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).

Figure 22-1 Basic science of bone.

Figure 22-2 Fracture patterns.

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).

When describing the relationships of the fragments to each other, it can be helpful to describe position and alignment. The position of the bone refers to the relationship to the normal anatomy of the bone; the fracture is displaced when there is a loss of apposition or when the bony fragments are overriding or rotated. Alignment refers to the bone fragment’s relationship to the longitudinal axis of the bone. Fractures that are not in good alignment are described as angulated. Often, the degree of displacement and angulation of the fracture are also described.

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).

Figure 22-3 Injury to growth plate (Salter-Harris classification).

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.

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).

Figure 22-4 Incomplete fracture in children.