a sterile dressing is applied. Repeat inspections involv-
ing dressing changes are minimized to avoid additional contamination or tissue
trauma. A picture can be taken so that additional care providers can appreciate the
wound(s) without exposing the wound(s) to further contamination. Gentle traction
should be used to realign gross deformities, thus reducing the tension on soft
tissues and establishing proper length. Early splinting before the patient is taken
to the radiology suite or operating room minimizes ongoing injury to soft tissues
and decreases pain.
Classifications
A child’s skin and soft tissues are more elastic and forgiving than the adults’.
Some closed fractures caused by violent force may result in extensive destruction
of the soft-tissue sleeve surrounding the tibia without resulting in an open lesion,
as seen in the Morelle–Lavalle lesion of the pelvis [25]. These closed fractures
with severe soft-tissue injury are characterized by skin contusions, deep abra-
sions, burns, or frank separation of the cutis from the subcuticular tissue. Even in
children, these lesions can result in partial or full tissue loss and secondary infec-
tion of the fracture site. While some severe soft-tissue injuries associated with
closed fractures may require debridement and aggressive wound management,
many of these wounds do not require surgical treatment in children. Recently, suc-
cessful use of percutaneous drainage and débridement of such lesions was reported
in adult patients [26] but little published information is available regarding
management in children.
The Tscherne [27] classification describes four grades of these injuries and may
prove useful in choosing among different treatment options. Grade 0 lesions have
minimal soft-tissue damage and are typically due to indirect violence. Simple frac-
ture patterns, such as a torsion fracture of the tibia, are typically seen. The skin
lesions seen in Grade 1 lesions are superficial abrasions or contusions caused from
pressure within. Fractures present in this grade are mild to moderately severe
configurations such as a pronation fracture dislocation of the ankle joint with a
resultant soft-tissue lesion over the medial malleolus. Grade 2 lesions are deep con-
taminated lesions associated with localized skin or muscle contusion. Impending
compartment syndrome may be present and fractures have a severe configuration.
An example of a Grade 2 lesion is a segmental tibia fracture secondary to a car
bumper. Grade 3 lesions have extensive skin contusions or crush injury with severe
underlying muscle damage. Decompensated compartment syndrome with or with-
out a major vascular injury is present and the fractures have a severe or comminuted
configuration [27].
The Gustillo and Anderson [28, 29] open fracture classification system is use-
ful in the evaluation of open fractures in children. In a small limb in particular,
however, absolute wound size is not as important a factor in type assignment as
the condition of the soft tissues and the degree of periosteal stripping. Fracture
type may be assigned in the emergency department but is more accurately done
in the operating room during irrigation and debridement. Type I fractures are
open injuries secondary to a low-energy puncture wound that measures less
than 1 cm, with little contamination, fracture comminution, or soft-tissue injury.
Table 10.1 Antibiotic indications

Antibiotic Pediatric dose Indication
Cefazloin (Ancef) 25 mg/kg/dose q8 All open fractures
Clindamycin 25–40 mg/kg/day divided for q6–q8 Type II and III open fractures
Penicillin (Aqueous 50,000–100,000 units/kg IV q4 Soil or fecal matter contaminated
Penicillin G) wounds
Vancomycin 15 mg/kg/dose q6 Suspected MRSA infections
Type II open injuries have skin wounds measuring 1–10 cm, without extensive
comminution or severe periosteal stripping. The soft-tissue envelope is adequate
for wound coverage. Type IIIA open fractures have heavily contaminated wounds
measuring greater than 10 cm, segmental or comminuted fractures, and adequate
soft-tissue coverage, whereas Type IIIB open fractures have similar characteris-
tics but require additional soft-tissue coverage. Type IIIC open fractures have an
associated arterial injury requiring repair.
Administration of Antibiotics
The crucial role of antibiotic administration in the management of open fractures

was established several years ago in a prospective randomized study by Patzakis
et al. [30]. These authors demonstrated that early administration of antibiotics
with activities against both gram-positive and gram-negative organisms was the
most important factor in reducing the infection rate. In the largest study of open
fractures in children [31], administration of intravenous antibiotics in the emer-
gency department was identified as the most important factor in decreasing the
risk of infection (see Table 10.1). A first generation cephalosporin is typically
administered to all patients with an open fracture. Patients with obvious contami-
nation and type-II or III open fractures are additionally given an aminoglycoside
to improve gram-negative coverage. Penicillin or one of its derivatives is given to
patients with open fractures that may be contaminated with fecal material or soil,
such as those open fractures that occur on a farm, to cover Clostridium species
and anaerobes. Clindamycin is commonly used instead of a cephalosporin for
patients with allergies to cephalosporins or penicillin. With the increase in
Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA)
infections, some have suggested that this traditional open fracture antibiotic regi-
men is not adequate. Currently there are no studies, however, that demonstrate a
benefit to the use of clindamycin, vancomycin, or other agents instead of a cepha-
losporin for prophylaxis for patients with an open fracture, and these alternatives
do not have the same record of proven efficacy for preventing infection of open
fractures.
Surgical Management
Timing of Debridement
Traditional teaching is that all open fractures must be surgically treated within 6–8 h
with delays thought to jeopardize limb survival [32]. However, current research
calls this dogma into question. Several studies have shown that delaying irrigation
and débridement to within 24 h after injury does not result in an increase in infection
rate as long as intravenous antibiotics are started upon presentation in the emer-
gency department [3, 31, 33]. All open tibia fractures, regardless of type, are best
treated with irrigation and debridement in the operating room within 24 h of injury
to minimize the risk of infection. Emergency surgery, however, must be considered
for those fractures with gross contamination, severe soft-tissue injury, a large area
of exposed bone from soft-tissue loss, and those associated with vascular compro-
mise of the extremity.
Irrigation and Debridement
Thorough irrigation and debridement in the operating room are key to infection pre-
vention after open fractures. After sterile prepping and draping, the open wound is
evaluated. Small wounds must be extended to permit adequate exposure of the ends
of the fracture fragments and permit safe access to the surrounding soft tissues.
Obvious debris and nonviable tissue is initially removed and the bone ends are curet-
ted if embedded dirt or other foreign material is present. The wound is then held
opened with the bone ends exposed and irrigation is initiated. The orthopaedic trauma
association (OTA) has established guidelines for the amount of “copious” irrigation
that is recommended for irrigation of open fractures in adults; however, there is no
set standard recommendation for children. Their recommendations include using 3 L
for Type I open fractures, 6 L for Type II open fractures, and 9 L for Type III open
fractures. The volume of irrigation, however, must be tailored to match the child’s
wound. Wound irrigation volume is based on the size of the wound, the size of the
patient’s limb, and the degree of contamination but rarely exceeds 5 L in most cases.
Excessive irrigation, especially when delivered under high pressure, may extravasate
into the deep soft tissues of a small limb, theoretically raising the risk of compart-
ment syndrome, and has deleterious effects on the early stages of bone healing [34].
The addition of antibiotics to the saline irrigant has not been shown to lessen the risk
of infection and may have a deleterious effect on wound healing [35]. In contrast a
gentle detergent or soap solution added to the irrigation may be effective in removing
bacteria more than saline alone [36]. It is our practice to use bulb irrigation or pulse
lavage at the lowest pressure setting without additives.
After irrigation, a thorough surgical débridement is then performed. The most
important principle in open fracture management is removal of all nonviable tissues
and foreign material that may enhance bacterial growth and hinder the host’s defense
mechanisms. A pneumatic tourniquet is applied as a safety measure but is not

inflated unless uncontrollable bleeding occurs. The extent of the “real injury,” which
often exceeds the “apparent injury” by a factor of 2–3, is then determined by careful
inspection of the soft tissues. Many clues alert the surgeon to the true size of the
injury zone, including an estimate of the energy involved at the injury event, the size
and location of bruises and secondary skin openings, and radiographic features such
as air pockets extending along tissue planes and the relationship of bony fragments
to neurovascular structures [37].
Children have superior healing potential compared to adults and, therefore, ini-
tial débridement of open tibia fractures may be different from that of similar wounds
in adults. It is best to retain soft tissue of questionable viability in children at the
time of the initial débridement and re-evaluate it at a second debridement. Often at
the second surgery, the tissue will appear healthy and well perfused. Damaged skin
and subcutaneous tissues are sharply débrided back to bleeding edges. Bone frag-
ments with soft tissue or periosteal attachments may be left in place but cortical
bone pieces that are obviously avascular should be removed. For most Type II and
III open fractures, a second debridement, or more as necessary, is recommended to
ensure that all contamination and nonviable tissue are removed as best as possible.
Fracture Stabilization
While splint or cast immobilization may be adequate for the majority of pediatric
tibia fractures, more formal fracture stabilization is recommended for most open
tibia fractures. Fracture stabilization reduces pain, prevents additional injuries to the
surrounding soft tissues, decreases the spread of bacteria, decreases inflammatory
markers, allows for early soft tissue and bone healing [38], and enhances the ability
to mobilize the child. Ideally, the method of stabilization allows for easy access to
the limb for dressing or vacuum assisted closure (VAC) changes and for neurovas-
cular and soft-tissue compartment evaluations. The choice of fixation must also take
into account the future needs for soft-tissue management such as skin grafting or
flap coverage in those cases with more severe injuries.
The surgical treatment options differ in a child because of the presence of an
open physis. Treatment options in the skeletally immature include external fixation,
intramedullary flexible nail fixation, percutaneous pinning, and plate-screw con-
structs. Older adolescents with a closing proximal tibial physis and tibial tubercle
may be treated as adults with reamed, locked, intramedullary nailing.
External Fixation
External fixation is an excellent option for the management of comminuted or

length unstable tibial diaphyseal and metaphyseal–diaphyseal fractures
(Fig. 10.1). Its ease of application, familiarity to most orthopedic surgeons, and
Fig. 10.1 (a) AP radiograph of right tibia of 6-year-old boy struck by motor vehicle. He sustained
a Grade 3A open tibia fracture with loss of cortical bone. (b) AP radiograph of the tibia after irriga-
tion, debridement, and external fixation. He required three debridements, a skin flap, and bone
grafting before he healed the fracture 12 months later
its versatility for managing many fracture patterns make it a commonly used
method for open tibia fracture stabilization. To provide optimal stabilization
with minimal complications, three basic criteria are used when external fixators
are applied: (1) Half pins or wires should not damage vital anatomy, (2) the
construct should provide sufficient wound access for débridement and second-
ary procedures, (3) the frame should be appropriate to the mechanical demands
of the patient.
For most tibia fractures in children, a simple uniplane frame secured with two
pins above and two pins below the fracture site is adequate. The diameter of the
fixator pins should not exceed a quarter of the diameter of the tibia. Generally, pins
with diameters ranging from 2.5 to 4 mm are most appropriate for children and are
ideally placed no closer than 2 cm from the fracture site. While most pins are placed
in diaphyseal or metaphyseal bone, occasionally the fracture pattern is such that an
epiphyseal pin is needed to secure fixation. Ring fixators with wires under tension
are useful for extensively comminuted tibial fractures and fractures extending close
to the epiphyses. Infrequently fixation across the knee, or, more commonly, across
the ankle is necessary for very proximal or very distal tibia fractures, respectively.
External fixation is associated with several common complications. Pin site
infections, postoperative pain, refracture after frame removal, and unsightly scars
are not uncommon. Because of these problems, many pediatric orthopedic surgeons
use internal fixation whenever possible for open tibia fracture management.
Flexible Intramedullary Nails
Flexible intramedullary nails (FIMN) are the treatment of choice for many pediatric
orthopedic surgeons when treating open tibia fractures (Fig. 10.2) as they are a simple
load-sharing device that are easy to insert and remove, do not cross physes, maintain
Fig. 10.2 (a) AP radiograph of 14-year-old boy who was stuck by a car while riding a motor-
cycle. He sustained a Grade 2 open tibia fracture. (b) He underwent irrigation, debridement, and
placement of flexible nails. (c) Six months after injury he had pain and an incomplete union of
the fracture with varus deformity. (d) AP radiograph taken 6 months after he underwent take-
down and iliac crest bone grafting of the incomplete union and fixation with a reamed, locked
intramedullary nail
alignment for most diaphyseal fracture patterns, do not obstruct wound care, and
permit rapid mobilization [39]. When compared to external fixation, flexible nailing
of tibia fractures has a shorter time to union, lower refracture rate, and better func-
tional outcome scores [40]. Several reports show the use of FIMN in open tibia
fractures with good results [39–42].
Introduced through medial and lateral proximal metaphyseal drill holes placed
just posterior to the tibial tubercle and approximately 2 cm distal to the physis, two
intramedullary nails of the same diameter are passed anterograde across the frac-
ture site into the distal metaphysis. For most children’s fractures, nails measuring
3.0–4.0 mm in diameter, ideally filling 80% of the canal at the isthmus, are adequate.
The nails may be prebent to promote maximal separation at the fracture site and
3-point contact within the bone, which are the keys to stable fixation with flexible
nails. Supplemental splint or cast immobilization is frequently utilized, particularly
immediately after surgery, to control rotation and for comfort.
Flexible nails, however, have some drawbacks. Fractures closer than 2–3 cm from
the physes of the proximal or distal tibia are not amenable to their use. Furthermore,
length-unstable fractures, either from comminution or bone loss, cannot be stabilized
adequately with flexible nails. Lastly, patients weighing more than 100 lb. may not
be ideal candidates for even the largest 4.0 mm titanium nails due to concerns for loss
of fixation. Most surgeons remove the nails 6–9 months after placement.
Percutaneous Pinning
Percutaneous pinning of unstable tibial shaft fractures is an option for very distal or
proximal fractures or for shaft fractures in younger children (Fig.10.3). Smooth or
threaded wires can act as internal splints to stabilize fractures that are unstable after
a satisfactory closed reduction with one or two wires being placed across the frac-
ture site. The entry point and pin configuration is dependent on the fracture pattern
and is best performed with real-time fluoroscopic guidance. The size of the pins
depends on the size and age of the patient with stouter pins utilized for larger and
older children. After fixation, patients are placed in a long leg cast and are not per-
mitted to bear weight. Following four weeks of immobilization, the pins are removed
and the cast is changed to permit progressive weight bearing. In our experience, this
technique is contraindicated for fractures with severe comminution (length-unstable
fractures), fractures associated with severe soft-tissue injury, and for children whose
body habitus does not permit application of a well-fitted long leg cast.
Plate and Screw Constructs
With the widespread use of flexible nails, open reduction and plate fixation are
less commonly utilized for open tibia fractures. Plates are best used to stabilize
Fig. 10.3 (a) AP radiograph of 9-year-old girl who had been struck by a motorcycle after closed
reduction and casting. (b) She underwent closed reduction and percutaneous pinning of the tibia
and percutaneous intramedullary fixation of the fibula. (c) C. AP radiograph 6 months after injury
shows a healed fracture
fractures located in the proximal or distal third of the tibia (Fig. 10.4). Plate
fixation for middle-third diaphyseal fractures is rarely indicated. Utilization of
plates in children has increased over the more recent years as more child-specific
contoured plates have become available and as percutaneous plating techniques
have evolved for pediatric applications. This technique, however, is associated
with an increased risk of infection in open fractures. Because other, potentially
easier and safer options are available for fixation of open tibia fractures, utiliza-
tion of plates is limited in most pediatric centers.
Fig. 10.4 (a) AP radiograph of 7-year-old girl hit on bicycle. The injury was closed and she had a
normal neurovascular exam. A closed reduction attempt in the ER was unsuccessful. (b) She
underwent open reduction and internal fixation of the tibia with a plate and screws
Wound Management
Following formal irrigation and debridement and fracture stabilization, the incised
(extended) skin incision is reapproximated with simple nylon or polypropylene
sutures. The traumatic wound may be closed over a drain or left open. Low-grade
open fractures can usually be treated adequately with a single procedure, whereas
type-III and severe type-II injuries typically should undergo débridement every
24–48 h until the soft tissues have stabilized, the remaining tissue appears viable,
and the wound is considered clean on the basis of visual inspection [14]. For
severe type-III injuries a multidisciplinary approach, including plastic surgery, is
beneficial.
Coverage of Large Wounds
A popular alternative treatment for wound coverage and closure of significant

wounds is the use of the vacuum-assisted wound closure (VAC) device. It has been
shown that use of these systems provides notable advantages over traditional wound
care in the younger population. Patients require fewer painful dressing changes and
the risk of wound contamination is diminished because the wound is sealed.
Reduction of soft-tissue edema and promotion of granulation tissue by removing
debris and soluble inflammatory mediators that inhibit wound healing are other
potential advantages [43]. Negative pressure wound therapy may also obviate the
need for free tissue transfers in some children.
For large wounds associated with soft-tissue loss, re-establishment of a well-
vascularized soft-tissue envelope is critically important because it enhances vascu-
larity at the fracture site, promotes fracture healing, allows for delivery of
antibiotics, and enhances action of the host defense mechanisms. Soft-tissue cover-
age prevents secondary wound contamination, desiccation, and damage to bone,
articular cartilage, tendons, and nerves [30]. Early local or free-flap coverage may
be indicated for large open wounds with exposed bone [44] and are alternatives for
wound management in children whose wounds are not amenable to vacuum-
assisted wound therapy.
Postoperative Care
The duration of antibiotic administration for open fractures is controversial.

