common pediatric fractures

COMMON PEDIATRIC FRACTURES

INTRODUCTION• ANATOMY OF THE GROWING BONE– INJURY PATTERN OF BONE

• PHYSEAL INJURIES• SPECIFIC SITES– DISTAL RADIUS– ELBOW– CLAVICLE– TIBIA

• CHILD ABUSE

RELEVANCE

• Nearly 20% of children who present with an injury have a fracture– 42% boys, 27% girls will

sustain fracture in childhood

INJURY PATTERN IN GROWING BONES

• Bones tend to BOW rather than BREAK• Compressive force= TORUS fracture– Aka. Buckle fracture

• Force to side of bone may cause break in only one cortex= GREENSTICK fracture– The other cortex only BENDS

• In very young children, neither cortex may break= PLASTIC DEFORMATION

INJURY PATTERN IN GROWING BONES

• Bones tend to BOW rather than BREAK• Compressive force= TORUS fracture– Buckle fracture

• Force to side of bone may cause break in only one cortex= GREENSTICK fracture– The other cortex only BENDS

• In very young children, neither cortex may break= PLASTIC DEFORMATION

INJURY PATTERN IN GROWING BONES

• Bones tend to BOW rather than BREAK• Compressive force= TORUS fracture• sForce to side of bone may cause break in only one

cortex= GREENSTICK fracture– The other cortex only BENDS– Buckle fracture

• DIn very young children, neither cortex may break= PLASTIC DEFORMATION

• In very young children, neither cortex may break= PLASTIC DEFORMATION

INJURY PATTERNSCON’T

• Point at which metaphysis connects to physis is an anatomic point of weakness

• Ligaments and tendons are stronger than bone when young– Bone is more likely to be injured with force– Periosteum is biologically active in children and

often stays intact with injury• This stabilizes fracture and promotes healing

INJURY PATTERNSCON’T

• Point at which metaphysis connects to physis is an anatomic point of weakness

• Ligaments and tendons are stronger than bone when young– Bone is more likely to be injured than soft tissue– Periosteum is biologically active in children and

often stays intact with injury• This stabilizes fracture and promotes healing

Fractures Peculiar to ChildrenA. Torus or bucklingB. GreenstickC. BowingD. Epiphyseal

Often only incomplete fracture line is seen

There are a variety of fractures that are more peculiar to children, and included in this list are the torus or the buckling fracture. The cortex becomes buckled or has a bump as a result of a compressive twisting injury. A greenstick fracture, much like when you try to break off a piece of a lilac bud on campus and it comes halfway off, breaks through one cortex and the other remains intact. A similar type of injury can occur in children. The bowing fracture, smooth curvature to the bone without disruption of the cortex. Epiphyseal fractures, a variety of fractures that actually involve the epiphyseal plate in various extents. Often only an incomplete fracture line will be identified.

Buckle (TORUS) fracture

• Compression failure of bone that usually occurs at the junction of the metaphysis and the diaphysis

• Commonly seen in distal radius.• Inherently stable• Heal in 3-4 weeks with simple immobilization.

Torus Fracture Radius

Can you identify the torus fracture on this pair of wrist films before I put the arrows in place? Look carefully; look for any disruption of the contours of the cortex. Normally the contour should be very smooth with no sharp angulations. Here we see a small bump on the cortex representing the site of the torus fracture; it’s also noted on the lateral view as well.

Torus Fracture Radius

Here is another example of a torus fracture involving the radius with buckling of the cortex as indicated by the yellow arrows.

Bowing Fracture

• Bowing fracture of right fibula

• Buckle fracture of right tibia

• Normal left for comparison

Note the bowing fracture of the right fibula. The fibula has a slight curvature convexity directed medially as a result of injury. There is also on the same individual a buckling of the distal tibia, a buckle fracture. Remember in paired bones, frequently both bones will either be fractured or there will be a fracture dislocation. The left lower leg, which is normal, is included for comparison purposes.

Greenstick fracture

• Bone is bent and the tensile/convex side of the bone fails.

• Fracture line does not propagate to the concave side of the bone, therefore showing evidence of plastic deformation.

Greenstick Fracture Radius

• Dorsal cortex remains intact

• Ventral cortex is disrupted

• Angulation is ventralHere is an example of an individual with a greenstick fracture. The dorsal cortex remains intact while the ventral cortex is disrupted. There is angulation directed towards the ventral or palmar aspect or anterior aspect of the forearm with the patient in anatomic position.

• If the bone undergoes plastic deformation, it is necessary to break the bone on the concave side to restore normal alignment, as the plastic deformation recoils the bone back to the deformed position

Complete fracture

• Fracture completely propagates through the bone.

• Classified as spiral, transverse, or oblique, depending on the direction of the fracture line.

ANATOMY OF GROWING BONE

• Epiphysis• Physis• Metaphysis• Diaphysis • Periosteum

Terminology• Epiphyseal Plate = Growth Plate = Physis

• Epiphysis– Secondary Ossification Center– Epiphysis and growth plate are NOT synonyms– The epiphysis is the bone located between the articular

surface and the physis• Metaphysis

– Bone adjacent to the physis on the opposite side of the epiphysis.

