Fractures in

children and
adolescents
Differences in fracture pattern and management
 A fracture is a break or disruption in
the continuity of the bone.
Fractures in children differ from those
FRACURE- in adults.
DEFINITION Fractures accounts for 15% of all
injuries in children.
Vary in different age groups (Infants,
children, adolescents)
 Children have different physiology
and anatomy

FRACTURES • Growth plate

• Bone
IN CHILDREN
• Cartilage
• Periosteum
• Ligaments
• Age-related physiology
 • Significant osteogenic potential and
more metabolically active
• Promotes union, callus formation
IMMATURE and remodeling
BONE • Periosteum is thicker
• Reduces displacement of fractures
and chance of open fractures
• Unique fracture patterns, greenstick
etc.
 Bend (bent 45 degrees more.mostly
ulnaand fibula)

FRACTURE Buckle or torus (compression of

porus bone raised or bulging
TYPES projection)

Green stick fracture (occurs when a

bone is angulated beyond the limits
of bending)
FRACTURE – • Neonatal period 2 to 3 weeks
BONE • Early childhood- 4 weeks

HEALING • Later childhood- 6 to 8 weeks

• Adolescence- 8 to 12 weeks
AGE
RELETED
PATTERN
• Infants diaphyseal
• Children metaphyseal
• Adoloscents epiphyseal
AGE
RELATED
PATTERN
GROWTH
PLATE
• In infants, GP is stronger than bone.
• Increased diaphyseal fractures
• Provides perfect remodeling power.
• Injury of growth plate causes
deformity.
• A fracture might lead to overgrowth.
BONE
Increased collagen: bone ratio
lowers modulus of elasticity
Increased cancellous bone reduces
tensile strength reduces tendency
of fracture to propagate less
comminuted fractures
Bone fails on both tension and
compression commonly seen
“buckle” fracture
CARTILAGE

Increased ratio of cartilage to bone

better resilience
difficult x-ray evaluation
size of articular fragment often under-
estimated
PERIOSTEUM Metabolically active
more callus, rapid union, increased
remodeling

Thickness and strength

Intact periosteal hinge affects

Fracture pattern
may aid reduction
PHYSIOLOGY

Better blood supply, so less incidence

of Delayed or non-union.
 Bones tend to BOW rather than BREAK
Compressive force = TORUS fracture/
INJURY Buckle fracture
Force to side of bone may cause break
PATTERN in only one cortex= GREENSTICK
fracture The other cortex only BENDS
In very young children, neither cortex
may break= PLASTIC DEFORMATION
 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
INJURY likely to be injured with force.

PATTERN Periosteum is biologically active in

children and often stays intact with
injury
This stabilizes fracture and promotes
healing.
GREEN STICK
FRACTURE
PLASTIC
DEFORMIT
Y
 Many childhood fractures involve the
physis
PHYSEAL 20% of all skeletal injuries in children
INJURY Can disrupt growth of bone
Injury near but not at the physis can
stimulate bone to grow more
 SALTER HARRIS CLASSIFICATION

Classification system to delineate risk of growth

disturbance
Higher grade fractures are more likely to cause
PHYSEAL growth disturbance
Growth disturbance can happen with ANY
INJURY- physeal injury
It has grade I upto grade V
CLASSIFICAT MOST COMMON: Salter Harris II
ION Followed by I, III, IV, V
Refer to orthopedics: III, IV, V
I and II effectively managed by primary care with
casting (most commonly)
Parents should be informed that growth
disturbance can happen with any physeal
fracture
SALTER
HARRIS
CLASSIFICATI
ON
S-H GRADE I

Fracture passes transversely through physis

separating epiphysis from metaphysis
S-H GRADE II

Transversely through physis but

exits through metaphysis

Triangular fragment
S-H GRADE
III
Crosses physis and exits through
epiphysis at joint space.
S-H GRADE IV

Extends upwards from

the joint line, through
the physis and out the
metaphysis
S-H GRADE V
Crash Injury to growth plate
 Tremendous power of remodeling

POWER OF Can accept more angulation and displacement

REMODELING Rotational mal-alignment? - does not remodel
Factors affecting remodeling potential