Dellinger et al. [45] demonstrated that a prolonged course (5 days) of antibiotic
administration was not superior to a 1-day course for prevention of fracture site
infections. Furthermore, prolonged antibiotic therapy does not reduce the rate of
infection and may promote the development of resistant organisms [6]. Several
studies have recommended 48 h or less of intravenous antibiotic administration
after open fractures [4, 46–48].
In the immediate postoperative period, the patient must be carefully observed for
signs of compartment syndrome and the development of a wound infection as evi-
denced by fever, erythema at the wound site, and wound drainage. The child is
mobilized out of bed on crutches or a walker once their pain is controlled. Most
patients are kept non-weight-bearing for 4 weeks but this may vary based on the
fracture pattern and fixation. Progressive weight-bearing and physical therapy are
subsequently initiated. Radiographs are taken at regular 4–6 week intervals to fol-
low bone healing.
Complications
Open fractures of the tibia in children have similar complications to the adult popu-
lation, although, as a general rule, children do much better than their adult counter-
parts. Age of the child seems to correlate most significantly with the incidence of
complications. Children under the age of 12 heal faster, have lower infection rates
and fewer complications than older children. Children over the age of 12 tend to
have complication rates similar to adults [8]. Infection occurs in 1–3% of open tibia
fractures [3] and is the most feared complication. Delayed union, malunion, and
nonunion are also concerns after open tibia fractures but occur less commonly com-
pared to adults. For many children, return of full function may be expected.
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Part V
Infection
Chapter 11
Septic Hip
Peter D. Pizzutillo and Megan Gresh
Abstract Joint sepsis is a surgical emergency in the pediatric population that must
be diagnosed and treated in a timely fashion to avoid lifelong limb deformity and
dysfunction. The child classically presents with fever, limping, inability to bear
weight, and painful range of motion of the hip. A full history and physical exam,
laboratory studies, and imaging studies are used to aid in the diagnosis. Treatment
consists of urgent surgical drainage of the affected hip followed by administration
of intravenous antibiotics. Complications of septic arthritis of the hip include chon-
drolysis, avascular necrosis, early physeal closure, leg length discrepancy, and
destruction of the femoral head.
Keywords Pediatric • Septic • Hip • Arthritis • Infection • Limp
Introduction
Joint sepsis is a common orthopedic surgical emergency, particularly in the pediat-

ric population. With the development of antibiotics, the focus of treatment of septic
arthritis of the hip has shifted from preservation of life to preservation of normal
growth and function of the hip joint. A child with an acutely irritable hip can present
P.D. Pizzutillo (*)

Department of Pediatric Orthopaedic Surgery, St. Christopher’s Hospital for Children,
3601 A Street, Philadelphia, PA 19134, USA
e-mail: peter.pizzutillo@tenethealth.com
M. Gresh
Department of Orthopaedic Surgery, St. Christopher’s Hospital for Children, 3601 A Street,
Philadelphia, PA 19134, USA
176 P.D. Pizzutillo and M. Gresh
a diagnostic challenge since the differential diagnosis is broad and the workup may
include invasive testing. Timely diagnosis of joint sepsis and initiation of treatment
are imperative to avoid the consequences of delayed treatment or diagnosis of septic
hip, which can result in lifelong limb deformity and dysfunction.
Epidemiology
Musculoskeletal infections, including septic arthritis of the hip, occur most often
in the first decade of life. Septic arthritis is about twice as common as osteomyeli-
tis and is more common in males (1). Joints in the lower extremity are more often
affected than joints in the upper extremity, with the hip involved in 50% of all
cases (2).
Etiology
While the primary source of the infection is infrequently identified, it is believed

that hematogenous spread to the joint is the main method of intra-articular bacter-
emia in this age group. The anatomy of the blood supply to the pediatric metaphy-
sis and epiphysis predispose these areas to infection (3) (Fig. 11.1). The proximal
femur is one of the four locations in the body that is characterized by an intra-
capsular metaphysis. The others include the proximal humerus, distal lateral tibia,
and proximal radius (1). This anatomic configuration can lead to joint sepsis when
infection occurs in the metaphysis of these bones. If a septic joint is diagnosed in
one of the aforementioned regions, osteomyelitis in the adjacent metaphysis must
be ruled out and vice versa.
Clinical Presentation
History
A detailed history is obtained from the child’s caretaker specifically investigating

for a history of immunosuppression, inflammatory diseases, recent illness, or
trauma. Pain is the most common complaint in patients with joint sepsis; however,
it is often difficult to assess in the pediatric patient. The child with an acute septic
hip classically presents with fever, limping, or inability to bear weight, and limited,
painful range of motion of the affected hip joint. In neonates or nonambulatory
infants, the diagnosis may be delayed due to atypical presentation or less acute
expression of signs and symptoms. These children may present only with irritability
or anorexia.
11 Septic Hip 177
Fig. 11.1 Line drawing depicting the vascular anatomy about the proximal femur. Note the
numerous tortuous blood vessels surrounding the physis. (Courtesy of Dan Zlotolow, MD)
Table 11.1 History and physical examination findings suggestive

of a septic hip
Pain
Irritability
Fever
Limping
Inability to bear weight
Decreased range of motion
Painful range of motion
Flexed, abducted, and externally rotated posture (late finding)
Physical Exam
Examination of a young child may be more effective if the child is allowed to

remain in the arms of his or her parent. Vital signs are obtained to assess for fever
and signs of systemic illness or sepsis (Table 11.1). Physical examination includes
evaluation of the abdomen, spine, pelvis, and both lower extremities. The lower
extremities are inspected to identify swelling, erythema, or skin changes. Each
limb is palpated to assess for tenderness of the long bones and for joint effusions
in the knee or ankle. Range of motion of the hip, knee, and ankle of both lower
extremities should be evaluated. The classically described physical exam findings
Fig. 11.2 Clinical photograph of a neonate with a severe case of right hip sepsis, demonstrating
the classic leg position of flexion, abduction, and external rotation
that include flexion, abduction, and external rotation of the hip as well as thigh
swelling or erythema are late findings (Fig. 11.2).
Laboratory Results
Initial laboratory tests should include a complete blood count with differential,
erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and blood cultures
prior to the administration of antibiotics. Lyme titers and rheumatologic studies
may also be drawn to avoid a second blood draw in the event that the diagnosis of
septic arthritis is not confirmed.
Imaging
Plain radiographs of the pelvis, hips, and both lower extremities will aid in indenti-
fying fractures, bone lesions, or periosteal reaction indicative of osteomyelitis or
tumor, and widening of the hip joint space suggestive of joint effusion. In many
cases of joint sepsis, plain radiographs appear normal (Fig. 11.3); however, initial
studies are required to narrow the differential diagnosis.
When the clinical suspicion for hip sepsis remains high after initial laboratory and
radiographic testing, an ultrasound of the hip is performed to assess for the presence
of a joint effusion. Ultrasound is noninvasive and can often be performed on a pedi-
atric patient without the need for sedation or general anesthesia (4, 5). The affected
hip can easily be compared to the contralateral side. If an effusion is identified on
ultrasound, an aspiration of the joint fluid is performed under ultrasound guidance to
11 Septic Hip 179
Fig. 11.3 This patient with hip sepsis had a normal AP pelvis Xray; however, this arthrogram of
the left hip demonstrated a large hip joint effusion
ensure correct location of the needle and that an adequate sample of synovial fluid is
obtained (Fig. 11.4). The gross appearance of the fluid should be noted and samples
are then sent for cell count, gram stain, culture, and sensitivity. Cloudy or purulent
fluid, cell count of greater than 50,000 white blood cells (WBC) with greater than
75% polymorphonuclear cells (PMNs) or a positive gram stain are findings diagnos-
tic for septic arthritis (6) (see Table 11.2).
Bone scan and magnetic resonance imaging (MRI) are useful tests in evaluating
musculoskeletal infections. Bone scan can be used to localize infection when a child
is ill but the location of infection is unclear. MRI can be used to rule out abscesses,
fasciitis, myositis, and osteomyelitis or to differentiate infection from tumor when
the site of involvement is known. In the pediatric population, general anesthesia is
often required for MRI testing. Bone scan and MRI are not routinely necessary in
the diagnosis of septic arthritis, but are helpful when the diagnosis is unclear (7).
Differential Diagnosis
Initially, the differential diagnosis of a child with an acutely irritable hip is broad
(Table 11.3).
Narrowing the differential can be challenging, but must be done expeditiously to
avoid the delay of urgent treatment of septic arthritis of the hip. Many of the diag-
noses in the differential can be eliminated by basic laboratory studies and imaging.
MRI evaluation of the spine, pelvis, or femur has been most helpful when the diag-
nosis is not firmly established after the initial workup.
Fig. 11.4 Ultrasound image of a hip joint effusion with a needle entering the capsule to perform
arthrocentesis
Table 11.2 Findings diagnostic of a septic hip

Cloudy or purulent fluid noted upon aspiration of the joint
Cell count > 50,000 WBC with > 75% polymorphonuclear cells
Positive gram stain
Table 11.3 Differential diagnosis of a child with an acutely

irritable hip
Septic arthritis
Toxic synovitis
Inflammatory arthropathy
Lyme disease
Osteomyelitis
Myositis
Fasciitis
Abscess (psoas muscle or retroperitoneal)
Neoplasm
Trauma (including child abuse)
11 Septic Hip 181
Table 11.4 Comparison of septic arthritis versus toxic synovitis

Septic arthritis Toxic synovitis
Hip range of motion Severe limitation Minimal limitation
Radiographs Normal or joint space widening Normal
Ultrasound Joint effusion Normal or small joint effusion
Laboratory studies (WBC, Elevated Normal to slight elevation
ESR, CRP)
Table 11.5 Kocher criteria utilized to diagnose a septic hip

Kocher criteria
Fever > 38.5°C
Refusal to bear weight
ESR > 40 mm/h
Serum WBC count > 12,000 cells/mm3
CRP > 2 mg/dL
Toxic synovitis is the most common condition in the differential diagnosis and
can be challenging to differentiate from hip sepsis. The child with toxic synovitis
typically presents with a limp for several days. In general, the child appears less ill
than the child with septic arthritis and exhibits minimal limitation of hip motion.
Radiographs of the hip and pelvis are normal. Laboratory studies are normal or
reveal slight elevation of the WBC count, ESR, and CRP. Ultrasound of the hip may
reveal a small amount of intracapsular fluid (Table 11.4). There have been several
studies attempting to identify which factors can be reliably used to differentiate
septic arthritis from toxic synovitis in the pediatric population (8–11). The original
Kocher criteria include a history of fever higher than 38.5°C, refusal to bear weight,
ESR greater than 40 mm/h, and serum WBC count of more than 12,000 cells/mm3
(8–10). A CRP greater than 2.0 mg/dL was later added as a fifth clinical predictor
(11) (Table 11.5). These five clinical factors have been shown to be strongly associ-
ated with septic arthritis of the hip and can be used to predict the probability that a
patient has hip sepsis versus toxic synovitis. If five of the factors are present, the
child has a 98% chance of having a septic hip. If four factors are present, the chance
of hip sepsis is 93%, three factors is 83%, two factors is 62%, one factor is 37%, and
zero factor is 17% (11). Fever is the best predictor, followed by elevated CRP (11).
Aspiration of the joint is indicated to confirm the diagnosis and to allow early
identification of organisms and antibiotic sensitivities.
Treatment
Once the diagnosis of septic arthritis of the hip is made, urgent surgical drainage of
the hip is indicated. While there are multiple approaches to the hip joint, the anterior
(Smith–Peterson) approach is most often utilized. The child is positioned supine on
Fig. 11.5 Line drawing of

the incision utilized to
drain a septic hip.
Typically, we utilize an
approximately 4 cm
obliquely oriented skin
incision that is in line with
the inguinal ligament, 2 cm
below the anterior–superior
iliac spine. (Courtesy of
Dan Zlotolow, MD)
the operating table with a small bolster placed under the involved buttock. The
entire limb is prepped and draped free. A 4 cm obliquely oriented skin incision is
made in line with the inguinal ligament, 2 cm below the anterior–superior iliac spine
(Fig. 11.5). The superficial fascia is incised and the interval between the tensor
fascia lata (innervated by the superior gluteal nerve) and the sartorius muscle (inner-
vated by the femoral nerve) is identified. Careful attention must be paid to avoid
cutting the lateral femoral cutaneous nerve. Retraction of the sartorius medially and
the tensor fascia lata laterally reveals the deeper interval between the rectus femoris
(innervated by the femoral nerve) and the gluteus medius (innervated by the supe-
rior gluteal nerve). Retract the rectus femoris medially and the gluteus medius later-
ally to reveal the anterior capsule of the hip joint (12). Excision of a 1-cm square
area of capsule is recommended to ensure continued drainage from the joint.
Cultures are obtained and the joint is then irrigated with at least 500 cc of sterile
saline infused through a large intravenous or small rubber catheter. The joint is
inspected for debris and a drain, such as a quarter-inch Penrose drain, is placed into
the joint capsule. The skin incision is loosely closed around the drain and a dressing
is applied. Postoperative immobilization or traction is unnecessary, and active range
of motion of the hip is encouraged. Following hip arthrotomy and drainage, osteo-
myelitis of the proximal femur or pelvis is ruled out by MRI evaluation.
Arthroscopic irrigation of the hip is an effective method of drainage, but is best
reserved for older children and adolescents. Drainage of the hip joint by serial aspi-
ration is not recommended. This technique involves repeated daily aspiration of the
hip joint, which results in increased pain and anxiety for the child. In addition, the
surgeon is unable to fully visualize, decompress, and irrigate the joint.
Immediately after surgical drainage, intravenous antibiotics are administered.
Empiric broad coverage antibiotic choices are made based on the child’s age and the
most likely causative organisms (Table 11.6), as well as the known resistance pat-
terns of organisms in the treating institution or local community. Our current broad
spectrum recommendations are presented in Table 11.7. The choice of empiric
11 Septic Hip 183
Table 11.6 Most common causative organisms for septic arthritis by age
Age Organism
Less than 3 months S. aureus, Group B streptococcus,
gram-negative bacilli
3 months–4 years S. aureus, Group A streptococcus, S.
pneumonia, H. influenzae, K. kingae
5 years and older S. aureus, Group A streptococcus, S.
pneumoniae
Table 11.7 Empiric antibiotic choices for septic arthritis by age at our institution
Age Antibiotic
Less than 3 months Nafcillin + Gentamicina
3 months–4 years Ampicillin–Sulbactam + Clindamycinb
5 years and older Nafcillin + Clindamycina
a
Subsitute vancomycin for nafcillin (clindamycin is contraindicated in the neonate)
b
Add vancomycin if: concomitant Staph-like skin or soft tissue infection, history of
MRSA, toxic, or septic clinical appearance
antibiotics, however, is based on known institutional and regional bacterial infection