• Diaphysis– The shaft of the bone

Growth Plate Injuries

• Occur by various mechanisms– Fracture – Frostbite– Disuse – Chronic Stress– Radiation – Iatrogenic injury– Infection – Neural involvement– Tumor – Electrical Injuries– Vascular impairment – Burns– Metabolic abnormality

Growth Plate Injuries

• When entire physis is arrested– Bone length is retarded– If bone ends are arrested, longitudinal bone

growth ceases completely

• When only part of physis is damaged– Length retardation can be accompanied by

angular deformity

PHYSEAL INJURIES

• Many childhood fractures involve the physis– 20% of all skeletal injuries in children– Can disrupt growth of bone– Injury near but not at the physis can stimulate

bone to grow more

SALTER HARRIS

• Classification system to delineate risk of growth disturbance– Higher grade fractures are more likely to cause

growth disturbance– Growth disturbance can happen with ANY physeal

injury

SALTER HARRIS CLASSIFICATION

• I– Fracture passes

transversely through physis separating epiphysis from metaphysis

• II• III• IV• V

SALTER HARRIS CLASSIFICATION

• I

• II– Transversely through physis

but exits through metaphysis– Triangular fragment

• III• IV• V

SALTER HARRIS CLASSIFICATION

• I• II

• III– Crosses physis and exits

through epiphysis at joint space

• IV• V

SALTER HARRIS CLASSIFICATION

• I• II• III

• IV– Fracture extends upwards

from the joint line, through the physis and out the metaphysis

• V

SALTER HARRIS CLASSIFICATION

• I• II• III• IV

• V– Crush injury to growth plate

PHYSEAL FRACTURES

• MOST COMMON: Salter Harris ___

PHYSEAL FRACTURES

• MOST COMMON: Salter Harris _II_– I and II effectively managed by primary care with

casting (most commonly)• Don’t forget to tell Mom and Dad that growth

disturbance can happen with any physeal fracture

IT’S GOOD TO BE YOUNG• Children tend to heal fractures faster than adults– Advantage: shorter immobilization times– Disadvantage: misaligned fragments become “solid”

sooner• Anticipate remodeling if child has > 2 years of

growing left– Mild angulation deformities often correct themselves– Rotational deformities require reduction (don’t

remodel)

IT’S GOOD TO BE YOUNG

• Fractures in children may stimulate longitudinal bone growth– Some degree of bone overlap is acceptable and may even

be helpful

• Children don’t tend to get as stiff as adults after immobilization

• After casting, callus is formed but still may be fibrous– Avoid contact activities for 2-4 weeks once out of cast

Diagnosis: Need Adequate Imaging

• Supplement plain x-rays

• High Index of Suspicion– Comparison

Views– CT scan– MRI

Adequate Imaging

• Child with knee pain

• Fracture difficult to see

Adequate Imaging

• Oblique X-ray– Easy to see– Salter III of the

distal femur

Adequate Imaging• Final after reduction

and internal fixation with comparison view

Adequate Imaging

• Child with ankle pain– Fracture

difficult to see

Adequate Imaging

• CT shows a Salter III (“Tilleaux”) fracture of the distal tibia– Tilleaux Fractures occur

near the end of growth as medial portion of distal tibial physis closes before the lateral side closes

Tilleaux Fracture• Post-operative and final x-rays after hardware

removal without residual deformity

Treatment

• Goal of treatment of all physeal fractures is to maintain function and normal growth– Attainment of these goals is most likely when all structures

are anatomically reduced– Therefore goal is to obtain and maintain anatomic

reduction• May be done by open or closed means• All reductions should be gentle to prevent damage to the delicate

physeal cartilage• Forceful, repeated manipulations should be avoided!

Peterson HA. Physeal Injuries and Growth Arrest. In Beaty JH, Kasser JR, eds. Fractures in Children. Philadelphia, PA: Lippincott Williams and Wilkins, 2001; 91-130.

FRACTURES OF ABUSE

• Majority of fractures in child < 1 year are from abuse– High percentage of fractures <3yo = abuse

• Greater risk of abuse: first-born, premature infants, stepchildren, children with learning or physical disabilities

• Most common sites: femur, humerus, tibia• Also: radius, skull, spine, ribs, ulna, fibula

Child Abuse Concerns

• Unexplained fractures in different stages of healing as shown on radiology

• Femoral fracture in child < 1 year• Scapular fracture in child without a clear

history of violent trauma• Epiphyseal and metaphyseal fractures of the

long bones• Corner or “chip” fractures of the metaphyses

CHILD ABUSE

• If suspected, skeletal survey should be considered

• Bone scan may be useful as complementary study

CONCLUSIONS

• Nearly 20% of children with injury have a fracture

• Always take post-reduction x-rays• Physeal injuries are common and may have no

radiographic findings– Treat as fracture!!

• Don’t forget to tell Mom and Dad about possible growth problems