Common Fractures

Published on 06/06/2015 by admin

Filed under Pediatrics

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 3739 times

22 Common Fractures

Monika Goyal

Pediatric orthopedic trauma comprises approximately 10% to 15% of all childhood injuries, and almost half of all children will sustain a childhood fracture. Because of the dynamic nature of skeletal growth and immaturity of the bony architecture, fractures in children differ from those in adults in regard to patterns of occurrence, diagnosis, and treatment. Injuries in children more frequently result in fractures than ligamentous injuries or sprains because the increased porosity and pliability of bones in children makes them more susceptible to fracture. Moreover, children are susceptible to growth plate injuries, which may be difficult to diagnose but can result in long-term growth abnormalities or growth arrest. Therefore, careful attention is required in the evaluation and management of pediatric patients presenting with orthopedic injuries.

Each age group has typical mechanisms of injury and common fractures. When evaluating newborns and infants with injuries, one should maintain a high index of suspicion for nonaccidental trauma because this is a leading cause of fracture in this age group (see Chapter 12). Injuries in toddlers and school-aged children most often result from falls. During adolescence, injuries become similar to those of adults and are often sustained in sports or through high-energy mechanisms, such as motor vehicle collisions.

The evaluation of a patient with a possible fracture begins with a thorough history and physical examination. Important information to gather on history includes mechanism of injury and the presence of any numbness or tingling. Physical examination should begin with visual inspection for obvious deformity; palpation for point(s) of maximal tenderness; and a thorough neurovascular examination, including comparison of pulses, capillary refill, sensation, and motor function between affected and unaffected regions. Radiographic evaluation should follow history and physical examination if suspicion for fracture remains and almost always begins with plain films. It is important to obtain multiple views, which include the joint above and below the area of injury.

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).

image

Figure 22-1 Basic science of bone.

image

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).

image

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.

Greenstick Fractures

Greenstick fractures are the most common fracture pattern in children. They describe an incomplete fracture of cortex in which the fracture line does not extend completely through the width of the bone. Depending on the degree of angulation, reduction by an orthopedic surgeon may be necessary (Figure 22-4).

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).

image

Figure 22-4 Incomplete fracture in children.

Bowing Fractures

Bowing fractures represent a plastic deformity of the bone and are unique to children. These fractures occur when a longitudinal force exceeds the bone’s ability to recoil to its normal position and results in a bend in the bone without a fracture. These fractures most commonly involve the radius and ulna. Bowing fractures can sometimes be subtle, and comparison views of the contralateral arm may be necessary. If the deformity occurs in a child younger than 4 years or if the deformation is less than 20 degrees, the angulation usually corrects with growth. However, open reduction may be required for these fractures if they have bowing greater than 20 degrees and the patient is older than 6 years old (see Figure 22-4).

Apophyseal Avulsion Fractures

Avulsion fractures are quite common in children. Tendons and ligaments attach to secondary ossification centers known as apophyses in the developing skeleton, and avulsion fractures occur when a fragment of bone is pulled off during muscle contraction. Common sites of injury occur in the pelvis, tibial tubercle, and phalanges. Apophyseal injuries do not interfere with growth and usually heal with conservative management.

Fractures of the Upper Extremity

Clavicle Fractures

The clavicle is the most commonly fractured bone in childhood. In neonates, these fractures can occur during the birthing process secondary to shoulder compression and can present with pseudoparalysis. Clavicle fractures in older children may be caused by a direct blow to the clavicle or indirect forces transmitted to the clavicle from a fall onto an outstretched hand. Most fractures involve the lateral two-thirds of the clavicle. Diagnosis can often be made on physical examination because patients typically have swelling, tenderness, and occasionally crepitus at the fracture site. Although neurovascular injury is rare, it is important to conduct a neurovascular examination to assess for any associated brachial plexus injury.

Most clavicle fractures heal well without complication, and management consists of immobilization in a figure-of-8 clavicle strap or sling and swathe. Patients with open fractures, neurovascular or respiratory compromise, significantly displaced midshaft fractures, or grossly unstable distal injuries need orthopedic consultation because closed reduction may be indicated. The vast majority of clavicle fractures heal quickly, usually within 3 to 6 weeks. A bony callus appears during the healing process but disappears with bone remodeling (Figure 22-5).

image

Figure 22-5 Fracture of clavicle in children.

Fractures of the Humerus

Fractures of the humerus include supracondylar fractures (discussed in the Elbow Fractures section below), proximal humerus fractures, and midshaft fractures. The latter two fractures are relatively rare. Child abuse should be considered when a child younger than 3 years of age presents with a spiral fracture of the humerus.