incidences. The antibiotic regimen is then altered based on culture results. For sep-
tic arthritis without osteomyelitis, a 3-week course of antibiotics, initially given
intravenously, and then converted to an oral regimen if possible, is adequate therapy
for most cases. When septic arthritis is accompanied by osteomyelitis of the adja-
cent femur or pelvis, intravenous antibiotics for 4–6 weeks is indicated (13). This
necessitates the placement of a PICC line or a Broviac catheter. The antibiotic regi-
men chosen, the route of administration (oral versus intravenous), and the duration
of treatment, however, must be individualized and must take into account many fac-
tors including the timing of presentation (acute versus chronic infections), the extent
of the infection, its location, the presence of systemic signs of illness, and the viru-
lence of the particular organism. Infectious disease consultation may be obtained
for recommendations regarding the best management strategies and to assist with
clinical follow-up.
Recently, the incidence of methicillin-resistant Staphylococcus aureus (MRSA)
infections has been shown to be on the increase (14, 15). MRSA infections can be
more virulent than MSSA infections leading to the development of deep venous
thrombosis (DVT), septic pulmonary emboli, and even acute multisystem failure
(15). It is essential to consider MRSA and treat it appropriately in any child who has
systemic signs of septic shock or lab markers nonresponsive to the initial empiric
antibiotics. Typically, rapid improvement in clinical state and in laboratory studies,
particularly the CRP, should be observed within 36 h of surgical drainage (16).
If clinical and laboratory parameters do not progressively improve, inadequate
surgical drainage, ineffective antibiotic regimen, or another source of infection must
be considered.
Fig. 11.6 AP pelvis radiograph demonstrating the late sequelae of hip joint sepsis. Note the
femoral head destruction and dislocation
Complications
Most children with septic arthritis of the hip who are diagnosed early and treated
appropriately will have an excellent outcome with a normal hip. Poor outcomes have
been correlated with age younger than 6 months at the time of diagnosis, delay in
treatment of longer than 5 days, inadequate irrigation and drainage, inappropriate anti-
biotic therapy, concomitant osteomyelitis of the proximal femur, and septic disloca-
tion of the involved hip (17). The growing hip joint sustains direct cartilage injury
from bacterial enzymes and the patient’s own inflammatory cascade. In addition, vas-
cular insult can occur secondary to prolonged increased intracapsular pressure and
vessel thrombosis from septic emboli. Potential complications include joint stiffness
and chondrolysis, avascular necrosis of the femoral head, partial or complete early
closure of the proximal femoral epiphysis or triradiate cartilage, leg length discrep-
ancy, acetabular insufficiency, dissolution of the femoral neck with pseudarthrosis
formation, and complete destruction of the femoral head and neck (Fig. 11.6).
References
1. Stans A. Osteomyelitis and septic arthritis. In: Morrissy R, Weinstein S, editors. Lovell and
winter’s pediatric orthopaedics. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins;
2006. p. 439–91.
2. Joshy S, et al. Comparison of bacteriologically proven septic arthritis of the hip and knee in
children, a preliminary study. J Pediatr Orthop. 2010;30(2):208–11.
3. Odgen JA, Lister G. The pathology of neonatal osteomyelitis. Pediatrics. 1975;55(4):474–8.
4. Zamzam MM. The role of ultrasound in differentiating septic arthritis from transient synovitis
of the hip in children. J Pediatr Orthop B. 2006;15:418–22.
11 Septic Hip 185
5. Wingstrand H, et al. Sonography in septic arthritis of the hip in the child: a report of four cases.
6. Bennett OM, Namnyak SS. Acute septic arthritis of the hip joint in infancy and childhood. Clin
Orthop. 1992;281:123–32.
7. Jaramillo D, et al. Osteomyelitis and septic arthritis in children: appropriate use of imaging to
guide treatment. Am J Roentgenol. 1995;165(2):399–403.
8. Kocher MS, Zurakowski D, Kasser HR. Differentiating between septic arthritis and transient
synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint
Surg. 1999;81(12):1662–70.
9. Kocher MS, et al. A clinical practice guideline for treatment of septic arthritis in children.
J Bone Joint Surg. 2003;85A(6):994–9.
10. Kocher MS, et al. Validation of a clinical prediction rule for the differentiation between
septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg. 2004;86A(8):
1629–35.
11. Caird MS, Flynn JM, Leung YL, et al. Factors distinguishing septic arthritis from transient
synovitis of the hip in children a prospective study. J Bone Joint Surg. 2006;88(6):1251–7.
12. Hoppenfeld S, et al. Surgical exposures in orthopaedics. 4th ed. Philadelphia, Pa: Lippincott
Williams & Wilkins; 2009. p. 405–19.
13. Wall EJ. Childhood osteomyelitis and septic arthritis. Curr Opin Pediatr. 1998;10(1):73–6.
14. Copley LA. Pediatric musculoskeletal infection: trends and antibiotic recommendations. J Am
Acad Orthop Surg. 2009;17:618–26.
15. Vander Have KL, Karmazyn B, Verma M, et al. Community-associated methicillin-resistant
Staphylococcus aureus in acute musculoskeletal infection in children: a game changer.
16. Unkila-Kallio L, Kallioi MJ, Peltola H. The usefulness of C-reactive protein levels in the
identification of concurrent septic arthritis in children who have acute hematogenous osteomy-
elitis. A comparison with the usefulness of the erythrocyte sedimentation rate and the white
blood cell count. J Bone Joint Surg. 1994;76(6):848–53.
17. Fabry G, Meire E. Septic arthritis of the hip in children: poor results after late and inadequate
treatment. J Pediatr Orthop. 1983;3:461–6.
Chapter 12
Necrotizing Fasciitis
Kevin J. Little and Joshua M. Abzug
Abstract Necrotizing fasciitis is a potentially deadly infection; however, with

early recognition and appropriate treatment, the morbidity and mortality can be
significantly decreased. This chapter provides a review of the etiologies and
pathogenesis of necrotizing fasciitis. Additionally, the clues necessary to diagnose
this potentially deadly infection are provided as well as the treatment modalities
currently available.
Keywords Necrotizing fasciitis • Infection • Cellulitis • Amputation • Death
Introduction
Necrotizing fasciitis is a rare, rapidly progressive, and potentially lethal soft-tissue

infection(s) that characteristically affects the fascia and subcutaneous tissues of
children and adults. While it is more common in immunocompromised patients,
it will afflict healthy adults and children, often with devastating results. Rapid diag-
nosis and aggressive treatment of necrotizing fasciitis are paramount to ameliorating
significant morbidity and mortality.
K.J. Little
Division of Pediatric Orthopaedic Surgery, Cincinnati Children’s Hospital Medical Center,
3333 Burnet Avenue, MLC 2017, Cincinnati, OH 45229, USA
e-mail: littlekevinj@gmail.com
J.M. Abzug, MD (*)
188 K.J. Little and J.M. Abzug
Necrotizing soft-tissue infections were identified as early as the fifth century

B.C.E. Hippocrates wrote: “The erysipelas would quickly spread in all directions.
Flesh, sinews, and bones fell away in great quantities” (1) Joseph Jones described
“Hospital Gangrene” in civil war patients in an 1,871 report, and the disease has
been identified by many monikers since, including streptococcal gangrene,
phagedena, phagedena gangrenosum, and hemolytic streptococcal gangrene. Wilson
first utilized the term “Necrotizing Fasciitis” in 1952 (2) when he described a soft
tissue infection predominantly located in the superficial fascia and deep subcuta-
neous tissues with associated gangrene of the skin. Recent high-profile clusters of
cases have led to popular terms such as “Galloping gangrene” caused by “flesh-
eating bacteria.”
Although uncommon, approximately 1,500 total cases of this surgical emergency
occur per year in the United States, with an incidence of 0.08 per 100,000 children
per year (3). The most common sites of necrotizing fasciitis in children are the
lower extremities and trunk with males being more frequently affected (4). Mortality
rates average about 30% in adults (5), but are lower in children, with reported rates
of 5–10% (4, 6). While numerous etiological entities have been described, a proxi-
mate causative factor is lacking in up to 20% of cases (4).
Microbiology and Classification
More than 40 causative bacterial agents have been identified in necrotizing fasciitis
patients, which can be subdivided into three types based on the microbiology of the
cultured specimen (see Table 12.1). Type I infections are polymicrobial encompassing
on average four or more cultured organisms in adults, although in children there may
be only two or three (F-M). Approximately 55–75% of necrotizing fasciitis cases are
Type I (7–9), with a mixture of Gram-positive cocci (except Group A b-hemolytic
streptococcus (GABHS)), Gram-negative rods and anaerobes. Type 2 infections are
monomicrobial, typically caused by GABHS, occasionally in association with
Staphylococcus aureus. Type I infections are more often encountered in healthy
Table 12.1 Classification of necrotizing fasciitis infections

Type Causative organism(s) Etiology
Type I Polymicrobial Healthy individuals
Gram + cocci
GABHS
Gram–rods
Anaerobes
Type II Monomicrobial Immunocompromised hosts
GABHS
Staphylococcus aureus
Type III Vibrio vulnificus Marine water exposure
12 Necrotizing Fasciitis 189
individuals, whereas Type II infections are more common in immunocompromised

hosts (9). Type III infections involve exposure to marine water leading to infections
caused by Vibrio vulnificus, and has a higher incidence in patients with liver failure
and Hepatitis B infections (10).
Pathogenesis
Necrotizing infections begin as bacteria are seeded in the fascial planes of the body.
Direct inoculation with bacteria (i.e., penetrating trauma or an open wound) is less
common in pediatric patients, although antecedent trauma or varicella infection to
the region is occasionally noted. Patients with immonudeficiency such as neutrope-
nia, diabetes, or immune-modulating medications, may be predisposed to necrotiz-
ing infections. Early in the disease process, bacteria rapidly proliferate along fascial
planes and invade the deep dermal adipose tissues. An overlying mild cellulitis may
appear at this point. The clinical signs of infection rapidly progress as the bacteria
produce and release virulent polypeptides known as superantigens (11, 12). These
molecules bypass normal antigen processing and directly cause T-Cell activation,
which in turn, leads to host cell release of inflammatory cytokines such as tumor
necrosis factor-alpha (TNF-a), interleukin-2 (IL-2), and interferon-gamma (INF-g)
(11). This release corresponds with a massive increase in edema and pain, as well as
systemic signs and symptoms of sepsis (tachycardia, fever, hypotension). Ultimately,
this immune-mediated cytokine release causes local liquefactive necrosis of the
fascia and deep dermal tissues with an aggressive vasculitis occurring which leads
to thrombosis of perforating arteries and veins, one of the hallmark signs of necro-
tizing fasciitis. Loss of the septal arteries induces local skin hypoperfusion and can
lead to the formation of serous, then hemorrhagic bullae on the skin surface.
Concomitant skin necrosis and ischemia to cutaneous nerves can lead to skin hypo-
or anesthesia, which may mask the severity of the infection. Further progression can
lead to myonecrosis, osteomyelitis, and complete skin necrosis if left untreated.
Presentation and Initial Treatment
The diagnosis of necrotizing fasciitis requires a high index of suspicion due to the
early paucity of clinical findings and variable history. Necrotizing fasciitis has been
reported following injections, improperly fit casts, blunt trauma, previous surgery,
superficial abrasions and in immunocompromised patients (13–17). Pediatric
patients typically present with mild erythema, significant edema, and decreased use
of the extremity. An antalgic limp may be noticed if the lower extremity is involved
(12). Mild symptoms predominate in the early course and the infection may be ini-
tially diagnosed and treated as a cellulitis by the primary care physician. As the
infection intensifies, systemic signs and symptoms begin, with rapid progression of
Fig. 12.1 Clinical

photograph of a patient
with left-hand dorsal
necrotizing fasciitis. Note
that the erythema has
spread beyond the
boundaries of three
separate markings within
24 hours despite
appropriate IV antibiotics.
(Courtesy of Cincinnati
Children’s Hospital)
the erythema despite appropriate intravenous antibiotics (Fig. 12.1), and increased
pain. The physical examination at this point is notable for pain out of proportion to
the clinical examination, and tenderness and tense edema beyond the boundaries of
the erythema. Serous bullae can be seen early in the course of disease and are one
of the few clinical hallmarks (9, 18). The diagnosis of necrotizing fasciitis is not
commonly made upon admission to the hospital when few systemic signs are pres-
ent (4, 9). In later stages, significant skin necrosis with hemorrhagic bullae is noted,
along with crepitance and fluctuance (18). Penetration of the infection into the deep
muscular tissues and surrounding neurovascular bundles can result in motor and
sensory deficits distally.
Once the diagnosis of necrotizing fasciitis is considered and/or suspected, the
child should be admitted to the hospital and broad spectrum antibiotics should be
initiated (see treatment section below). Additionally, the limb should be splinted to
provide comfort; however, the limb must be accessible to permit serial examina-
tions. These serial examinations should include assessment for the progression of
cellulitis, skin tenderness, edema, loss of function, and/or worsening pain. It is
essential to monitor the vital signs closely for tachycardia and/or hypotension,
which can occur with necrotizing fasciitis yet are uncommon with cellulitis or other
infections. If these signs are present, one should recognize that this is the beginning
of septic shock and the child should be brought emergently to the operating room
for a thorough debridement (see Table 12.2).
Laboratory and Radiographic Findings
Establishing the diagnosis of necrotizing fasciitis can be augmented by laboratory

and radiographic investigations. A complete blood count (CBC) with differential,
Chem-7, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) should
be obtained upon admission and serially repeated if the diagnosis is unclear. Elevated
Table 12.2 Initial treatment of suspected necrotizing fasciitis

