22 Common Fractures
Pediatric orthopedic trauma comprises approximately 10% to 15% of all childhood injuries, and almost half of all children will sustain a childhood fracture. Because of the dynamic nature of skeletal growth and immaturity of the bony architecture, fractures in children differ from those in adults in regard to patterns of occurrence, diagnosis, and treatment. Injuries in children more frequently result in fractures than ligamentous injuries or sprains because the increased porosity and pliability of bones in children makes them more susceptible to fracture. Moreover, children are susceptible to growth plate injuries, which may be difficult to diagnose but can result in long-term growth abnormalities or growth arrest. Therefore, careful attention is required in the evaluation and management of pediatric patients presenting with orthopedic injuries.
Each age group has typical mechanisms of injury and common fractures. When evaluating newborns and infants with injuries, one should maintain a high index of suspicion for nonaccidental trauma because this is a leading cause of fracture in this age group (see Chapter 12). Injuries in toddlers and school-aged children most often result from falls. During adolescence, injuries become similar to those of adults and are often sustained in sports or through high-energy mechanisms, such as motor vehicle collisions.
Fracture Description
After a fracture has been identified, to effectively communicate with orthopedic consultants and other health care providers, it is important to use fracture nomenclature so that appropriate decisions can be made regarding management and treatment. Consultants should always be made aware of the patient’s neurovascular status. Radiographic interpretation of the fracture should include the type of image; anatomic location (Figure 22-1); whether it is complete or incomplete, open or closed, and intra- or extraarticular; and the presence of physeal (growth plate) disruption, displacement, angulation, shortening, or comminution (Figure 22-2).
Fractures that extend across the width of a bone are complete fractures, and those that do not extend all the way across are incomplete fractures. Incomplete fractures are more common in children than adults and are described in more detail below. Complete fractures can be further characterized according to their orientation as transverse fractures (those running at right angles to the long axis of the affected bone), oblique fractures (those that cross the shaft at an angle), and spiral fractures (fractures in which the break is helical). Any fracture that divides the bone into more than two separate segments is said to be comminuted (see Figure 22-2).
Perhaps the most important feature of a fracture is the distinction between an open and closed fracture (see Figure 22-2). In open fractures, the overlying skin is disrupted, and the fracture communicates with the outside environment, thus leading to increased risk of infection. Open fractures are an orthopedic emergency and necessitate operative repair.
Common Fracture Types in Children
Physeal Fractures
Fractures involving the physis occur frequently in children and account for up to 20% of all pediatric fractures. Although several classification systems for the description of physeal fractures exist, the Salter-Harris classification system is the most widely used. This classification system, based on the radiographic appearance of the fracture, describes the degree of involvement of the physis, epiphysis, metaphysis, and joint and has both prognostic and therapeutic implications (Figure 22-3).
Salter-Harris Type I Fracture
A Salter-Harris type I fracture involves separation of the epiphysis and most of the physis from the metaphysis. Diagnosis can be difficult if displacement is minimal because radiographs often appear normal. Therefore, this type of fracture is diagnosed clinically when there is swelling and tenderness over a growth plate. Management consists of immobilization and orthopedic follow-up because healing usually occurs within 3 to 4 weeks, and complications are rare. These fractures rarely result in growth disturbance.
Salter-Harris Type II Fracture
Salter-Harris type II fractures are the most common type of pediatric physeal fractures. These fractures extend through the physis into the metaphysis. Similar to Salter-Harris type I fractures, these fractures rarely result in growth disturbance, and management consists of immobilization and orthopedic follow-up.
Salter-Harris Type III Fracture
Salter-Harris type III fractures extend through the physis and then propagate through the epiphysis into the intraarticular space. Growth disturbance may occur if anatomic position is not reestablished. Therefore, these fractures require emergent orthopedic consultation and may need surgical reduction.
Salter-Harris Type IV Fracture
Salter-Harris type IV fractures involve the metaphysis, physis, articular surface, and epiphysis. Similar to Salter-Harris type III fractures, these fractures may result in growth arrest and deformity if anatomic position is not reestablished, often through surgical repair. As such, emergency orthopedic consultation is required.
Salter-Harris Type V Fracture
Salter-Harris type V fractures result from a compression or crush injury with resultant disruption of the growth plate. Similar to Salter-Harris type I fractures, these fractures can be difficult to diagnose because radiographs may be normal, and the diagnosis is often made in hindsight. Because these fractures disrupt the germinal matrix, they can cause severe injury with growth arrest and can have a poor prognosis. When recognized, these fractures again merit emergent orthopedic consultation.
Greenstick Fractures
Greenstick fractures are the most common fracture pattern in children. They describe an incomplete fracture of cortex in which the fracture line does not extend completely through the width of the bone. Depending on the degree of angulation, reduction by an orthopedic surgeon may be necessary (Figure 22-4).
Torus Fractures
Torus, or buckle, fractures are common fractures in young children. They result from a compressive load resulting in metaphyseal compaction of trabecular bone and buckling of cortical bone. These fractures are often seen in the distal radius after a fall onto an outstretched hand. As the child matures, the stiffness of the metaphyseal region increases, and the incidence of torus fractures decreases. These fractures are stable and can be managed with simple immobilization for 3 to 4 weeks and orthopedic follow-up (see Figure 22-4).
Bowing Fractures
Bowing fractures represent a plastic deformity of the bone and are unique to children. These fractures occur when a longitudinal force exceeds the bone’s ability to recoil to its normal position and results in a bend in the bone without a fracture. These fractures most commonly involve the radius and ulna. Bowing fractures can sometimes be subtle, and comparison views of the contralateral arm may be necessary. If the deformity occurs in a child younger than 4 years or if the deformation is less than 20 degrees, the angulation usually corrects with growth. However, open reduction may be required for these fractures if they have bowing greater than 20 degrees and the patient is older than 6 years old (see Figure 22-4).
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