Pediatric emergency medicine trisk 3500 3500
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FIGURE 111.40 Common fractures of the knee in children: distal femoral physis (A ), tibial
spine (B ), tibial tubercle (C ), patella (D ), and proximal tibial physis (E ).
Distal Femoral Fractures
This injury is typically the result of very high shear and translational forces.
These fractures are usually associated with a knee effusion, local soft tissue
swelling, and physeal tenderness. On examination, tenderness and swelling may
be noted proximal to the joint line, usually on bilateral sides of the distal femoral
physeal site. With displaced fractures, there may be obvious deformity, and soft
crepitus with motion may be felt ( Fig. 111.41 ). If the fracture is anteriorly
displaced, the patella may be prominent with dimpling of the anterior skin ( Fig.
111.42 ). If the epiphysis is posteriorly displaced, the distal metaphyseal fragment
becomes prominent above the patella. These fractures can also cause damage to
the popliteal vessels or peroneal nerve by direct compression. Intra-articular
physeal fractures (Salter–Harris type III and IV) are transitional fractures that
occur when the physis is starting to close. These injuries may be missed by x-ray.
Advanced imaging (e.g., CT or MRI) should be obtained for evaluation if the
adolescent patient has a large knee effusion. Nondisplaced fractures should be
splinted in place with urgent orthopedic consultation for casting. Displaced
fractures should have immediate orthopedic consultation for reduction under
anesthesia. Unlike other epiphyseal fractures, even Salter-Harris type I and II