Broad-spectrum antibiotics
Splint the limb
Serial examinations
Progression of cellulitis
Progression of skin tenderness
Progression of edema
Increasing loss of function
Worsening pain
Monitor vital signs closely for septic shock
Tachycardia
Hypotension
Emergent debridement and/or amputation once diagnosis is
confirmed or signs of septic shock are present
Table 12.3 The laboratory risk indicator for necrotizing fasciitis (LRINEC) score (16). A score
of ³ 6 indicates a high suspicion for the diagnosis of necrotizing fasciitis, while a score ³ 8 is
strongly predictive of the disease
Parameter (units) Value Score
C-reactive protein (mg/L) < 150 0
³ 150 4
Total WBC count (per mm3) < 15 0
15–25 1
> 25 2
Serum hemoglobin (g/dL) > 13.5 0
11–13.5 1
< 11 2
Serum sodium (mmol/L) ³ 135 0
< 135 2
Serum creatinine (mg/dL) £ 1.6 0
> 1.6 2
Serum glucose (mg/dL) £ 180 0
> 180 1
CRP (> 150 mg/dL), white blood cell (WBC) count (> 15/mm3), serum creatinine
(> 1.6 mg/dL), and serum glucose (> 180 mg/dL) as well as decreased serum
Hemoglobin(< 13.5 g/dL) and serum sodium (< 135 mmol/L) were found to be inde-
pendent predictors of necrotizing fasciitis compared to severe soft-tissue infections
(19). Additionally, a WBC > 25/mm3 or a hemoglobin < 11 g/dL indicated a higher
likelihood of necrotizing fasciitis. The authors developed a scoring system called
the LRINEC (laboratory risk indicator for necrotizing fasciitis) based on their
regression analysis (Table 12.3), where a score of six or greater should raise suspi-
cion for necrotizing fasciitis and a score > 8 was strongly predictive of the diagnosis.
In the absence of systemic symptoms early in the disease course, these levels may
be normal and serial laboratory testing may reveal the diagnosis when a rapid
increase in these parameters is encountered.
Fig. 12.2 Radiograph of a 9-year-old immunocompromised girl’s pelvis demonstrating gas in the
soft tissues overlying the left hip and pelvic regions. During her debridement, the infection was
noted to track along the fascial planes and extended into her abdomen and low back regions.
(Courtesy of St. Christopher’s Hospital for Children)
Obtaining radiographic studies may support the diagnosis of necrotizing fasciitis;

however, these must be performed expeditiously as any delay in surgical debride-
ment can lead to an increased risk of morbidity, amputation, and death. Plain
radiographs are of limited value in a non-traumatic setting, as they typically show
isolated soft tissue swelling, although in the rare case that subcutaneous gas is
present (16%) (9), the diagnosis can be confirmed (Fig. 12.2). Advanced imaging
studies are additionally helpful if the diagnosis is in question and the patient is
stable. Ultrasound has been advocated since it is readily available, can be done at the
bedside, and does not pose a radiation risk to children (20). Ultrasound findings
include hypoechogenic signals in the subcutaneous fat, fascia, and muscle, but should
not be relied upon to rule out the disease (21).
Computed tomography (CT) is an additional modality that can be performed
quickly and efficiently in systemically involved patients with a sensitivity of 80%
(22). Typically, CT imaging shows asymmetric thickening of the fascial layer and
subcutaneous edema with multiple abscess formation. This modality is the best for
detecting soft tissue gas. The addition of IV contrast does not appear to improve the
diagnostic accuracy as post contrast enhancement is variably present due to the
extensive thrombosis present in the disease process.
Fig. 12.3 (a) Coronal MRI of an 8-year-old girl who presented with painful calf swelling and a
fever for 2 days. (b, c) Axial T1 and T2 images of the same patient demonstrating the significant
soft tissue swelling and fluid tracking along the fascial planes. Intraoperative cultures obtained
during her debridement confirmed the diagnosis of necrotizing fasciitis. (Courtesy of St.
Christopher’s Hospital for Children)
Magnetic resonance imaging (MRI) is the most sensitive modality (90–100%)

for the diagnosis of necrotizing fasciitis (23), although it lags behind in specificity
(50–85%). Necrotizing fasciitis is characterized by increased fluid signal intensity
along thickened fascial planes (Fig. 12.3). Fat-suppressed and short-Tau inversion
recovery (STIR) imaging shows inflammatory changes around the fascia and soft
tissue gas is characterized by signal voids, best seen on gradient echo sequences
(24). MRI is often not available to critically ill patients and can result in a delay in
treatment; however, limited MRI sequences can be performed expeditiously to
confirm the diagnosis prior to surgical treatment.
In the event that a clear diagnosis cannot be made given indeterminate clinical,
laboratory, and radiographic tests, a skin biopsy can be performed to confirm the
diagnosis with frozen section histology (14). In children, this biopsy should be
coordinated in the operating room such that if the diagnosis is made then surgical
treatment can be immediately initiated. The biopsy should include skin, subcutane-
ous tissue, fascia and muscle in one section and be submitted en bloc for interpreta-
tion. Characteristic findings include an infiltrative panniculitis with micro- and
macro-abscess formation (Fig. 12.4a), microabscesses (Fig. 12.4b), and vasculitis
with thrombosed and occluded lumens (Fig. 12.4c).
Treatment
Successful treatment of necrotizing fasciitis requires careful coordination between

the surgeon and intensivist. Broad-spectrum IV antibiotics are started and aggres-
sive fluid resuscitation and pressure support should be initiated prior to emergent
surgical debridement. A delay in surgical treatment of more than 24 hours can lead
to a ninefold increase in mortality (9) and antibiotic therapy in the absence of deb-
ridement is ineffective (16).
Fig. 12.4 High-powered photomicrographs of a tissue sample which confirmed the diagnosis
of necrotizing fasciitis. Note the (a) extensive inflammation in the subdermal adipose tissue,
(b) large collection of inflammatory cells in an abscess around the fascial tissue (left of image),
and (c) vasculitis with obliteration of the central lumen of the vessel. (Courtesy of Cincinnati
Initial antibiotic therapy should be broad spectrum and can be tailored per
institution based on previous institutional data for bacterial sensitivities. The
duration of antibiotic therapy has not been formally evaluated; however, most
infections are treated for at least 14 days, with longer durations for patients with
osteomyelitis and septic arthritis. Intravenous Vancomycin is often used in loca-
tions where Methicillin-resistant Staphylococcus auerus (MRSA) is frequently
encountered, but is ineffective against gram-negative bacteria. Fluoroquinolones
offer excellent gram-negative coverage and soft tissue penetration with near full
oral bioavailability; however, their use in children is contraindicated due to their
side-effect profile. Group A b-hemolytic strep is best treated with IV penicillin,
although it loses effectiveness later in the disease process when bacteria reach a
steady state. This is due to the Beta-lactam inhibition of cell wall synthesis during
replication. The addition of clindamycin offers a synergistic, dual-action response,
by acting at the ribosomal level to inhibit bacterial activity and replication as well
as decrease the production of local toxins and superantigens (14).
Table 12.4 Zones of infection

Zone Description Physical exam findings Treatment
Zone 1 Nonviable tissue at the Severe, violacious erythema Excise all tissues down to
epicenter of the Hemorrhagic bullae fascia or necrotic
infection Decreased skin perfusion muscle if present
Zone 2 Advancing infection in Tense swelling Excise necrotic fascia
the perifascial and Woody induration Maintain skin and
subcutaneous tissues +/− Serous bullae subcutaneous tissues
Tenderness to palpation if healthy and viable
Zone 3 Noninfected tissue Normal, healthy appearing No treatment needed
skin
Fig. 12.5 Clinical photograph of the same patient as seen in Fig. 12.1. According to the
classification of Wong and Yam, Zone 1 was within the border of the first margin, Zone 2 was
within the boundaries of the intermittent line proximally, indicating an area of tenderness without
cutaneous findings, and Zone 3 was proximal to the intermittent marking. (Courtesy of Cincinnati
Careful preoperative evaluation of the patient will help in the appropriate exci-
sional debridement of nonviable tissue. Wong and Yam (25) described three zones
of infection, which should be mapped out prior to the operating room (see Table 12.4).
Zone 1 includes nonviable tissue at the epicenter of the infection, typically marked
by severe, violacious erythema, hemorrhagic bullae, and decreased skin perfusion.
Zone 2 contains the advancing infection in the subcutaneous and perifascial tissues,
with limited skin damage. This zone contains areas of tense swelling, woody indu-
ration, and possibly serous bullae, typically identified clinically by areas of tender-
ness within and surrounding the areas of obvious dermatological findings. Zone 3
includes all healthy, viable, and uninfected tissues (Fig. 12.5).
Once these zones are delineated, then surgical debridement can commence. Our
preference is to make incisions that are similar to those utilized when performing
fasciotomies of the involved areas. Tissues in zone 1 should be excised in their
entirety from skin down to fascia and necrotic muscle if present. It is in these tissues
that the pathognomonic features of necrotizing fasciitis are identified; grayish and
Fig. 12.6 Clinical

photograph of the same
patient after debridement
including complete
excision of zone 1 and
exploration of zone 2.
necrotic fascial tissues that do not impart resistance to finger blunt dissection,
pockets of abscess with foulsmelling, “dish water” purulence, and decreased vascu-
larity and lack of bleeding in the subcutaneous tissues with thrombosed vessels
(25). Failure to properly identify and excise this tissue in its entirety can lead to
significantly increased rates of morbidity, amputation, and death. Necrotic fascia is
typically identified in zone 2 and must be excised back to healthy, robust fibrous
tissues. However, skin and subcutaneous tissues in zone 2 may be spared from total
excision if they are well vascularized and the debridement is initiated promptly in
combination with appropriate antibiotics (Fig. 12.6). Some authors have demon-
strated an increased risk of mortality and morbidity if aggressive surgical debride-
ment is not performed at the initial surgery (9, Mok).
Once a thorough debridement has been performed, the wounds are irrigated
copiously. The use of pulsatile lavage is controversial as it has been shown to decrease
bacterial load more effectively than bulb syringe (26), while simultaneously seeding
bacteria further into soft tissues (27). The authors’ preference is to use a bulb syringe
for irrigation, as most of the bacteria should be removed with the initial debridement.
Wounds should be left open and covered with wet-to-dry dressings after the initial
surgical debridement. It may be necessary to return the child to the operating room
on a daily basis to perform debridements until the infection is stabilized. Amputation
of the limb may be required as a life-saving measure if the child does not respond
quickly to the debridements and their vital signs remain unstable.
Vaccum-assisted closure (VAC) therapy is typically not initiated after the first
debridement due to the increased risk of blood loss, but is a mainstay of treatment
thereafter to decrease edema and prepare the excised wound bed for eventual wound
reconstruction (Fig. 12.7). We typically employ the assistance of plastic surgeons to
aid in wound coverage and reconstruction when the trunk and pelvis require
significant debridements (Table 12.5).
Recently, several authors have proposed conservative treatment for children
with necrotizing fasciitis (28, 29). In their patients, treatment with antibiotics
resulted in the infection being localized to the initial site of infection, which then
Fig. 12.7 Reconstruction

for the patient included
(a) dermal matrix allograft
(Integra dermal
regeneration template,
Integra Life Sciences,
Plainsboro, NJ) after serial
debridement and partial
wound closure, followed
by (b) split-thickness skin
grafting 3 weeks later with
good functional results.
Table 12.5 Operative treatment pearls

Incisions similar to fasciotomy incisions
Excise all nonviable tissue
Incise and thoroughly irrigate areas that are viable until normal tissue is reached
Utilize bulb syringe for irrigation
Leave wound open and cover initial debridement with wet-to-dry dressings
Return to the operating room within 24–48 h for subsequent debridements
Amputate the limb if the child remains in septic shock or is continuing to decline
turned necrotic. The eschar could then be debrided at the bedside with minimal
blood loss. Later reconstruction was provided for wounds too large to heal by
secondary intention. However, it should be cautioned that this approach can lead to
a mortality rate of up to 20% (29), or even higher in immunocompromised patients
such as neonates.
Other authors have advocated the use of hyperbaric oxygen (HBO) therapy to
improve bacterial eradication (30, 31). HBO works by increasing the tissue partial
pressure of oxygen, which has a dual bacteriocidal effect by directly inhibiting
bacterial growth, especially with anaerobic bacteria, and increasing the neutrophil
oxidative burst of the patient’s own immune system (10). However, there is limited
data to prove that this treatment is effective in reducing morbidity, mortality and the
amount of surgical debridement required, especially in the treatment of necrotizing
fasciitis in children.
In conclusion, it is imperative that the physician be mindful of necrotizing fascii-
tis whenever a child presents with any cellulitis and/or rapidly worsening laboratory
findings. It is critical to make the diagnosis early and perform an extensive debride-
ment to obtain the best chance of decreasing the morbidity and mortality.
References
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Cambridge, MA: Cambridge Harvard University Press; 1868. p. 193–4.
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features. Int J Dermatol. 2007;46(10):1036–41.
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score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care
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ence of the Israel Naval Medical Institute. Pediatrics. 1998;102(5):E53.
Part VI
Other
Chapter 13
Slipped Capital Femoral Epiphysis
Panagiotis Peter Glavas and B. David Horn
Abstract Slipped capital femoral epiphysis or SCFE is the most common adolescent
hip disorder. The preferred classification system relates to physeal stability. The
majority of cases are of the stable type and the recommended treatment consists of
a single percutaneous screw placed in the center–center position. The treatment of
unstable SCFE is more controversial. There are two main complications of
SCFE: osteonecrosis and chondrolysis. Finally, osteoarthritis can develop from
impingement in the more severe slips and may necessitate more advanced treatment
techniques.
Keywords Slipped • Capital • Femoral • Epiphysis • SCFE • Stable • Unstable
Introduction
Slipped capital femoral epiphysis (SCFE) is a hip condition that primarily affects
adolescent children in their rapid pubertal growth spurt. The overall incidence of
SCFE in the United States is reported to be 10.8 per 100,000, making SCFE the
most common hip disorder of adolescence (1).
Historically, Howorth (2) suggests that SCFE was first described in the French
literature in 1552 by Paré (3):
P.P. Glavas
Sainte-Justine University Hospital Center, 3175 Cote-Sainte-Catherine, Montreal,
QC, Canada H3T 1C5
B.D. Horn (*)
Department of Orthopaedic Surgery, The Children’s Hospital of Philadelphia,
34th & Civic Center Boulevard, Philadelphia, PA 19104, USA
e-mail: hornd@email.chop.edu
204 P.P. Glavas and B.D. Horn
“The epiphysis of the head or the femur sometimes becomes disjointed and
separates in a such a way that the surgeon is misled, thinking that it may be luxation
and not separation of the epiphysis of this bone.”
This terminology can be misleading as the femoral epiphysis does not “slip”
within the acetabulum, but rather it is the femoral neck and shaft that displaces
relative to the normal relationship of the epiphysis in the acetabulum. Most com-
monly, the neck displaces in an anterior direction. When describing the direction
of the slip, this chapter will reference by convention the epiphysis as “displacing”
relative to the femoral neck. As such, the direction of slip in a typical SCFE is
referred to as being posterior. Infrequently, the slip can be lateral (valgus slip)
(4–8) or anterior (9–11).
Epidemiology
In an international multicenter trial by Loder (12) that reviewed data from 1993
cases of SCFE from six continents, it was shown that SCFE occurred at a mean age
of 13.5 years for boys and 12 years for girls with boys more frequently affected than
girls (58.8% vs. 41.2%). In unilateral involvement, the left hip was affected more
often than the right (60% vs. 40%). The cause of this predilection for boys and for
the left hip is incompletely understood. However, it does appear that this trend is
decreasing. In a previous study by Hägglund et al. (13), the authors reported a male
to female ratio of 2:1 and a predilection for left hip involvement of 2:1. The trend
toward equalization between the sexes may be due in part to the increasing partici-
pation of girls in sports (14).
The incidence of SCFE also varies by season (1, 15, 16), race (1, 12) and geo-
graphic location (17) of the involved children. In North America, the incidence of
SCFE is higher during the summer months in colder regions but does not vary with
the time of year in warmer areas, such as the American South. According to Loder
(12), the relative racial frequency is highest in Polynesian children and lowest in
Indo-Mediterranean children. Lehman et al. (1) reported that SCFE frequencies
were almost four times higher in black children and 2.5 times higher in Hispanic
children than in white children. In a recent study by Benson et al. (18), the authors
reported that the overall incidence of SCFE in New Mexico has increased to 4.33
per 100,000 during the 12 year period between 1995 and 2006. The authors state
that better access to pediatric orthopedic care and the dramatic rise in childhood
obesity (> 95 percentile for body mass index, BMI) rates, which have more than
tripled since 1970 to include 16% of children aged 9–16 years, are key contributing
factors (18, 19).
The relationship with childhood obesity as a risk factor for SCFE has been
explored in the literature. Loder (12) reported that more than 60% of children with
SCFE are within the upper tenth percentile for weight. Murray et al. (19) reviewed
1,169 cases of SCFE from the national database of the Scottish National Health
Service from 1981 to 2000. They found a three-fold increase in the incidence of
13 Slipped Capital Femoral Epiphysis 205
SCFE during this period (from 3.78 per 100,000 in 1981 to 9.66 per 100,000 in
2000). In addition, they found a statistically significant decrease in age of onset
between 1985 and 2005. In boys, the mean age of onset fell from 13.4 to 12.6 years
and in girls it fell from 12.2 to 11.6 years. Concomitantly, the overweight rate (BMI
greater than 85th percentile) in children 13–15 years old doubled between 1981 and
2005 (19). In a retrospective study by Bhatia et al. (20), the authors found that the
average BMI of patients in their study was within the overweight and obese range.
Furthermore, the patients who sustained a contralateral SCFE had a significantly
greater mean BMI than the patients who did not progress (30.1 vs. 25.1) (20). These
studies suggest that there is an increasing trend in the frequency of SCFE that
mirrors the increase in childhood obesity.
Typically, the rate of bilateral involvement is reported to be between 20 and 25%
(14), but has been reported to be as high as 81% (21). Sixty percent of patients
present with simultaneous slips while 40% present sequentially (12). In over 80%
of the cases with unilateral involvement that progress to bilateral involvement, the
second hip becomes involved within 18 months of the initial presentation (12). Thus
in patients with unilateral SCFE, it is important to examine the contralateral side for
signs of the condition. Patients with endocrinopathies and younger patients are at a
higher risk of developing bilateral involvement (14).
Etiology
The exact cause of SCFE remains unclear, but a combination of mechanical and
endocrine factors plays an important role in creating the failure of the physis
(22, 23) (see Fig. 13.1).
Mechanical Factors
Mechanical factors include obesity, relative femoral retroversion, increased acetab-

