Pediatric fractures

Pediatric fractures often have distinct patterns due to the unique properties of growing bones. As the periosteum in growing bones is thicker and stronger than in adult bones, children are more prone to incomplete fractures, such as greenstick fractures or torus fractures. In addition, pediatric fractures heal faster than those in adults because the periosteum in children is metabolically active. Salter-Harris fractures involve the epiphyseal plate, also known as the growth plate or the physis of long bones, and only occur in children and adolescents, whose skeletal growth is not yet complete. These fractures are classified according to the extent of damage to the growth plate and joint involvement.

Overview

• Definition: fractures in which either there is no fracture line or the fracture line does not completely traverse the width of the bone (an intact periosteum and cortex are seen on imaging on at least one side)
• Mechanism of injury: : usually an indirect axial force, e.g., a fall on an outstretched hand or a fall from a height

In greenstick fractures, the bone bends and breaks on one side like a green (young) stick.

Approach to incomplete fractures ^[1][2][6][8]

• Evaluate for signs of fracture.
• Obtain x-rays.
  • PA and lateral views
  • Signs of wrist or elbow fractures: Add an oblique view.
• Consider additional imaging (e.g., CT, MRI) if x-ray is equivocal or another diagnosis is suspected.
• Evaluate for patterns suspicious for nonaccidental injury in children.
• Manage acute pain.
• Perform fracture-specific treatment (see “Buckle fracture,” “Greenstick fracture,” and “Bowing fracture”).
• Discuss activity modification and return precautions (e.g., signs of compartment syndrome) with the patient.

Buckle fracture (torus fracture)

Description

• Compressed side: buckling deformity of cortex due to impaction
• Tension side: intact cortex
• Characteristic location: metaphyseal-diaphyseal junction, especially the radius and/or ulna ^[4]

Radiographic findings ^[6][9]

• Compressed side: cortical bulging
• Tension side: intact periosteum
• May appear as a circumferential bulge
• No fracture lucency or disruption extending to the physis
• Minimal angulation

Follow-up radiography for buckle fractures is not recommended if there is no pain or tenderness. ^[6]

Treatment ^[2][3][6]

• Reduction is generally unnecessary.
• Apply a removable splint for 3–4 weeks. ^[6]
• The necessity of follow-up evaluation is uncertain; use clinical judgment and follow local protocols. ^[10][11]

Greenstick fracture

Description

• Compressed side: intact cortex
• Tension side: break and discontinuity of the cortex due to bending stress
• Characteristic location: diaphysis of long bones (e.g., radius, ulna, tibia, fibula)

Radiographic findings ^[1][6]

• Compressed side: intact periosteum, possible cortical bulging
• Tension side: cortical discontinuity
• Angulation is usually present.

Treatment ^[1][6]

• Perform immediate reduction; or consult orthopedics urgently if x-ray findings do not show an acceptable degree of angulation
• Acceptable degrees of angulation:
  • 0–5 years: lateral view ≤ 35°; AP view ≤ 10°
  • 6–10 years: lateral view ≤ 25°; AP view ≤ 10°
  • > 10 years: lateral view ≤ 20°; AP view 0°
• Apply a short-arm cast for 4–6 weeks.
• Arrange follow-up with an orthopedic surgeon. ^[12]

Bowing fracture

Description

• Bowing and/or bending deformity of the bone without discontinuity of the cortex or periosteum
• Characteristic location: diaphysis of the ulna or fibula

Radiographic findings ^[1][8]

• Bowing or bending (plastic deformation) of bone without cortical discontinuity
• Angulation is present.
• Late diagnosis (4–6 months after injury): may show cortical broadening on the concave side without a callus

Maintain a high index of suspicion for bowing fractures, as physical examination may be unremarkable and there are no visible cortical discontinuities. ^[8]

Treatment ^[8]

There are no widely accepted protocols for the treatment of bowing fractures. Follow local protocols and consult orthopedics if necessary.

