Common Fractures in Children

Blaze D. Emerson

Bijan J. Ameri

Pediatric fractures are a very common reason for physician visits with 17.6% to 20% of pediatric injuries associated with fractures.¹,² Furthermore, it is estimated that 42% of boys and 27% of girls will sustain a fracture of some form before the age of 16 years.²
Fracture incidence increases linearly with age, peaking at approximately 12 years, then decreasing until 16 years of age. This is possibly related to a decline in female fractures with more advanced skeletal maturity.²
Most commonly, fractures are due to low-energy trauma and occur in the upper extremity, especially the distal radius.²,³
- The incidence of specific fractures, in descending order, is distal radius 23.3%, hand 20.1%, elbow area 12.0%, clavicle 6.4%, radius shaft 6.4%, tibia shaft 6.2%, foot 5.9%, distal tibia 4.4%, femur 2.3%, humerus 1.4%, and other 11.6%.²

BONE PHYSIOLOGY

Pediatric fractures in children are challenging, as they often involve regions of growing bone. The unique anatomy of the immature skeleton includes the epiphysis, metaphysis, and diaphysis (Figure 10.1).
The epiphysis is a secondary ossification center and is separated from the metaphysis by the cartilaginous physis.
The epiphysis and physis are primary growth centers, and damage may lead to growth derangements including angu-lar deformity, limb-length discrepancy, and/or epiphyseal distortion.²
Physeal injuries in children are common and may account for up to 30% of all pediatric fractures.²
The age of ossification of the epiphysis is variable, which makes fracture identification difficult. X-rays of the unaffected side may be needed for comparison.
The unique physiology of immature bone gives rise to several unique fracture patterns. As discussed previously, physeal fractures are common.
The Salter-Harris classification system stratifies injuries based on their likelihood of growth derangement, with higher numbers being severe (Figure 10.2).
Also, children have thicker periosteum with a greater osteo-genic potential than that of an adult’s.⁴ This unique periosteal profile within children’s bones leads to a greater propensity to bend rather than break when exposed to stress.
A torus fracture (buckle fracture) occurs when a longitudi-nal force causes the periosteum to fail in compression rather than breaking completely (Figure 10.3).
Greenstick fractures occur when the bone fails on the ten-sion side of the cortex as the result of a lateral force being applied to a long bone (Figure 10.4). Both torus and greenstick fractures are incomplete.

Figure 10.1 Development and growth of a long bone. A, The formation of primary and secondary ossification centers is shown. B, Growth in length occurs on both sides of the cartilaginous epiphyseal plates (double-headed arrows). The bone formed from the primary center in the diaphysis does not fuse with that formed from the secondary centers in the epiphyses until the bone reaches its adult size. When growth ceases, the depleted epiphyseal plate is replaced by a synostosis (bone-to-bone fusion), observed as an epiphyseal line in radiographs and sectioned bone. (Reprinted with permission from Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. 7th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2014.)

Figure 10.2 Salter-Harris classification of epiphyseal injuries. Type I injury is an epiphysiolysis of the involved growth plate without associated fracture. Type II has an additional metaphyseal fracture fragment; type I and II injuries have a good prognosis and are usually treated with closed reduction and cast-ing. Type III injury results in a fracture through the growth plate and epiphysis. Type IV fracture crosses the epiphysis, growth plate (physis), and metaphysis. Type III and IV injuries require careful open reduction and internal fixation if displaced. Type V injury involves a crush of the growth plate without a fracture and is usually detected late by asymmetric or premature closure of the growth plate. (Reprinted with permission from Fiser SM. The ABSITE Review. 4th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2013.)

Figure 10.3 Left wrist PA, oblique, and lateral radiographs. Torus fracture (arrows) or a nondisplaced fracture of the distal left radius. (Reprinted with permission from Smith WL. Radiology 101. 4th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2014.)

Figure 10.4 Greenstick fracture (arrows) of the forearm. Greenstick fractures are common in the forearm, as the bone bends before it fractures and the peri-osteal sleeve maintains apposition. (Reprinted with permission from Staheli LT. Fundamentals of Pediatric Orthopedics. 5th ed. Philadelphia, PA: Wolters Kluwer; 2015.)