ular coverage, and physeal obliquity (23). Obesity increases the shear stress across
the physis (22) and is also associated with relative femoral retroversion. In the obese
child, anteversion is decreased to 0.4° compared to 10.6° in the normal weight
patient (23, 24). In addition, in patients with unilateral SCFE, there is a decrease in
the femoral anteversion of the affected side compared to the unaffected, contralat-
eral side (1.0° vs. 6.3°) (25). The authors demonstrated that relative retroversion
was a consistent finding regardless of the child’s weight (25). Pritchett et al. (26)
showed that a ten degree decrease of femoral anteversion increased the shear stress
acting on the physis by 20%.
Kitadai et al. (27) found that in patients with SCFE the center edge angle of
Wiberg was significantly higher than controls. They proposed that a deeper acetab-
ulum produces more shearing stress across the physis which, in addition to other
mechanical and chemical factors, may lead to SCFE (27).
SCFE ETIOLOGY
MECHANICAL FACTORS ENDOCRINE FACTORS

RELATIVE HYPOTHYROIDISM
FEMORAL GROWTH HORMONE DEFIENCY
INCREASED
RETROVERSION
PHYSEAL
OTHER ENDOCRINE ABNORMALITIES
OBESITY
SHEER (DIAGNOSED AND UNDIAGNOSED )
DEEP ACETABULUM
STRESS
INCREASED
PHYSEAL
OBLIQUITY
WEAKENING OF
THE PHYSIS
SCFE IN NORMAL
PHYSES
SCFE IN WEAKENED
PHYSIS
Fig. 13.1 Proposed etiology of SCFE
Finally, the vertical inclination of the physis of a patient with SCFE is on average
11° more on the affected side compared to control subjects and 4.8° more than the
contralateral unaffected side (22, 23, 28). Together, the increased forces acting on
the physis may be enough to cause the femoral head to slip in the normal child
without any underlying endocrine factors.
Endocrine Factors
Since SCFE occurs most frequently during the rapid growth spurt of puberty, an
association with hormonal factors has been considered (14, 23). Also, the fact that
there is an increased prevalence of SCFE in patients with endocrinopathies suggests
an association between SCFE and endocrine dysfunction (22). In a retrospective
review (29) of patients with SCFE and a known endocrine disorder, it was shown
that hypothyroidism was the most common abnormality (40%) followed by growth
hormone deficiency (25%) and other abnormalities in 35% of patients, including
disorders such as panhypopituitarism, craniopharyngioma, hypogonadism, hyper-
parathyroidism, growth hormone excess, multiple endocrine neoplasia, and Turner’s
syndrome. Only the patients with hypothyroidism and growth hormone deficiency
presented at a younger age than the typical age for SCFE (i.e., 10–16 years old). All
other patients were seen within or older than the typical age. (See Fig. 13.1).
Pathology
The plane of cleavage in SCFE occurs through the hypertrophic zone of the physis
in an undulating fashion (30–32). It is in the hypertrophic zone and the adjacent
proliferative zone that most of the pathological changes occur. There is a widening
of these zones and a decrease in the number and size of chondrocytes relative to the
amount of matrix. As compared to the normal columnar organization of chondro-
cytes in the normal physis, the chondrocytes in a slipped physis are enlarged, irreg-
ular, and appear disorganized and misaligned. Furthermore, the chondrocytes exhibit
increased degeneration and death. The cell matrix contains less collagen than in
controls and it is oriented haphazardly with the majority of the matrix being non
banded fibrils. This creates a weakness of the supporting collagenous network
(33, 34). Whether this is a primary change or secondary to the slip is unknown (23).
However, with fixation across the physis, there is a tendency toward remodelling
and normalization of physeal cytoarchitecture (35, 36).
Classification
Chronology of Symptoms
Historically, the classification of SCFE was based on chronology of symptoms

(22, 23). This classification includes a preslip, acute slip, chronic slip, and an acute-
on-chronic slip. In the preslip stage, the patient manifests weakness and a limp in
the involved extremity and pain in the groin, thigh, or knee. On physical examina-
tion, the patient may only show decreased internal rotation. The radiographs may
reveal disuse osteopenia around the hip and irregularity of the proximal femoral
physis (23).
The acute slip accounts for about 10–15% of the patients and the duration of the
symptoms by definition is less than 3 weeks (23). It is similar to an acute Salter–
Harris type 1 fracture, SH1. However, a distinction should be made between the
two. In the acute slip, there is typically a prodrome of groin, thigh, or knee pain.
This is followed by an acute episode of severe thigh pain incurred from a trivial,
low-energy trauma like a twisting motion when coming out of a car. In contrast, the
SH1 fracture of the proximal femur involves high energy, major trauma in a normal
patient without any prodromal symptoms and can be associated with hip dislocation
(14). Both, however, are true orthopedic emergencies. On the physical exam of a
patient with an acute slip, pain severely limits range of motion of the hip, the leg is
held in external rotation, and it appears shortened. Radiographs usually show no
remodeling of the physis as in the chronic slip (14, 23).
Chronic slips are the most common type accounting for 85% of the cases of
SCFE (12). By definition, the symptoms are more than 3 weeks in duration (23).
Children usually complain of pain in the hip, groin, or knee and they may walk with
Fig. 13.2 Obligate external rotation. As the patient flexes the hip, the hip externally rotates
a limp. Decreased hip internal rotation and pain at the end of the movement are key
clinical findings. Hip abduction and flexion may also be limited depending on the
severity of the slip (14, 23). With flexion at the hip, it progressively externally
rotates. This is called obligate external rotation and is essentially pathognomonic of
SCFE (37) (see Fig. 13.2).
Finally, the acute-on-chronic SCFE shares signs and symptoms of both the acute
and chronic type. The patient typically reports longstanding prodromal symptoms
(pain in the groin, thigh, or knee) of more than 3 weeks durations and an acute
exacerbation of the pain. On the X-ray, signs of physeal remodeling are visible with
the epiphysis having slipped beyond the remodeling (14).
Loder Classification
Although the chronologic classification is easy to use, it has two major limitations.
First, it does not offer any indication of physeal stability and second, it relies on
patient and family recall which may be inaccurate (32, 38, 39). Therefore, currently,
the preferred classification is based on physeal stability as determined by the
patient’s ability to ambulate with or without crutches. As devised by Loder et al.
(38) in 1993, a stable SCFE is characterized by a patient being able to walk with or
without crutches. In an unstable SCFE, which accounts for only 5% of all SCFEs
(39), the patient cannot ambulate even with the aid of crutches and regardless of
duration of symptoms. Classification based on physeal stability rather than duration
of symptoms is prognostic of outcome. Loder et al. (38) showed that nearly half of
the patients (47%) in the unstable group developed osteonecrosis while no child in
the stable group went on to osteonecrosis.
Clinical Presentation
The classic patient with SCFE is an obese, hypogonadal boy between the ages of
11–16. For girls the presenting age is younger, between 10 and 14 years of age, and
they are typically pre-menarchal (14, 32). Outside of these age ranges, there should
be a careful consideration of an atypical SCFE and underlying endocrinopathy
(30). More specifically, Loder et al. (40) devised a simple test to help guide the
clinician as to which patients with an SCFE will need further laboratory workup.
The age–weight test (40) groups the patient’s age in three categories: less than
10 years, 10–16 years, and greater than 16. The patient’s weight is categorized
into two groups: less than the 50th percentile and greater than or equal to the 50th
percentile. The test is considered positive if: the patient’s weight is less than the
50th percentile regardless of the age or if the weight is greater than or equal to
the 50th percentile and the patient is older than 16 years of age. Conversely, a nega-
tive test occurs when the child is equal to or over the 50th percentile in weight and
is younger than 16 years of age. The value of this test lies in its high negative pre-
dictive value (93%). This means that a child with a negative age–weight test is
highly unlikely to have an atypical SCFE and further laboratory workup is unnec-
essary. However, when the age–weight test is positive, Loder et al. (40) recom-
mend that blood be drawn to test for renal osteodystrophy, hypothyroidism, or
other types of endocrinopathy. Furthermore, the patient’s height has been shown to
have a better negative predictive value (41, 42). Therefore, a negative height test
(the patient is below the 10th percentile for age) is a strong indicator that the slip
is not associated with an underlying endocrinopathy and no workup is required.
However, when the height of the patient is not known, Loder et al. (42) suggest
using the age–weight test to guide further investigations.
The main clinical findings in SCFE are pain, limp, and decreased range of
motion, ROM, of the hip and they vary according to the stability of the slip (37).
Stable SCFE
The patient with a stable SCFE typically complains of a dull or vague pain that may
be aggravated by physical activity. The pain may be either constant or intermittent
with an onset of pain usually weeks to months in duration (14). The pain is usually
localized to the groin or upper thigh region, but may be referred to the distal thigh
or knee in between 15% and 50% of patients (43, 44). This may lead to a delay in
the diagnosis, inconclusive imaging studies (e.g., magnetic resonance of the knee),
unnecessary treatments (e.g., knee arthroscopy) and, presumably, to slip progres-
sion (43, 45). Therefore, it is imperative that any peripubertal adolescent with hip,
thigh, or knee pain that presents to a health professional be closely evaluated for
SCFE before any knee pathology is considered.
On physical examination, the ROM of the hip is abnormal. External rotation is
increased. Internal rotation is decreased and can be painful at the end of the
range. Because of weakness in the abductors, hip abduction is limited. Hip flexion
is usually limited to less than 90°. As mentioned, in the sitting position as the
patient flexes the hip, it will progressively fall in external rotation. This obligate
external rotation with hip flexion is considered pathognomonic of SCFE (37) (see
Fig. 13.2).
In a patient with a stable SCFE, observational gait analysis is a helpful tool as the
patient walks into the examination room. Hip abductor weakness will manifest as a
Trendelenburg gait. Because the neck is in external rotation relative to the capital
epiphysis, the child will walk with an externally rotated gait on the affected side. If
both hips are affected, the child will have a “waddling” gait pattern and the foot
progression angle of both feet will be positive (37).
Care should be taken not to incite further trauma to the physis by having the
patient perform strenuous maneuvers (14). For example, the physician should refrain
from performing manual muscle testing of the hip, asking the patient to jump, hop,
or squat as is done for a knee exam. Theoretically, these examination techniques can
result in a stable SCFE becoming unstable (14). Finally, because of the likelihood
of bilateral disease, signs and symptoms of SCFE in the contralateral hip should
be elucidated.
Unstable SCFE
Patients presenting with an inability to bear weight with or without support are
classified as having an unstable SCFE (38). The child typically presents after a
trivial fall with an acute fracture-like pain in the hip region. The patient lies with
their affected limb in external rotation and the limb may appear to be shortened.
Any attempts at moving the limb will cause intense pain and an unhappy patient and
family. Therefore, a routine hip exam should be limited (14).
Imaging Studies
Plain AP and frog-leg lateral radiographs of the pelvis are often all that is needed for
diagnosing SCFE (see Fig. 13.3). In the chronic SCFE, signs of physeal remodeling
can be seen. These include widening and irregularity of the physis (14), resorption
of the anterosuperior metaphysic (23), and new bone formation in the posteroinfe-
rior metaphysic (23). In the acute SCFE, little or no remodeling is seen.
In the normal hip, a line (Klein’s line) (46) drawn tangential to the superior
femoral neck should intersect a portion of the physis in the AP view of the hip. In
SCFE, Klein’s line does not intersect the femoral epiphysis (see Fig. 13.3). Steel
(47) described a metaphyseal blanch sign of the femur on the AP X-ray. This is a
result of the posteriorly displaced epiphysis that overlaps the medial metaphysis
adjacent to the physis. It is seen on the AP radiograph as a crescent-shaped area of
increased density. Often, however, these changes in the AP view can be missed.
Therefore, a lateral view of the hip should be routinely obtained to visualize the
usual posterior and inferior displacement of the epiphysis in relation to the neck. If
the patient is in too much pain, as is seen in an unstable slip, the physician should
not obtain a frog-leg lateral view as the movement can theoretically cause further
physeal displacement (39). For these patients, a shoot-through lateral view of the
hip and a CT scan are more appropriate studies.
The severity of the slip can be quantified by measuring the slip angle as described
by Southwick (48). In the frog–leg lateral, the epiphysis-shaft angle is measured and
compared to the normal contralateral side. If the difference between the two sides is
less than 30°, the slip is mild. If the difference is between 30° and 60°, the slip is
moderate, and if it is more than 60°, then the slip is considered severe (14, 23).
When the contralateral side is also slipped, then the slip is compared to a normal
value of 10° posterior on the lateral radiograph (48) (see Fig. 13.4a). Alternatively,
the severity of the slip can be measured as a percentage of the displacement of the
epiphysis on the metaphysic (23): mild slip < 33%, moderate slip 33–50%, severe
slip > 50% (see Fig. 13.4b).
Advanced imaging is usually unnecessary to make the initial diagnosis of SCFE.
Computed tomography and three-dimensional CT can be useful in the follow-up of
patients with SCFE. They can demonstrate pin penetration into the joint and can
help assess residual deformity and planning of corrective osteotomies (14, 32).
Technitium-99 bone scans can help assess head perfusion for signs of osteonecrosis
and chondrolysis (14). Magnetic resonance imaging (MRI) scan can be useful in
determining the presence and extent of osteonecrosis (37). MRI has also been
employed for the initial diagnosis of a “pre-slip” SCFE (49). In these cases, MRI
shows periphyseal bone marrow edema and/or physeal distortion before the devel-
opment of radiographically detectable SCFE (49).
Fig. 13.3 AP and frog–leg lateral (from two different patients) showing characteristic radiologic
findings in chronic SCFE: (a) Klein’s line, (b) physeal remodeling and irregularity, (c) anterosuperior
metaphyseal resorption, (d) posteroinferior metaphyseal new bone formation
Fig. 13.4 (a) Southwick’s slip angle. Moderate slip of 58° on the left hip (68–10°). Mild slip of
17° on the right hip (27–10°). See text for details. (b) Frog–leg lateral of a left SCFE depicting the
slip severity as a percentage of the displacement of the epiphysis on the metaphysis. (Mild slip
< 33%, moderate slip 33–50%, severe slip > 50%)
Treatment
The initial treatment of confirmed SCFE should consist of immediate hospitalization