• Children < 4 years of age
  • Bowing ≤ 20°: Apply forearm immobilization (cast or removable splint) and arrange follow-up with an orthopedic surgeon.
  • Bowing > 20°: Consult orthopedics for closed reduction under general anesthesia.
• Children ≥ 4 years of age: Consult orthopedics for consideration of closed reduction under general anesthesia in patients with bowing > 10°, deformity, and/or loss of function. ^[8]

Background ^[13]

• Definition: physeal or growth plate fracture
• Peak incidence: during growth spurts at the beginning of puberty (11–12 years of age for girls and 13–14 years of age for boys) ^[14]
• Most common sites: distal radius and distal humerus

Clinical features

• Joint pain at rest or with movement
• Joint or soft tissue swelling
• Hematoma
• Focal tenderness to palpation around the physis
• Decreased range of motion
• Inability to bear weight on the injured limb

Salter-Harris fracture classification ^[1][15]

• Type I
  • Transverse fracture through the physis
  • Separates the epiphysis from the metaphysis
• Type II
  • Most common
  • Transverse fracture through the physis and metaphysis
  • Often results in a metaphyseal fragment
• Type III
  • Transverse fracture through the physis that extends into the epiphysis
  • Extends to the joint; considered an intraarticular fracture
• Type IV
  • Fracture extending from the physis to the epiphysis and metaphysis
  • Intraarticular fracture; unstable
• Type V
  • Crush injury of the physis due to compression
  • Poor prognosis

SALTER: Straight across the joint (type I); Above the joint (type II); Lower (type III); Through Everything (type IV); Ruined or rammed (type V)

Diagnosis ^[16][17]

• Physical examination: may show signs of fracture
• X-ray: (AP and lateral views)
  • May show characteristic findings depending on fracture type (see “Salter-Harris fracture classification”)
  • Findings may be subtle or nonspecific (e.g., joint effusion, soft tissue swelling).
• MRI: may be useful for diagnostic confirmation and/or further evaluation of equivocal x-ray findings ^[18]

Perform a detailed physical examination and maintain a high level of suspicion for injury, as Salter-Harris fractures (especially types I and V) may not be obvious on x-ray. ^[17]

Treatment ^[1][17]

• Salter-Harris types I and II
  • Perform closed reduction if displaced and immobilize in a cast or splint; arrange orthopedic follow-up within one week.
  • In cases of severe displacement, consult orthopedics for possible surgical intervention. ^[19]
• Salter-Harris types III, IV, and V: Consult orthopedics urgently for surgical intervention (e.g., open reduction and internal fixation, followed by casting).

Complications ^[1][17]

• Disruption of growth and bone deformity (especially Salter-Harris types III–V)
  • Results in limb-length discrepancies and/or angular deformities ^[17]
  • Younger patients are more likely to experience growth arrest. ^[16]
• See also “General complications of fractures.”

Avulsion fractures in children often occur at apophyseal tendinous attachments as well as epiphyseal ones.

• Epidemiology: most common in adolescent athletes ^[20][21]
• Common locations ^[20][22][23]
  • Pelvis: ischial tuberosity, anterior superior iliac spine, anterior inferior iliac spine
  • Lower extremity: tibial tuberosity, calcaneus, hip trochanters
  • Medial epicondyle
• Differential diagnosis: traction apophysitis (e.g., Osgood-Schlatter disease), calcaneal apophysitis ^[24]
• Diagnostics ^[20]
  • Initial study: x-ray of the affected bone
  • Confirmatory studies: MRI or CT may be helpful in lower extremity and pelvic avulsion fractures.
• Management: All patients require orthopedics consultation; management is based on avulsion fracture location, characteristics, and complications. ^[20][23]
  • Pelvic avulsion fractures
    • Initial nonoperative management (NOM) is the typical approach, e.g., a trial of non-weight-bearing, graded return to activity, and pain management.
    • Surgery may be indicated for complications, e.g., significant displacement or pain, heterotopic ossification, and/or nonunion.
  • Tibial tuberosity avulsion fracture: immediate surgery ^[20]
  • Calcaneal avulsion fracture: management tailored to the patient ^[20]
  • Hip trochanter avulsion fracture: NOM for most patients; surgery for complicated cases
  • Medial epicondyle avulsion fracture ^[22]
    • Nondisplaced and uncomplicated: NOM for most patients
    • Significantly displaced or complicated (e.g., nerve or fracture fragment entrapment): Surgery may be required.

Upper extremity

• Distal radius fracture ^[25]
• Forearm fractures, e.g., radial head fracture, Monteggia fracture, Galeazzi fracture
• Clavicular fracture (including neonatal clavicle fracture)
• Supracondylar humerus fracture ^[26]
• Finger fractures

Lower extremity

• Tibial fracture, i.e., toddler fracture
• Femoral shaft fracture ^[27]

Axial skeleton

• Skull fracture
• Fracture locations that raise suspicion of nonaccidental injury to a child, e.g., posterior rib fractures
• Pelvic avulsion fracture (See “Avulsion fractures in children.”)