Pediatric Fractures

Fractures are more common in children than in adults.  This is due in part to their activities as well as their bone properties.  Children, for the most part, are more active than adults.  Their bone also has properties that make it more pliable than adult bone.  Managing fractures in children is also somewhat different than in adults.  Below is an overview of fractures in general and the basics on fracture management and healing.

What is a fracture?

A fracture is the medical term for a broken bone.  It means the integrity of the bone has been disrupted, usually by external force.  A "break", "broken bone" and "fracture" all mean the same thing and these terms have no association with regards to the severity of injury.

Anatomy of bones

The different areas on the long bones are known as the epiphysis, physis, metaphysis and diaphysis.  Some bones, such as ribs, the scapula, carpal and tarsal bones, do not have these specific areas.

The epiphysis is the end of the long bone with joint cartilage on the ends.  The physis is the area also known as the growth plate.  This area is made up of cartilage cells that create solid bone with growth, hence the name growth plate.  The metaphysis is the wide area below the physis, closest to the shaft.  The shaft is also known as the diaphysis.

There is also another key component to children’s bones.  This is the periosteum.  The periosteum is the thick nutrient layer that wraps circumferentially around the bone.  It serves a major role in healing the outer layer of the bone called the cortex.

What exactly is the Growth Plate?

The growth plate is the area of a child’s bone that is made up of cartilage cells that create solid bone with growth.  A growth plate fracture is a fracture of physis.  Fractures occur here more frequently because it is an area of weakness.  Growth plate fractures have their own classification known as Salter-Harris fractures.   There are five different fracture patterns in this system.

How do you diagnose a Growth Plate fracture?

Children will usually complain of pain and localized tenderness over the growth plate.  There may or may not be swelling or an obvious deformity.  Clinical exam and x-rays are necessary to diagnose a growth plate fracture.  With certain type of growth plate fractures, the x-rays may only show soft tissue swelling and no obvious break of the bone.

How do you treat growth plate fractures?

If the fracture is non-displaced, meaning it is in the correct anatomic position, casting is the treatment method.  If the fracture is displaced, a reduction is usually needed.  The reduction can be done in the office, emergency room, or the operating room.  A reduction is usually done under local or general anesthesia.  X-ray will be taken to confirm the correct position of the fracture in the cast after the reduction.  Sometimes surgery is required to reposition a growth plate fracture into an acceptable healing position. 

What happens if the growth plate is damaged?

After the initial fracture treatment, your doctor will check you again several months from the time of injury.  X-rays at that time should indicate normal growth.  If a premature growth arrest or deformity is noted on the x-rays at that time, further treatment may be necessary.  The chance of having a growth disturbance depends on several factor including the amount of force that caused the fracture, the fracture pattern and which bone is involved.

Other types of fractures

Non-displaced fractures

A fracture of the bone in which no movement has taken place and the bone is anatomically aligned.

 

Torus/Buckle fractures

A torus/buckle fracture is one of the most common fractures in children.  It results from an end-to-end compression of the bone, which results in the sides of the bone giving way or buckling. 

 

Greenstick fractures

A greenstick fracture is unique to children because of the pliability of their bones.  This fracture involves one side of the bone, which bends like a “green stick” but does not break.  This fracture often requires a reduction to straighten the bone before treating it in a cast. 

 

Displaced fractures

A displaced fracture means the fracture is complete with the broken ends out of anatomical alignment.  There are varying degrees of displacement.  A displaced fracture in a child does not have to be reduced to a perfect anatomic alignment.  This is due to the forgiving nature of the periosteum.  

 

Closed fractures

A closed fracture simply means that the fracture has not broken through the skin.

 

Open fractures

An open fracture means that the fracture has broken through the skin.  An open fracture requires surgical attention to fix the fracture and clean out the wound in a sterile environment.  An open fracture increases the chance of infection or that a fracture does not heal. 

 

Comminuted fractures

A fracture that is broken in three or more pieces and usually needs surgical fixation.

 

Pathologic fractures

A pathologic fracture is usually not caused by external force, but by an internal weakness of the bone.  This is usually due to a bone cyst, tumor or infection. 

 

Stress fractures

A stress fracture is the result of stress to the bone over time.  It is usually difficult to see on plain x-rays.  A good clinical exam can diagnose this type of fracture.  A bone scan can also be done to confirm the diagnosis.  The goal of treatment is to reduce the amount of stress applied to the affected area.

 Intra-articular fracture

Fractures that occur at the end of bones have a potential to displace the articular (joint) cartilage.  These fractures need to be aligned in an anatomic position, even in young children.  This often requires surgical treatment.  If a fracture that enters the joint is not aligned properly, the potential for early arthritis may exist.

How do you treat fractures?

The decision to treat a fracture in a cast as opposed to one that needs a reduction is based on angulation, displacement, rotation and length. 

For each different part of the body, there are different degrees of acceptability of angulation, displacement, rotation and length.  Remember, fractures that are not reduced to exact anatomic position, but are within our acceptable limits will heal.  They heal due to a process know as remodeling.

 

Not all fractures need a cast immediately, even angulated and displaced fractures.  Many fractures can be preliminarily placed in a splint and evaluated in our office within a couple of days.  This typically occurs when patients are seen at urgent care centers, emergency rooms or pediatrician offices. 

What is remodeling?

Remodeling is the process that occurs over time as a child’s bone reshapes itself to an anatomic position.  This is why some fractures do not have to line up perfectly when you see them on the x-rays.  Remodeling will continue for one to two years after a fracture. 

When to see the doctor?

After a know injury, there are some simple things to do before seeking medical attention.  If there is an obvious deformity, splint the extremity with a homemade device such as a magazine and seek medical attention immediately.  If there is not obvious deformity, stop the child’s activity and encourage rest.  You can use ice to decrease swelling. Wrap the extremity with an ACE wrap for comfort.  Elevate the extremity if there is any swelling.  Children’s Motrin can be used for pain, take as directed on the bottle.  It is best to treat children’s injuries with caution.  Young children are sometimes unable to express to you that they are hurt. If they are not playing or acting like their usual self for 1-2 days after an injury, please have us take a look.   We would be more than happy to evaluate and treat your child!