and bedrest for the child until definitive orthopedic care is achieved. Patients with a
stable SCFE who are allowed to go home even on crutches or in a wheelchair may
risk transforming a stable SCFE into an unstable one and further increase the amount
of slip (32, 50). At our institution, these children are generally done “on-call” the
next day, typically within 24 h of admission. Those with unstable SCFEs, who are
frequently in severe pain, must be admitted and urgently treated.
Stable SCFE
Currently, our treatment of choice (14, 32, 37, 51) for a stable SCFE is percutaneous
in situ single screw fixation. The technique employed at our institution has been
detailed elsewhere (52) (see Fig. 13.5). The surgeon positions the patient on a radi-
olucent table. The entire limb is draped free to the umbilicus. In cases where a
prophylactic contralateral pinning is indicated, the opposite side is also prepared
and draped sterilely. The C-arm and monitor are positioned on the opposite side of
the table away from the hip that is being pinned. No intentional manipulative reduc-
tion is performed. Next, a guidewire is placed over the patient and an AP view of the
hip. The hip is rotated to obtain a view with the longest appearing femoral neck. In
this position, the neck will be horizontal to the table. The guidewire should project
over the center of the epiphysis and perpendicular to the physis in this position.
A line is then drawn along the projected pathway of the screw on the patient’s skin.
Next, an AP image is taken to verify the starting point in the sagittal plane by flexing
the hip to 90° and abducting it to 45°. The neck-to-head angle is estimated on the
image intensifier by drawing a line at the center of the head and perpendicular to
the physis with a line drawn along the longitudinal axis of the neck. The angle thus
created represents the angle the guidewire needs to adopt with respect to the sagittal
plane. The entry point on the skin and along the line drawn on the patient’s skin is
determined as follows: The center of the head represents the 90° mark and the
lateral femur represents the 0° mark. If, for example, the neck- to- head angle previ-
ously measured is 30°, then the skin entry point should be one third of the way
toward the femoral head starting from the lateral femur and along the line drawn on
the skin. A 1–2 cm incision is made along this line. A hemostat is spread down to
the bone in the same direction. The guidewire is then drilled into the neck for
Fig. 13.5 Surgical technique for in-situ fixation of a stable SCFE. (a) Preparation and draping for
a bilateral in-situ fixation on a radiolucent table. (b) Marking of pin trajectory in the AP plane.
(c) Determination of the neck-to-head angle. (d) Guide pin is advanced and the trajectory is verified
in the AP and lateral planes (Note that the cannulated depth gauge is utilized to protect the guide
pin against bending). (e) Fully threaded cannulated 7.3 mm stainless steel screw is advanced after
reaming was done. (f) Final AP X-ray. (g) Final frog-leg lateral
Fig 13.5 (continued)
Fig 13.5 (continued)
1–2 cm. Images are obtained in the AP and lateral planes and adjustments are made
as needed. Care must be taken to avoid bending of the guidewire when obtaining the
lateral image. The guidewire is then advanced into the head and to about 3 mm from
the joint surface. The screw length is measured and a cannulated drill bit is drilled
over the guidewire with care taken to avoid bending or inadvertently advancing
the guidewire. This is confirmed under fluoroscopy. The screw is then inserted
over the guidewire.
Extra-articular placement of the screw is verified using an “approach–withdraw”
technique (23, 53). This technique involves rotating the hip from internal to external
rotation under live fluoroscopic imaging and helps the surgeon avoid screw penetra-
tion into the joint. As the hip is rotated, the screw will appear to be getting closer to
the subchondral bone (approach) and then appears to get further away from it
(withdrawal). Where the change occurs from approach to withdrawal is the true
position of the screw tip in the femoral head (23, 53).
Our preference is to use a single, fully threaded self-tapping 7.3 mm stainless
steel screw. For optimal positioning, the entry point of the screw into bone should
be in the anterolateral aspect of the neck; in the center of the head in both the AP
and lateral planes, and perpendicular to the physis (23). Four to five threads should
cross the physis for maximal stability (54), but without penetrating the joint. If
using a partially threaded screw, Upasani et al. (55) have advocated that an equal
distribution of the threads across the physis procures the greatest strength and stiff-
ness in an animal model rather than the absolute number of threads across the
physis. However, a follow-up study comparing an equally distributed, partially
threaded screw to a fully threaded screw with three threads across the physis did not
find any difference in stability between the two types of screws (56). We believe that
in the event of hardware removal, a fully threaded screw will be easier to remove
than a partially threaded one.
As mentioned, in the great majority of cases, the epiphysis is relatively fixed in
the acetabulum and it is the neck that displaces anteriorly. With increasing severity
of slip, an increasing portion of the head lies posterior relative to the neck. This
implies that the entry point will be more proximal on the neck and approaching a
near vertical direction. Similarly in cases with a valgus slip, the epiphysis is dis-
placed laterally such that the entry point of the screw may need to be medial and
anterior on the hip. This may place the neurovascular bundle at risk. In such cases,
a limited open incision to protect the neurovascular bundle can be utilized (5, 8).
Postoperative Care
In the postoperative period, the patient is instructed to partial weight bear with
crutches in a four-point gait pattern for 3–4 weeks and a gradual return to full activity
is permitted within 4–6 months. The patient is monitored with periodic X-rays at
3- to 6-month intervals to evaluate for physeal closure. In cases of a unilateral
percutaneous fixation, the patient is routinely examined for contralateral SCFE.
Any suspicions of patients with endocrinopathy are referred to the appropriate

specialists. Finally, the obese patient is counselled on a weight reduction program
and resources are provided.
Results
Stable SCFE
The results of single screw fixation for stable SCFE have been shown to be good to
excellent. Aronson et al. (57) prospectively reported on 58 SCFEs in 44 children
with a minimal follow-up of 2 years. The cases were categorized as acute (5 of
58 cases) or chronic (50 of 58 cases) and the degree of slip was noted as mild,
moderate, or severe. The results were good to excellent in 36 of 38 mild slips, 10 of
11 moderate slips, and 8 of 9 severe slips. There was one case of osteonecrosis in an
acute slip, no chondrolysis, two patients lost fixation, and one patient sustained a
subtrochanteric fracture. Goodman et al. (58) reported on 21 hips with either acute
or acute-on-chronic SCFE with an average follow-up of 29 months. They concluded
that 17 of 21 hips had excellent results, three had good results, and one patient had a
poor result. There were no failures. Similarly, de Sanctis et al. (59) compared
fixation with one screw, two screws, or Kirschner wires and spica cast in 51 patients
with 55 acute or acute-on-chronic slips. The authors found that the best results and
lowest complications rate were in the single screw fixation group. In a more recent
article, Castaneda et al. (60) reviewed 105 patients with 129 severe slips with a
mean follow-up 66 months. They found that 80 of 105 patients had good to excel-
lent results as evidenced by an Iowa Hip Score of greater than 75.
Unstable SCFE
The treatment of unstable SCFE is more controversial (61). Driving this debate is
the high risk of osteonecrosis associated with unstable SCFE (38). The timing of
surgery, the ideal surgical technique, and capsular decompression are topics of
heated debate among pediatric orthopedic surgeons. A recent survey of pediatric
orthopaedic society of North America (POSNA) members (62) reported that 57% of
surgeons felt that unstable SCFE should be managed urgently but not emergently
(31%). Fifty-seven percent of members favored a single screw fixation while
40% favored two screws. However, when volume of procedures was factored in,
surgeons who treated more than ten stable SCFEs per year were significantly less
likely to treat unstable SCFE with only one screw. Capsular decompression was
performed by 35% of the respondents and 26% of these respondents did the decom-
pression as part of an open procedure while 73% performed the decompression as a
closed aspiration and drainage technique. Finally, only 3% favored open reduction,
12% favored in-situ pinning after formal manipulation, and 84% favored in-situ
pinning with no intentional manipulation.
Timing of Surgery
There is a lack of data supporting an association between the timing of fixation

and osteonecrosis in SCFE (63, 64). However, most authors recommend urgent
fixation within 24 h (23, 39, 63, 65, 66). We are in agreement with early fixation
within 24 h.
Closed Reduction
The use of an intentional manipulative reduction technique remains an unresolved

issue in the literature. Proponents of manipulation cite the decreased rates of
osteonecrosis in patients who underwent early reduction within 24 h (66). Peterson
et al. (66) reported that the rate of AVN was 7% in the 42 hips that were reduced
within 24 h, while 20% of the 49 hips reduced after 24 h went on to develop osteone-
crosis. However, other authors reported that the incidence of osteonecrosis increased
in patients who underwent partial or complete reduction (67). Still other authors
(63) have found no association between the amount of reduction and the risk for
osteonecrosis. At our institution, we accept a gentle positional reduction when the
patient is placed on a fracture table. This is in agreement with the opinion of other
authors (39, 51).
Screw Fixation
Currently, although the treatment of choice for unstable SCFE remains contro-
versial, there seems to be some consensus that urgent in situ fixation with one or
two screws is necessary (23, 39, 51, 62). The use of one versus two screws
should be decided by weighing the benefit-to-risk ratio: the added stability and
strength afforded by a second screw should be weighed against the increased
risk of damaging the blood supply to the femoral head and intra-articular screw
penetration with the second screw (39, 68, 69). When a second screw is deemed
necessary, care should be taken to place the second screw inferior to the first
( 39). This avoids the superior retinacular vessels which are the main blood
supply to the femoral head and enter the epiphysis in the anterosuperior quad-
rant (70, 71).
Open Reduction
Recently, some authors have described favorable outcomes with open reduction and
internal fixation of unstable SCFE (72, 73). Ziebarth et al. (72) reported the results
of a modified Dunn procedure of capital realignment by using a surgical hip disloca-
tion technique as described by Ganz (74). The authors from two highly specialized
centers where the technique was developed pooled 40 cases of stable and unstable
SCFE treated with this procedure. No case of osteonecrosis was reported and the
short-term clinical outcomes were near normal (72).
Parsch et al. (73) described an open technique that employs a limited exposure
via a Watson–Jones approach, gentle finger reduction of the slip, evacuation of
the intra-articular hematoma, and Kirschner wire fixation. Of the 64 cases with
unstable slips, three children developed osteonecrosis, all within 6 months. Although
nine of the cases did not strictly qualify as being unstable as per the Loder criteria
(38), this open approach may prove to be less invasive than surgical dislocation with
equally favorable outcomes.
With no control group in either of these two studies, it is difficult to draw any
firm conclusions about the superiority of the open techniques over the in situ fixation
group. Randomized trials that compare the open reduction techniques to traditional
in situ fixation are needed. Nonetheless, the ability to acutely correct the deformity
that is thought to lead to impingement and to the development of arthritis is attrac-
tive and merits further study (51).
Capsular Decompression
The argument for hematoma evacuation in unstable SCFE has gained ground since
it was reported in 2002 by Gordon et al. (75). The decompression can be done via
an open capsulotomy or percutaneously (75, 76). It is believed that decompression
of the hematoma can relieve the intracapsular tamponade and improve the venous
outflow and circulation to the femoral head (76). Herrera-Soto et al. (77) showed
increased intracapsular pressures in 13 unstable SCFEs. The authors strongly rec-
ommended decompressive capsulotomy of the hip joint. Chen et al. (76) reported on
30 unstable slips. In all four cases that developed osteonecrosis, no capsulotomy
was performed. Although the numbers from these studies are small, hematoma
evacuation is likely an important factor in reducing the risk of osteonecrosis for
unstable SCFEs. We currently decompress the hip joint in unstable SCFE. This is
performed by fluoroscopic-guided percutaneous capsulotomy of the hip joint.
Postoperative Care
Regardless of the treatment modalities employed for the unstable slip, we keep the
patient nonweight bearing for 6–8 weeks. Weight bearing is progressively increased
as the patient shows signs of callus formation and return to full weight bearing is
allowed by about 4 months. Close follow-up is necessary to evaluate for any oste-
neocrosis that may develop. This usually occurs within the first year (61).
Prophylactic Pinning of the Unaffected Contralateral Hip
Pinning the contralateral unaffected hip is controversial. Mooney et al. (62) reported
that only 12.2% of the respondents of a POSNA members survey routinely recom-
mended prophylactic pinning. Some authors favor prophylactic pinning of the
unaffected side in all children with SCFE (78), whereas others (79) recommend that
patients be followed every 3–4 months with serial radiographs until the growth plate
starts to close and that pinning should be performed only when the hip develops a
definite SCFE.
Some authors have suggested that, rather than prophylactically pin all contral-
ateral hips of children with a unilateral SCFE, only those at high risk for a con-
tralateral slip should be considered for prophylactic pinning. Those children at
high risk for the development of a contralateral slip after a unilateral SCFE has
been diagnosed include those who present at younger ages (80) and those with
endocrinopathies (29). Loder et al. (80) showed that in patients with a unilateral
SCFE that subsequently developed a contralateral SCFE, the mean age was 12 years
old compared to 13 years in the group that did not develop a contralateral slip. These
authors recommended that any girl who is 12 years old or younger and any boy who
is 14 or younger be monitored frequently for evidence of contralateral hip involve-
ment (80). Similarly, Riad et al. (81) found that 100% of boys younger than 12 and
girls younger than 10 went on to develop a contralateral slip. The authors strongly
recommended prophylactic pinning in these patients (81). In one series of children
with endocrinopathies, 61% of patients had bilateral SCFEs; of these, two-thirds
were diagnosed simultaneously while one-third occurred sequentially (29). Based
on these findings, the authors strongly recommended prophylactic pinning of the
contralateral unaffected hip in children with endocrinopathies who present with a
unilateral SCFE (29).
Decision-analysis methods have also been developed to help guide treatment
(82, 83). This approach can result in different treatment strategies (82, 83) depend-
ing on the methodology used and may be difficult to apply in the day-to-day clinical
setting (84). Radiological parameters have also been evaluated as predictors for a
contralateral SCFE. In one study, the probability for a contralateral SCFE was esti-
mated to be 4% in the presence of a closed triradiate cartilage (85). However in
another study (86), an open triradiate was not significantly associated with develop-
ment of a contralateral slip. More recently, the posterior sloping angle, PSA, has
shown to be a promising predictor of contralateral involvement (87–89). This angle
is measured on the unaffected hip (see Fig. 13.6). It is subtended by a line parallel
to the growth plate and the perpendicular to the longitudinal axis of the neck with
the patient’s unaffected limb in 90° of flexion and maximal abduction (87). Barrios
Fig. 13.6 Posterior sloping angle. Angle subtended by a line parallel to the physis and the perpen-
dicular to the long axis of the femoral neck
et al. (87) showed that a PSA greater than 12° is highly predictive of development
of contralateral slip and recommended prophylactic pinning for patients with this
finding. Zenios et al. (88) proposed a value of 14.5° as the cut-off value at which
prophylactic pinning is recommended, while Park et al. (89) concluded that prophy-
lactic pinning should only be considered for girls with a PSA of 13°.
Because no definitive patient factors have been consistently identified, ultimately
the decision to pin the unaffected side should be shared between the patient, the
guardians, and the surgeon. Important clinical factors to consider include the age
and skeletal maturity of the patient, the presence of underlying endocrinopathies, and
radiographic parameters such as the status of the triradiate cartilage and the posterior
sloping angle of the unaffected hip. Other factors to consider include the patient’s
and guardians’ personal preferences as well as the anticipated compliance with post-
operative care and follow-up. The risk of prophylactic surgery must outweigh the
risk of a delayed presentation of a stable SCFE or the risk of an unstable one.
Complications
Osteonecrosis
Osteonecrosis of the femoral head is a complication that is devastating for the