Humeral fractures have a remarkable ability to remodel and thus rarely result in nonunion. Most of these fractures can be managed with a shoulder immobilizer or sling and swathe with orthopedic referral.

Elbow Fractures

Anatomy of the Elbow

When evaluating elbow injuries, it is important to understand the ossification centers of the elbow and the average ages at which they appear because it is easy to mistake an ossification center for a fracture on radiography. A mnemonic aid for remembering the order in which these ossification centers appear is CRITOE (capitellum, age 1 year; radial head, age 3 years; internal [medial] condyle, age 5 years; trochlea, age 7 years; olecranon, age 9 years; external [lateral] condyle, age 11 years).

An adequate radiographic evaluation of the elbow consists of an anteroposterior view of the joint in extension and a lateral view with the elbow flexed at 90 degrees (Figure 22-6). When evaluating elbow radiography, it is important to look for abnormalities of the fat pads, the anterior humeral line, and the radiocapitellar line on lateral views of the elbow. There are two elbow fat pads that overly the joint capsule along the distal humerus, one anterior and another posterior. Of the two, only the anterior fat pad is normally visible on a lateral radiograph as a small lucency just anterior to the coronoid fossa. When there is fluid in the joint space, as with a hemarthrosis from a fracture, the fat pads are displaced upward and outward thereby accentuating the anterior fat pad and making the posterior fat pad visible. The posterior fat pad sits deep in the olecranon fossa and is not visible under normal circumstances (see Figure 22-6). The anterior humeral line is also used to identify occult elbow injury. It is drawn along the anterior cortex of the distal humerus on a true lateral view of the elbow and should normally intersect the middle third of the capitellum; displacement may be consistent with a supracondylar fracture. The radiocapitellar line is drawn down the radius and should bisect the capitellum. Failure to do so may suggest an occult radial neck fracture or radial head dislocation.

image

Figure 22-6 Bones and fractures of the elbow.

Supracondylar Fractures

Supracondylar fractures account for more than half of all elbow fractures in children and often occur from a fall onto an outstretched hand with hyperextension of the elbow. Most supracondylar fractures require open or closed reduction. Only minimally displaced or nondisplaced supracondylar fractures may be immobilized with orthopedic referral.

Neurovascular injury is a common complication of supracondylar fractures. Although actual laceration of the brachial artery is rare, the vessel may be compressed or contused or undergo vasospasm at the fracture site, leading to distal ischemia. Patients are also at risk for developing a forearm compartment syndrome, which can lead to Volkmann’s ischemic contracture and a nonfunctional hand and wrist. Neurologic deficits, usually transient, are also common, and radial, medial, and ulnar nerve palsies have all been associated with supracondylar fractures (see Figure 22-6).

Forearm Fractures

After the clavicle, the radius and ulna are the most frequently broken bones in children. The most common mechanism of injury is a fall onto an outstretched hand. Most of these fractures involve the distal forearm, with the majority of them being torus or greenstick fractures. Although an isolated fracture of one of the bones can occur, there is often concomitant injury to the paired bone. Additionally, a fracture or dislocation at one end may be associated with a similar abnormality at the opposite end; therefore, it is important to include the wrist and elbow when ordering radiographs of the forearm.

In general, isolated fractures of the ulna are rare. A fracture of the proximal ulna may be associated with concomitant dislocation of the radial head, know as a Monteggia fracture. A fracture at the distal third of the radius in association with distal radioulnar joint dislocation is called a Galeazzi fracture (Figure 22-7). These fractures require closed reduction. Most proximal radius fractures in young children involve the radial neck, usually resulting in Salter-Harris type I and type II radial neck fractures. Proximal radius fractures can occur in conjunction with elbow dislocations and are often associated with medial epicondyle, olecranon, and coronoid process fractures. Nondisplaced or minimally displaced fractures of radial head and neck can often be treated with splinting and orthopedic follow-up. Fractures with a high degree of angulation or displacement may need reduction or surgical repair.

image

Figure 22-7 Monteggia fracture.

Most fractures of the radius and ulna heal without significant complications. However, rotational abnormalities must be accurately corrected. Although complications are uncommon, vascular compromise or compartment syndrome can develop with any forearm fracture; therefore, a thorough neurovascular examination is imperative when evaluating forearm injuries.

Fractures of the Hand and Wrist

Fractures of the Wrist

Wrist fractures are common in children and mostly involve the distal radius. These are often caused by a fall on an outstretched hand. Most often, these fractures are Salter-Harris type I and II fractures. Most are conservatively managed with immobilization and orthopedic referral.

