Dr. Kelsey Lena is Emergency Medicine Resident and interested in pediatric emergency medicine and medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, and supervision of Dr. Danielle Sutton, a Pediatric Emergency Medicine specialist, and Dr. Virginia Casey, a Pediatric Orthopedic Surgeon, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
- Buckle Fracture
- Greenstick Fracture
- Displaced Radial and Ulnar Fractures
- Non-Displaced Radial and Ulnar Fractures
- Comminuted Radial Fractures
- Monteggia Fracture
This PowerPoint helps students to consider the concept of infinity.
Dr. Kelsey Lena’s CMC Pediatric Orthopedic X-Ray Mastery Project: September Cases
1. Pediatric Orthopedic Imaging Case Studies
Kelsey Lena, MD1, Danielle Sutton, MD1, Virginia Casey, MD2
Department of Emergency Medicine1
Atrium Health Musculoskeletal Institute & OrthoCarolina2
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs, MD - Faculty Editor
Pediatric Orthopedic Imaging Mastery Project
September 2021
2. Disclosures
▪ This ongoing pediatric orthopedic imaging interpretation series is proudly
sponsored by the Emergency Medicine Residency Program at Carolinas
Medical Center
▪ The goal is to promote widespread imaging interpretation mastery.
▪ There is no personal health information [PHI] within, and ages have been
changed to protect patient confidentiality.
4. The Physics of X-Rays
• How far an X-ray projects depends on the density of tissue that is to be
penetrated
• If there is no tissue, the color of the x-ray will be black
• The greater the density, the lighter the color
5. Reading Systematically
• Identify you are reviewing the correct patients imaging
(name, date of birth, date of imaging)
• Review both AP and lateral views, as this can help you
describe the fracture/deformity in both planes
• X-rays of two adjacent joints must be taken or a joint
injury could potentially be missed
• Identify which bone and what fractured part of the bone is
injured
Diaphysis
Metaphysis
Epiphysis
6. CASE #1:
A 7-year-old female
presents to the Emergency
Department after being
involved in an altercation
with her brother, causing
her to fall onto her left
outstretched hand. The
patient is now complaining
of left wrist pain.
Diagnosis?
CBD
SMV
SMA
duodenum
Gallbladder
Pancreas with dilated duct
Portal vein
CBD and PD
duodenum
7. CBD
SMV
SMA
duodenum
Gallbladder
Pancreas with dilated duct
Portal vein
CBD and PD
duodenum
Mildly Displaced Fracture Of The Distal Radial Diaphysis
CASE #1:
A 7-year-old female
presents to the Emergency
Department after being
involved in an altercation
with her brother, causing
her to fall onto her left
outstretched hand. The
patient is now complaining
of left wrist pain.
Diagnosis?
Buckle fracture of the
distal radius
9. Portal vein
CBD/PD
terminating
at duodenum
duodenum
Gallbladder
Hepatic
duct
Articular Alignment Is Still
Maintained
Distal Radial And
Ulnar Metaphyseal
Fracture
CASE #2:
An 8-year-old male presents
to the Emergency
Department after being
injured during a baseball
game, when he slid into
home base and his arm was
subsequently stepped on.
Diagnosis?
Buckle fracture of the
radius and ulna
10. Another Buckle Fracture. Note The
Disruption At The Radial Diaphysis With No
Significant Angulation Or Displacement
11. Lateral Radiograph Of A Buckle
Fracture. Note The Disruption To Both
The Radial And Ulnar Diaphysis.
12. CASE #3:
A 12-year-old female presents to
the Emergency Department with
her parents complaining of arm
pain after attempting to perform a
cart-wheel at home.
Diagnosis?
13. Midshaft Left Radius And
Ulnar Fracture With Minimal
Anterior Angulation
CASE #3:
A 12-year-old female presents to
the Emergency Department with
her parents complaining of arm
pain after attempting to perform a
cart-wheel at home.
Diagnosis?
Greenstick Fracture
14. CASE #4:
A 15-year-old male
presents to the
Emergency Department
tearful and supporting
his arm. There is
apparent closed
deformity of his left
forearm. The patient
states he fell during a
soccer game and
attempted to catch his
fall.
Diagnosis?
15. Transverse Fracture
Through The Radius
And Ulna
With Moderate
Anterior Angulation
And No
Displacement
CASE #4:
A 15-year-old male
presents to the
Emergency Department
tearful and supporting
his arm. There is
apparent closed
deformity of his left
forearm. The patient
states he fell during a
soccer game and
attempted to catch his
fall.
Diagnosis?
Mid-diaphysis radial
and ulnar fracture
16. Another Example Of A Radial Diaphysis
Fracture. However, This Fracture Is More Distal
And Markedly Displaced.
Also Note The Displaced And
Angulated Distal Ulnar Diaphysis
Fracture And Ulnar Styloid
Fracture
17. Displaced
Fracture Of The
Distal Ulna
Displaced
Transverse
Fracture Of
The distal
Radial
Diaphysis
Here is
another
example:
PA View PA View Lateral View
18. Note Displacement
Of The Distal
Fractured Fragment
Ulnar Styloid Fracture
Comminuted
Distal Radius
Fracture
19. Transverse Fracture Of The
Distal Right Radial
Metadiaphysis With Medial
Angulation. Note The Callus
Formation At The Site Of The
Fracture, Indicative Of Healing
At The Site.