adolescent patient (see Fig. 13.7). The incidence of osteonecrosis is related to physeal
stability and is reported to occur almost exclusively in unstable SCFE (38, 67, 90).
Fig. 13.7 Development of osteonecrosis after in-situ fixation of an unstable left SCFE
Up to 47% of unstable SCFE develop signs of osteonecrosis (38) while the inci-
dence in stable SCFE is virtually zero (38, 67, 90). A recent meta-analysis showed
that patients with unstable SCFE had a 9.4-fold greater risk of developing osteone-
crosis than patients with stable SCFE (91).
The underlying cause of osteonecrosis is a disruption of the blood supply to the
femoral head followed by necrosis of all or part of the epiphysis (92). The necrotic
bone is subsequently resorbed resulting in a variable amount of epiphyseal collapse
(14, 37). The first radiographic signs of osteonecrosis are typically apparent within
12–18 months after presentation (22, 93) and appear as a sclerotic density in the
epiphysis (32). The usual evolution is a progressive decline of hip function (22, 51).
Patients will complain of groin pain that may be referred to the knee. The hip is
irritable with movement and the range of motion is decreased especially in internal
rotation (22). Invariably, patients with osteonecrosis will develop osteoarthritis (93).
Once osteonecrosis has been documented, there exists no satisfactory treatment.
Patients diagnosed in the precollapse phase may benefit from protected weight
bearing, ROM exercises, and antiinflammatory medication (37). A redirectional
proximal femoral osteotomy may be attempted in the hope of placing a preserved
area of the head into a weight-bearing position (94). In severe cases, however, the
only viable options may be to undergo total hip arthroplasty or hip arthrodesis
(14, 22, 23, 32, 37, 93, 94).
Chondrolysis
Another major complication specific to SCFE is chondrolysis. Since its initial descrip-
tion by Waldestrom (95), chondrolysis of the hip after SCFE remains poorly under-
stood (96). It will usually occur within the first year following the SCFE (97). It is
defined as a painful irritable hip with decreased ROM and radiographic joint space
narrowing (37, 51, 98, 99) with a joint space width of less than 50% compared to the
unaffected side, or less than 3 mm if there is bilateral disease (23, 51, 99, 100).
Historically, the overall incidence of chondrolysis following SCFE was estimated
to be about 7% (92). However, in series with modern fixation techniques with a
single screw in the center–center position, the incidence of chondrolysis is less than
1% (57, 60).
It is thought that unrecognized pin penetration may lead to chondrolysis, but
there have also been cases of chondrolysis reported before any treatment and after
treatment with a hip spica cast without pinning (23, 100). In these cases, an autoim-
mune process is thought to play a role (22, 23, 92).
Clinically, the patient with chondrolysis after SCFE treatment will exhibit a
decrease in motion, especially internal rotation, and hip, groin, or knee pain (23).
The limb will be held in abduction and may lead to an abduction contracture (37).
Alternatively, a flexion contracture may develop. It is suggested that nonoperative
treatment be attempted first in chondrolysis as it has been shown that a progressive
recovery of the joint space and improved function can occur as late as 3 years
following the onset of the disease (100–102). Nonoperative measures include
improving hip motion, protected weight bearing, and anti-inflammatory medica-
tion. If the hip remains stiff and painful, then surgical strategies such as arthrodesis
or arthroplasty may be required.
Osteoarthritis
Premature osteoarthritis is a potential complication of SCFE, especially those with

residual proximal femoral deformity from moderate and severe slips. Carney et al.
(103) found that 36% of hips with mild SCFE had no radiographic evidence of
degenerative joint disease while all cases of moderate and severe SCFE showed
signs of arthritis in a study with a mean follow-up of 41 years.
The degenerative changes in patients with SCFE are different than those seen
with primary osteoarthritis (104). The changes in SCFE are characterized by: a loss
of head–neck offset, femoral acetabular impingement, and a loss of superior periph-
eral articular cartilage. In contrast, in primary osteoarthritis, the head–neck offset is
preserved, there is no impingement seen and the superior peripheral articular carti-
lage is intact (104).
It is believed that the loss of offset can lead to femoral acetabular cam-type
impingement. This can produce labral and chondral damage that, over time, may
cause anterior groin pain with activity and osteoarthritis (105). These findings have
been corroborated in patients undergoing surgical dislocation for chronic symp-
toms after in situ pinning of stable SCFE (106). Impingement, in some cases, may
also result from a prominent screw head. This “screw-head impingement” has
recently been described by Goodwin et al. (107) in a biomechanical, cadaveric
SCFE model.
Because of the good-to-excellent results with in situ fixation (57, 58), even in
severe slips (60), we believe that there is no place for corrective osteotomies in the
initial management of SCFE. In mild cases of impingement, hip arthroscopy may be
sufficient to alleviate pain and improve hip range of motion. In more severe cases
without advanced osteoarthritis, the treatments range from surgical dislocation and
osteoplasty to a variety of femoral osteotomies (14, 23, 51), all are designed to
preserve the hip joint. Total hip replacement is the best salvage treatment for those
patients with end-stage hip disease.
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Index
A AP radiographs
AARF. See Atlantoaxial rotatory fixation SCFE, 209
(AARF) tibial fractures, 166
ABI. See Ankle brachial index (ABI) ARDS. See Acute respiratory distress
Above-knee amputation, 22 syndrome (ARDS)
Abzug, J.M., 3, 17, 91, 113, 189 Aronson, D.D., 221
Acquired limb deficiency, 17, 25 Arthritis. See Septic arthritis, of hip
Acute respiratory distress syndrome (ARDS), Atlantoaxial rotatory fixation (AARF)
11, 12 acute, 54
Advance trauma life support (ATLS), 20, chronic, 53–54
115–116 Atlanto-dental-interval (ADI), 48
Age-weight test, for SCFE, 211 Atlanto-occipital dislocation (AOD)
Agitation, 31, 38 motor vehicle accident (MVA), 52
American Academy of Orthopedic Surgeons neurological injury, 51
(AAOS), 13, 69 ATLS. See Advance trauma life support
American Academy of Pediatrics (AAP), 69 (ATLS)
Amputation Avascular necrosis (AVN), 136
above-knee, 22
below-knee, 23
bony overgrowth, 24 B
knee disarticulation, 23 Bae, D.S., 107
vs. limb salvage, 20 Baker, G.L., 124
Analgesia, 31, 38 Baker, H.L. Jr., 51
Anderson, J.T., 162 Barrios, C., 224
Ankle brachial index (ABI), 146 Bashyal, R.K., 105
Anterioposterior (AP) radiograph, of pelvis, 131 Basicervical fractures, 131
Anterior humeral line, for supracondylar Basion-dens interval. See Harris’s basion-dens
humerus fractures, 95–96 distance
Antibiotic choices, for septic arthritis, 185 Baumann angle, for supracondylar humerus
Antibiotics administration, for open tibia fractures, 95
fractures, 163 Below-knee amputation, 23
Antibiotic therapy, necrotizing fasciitis, Benson, L.S., 114
195, 196 Beris, A.E., 124
Anxiety, 31, 38 Bhatia, N.N., 207
AOD. See Atlanto-occipital dislocation (AOD) Birney, T.J., 44, 50, 56
AO/Magerl classification, thoracolumbar Bony chance fractures, 80
fractures, 73 Brown, R.L., 50, 57, 59
DOI 10.1007/978-1-4419-8005-2, © Springer Science+Business Media New York 2012
234 Index
Brunn, M.A., 50 Chondrolysis, 227

Bruwer, A.J., 51 Cirak, B., 57
Burst fractures, 71, 75–76 Closed reduction, supracondylar humerus
fractures, 100–104
Coban™, 103
C Compartment syndrome, 161, 162
Cahill, P.J., 67 complications, 37
Capsular decompression, SCFE, 223 diagnosis, 32, 34
Capsulotomy, 135 distal pulse preservation, 32
Cartilaginous/synchondrosis, 55–56 fasciotomies, 36–37
Castaneda, P., 221 features, 30
Cellulitis, 191 femur fractures, 38
Cervical spine injuries (CSI) high risk circumstances, 37
bimodal age distribution, 44 limb fasciotomies, 36–37
diagnostics missing, in supracondylar humerus
anteroposterior (AP) view, fractures, 108–110
evaluation, 46 pathophysiology of, 30
atlanto-dental-interval, 48 patient assessment, 30–31
CT imaging, 48–49 physical examination, 31–32
Harris’s basion-dens distance, 46 pressure measurement
MRI, 49–50 diagnosis, 32
NEXUS, 45–46 indications for, 33
Powers ratio, 48 tibia fractures, 37–38
soft tissue and osseous components, 46 treatment
Swischuk line, 48 anterolateral longitudinal incision, 36
Wackenheim clivus line, 46 medial incision, 34
features, 51 superficial and deep compartments,
influencing factors, 44 33, 34
injury patterns volar Henry approach, 33–34
atlantoaxial rotatory fixation (AARF), wound management, 36
53–55 Compression fractures, 71, 74
atlanto-occipital dislocation (AOD), Computed tomography (CT), 194
50–53 Condylar gap, 48
cartilaginous/synchondrosis, 55–56 Coxa vara, 136–137
Os odontoideum, 54–55 Cozen fractures, 153–156
osseous injury, 50 CSI. See Cervical spine injuries (CSI)
SCIWORA, 57 CT. See Computed tomography (CT)
spinal cord injury, 56 Cubitus varus, supracondylar humerus
lateral radiograph, 46, 47 fractures, 105–106
motor vehicle accidents, 44
pediatric cervical instrumentation,
59, 60, 62 D
pseudo-subluxation of C2 on C3, 48, 49 Damage control orthopaedics, 11–12
treatment Debridement, open tibia fractures
emergent decompression and irrigation and, 164–165
stabilization, 58 Definitive fracture stabilization, 12–13
halo placement, 58 Delbet classification, of pediatric femoral neck
instrumented fusion, 59 fractures, 131
rigid cervical collars, 59 Denis classification system, 72, 73
Cervical spine trauma, 50 Denis, F., 72, 73
Chance, G.Q., 76 de Sanctis, N., 221
Cheng, G.L., 124 Distal humerus, olecranon fossa and coronoid
Chen, R.C., 223 fossa, 92
Childhood obesity, SCFE, 206, 207 du Plessis, S., 51, 52
Index 235
E Herman, M.J., 3, 17
Emergency department evaluation, open tibia Herrera-Soto, J.A., 223
fractures, 161–163 Hertel, R., 25
Endocrine factors, for SCFE, 208 Hip dislocation children
External fixation, of open tibia fractures, classification, 138
165–166 complications, 140–141
emergency room considerations, 137–138
imaging, 138
F treatment
Farm machinery injury, 18, 22 care post-reduction, 140
Fasciotomy, 36–37 closed reduction, 138–140
Femoral head fixation, after pediatric hip open reduction, 140
fracture, 130 Hip fracture children
Femoral neck fracture children, 134 capsulotomy, 135
Femur fractures, 38 classification, 131
Fielding, J.W., 53, 54 complications, 135–137
Flexible intramedullary nails (FIMN), 167–168 avascular necrosis, 136
Flexion distraction injuries, 76, 79–80 coxa vara, 136–137
Floating elbow, compartment syndrome, 37 nonunion, 137
Fracture dislocation injuries, 81–82 premature physeal closure, 137
Fracture management emergency room considerations, 130–131
damage control, 11–12 femoral head fixation, 131
definitive fracture stabilization, 12–13 imaging, 131
Frank, J.B., 49 pathologies of, 130
postoperative care, 135
surgical treatment, 131–135
G spica cast immobilization, 132, 134
Gait analysis, stable SCFE, 212 type I, 132–133
Gandhi, S.D., 17, 129 type II and type III, 133
Ganz, R., 223 type IV fractures, 134–135
Garcia, V.F., 50 Hip sepsis. See Septic arthritis, of hip
Gardner, M.J., 13 Holdsworth, F., 72
Garg, H., 67 Horn, B.D., 205
Genu valgum, 156 Hosalkar, H.S., 52, 55
Georgiadis, G.M., 25 Howorth, B., 205
Glasgow Coma Score (GCS), 6 Humeral capitellar angle. See Baumann angle,
Glavas, P.P., 205 for supracondylar humerus fractures
Goodman, W.W., 221 Humerus fractures. See Supracondylar
Gordon, J.E., 223 humerus fractures
Gregg, S., 51, 52 Hwang, S.W., 43
Gresh, M., 177 Hyperbaric oxygen (HBO), 199
Guilford, G.A., 54
Gumley, G., 76
Gustilo, R.B., 162 I
Imaging
in hip dislocation, 138
H in hip fracture, 131
Hägglund, G., 206 Impingement, osteoarthritis, 228
Halo vest, Cervical spine injuries, 54, 59 Intertrochanteric fractures, 131, 134
Hanley, E.N. Jr., 44, 50, 56
Harris’s basion-dens distance, 46
Hawkins, R.J., 53, 54 J
HBO. See Hyperbaric oxygen (HBO) Jaffe, D.M., 46
Hennrikus, W., 143 Jea, A., 43
236 Index
Joint sepsis, in pediatric population, 177, 180, demographics, 18