Although the carpal bones are rarely fractured in childhood, scaphoid fractures are the most common carpal fracture. These typically occur in adolescence from falling onto an outstretched hand. Examination may elicit tenderness along the anatomic snuffbox, pain with wrist extension and flexion, pain with forced supination, and pain with longitudinal compression of the thumb. Plain radiographs often do not reveal an acute fracture; therefore, if a scaphoid fracture is clinically suspected, the wrist should be immobilized with orthopedic referral. Radiographs can then be repeated 7 to 14 days after injury or a magnetic resonance imaging (MRI) or computed tomography (CT) scan can be obtained to better elucidate the fracture. Because the rate of nonunion for scaphoid fractures in pediatric patients is low, many can be managed nonoperatively.

Metacarpal Fractures

The most commonly encountered metacarpal fracture in children is a fractured distal fifth metacarpal, which often results from striking something with a closed fist (the so-called boxer’s fracture). These require closed reduction if angulation is more than 30 to 40 degrees but can usually be managed with immobilization and orthopedic follow-up. Most other metacarpal fractures are nondisplaced or minimally displaced and are treated by immobilization for 2 to 4 weeks.

Fractures of the Phalanges

The different phalangeal fracture patterns in children include physeal, diaphyseal, and tuft fractures. Evaluation of the fractured digit should include assessment of the skin integrity, the nail bed, any gross deformity, tendon function, and rotational alignment. The most common fractures of the hand in pediatrics are distal phalanx fractures, or tuft fractures. These are usually crush injuries complicated by lacerations. These injuries are treated with wound care, nailbed repair, and finger splinting. Middle and proximal phalangeal fractures commonly occur at the physis and are usually Salter-Harris type II fractures. When evaluating patients with these fractures, it is important to assess for rotational deformity with the fingers flexed because any malrotation or angular deformity requires closed reduction to preserve hand function (Figure 22-8).

image

Figure 22-8 Fracture of the proximal phalanx.

Fractures of the Pelvis and Lower Extremities

Fractures of the Pelvis

Pelvic fractures in children include pelvic ring fractures, avulsion fractures, and acetabular fractures. Pelvic ring fractures are rare in children and involve high-energy accidents. These are discussed in more detail in Chapter 8. Acetabular fractures are also rare in children and are often associated with hip dislocation. Avulsion fractures are described earlier in this chapter and in Chapter 25.

Fractures of the Femur

Femur fractures occur commonly in children. The majority of femur fractures result from low-energy events, such as falls from playground equipment or sports-related injuries. These occur primarily in children age 5 to 10 years old. Femur fractures in children younger than 2 years old should raise concern for nonaccidental trauma (see Chapter 12). Femur fractures can also result from high-energy events such as motor vehicle collisions.

Because femur fractures can result in significant blood loss, the patient’s hemodynamic status must be assessed, and a thorough neurovascular evaluation should also be performed. Immediate management consists of traction and splinting to minimize blood loss. Definitive management of femur fractures most often includes a period of hospitalization for skeletal traction followed by application of a spica body cast.

Stress fractures of the femoral neck are becoming increasingly recognized in young athletes. See Chapter 25 for a discussion of these fractures.

Fractures of the Tibia and Fibula

Tibial and fibular shaft fractures are the most common fractures of the lower extremity in children. These types of fractures result from low-energy injuries such as falls or athletics or from high-energy injuries such as motor vehicle collisions or automobile–pedestrian injuries. Adolescent athletes performing in activities that involve jumping can occasionally present with tibial tuberosity fractures, which are avulsion fractures of the tibial tuberosity apophysis.

Patients with lower leg injuries may present with pain, swelling, deformity, and inability to bear weight on the affected limb. Evaluation of these injuries includes performing a thorough neurovascular examination. Diagnosis is confirmed with radiographs. Most of these injuries can be managed with immobilization and orthopedic referral as long as the neurovascular status is normal, but orthopedic consultation is often indicated to determine whether emergent reduction is necessary. Patients with significant tibial and fibular fractures are also at risk for compartment syndrome, which mandates an emergent orthopedic consultation.

Toddler’s Fracture

Toddler’s fractures occur in young ambulatory children, usually from 1 to 4 years of age. These injuries often occur after a seemingly insignificant fall, which is often unwitnessed. Young children often present with limp or refusal to walk. Most patients have no obvious deformity or swelling on examination, although gentle twisting of the lower leg or heel tapping may elicit pain. Radiography may reveal a spiral or oblique fracture through the distal third of the tibia on anteroposterior or lateral views, but oblique views are sometimes required to visualize the fracture if clinical suspicion is strong. Treatment consists of immobilization with a long leg cast for 3 to 4 weeks. With a high clinical suspicion but negative radiographs, a long leg splint or cast may still be considered.