•Years of remaining growth – most important

factor
•Position in the bone – the nearer to physis the
better
•Plane of motion –greatest in sagittal, the frontal,
and least for transverse plane
•Physeal status – if damaged, less potential for
correction
•Growth potential of adjacent physis e.g. upper
humerus better than lower humerus
REMODELING
REMODELING
REMODELING
 Children tend to heal fractures faster
than adults requiring shorter
immobilization time.
Anticipate remodeling if child has >2 yrs
of growing left – mild angulation
deformities often correct themselves
REMODELIN but rotational deformities requires
reduction.
G Fractures in children may stimulate
longitudinal growth – some degree of
overlap is acceptable and may even be
helpful.
Children don’t tend to get as stiff as
adults after immobilization.
 Law of Two’s
RADIOGRAP
• Two views
HIC • Two joints
EXAMINATIO • Two limbs
N – X-RAY • Two occasions
• Two physicians
X-RAY EVALUATION- EXAMPLE
X-RAY EVALUATION - EXAMPLE
PRINCIPLE OF Mostly conservative – closed
reduction and cast immobilization
MANAGEMENT
Open reduction & internal fixation

Titanum elstic nail - TEN

External fixation
 Displaced intra articular fractures
( Salter-Harris III-IV )
INDICATION Fractures with vascular injury
FOR Compartment syndrome
OPERATIVE Fractures not reduced by closed
reduction ( soft tissue interposition,
TREATMENT button-holing of periosteum )
If reduction cannot be maintained or
could be only maintained in an
abnormal position
INDICATO
N FOR
OPERATIV
E
TREATME
NT
METHOD OF IMMOBILISATION
Casting—the commonest.
METHOD OF IMMOBILISATION
CASTING – SYNTHETIC MATERIAL
METHOD OF STABILISATION
K-wires : most commonly used. Metaphyseal fractures
METHOD OF FIXATION
Intramedullary wires, elastic nails
Very useful, Diaphyseal fractures, TITANIUM ELASTIC NAIL - TEN
METHOD OF FIXATION
EXTERNAL FIXATION – IN OPEN FRACTURES
METHOD OF FIXATION
SCREWS
METHOD OF FIXATION
PLATES AND SCREWS – MULTIPLE FRACTURES
METHOD OF FIXATION
Intramedullary nail – adolescent only. Chance of growth disturbace
 Purposes

To provide rest for an extremity

To help prevent or improve contracture
TRACTION deformity
To correct a deformity
To treat a dislocation
To provide poistioning and allignment
To reduce muscle spasm
 Types of traction
TRACTION • Upper extremity traction
Overhead suspension traction
Dunlop traction

• Lower extremity traction

Bryant traction
Buck traction
Russel traction
Balance suspension traction

• Cervical traction
OVERHEAD
SUSPENSION
TRACTION
The arm bent at the elbow is
suspended vertically by skin or
skeletal attachment and traction is
applied to the distal end of the
humerus
DUNLOP
TRACTION
The arm is suspended
horizontally using skin or
skeletal attachment
BRYANT'S
TRACTION
It is a type of running traction in which the
pull is in only one direction.legs are flexed at
90 degree of the hips
BUCK'S
TRACTION
Type of traction in which the legs are
in extended position
Used for short term immobilisation
RUSELL
TRACTION
Uses skin traction on the lower leg
and a padded sling under the knee
two lines of pull one along the
longitudinal line and the other
perpensdicular to the leg
BALANCE
SUSPENTI
ON
TRACTION
A Thomas splint from the
groin to above the foot.
Pearson attachment to
support the lower leg
CERVICAL
TRACTION
 COMPLICATION

Malunion is not usually a problem (except

cubitus varus)
Nonunion is hardly seen (except in lateral
condyle of humerus)
Growth disturbance – epiphyseal damage
Vascular - Volkmann’s ischemia
Infection - rare
 Battered Baby Syndrome:

Soft tissue injuries - bruising, burns

Non- Intra-abdominal injuries

accidental
Intracranial injuries
injury
Delay in seeking treatment

Injuries/fractures in different stage of

healing
Radiology of child abuse
Radiology of child abuse - Corner’s fracture
(traction and rotation)
 PATHOLOGICAL FRACTURES
SIMPLE BONE CYST, DEFECTUS FIBROSUS, FIBROSUS CORTICAL DEFECT, NON-OSSIFYING FIBROMA
 30-month-old female fell down on
CASE #1 floor when playing on bed.
Complaining of left elbow pain and
decreased ROM.
Case #1
X-ray
 • Check true lateral
• Check anatomical alignment
• Anterior humeral line (less than 1/3 of
the capitulum lies in front of the line)
• Radiocapitellar line
CASE #1 • Fat pad signs
• Check cortex
• Check radial head
• Check AP cortex
• Ossification centres
CASE #1 –
ossification
centres
• Capitellum (1 year)
• Radial head (3y)
• Internal (Medial) epicondyle (5y)
• Trochlea (7y)
• Olecranon (9y)
• External (lateral) epicondyle (11y)
 A 6- year- old girl with deformed right
CASE #2 elbow since a fall today
CASE #2
X- ray
CASE #2
• X-ray
CASE #2 – Gartland Classification
 • Collar and cuff
CASE #2 - • Close reduction + cast
Treatment • Open reduction + cast
 10-year-old girl presented having
CASE #3 fallen onto outstretched hand
Tender distal radius and ulna
CASE #3
 • Buckle fracture
• Compression failure from longitudinal
force
• Usually at metaphyseal / diaphyseal
CASE #3 junction
• Stable
• Can be managed in a splint – (3 weeks
continuous and no sport)
 A 4-year-old with fall onto
CASE #4 outstretched hand
Tender distal radius
CASE #4
 Buckle fractures that are not suitable for
a wrist splint

*Volar angulation
*Cortical disruption (= greenstick
fracture)
CASE #4 *Ulna greenstick, complete or styloid
fracture
*Greater than 15 degrees angulation or
obvious clinical deformity – will likely
need reduction
 5-year-old boy fell from the monkey bars
CASE #5 Tender proximal forearm
CASE #5
 Ulnar shaft fracture and radial head
dislocation- MONTEGGIA FRACTURE
*Rare – only 2% of elbow injuries
*Mechanism is usually hyperextension
at the elbow
*Isolated ulna injuries are rare.
CASE #5 Examine and xray the joint above and
below
*The posterior interosseous nerve is the
most commonly affected – deep
extensor muscles
*Requires immediate orthopaedic
referral
 A 7-year- old boy fell from play
CASE #6 equipment. Swollen right ankle
Non weight bearing.
CASE #6
 A 9-year-old boy who fell off skateboard
Presents with swelling to the left ankle
CASE #7 and unable to weightbear
CASE #7
 • Most common and most missed –S-H
TYPE I
*Diagnosed clinically
*Tenderness over fibula physis (as
CASE #7 opposed totenderness over the ATFL)
+/- swelling
*Xray may be normal or there may be
swelling laterally
*Mx plaster
CASE #8
 Undisplaced Salter-Harris II fractures of
CASE #8 - the distal tibia: non weight bearing
below knee plaster backslab + clinic in 7
TREATMENT days
CASE #9
5 years old fell onto thumb
whilst on bouncy castle
CASE #10
A 2-years-old.
Irritable today and limping
No history of falls
 TODDLER FRACTURE - Occur in children
learning to walk
*Usually after a fall which may not be
seen by parents
*Subtle examination findings, limping
CASE #10 but often no swelling
* Differentials include septic joints
*Undisplaced fractures can be managed
in an above knee back slab and ortho
clinic in 10 days
CASE # 11
A 13-year-old girl externally rotated ankle, c/o pain on weightbearing
Case #11
• TILLAUX FRACTURE - Salter Harris III of the distal tibia –
• avlusion of the anterolateral part of the epiphysis
• *If non-displaced can be managed with
• below knee back slab. Discuss with
• orthopaedics as to CT needed to confirm
• non displacement – displaced fractures
• require an operation
 A 9 year old BOY who fell off a
CASE #12 skateboard awkwardly
• Pain ++ mid leg
CASE #12
 A 10-year-old boy who inverted his foot
CASE #13 and presents with pain at the base of
the fifth metatarsal
CASE #13
 • Fell off couch
CASE #14 • Swelling pain and tenderness,
decreased ROM
CASE #14
 A 6 - yearIold male with a fall onto an
CASE #15 outstretched HAND.
DECREASED ROM of elbow.
CASE #15
 • A 3-year-old boy His father pulled his
CASE #16 hand , on extended arm
• Limitation ROM of the elbow.
CASE #16 – Nursemaid's elbow