HEALING AND REMODELING

Anatomic reduction in a pediatric patient is not as crucial as in an adult because of the bone remodeling potential of children. Remodeling in the diaphysis and metaphysis may realign previously maligned fragments; however, anatomic reduction should always be the goal owing to the unpredictability of the remodeling process.
- The potential for complete remodeling of the fracture is greater with younger age, fractures closer to the physis, and alignment of angulation in the normal plane of motion.²
Furthermore, children are better able to withstand prolonged immobilization and usually do not suffer from postimmobili-zation stiffness and decreased range of motion, which can be a debilitating problem in adults.
Children’s bones remodel and grow at an accelerated rate. As a result, pediatric fractures often exhibit an increased rate of longitudinal growth after a fracture. Therefore, it is some-time recommended that during realignment there exists some shortening or overlap of the fragments to account for this expected longitudinal growth.¹
In general, pediatric patients have an excellent prognosis after a fracture. It is recommended to consult an orthope-dic surgeon when the fractures are displaced, especially with Salter-Harris type classifications above III.¹
If the clinician decides to manage the fracture, it is suggested that X-ray views are obtained monthly for 3 to 6 months to ensure optimal healing response.¹

DISTAL RADIUS

Epidemiology

Distal radius fractures are the most common pediatric frac-ture with an incidence of 23.3% and are 3 times more common in boys than girls.²
- Fracture incidence is increased around the adolescent growth spurt phase and is usually secondary to a sporting event.

Mechanism

A direct fall on an outstretched hand is the usual mechanism of injury (Figure 10.5).

Presentation

Generally, patients present with dorsal displacement/angula-tion of the carpus relative to the forearm (Figures 10.6 and 10.7). However, patients may present with volar displacement when the mechanism is a fall on a flexed wrist (Figure 10.8).
Patients will complain of pain, swelling, and limited motion of the wrist and hand.
Deformity will depend on the degree of fracture displacement; however, a “dinner fork” deformity may be noted with dorsally displaced fractures (Figure 10.9).

Figure 10.5 Colles fracture. (Reprinted with permission from Anatomical Chart Company. Hand and Wrist Anatomical Chart. Lippincott Williams & Wilkins; 2000.)

Figure 10.6 X-ray of Colles fracture. (Reprinted with permission from Silverberg M. Colles’ and Smith’s fractures. In: Greenberg MI, ed. Greenberg’s Text-Atlas of Emergency Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:483.)

Figure 10.7 Posteroanterior (A) and lateral (B) radiographs of the distal forearm demonstrate the features of Colles fracture. On the posteroanterior projection, a decrease in the radial angle and an associated fracture of the distal ulna are evident. The lateral view reveals the dorsal angulation of the distal radius as well as a reversal of the palmar inclination. On both views, the radius is foreshortened secondary to bayonet-type displacement. The fracture line does not extend to the joint (Frykman type II). (Reprinted with permission from Greenspan A. Orthopedic Imaging. 6th ed. Philadelphia, PA: Wolters Kluwer Health; 2014.)

Figure 10.7—cont’d

Management

Standard anteroposterior (AP) and lateral X-ray views should be ordered if a fracture is suspected. Neurovascular examination includes the median, radial, and ulnar nerves.
The physician should also rule out compartment syndrome.
Always inspect the joints above and below the injury to detect associated injuries.
Nondisplaced and minimally displaced Salter-Harris types I and II fractures may be treated with closed reduction and cast immobilization.
- Of note, Salter-Harris type I fractures of the distal radius are easily missed. Presence of the pronator fat pad on lat-eral radiograph is an indication of an occult Salter-Harris type I fracture (Figure 10.10).⁵
Closed reduction and percutaneous pinning is indicated for neurovascular compromise and physeal fracture involve-ment. Open reduction is reserved for irreducible fractures, displaced Salter-Harris types III, IV, V, and open fractures.²

Figure 10.8 Smith fracture. A fracture of the distal radius with volar angula-tion such as this is called a Smith fracture. This is a much less common injury than the Colles fracture. (Reprinted with permission from Brant WE, Helms C. Fundamentals of Diagnostic Radiology. 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.)

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