Fractures of the Ankle and Foot

Distal Tibial and Fibular Fractures

Ankle fractures often result from inversion and eversion injuries. Unlike adults, in whom ankle sprains are more common than fractures, in children, the strength of the ankle ligaments makes injury to the distal tibial and fibular epiphyses more likely than a ligamentous disruption. Patients often present with painful, swollen ankles and limited ability to bear weight.

Although any Salter-Harris type injury can be seen in ankle injuries, because the distal tibial epiphysis is the weakest structure in the ankle, Salter-Harris type II fractures of the distal tibia are the most common fractures of the ankle. Of the fractures of the distal fibula, a Salter-Harris type I injury is the most common. Management of both these types of injuries consists of splinting followed by orthopedic referral and casting.

A Tillaux fracture is a Salter-Harris type III injury of the ankle that occurs as the medial distal tibial physis begins to close in adolescents who are nearing skeletal maturity, usually between the ages of 11 and 15 years. Forced external rotation of the foot leading to external rotation of the distal fibula causes the anterior tibiofibular ligament to avulse a piece of the anterolateral tibial epiphysis (Figure 22-9). This injury usually results from low-energy trauma such as in skateboard and baseball sliding injuries. Diagnostic work-up should begin with radiography, but after diagnosis has been made, a CT or MRI scan should be obtained to determine whether the fracture requires closed or open reduction.

image

Figure 22-9 Fractures of the ankle and foot.

Another fracture of the ankle unique to adolescent patients is the triplane fracture, a multiplanar fracture in which the fracture extends through the growth plate (transversely), epiphysis (sagittally), and distal tibial metaphysis (coronally) resulting in a Salter-Harris type IV fracture with three classically described fragments (see Figure 22-9). These fractures also occur in adolescents between the ages of 11 and 15 years before completion of the distal tibial physis closure. As with Tillaux fractures, the diagnostic workup should begin with radiography followed by CT or MRI to delineate the amount of displacement because many of these fractures require operative management.

Fractures of the Foot

Metatarsal and phalangeal fractures are common in children and account for the majority of fractures in children’s feet. Most metatarsal and phalangeal fractures present with pain and swelling, occasionally accompanied by deformity. These injuries should be evaluated radiographically, and most can be treated with bulky splints and crutches. The fifth metatarsal fracture is the most common midfoot fracture. Proximal avulsion fractures of the tuberosity at the base of the fifth metatarsal are very common. They are usually associated with lateral ankle strain and heal well with brief immobilization. It is important to distinguish these fractures from Jones fractures, which can look very similar. Jones fractures are transverse fractures of the fifth metatarsal. Although far less common than avulsion fractures, they are associated with greater morbidity. If unrecognized, they have a high rate of nonunion, which can require bone grafting and internal fixation (see Figure 22-9).

Future Directions

Despite prevention efforts, the overall rate of fractures is increasing, largely because of the growth of organized sports. Therefore, pediatricians must maintain a focus on injury prevention. Moreover, as childhood exposure to radiation continues to face increasing scrutiny, the utility of ultrasonography for the diagnosis of many fractures is currently being explored.

Suggested Readings

Eiff MP, Hatch RL. Boning up on common pediatric fractures. Contemp Pediatr. 2003;20:30-42.

Fleisher GR, Ludwig S, Henretig FM. Orthopedic trauma. In: Textbook of Pediatric Emergency Medicine. Philadelphia: Lippincott Williams & Wilkins; 2006:1525-1570.

Hart ES, Albright MB, Rebello GN, Grottkau BE. Broken bones: common pediatric fractures—part I. Ortho Nurs. 2006;25(4):251-256.

Hart ES, Grottkau BE, Rebello GN, Albright MB. Broken bones: common pediatric upper extremity fractures—part II. Ortho Nurs. 2006;25(5):311-323.

Hart ES, Luther B, Grottkau BE. Broken bones: common pediatric lower extremity fractures—part III. Ortho Nurs. 2006;25(6):390-407.

Jadhav SP, Swischuk LE. Commonly missed subtle skeletal injuries in children: a pictorial review. Emerg Radiol. 2008;15(6):391-398.

Nofsinger CC, Wolfe SW. Common pediatric hand fractures. Curr Opin Pediatr. 2002;14(1):42-45.

Shrader MW. Pediatric supracondylar fractures and pediatric physeal elbow fractures. Orthop Clin North Am. 2008;39(2):163-171.

Related posts:

Diabetic Ketoacidosis Neurologic Emergencies Resuscitation Cerebral Palsy Congenital Anomalies of the Kidney and Urologic System Sinusitis