Acute On Chronic
Fracture Of The Distal
Radius With Progressive
Healing.
20. Pediatric Forearm Fractures
• Annual incidence 1:100 children, 80% in children >5 years
• Accounts for approximately 30-50% of all pediatric fractures
• Occurs in males 2-3 times more often than females
• Most common mechanism is fall onto an outstretched arm
• Most common location of fracture:
-Distal 1/3 > Middle 1/3 > Proximal 1/3
21. Pediatric Forearm Fractures: Classification
Buckle
Fractures
• Also known as ”torus fractures”
• Considered an incomplete fracture when the bone “buckles”
without a break on the opposite side
• The fracture is unicortical and non-displaced
Greenstick
Fractures
• Bone bends/cracks instead of breaking into pieces
• Incomplete fracture with a typical plastic deformity along the
compression side
Colles’
Fractures
Distal radius fracture with the bone fragment displaced dorsally
Smith’s
Fractures
Distal radius fracture with the bone fragment displaced volarly
Both Bone Forearm Fractures
22. Pediatric Forearm Fractures: Clinical Presentation
Physical
Exam
Ranges from edema and ecchymosis at the site of injury to gross
deformity with limited range of motion
Neurologic
Assessment
Radial Nerve1
Inability to extend wrist, MCP joint, thumb IP joint
Median Nerve
Absent sensation over the dorsal index finger
Ulnar Nerve
Inability to spread fingers
Anterior Interosseous Nerve
Inability to perform the “A Ok” Sign
Vascular
Assessment
• Assess for warm, pink skin with capillary refill <2 seconds
• Ensure radial pulses are present with palpation or doppler signal
1A radial neuropraxia may also result from a radial artery injury.
23. Pediatric Forearm Fractures: Complications
Monteggia
Fracture
Proximal ulna fracture + radial head dislocations
Floating Elbow Definition: supracondylar + forearm or wrist fracture
Diagnosis: get X-rays of the joint above and below!
Management: immediate operative intervention
Compartment
Syndrome
A potential complication of tight casts
Monteggia Fracture
Floating Elbow
24. Pediatric Forearm Fractures: Management
Closed Reduction And Casting
• Recommend weekly re-evaluation and x-ray imaging the first 3 weeks
• Typically casting for 6-8 weeks until radiographic healing is seen
• Buckle fractures require short arm cast immobilization for 2-3 weeks
Indications For Closed Reduction And Percutaneous Pinning:
• Open fractures
• Irreducible or unstable fractures
• Failure of closed management
• Associated vascular injury
• Floating elbow
• Refracture
25. orthobullets.com
Important Considerations:
-Deformities in the plane of joint motion are acceptable
-Distal deformity is more acceptable than mid-shaft deformity
-Rotational deformities do not remodel properly and are becoming unacceptable
26. Casting
Good Casting
Aim for 10-15 degrees of angulation,
straight ulnar border, supracondylar
mold and interosseous mold.
Bad Casting
Lacks the supracondylar and
interosseous mold, leading to a “banana”
presentation with minimal angulation.
27. 8 weeks post-reduction and casting
Mid-diaphysis radial and ulna
fracture with angulation
30. No specific factor can predict
treatment failure, however…
• Approximately 80% of
patients that failed closed
reduction and casting as
assessed at 2nd week.
• Of those that failed closed
reduction and casting, an age >
10 years and initial proximal
fracture identified on
radiographic imaging were
predictors of failure.
31. Retrospective review of
children with both-bone
fractures who were treated with
either closed reduction and
casting vs. open reduction
internal fixation (ORIF) vs.
intramedullary nailing (IM):
• The study concludes that
closed reduction and casting of
forearm fractures remains
excellent and rarely results in
non-union or clinically significant
malunion.
• When comparing treatments,
there are significantly more
complications following
operative repair.
33. Resources
• Herman and Marshall. Forearm fractures in children and adolescents: a practical approach. Hand
Clinic. 2006 Feb;22(1): 55-67. doi: 10.1016/j.hcl.2005.10.003.
• Boyer, et al. Position of immobilization for pediatric forearm fractures. J Pediatric Orthop. March
2002;22(2):185-7.
• Bae. Pediatric distal radius and forearm fractures. J Hand Surg Am. 2008 Dec;33(10):1911-23.doi:
10.1016/j.jhsa.2008.10.013.
• Flynn, J.M., et al., Eleven years experience in the operative management of pediatric forearm
fractures. J Pediatr Orthop, 2010. 30(4): p. 313-9.
• Smith, et al. treatment of pediatric both bone forearm fractures. J Hand Surg A. Jun 2005;25(3):309-
13. doi: 10.1097/01.bpo.0000153943.45396.22.
• Zionts, L.E., C.G. Zalavras, and M.B. Gerhardt, Closed treatment of displaced diaphyseal both-bone
forearm fractures in older children and adolescents. J Pediatr Orthop, 2005. 25(4): p. 507-12.
• https://www.orthobullets.com/pediatrics/4014/distal-radius-fractures--pediatric
![Disclosures
▪ This ongoing pediatric orthopedic imaging interpretation series is proudly
sponsored by the Emergency Medicine Residency Program at Carolinas
Medical Center
▪ The goal is to promote widespread imaging interpretation mastery.
▪ There is no personal health information [PHI] within, and ages have been
changed to protect patient confidentiality.](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)