Common Fractures

Published on 06/06/2015 by admin

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Last modified 06/06/2015

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22 Common Fractures

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).

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).

Bowing Fractures

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