186. See also Septic arthritis, of hip emergency room considerations
Jones, J., 190 ATLS protocols, 20
evaluation and preparation for surgery,
20–22
K farm machinery, 22
Kelly, R.P., 72 limb salvage or amputation, 20
Kirschner wire placement, for supracondylar MESS, 20
humerus fractures, 104, 106, 107 orthopedic surgeon, 21
Kitadai, H.K., 207 presentation, 18–19
Kleinert, J.M., 124 lawn mower injuries, 18, 22
Knee disarticulation, 23 orthopedic surgeons decision, 21
Kocher, M.S., 183 reconstruction, 22
Korbeek, J.B., 51, 52 surgical treatment
Kozin, S.H., 91, 113 amputation, 22–23
Kulkarni, M.V., 72 limb salvage, 23–24
open tibia fracture, 24
Mangled Extremity Severity Score
L (MESS), 20
Laboratory Risk Indicator for Necrotizing Mangled limb, 20
Fasciitis (LRINEC) score, 193 Mann, D.C., 143
Launay, F., 57 McCarthy, J.J., 129
Lawn mower injuries, 18, 22 Medial incision, compartment syndrome, 34
Lee, S.L., 46 MESS. See Mangled Extremity Severity
Leet, A.I., 57 Score (MESS)
Lehman, C.L., 206 Metaphyseal fractures, 153–156
Leitch, K.K., 97, 99 Methicillin resistant Staphylococcus aureus
Letts, M., 12 (MRSA) infections, 163, 185
Limb loss, psychosocial consequences, 25 Minor fractures, 82
Limb salvage Modified injury severity scale (MISS), 6
vs. amputation, 20 Mooney, J.F., 224
failure, 25–26 Motor vehicle accidents (MVA), 68
implications, in reconstruction, 22 MRI. See Magnetic resonance imaging (MRI)
surgical treatment, 23–24 Mubarak, S.J., 150
Little, K.J., 189 Mutilating hand injuries, 114
Li, V., 54
Loder, R.T., 12, 206, 211, 223, 224
N
National Emergency X-Radiography
M Utilization Study (NEXUS), 45–46
Magnetic resonance imaging (MRI) Necrotizing fasciitis
hip fractures, 131 amputation and death, 198
indications for, 72 cellulitis, 193
for necrotizing fasciitis, 195 laboratory and radiographic findings
septic hip, 181 biopsy, high-powered
Mangled extremity photomicrographs of, 196
causes, 18 CT, 194
complications and outcomes LRINEC score, 193
bony overgrowth after amputation, 24 MRI, 195
limb salvage failure, 25–26 ultrasound, 194
phantom pain, 25 microbiology and classification, 190–191
psychosocial consequences of limb pathogenesis, 191
loss, 25 presentation and initial treatment, 191–192
definition, 17 soft-tissue infections, 189, 190
Index 237
treatment P
antibiotic therapy, 195, 196 Pahys, J., 67
hyperbaric oxygen (HBO) therapy, 199 Pain, compartment syndrome, 30, 31, 38
operative treatment pearls, 199 Pang, D., 54, 82, 83
reconstruction, 19, 198 Park, S., 225
surgical debridement, 195, 197, 198 Parsch, K., 223
zones of infection, 197 Patzakis, M.J., 163
Nonfatal injury, 4 Pediatric advanced life support (PALS), 116
Nonunion, in hip fracture children, 137 Pediatric amputation,122
Noonan, K.J., 129 Pediatric elbow fractures, 91
Pediatric femoral neck fracture, 133
Pediatric hand trauma, 114
O Pediatric hip fracture. See Hip fracture
Obligate external rotation, SCFE, 210 children
O’Driscoll, S.W., 105 Pediatric replantation, 124
Ogden, J.A., 147 Pediatric spine, 68, 72
O’Hara, L.J., 98 Percutaneous pinning
Open reduction and internal fixation (ORIF) of supracondylar humerus fractures,
of proximal tibial physeal fracture, 152 100–104
supracondylar humerus fractures, 105 of unstable tibial shaft fractures, 168–170
of tibial tubercle fracture, 146–149 Periosteum, 4
Open tibia fractures, in children and Phantom pain, 25
adolescents Physeal closure, premature, 137
antibiotics, administration of, 163 Physeal fractures, 149–153
associated injuries, 160 Pizzutillo, P.D., 177
child vs. adult, 160 Polytrauma
classifications child vs. adult
Gustillo and Anderson system, 162–163 anatomic considerations, 4–5
Tscherne classification system, 162 physiologic considerations, 5–6
complications, 171 Waddell’s triad, 5
emergency department evaluation, 161–162 injury prevention, 13–14
post-operative care, 171 mandated child safety, 13, 14
surgical management nonfatal injury, 4
coverage of large wounds, 170–171 outcomes, 13
external fixation, 165, 166 patient evaluation and management
FIMN, 167–168 backboards utilization, 8
fracture stabilization, 165 damage control orthopedics, 11–12
irrigation and debridement, 164–165 definitive fracture
percutaneous pinning, 168–170 stabilization, 12–13
plate and screw constructs, 168–170 fracture management, 11–13
timing of debridement, 164 hemodynaic instability, 9, 10
wound management, 170–171 imaging, 10–11
VAC, 165 primary survey and resuscitation, 7–9
Orenstein, J.B., 59 secondary survey, 9–10
ORIF. See Open reduction and internal fixation trauma team, 11
(ORIF) trauma scoring systems, 6–7
Orthopaedic surgeon, 9 two-hit hypothesis, 11, 12
Orthopaedic Trauma Association (OTA), 164 unintentional injury, 3
Os odontoideum, 54–55 Popliteal artery injury, 145, 152
Osseous injury, 50 Potoka, D.A., 13
Osteoarthritis, 227–228 Powers ratio, 48
Osteonecrosis, 225–227 Prophylactic pinning, of unaffected
OTA. See Orthopaedic Trauma Association contralateral hip, 224–225
(OTA) Proximal femur, vascular anatomy, 179
238 Index
Proximal tibial fractures, with vascular Seat belt fractures, 76, 79–80
compromise Septic arthritis, of hip
anatomical considerations clinical presentation
bony, 144 differential diagnosis, 181–183
soft tissue, 144–145 findings diagnostic of, 182
vascular, 145 flexion, abduction and external rotation,
metaphyseal, Cozen fractures 180
classification, 153 history, 178–179
complications, 155 imaging, 180–181
displaced fracture, 153 Kocher criteria, 183
mechanism of injury, 153 physical exam, 179–180
pulseless limb, management algorithm, toxic synovitis, 183
154–155 complications, 186
treatment, 154 epidemiology, 178
physeal fractures etiology, 178
complications/associated injuries, limp, 179
151–153 treatment
mechanism of injury, 153 anterior Smith-Peterson approach, 183
Salter-Harris classification, 149–150 causative organisms, by age, 185
treatment, 150–151 empiric antibiotic choices, by age, 185
signs and symptoms, 145–146 MRSA, 185
tibial tubercle fractures vascular anatomy, proximal femur, 179
complications/ associated injuries, Skaggs, D.L., 95
148–149 Slipped capital femoral epiphysis (SCFE)
displaced, from pull of extensor classification
mechanism, 147 chronology of symptoms, 209–210
mechanism of injury, 146–147 loder classfication, 211
Ogden classification, 147–148 obligate external rotation, 210
treatment, 148 clinical presentation, 211–212
Pylawka, T., 143 age-weight test, 211
stable SCFE, 212
unstable SCFE, 212–213
R complications
Radiograph chondrolysis, 227
floating elbow, 93, 94 osteoarthritis, 227–228
hip fracture children, 130 osteonecrosis, 225–227
supracondylar fracture, 97 epidemiology
Rajmaira, S., 143 bilateral involvement, 207
Riad, J., 224 childhood obesity, 206, 207
Rosenblatt, J., 159 left hip, 206
season, race and geographic
location, 206
S etiology
Sacral-sparing, thoracolumbar spine endocrine factors, 208
injuries, 71 mechanical factors, 207–208
Safier, S.D., 159 imaging studies
Salter-Harris type 1 fracture (SH1), 209 AP and frog leg lateral
Samdani, A.F., 43 radiographs, 213
Sankar, W.N., 55, 105 computed tomography, 213
SCFE. See Slipped capital femoral epiphysis Klein’s line, 213
(SCFE) MRI, 213
SCIWORA. See Spinal cord injury without Southwick’s slip angle, 215
radiographic abnormality in literature, 205
(SCIWORA) pathology, 209
Index 239
results physical examination

capsular decompression, 223 neurologic exam, 93, 94
closed reduction, 222 palpation, 93
open reduction, 223 vascular status of, 94
posterior sloping angle, 225 treatment, by fracture type
post-operative care, 223–224 pink, pulseless hand treatment, 100
prophylactic pinning, of unaffected type I fractures, 97–98
contralateral hip, 224–225 type II fractures, 98–99
screw fixation, 222 type III fractures, 99
stable SCFE, 221 type IV fractures, 99–100
timing of surgery, 222 Swischuk, L.E., 48
unstable SCFE, 221–222 Swischuk line, 48
treatment
approach-withdraw technique, extra-
articular placement of screw, 220 T
percutaneous in situ single screw Thoracolumbar injury classification and
fixation, 216 severity score (TLICS), 73
post-operative care, 220–221 Thoracolumbar spine injuries
stable SCFE, 221 classification of
Southwick, W.O., 213 burst fractures, 75–76
Spinal cord injury (SCI), 56 compression fractures, 74
bulbocavernosus reflex, 70–71 Denis classification system, 72, 73
neuromuscular scoliosis, 84 flexion distraction, 76, 79–80
patients management, 83–85 fracture dislocation, 81–82
Spinal cord injury without radiographic minor fractures, 82
abnormality (SCIWORA), 57, 82–83 SCIWORA, 82–83
Sponseller, P.D., 57 TLICS grading scale, 73
Stable slipped capital femoral epiphysis vertebral apophyseal injuries, 82
(Stable SCFE), 212 clinical presentation and examination
Steel, H.H., 213 bulbocavernosus reflex, 70–71
Supracondylar humerus fractures, 37 high energy injuries, 69
classification importance of, 69
type IIA and type IIB fracture, neck examination, 70
radiograph of, 97 neurological examination, 70, 71
type III fracture, fluoroscopic sacral-sparing, 71
image of, 98 spinous processes, 70
complications epidemiology, 68–69
bicortical fixation, failure of, 105, 106 imaging of
cubitus varus, 105–106 CT scans, 71
Kirschner wires, 106, 107 magnetic resonance imaging (MRI),
missing compartment syndrome, 108–110 71–72
differential diagnosis, 95 mechanism of, 68–69
extension-type fractures, 92 motor vehicle accidents (MVA), 68
floating elbow, 93, 94 spinal cord injury (SCI), 83–85
imaging Tibia fractures, 37–38
anterior humeral line, 95–96 Tibial tubercle fractures
Baumann angle, 95 complications/ associated injuries,
lateral radiograph, of pediatric elbow, 96 148–149
olecranon fossa and coronoid fossa, distal displaced, from pull of extensor
humerus, 92 mechanism, 147
operative techniques mechanism of injury, 146–147
closed reduction and percutaneous Ogden classification, 147–148
pinning, 100–104 treatment, 148
open reduction and internal fixation, 105 Toxic synovitis vs. septic hip, 183
240 Index
Transcervical fractures, 131 skin closure, 120

Transphyseal fractures, 131 venous repair, 120
Trauma scoring systems upper limb replantation, 118
Glasgow Coma Scale, 6
MISS, 6
Triss-Scan, 7 V
Trauma team Vaccaro, A.R., 73
Traumatic amputation, 17, 18 Vacuum-assisted wound closure (VAC),
Trobisch, P.D., 43 36, 165
Vascular anatomy, of proximal femur, 179
Vascular injury, 146
U Vertebral apophyseal injuries, 82
Ultrasound Viccellio, P., 45
necrotizing fasciitis, 194 Volar Henry approach
septic hip, 180 forearm compartments, 33, 34
Unintentional injury, 3 superficial and deep compartments, 33, 34
Unstable SCFE. See Unstable slipped capital
femoral epiphysis (Unstable SCFE)
Unstable slipped capital femoral epiphysis W
(Unstable SCFE), 212–213 Wackenheim clivus line, 46
Upper extremity replantation Waddell, J.P., 2
anatomic differences, 114 Waddell’s triad, 5
indications, 118 Waldenstrom, H., 227
mechanism and etiology Watson-Jones, R., 72
avulsion-type amputation, 114, 115 Whitesides, T.E. Jr, 72
exercycle injuries, 114, 116 Wholey, M.H., 51
guillotine amputations, 115 Wilberger, J.E. Jr, 82
monitoring, 123 Wilkins, K.E., 97
outcomes, 124 Willis, B., 29
patient evaluation Wilson, B.L., 190
amputation part, preservation, 117 Wong, C.H., 197
ATLS, 115–116 Wound management, in open tibia fractures,
PALS, 116 170–171
replantation, 117
tourniquet application, 117
replantation failure, 123 Y
technique Yam, A.K., 197
cleansing and irrigation of parts, 119 Yian, E.H., 7
in digital replantation, 119
fasciotomies, 120
microvascular surgery, 120 Z
post-operative care, 122 Zenios, M., 225
in proximal amputation, 120 Ziebarth, K., 223
skeletal fixation, 120 Zlotolow, D.A., 91, 113

Pediatric Orthopedic Surgical Emergencies

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Pediatric Orthopedic Surgical Emergencies

Pediatric Orthopedic Surgical

ISBN 978-1-4419-8004-5 ISBN 978-1-4419-8005-2 (eBook)

Library of Congress Control Number: 2012936120

© Springer Science+Business Media New York 2012

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

This book is dedicated to Gabrielle, Ann,

It is my great pleasure to introduce the first edition of Pediatric Orthopedic Surgical

Cincinnati, OH, USA James J. McCarthy

Part I Trauma Overview

1 Polytrauma in the Pediatric Patient ..................................................... 3

4 Cervical Spine Injuries in Children ..................................................... 43

Part III Upper Extremity

6 Supracondylar Humerus Fractures ..................................................... 89

Part IV Lower Extremity

8 Pediatric Hip Fractures and Dislocations ............................................ 127

9 Pediatric Proximal Tibial Fractures

11 Septic Hip................................................................................................ 175

13 Slipped Capital Femoral Epiphysis ...................................................... 203

Index ................................................................................................................ 233

Joshua M. Abzug Department of Orthopedics, University of Maryland School of

James J. McCarthy Department of Orthopedic Surgery, Cincinnati Children’s

Joshua M. Abzug and Martin J. Herman

Keywords Polytrauma • Pediatric polytrauma • Multiply injured child • Pediatric

J.M. Abzug, MD (*)

Differences Between the Child and Adult

The skeleton of the child responds differently to traumatic injury compared to an

The physiologic response secondary to the stress of trauma is different in children

their blood pressure decreases due to more effective physiologic compensatory

Trauma Scoring Systems

Patient Evaluation and Management

Primary Survey and Resuscitation

emergency evaluation and resuscitation the child’s body is exposed, frequently

for compartment syndrome. Prior to imaging, extremities with gross deformity

Standard trauma imaging typically includes anteroposterior (AP) radiographs of the

Table 1.1 Components of a Pediatric Trauma Team

Management of the polytraumatized child is best accomplished through a multi-

The concept of “damage control orthopedics,” introduced by adult orthopedic

compartment syndrome, however, is sometimes necessary. At our institutions, a

Definitive Fracture Stabilization

Preventing unintentional injury in children is the responsibility of the global com-

Despite improved preventive measures, pediatric trauma continues to occur on a

1. Ramenofsky ML. Pediatric abdominal trauma. Pediatr Ann. 1987;16:318–26.

Sapan D. Gandhi, Joshua M. Abzug, and Martin J. Herman

Abstract A mangled extremity is an extremity that has sustained severe traumatic

Keywords Mangled extremity • Mangled limb • Traumatic amputation • Acquired

A mangled extremity is defined as severe traumatic injury to at least 3 out of 4 systems

S.D. Gandhi (*)

of these injuries present as an amputated or near-amputated limb. Although

Demographical information for children sustaining severe trauma to the extremities is

Emergency Room Considerations

Evaluation and Preparation for Surgery

The mechanism of injury should also be considered when deciding whether to

Limb salvage requires a multidisciplinary surgical approach, including contribu-

Complications and Outcomes

Bony Overgrowth After Amputation

Bony overgrowth after amputation can be a significant problem, especially due to

Psychosocial Consequences of Limb Loss

Limb Salvage Failure

Abstract Early recognition and prompt treatment of compartment syndrome in

Keywords Compartment syndrome • Pain • Anxiety • Agitation • Increasing

Compartment syndrome is a constellation of symptoms caused by elevated pressure

Arterial or arteriolar lesion Hemorrhage