Fractures In Children

Kitiwan Vipulakorn
Department of Orthopedics
Faculty of Medicine
KKU

Objectives

2.2 // ()
1 //

injury /accident : head & neck injury, fracture,

dislocation, body and limb injuries, serious injury,
electrical injury, burns, near-drowning & submersion

Incidence
1.5-2% per year
17.8% in patient presented with
injuries
Peak in 12-15 years old

Incidence of fractures in long bones

Radius

45.1%

Humerus

18.4%

Tibia

15.1%

Clavicle

13.8%

Femur

7.6%

Incidence
Physeal injuries 14.7%
Open fractures 2.9%
Multiple fractures 3.6%

Etiologic factors
Home environment
83% of all injuries / 37% of all fractures

School environment
53% of injuries related to athletic events /20% of all
fractures

Motor vehicle accidents

10% of all injuries / high incidence of femoral shaft
fracture in pedestrian / high incidence of spinal and
pelvic fractures

Prevention is important

Prevention is important

Biological aspects
Anatomical difference
Histological difference
Remaining of growth and
remodeling potentials

Anatomical differences

Anatomical difference
Apophysis

Epiphyseal
plate or physis

Metaphysis

Epiphysis

Secondary ossification
center

Physis / Epiphyseal plate

Rapid , integrated longitudinal and
latitudinal growth

Metaphysis
Thinner cortex and more porous

Torus of Buckle fracture

Diaphysis
Extremely vascular in neonate and young
children , less dense than maturing bone
Affected rate of healing
More elasticity : resisted to tensile stress
Produce plastic deformation /
incomplete or greenstick fracture

Plastic deformation

Incomplete or greenstick fracture

Periosteum
Thicker , greater osteogenic potentials
Loosely attach to diaphysis and metaphysis
, dense attach to physeal periphery
Affected fracture displacement and
reduction , rate of subperiosteal callus
Effective internal restrain in reduction

Periosteum

Apophysis
Epiphysis functioned as attachment of
muscle or ligament : tibial tuberosity ,
greater trochanter , greater tuberosity of
humerus
Tensile responsive structure
Reactive overgrowth :
Osgood-Schlatters lesion

Biological aspects
Anatomical difference
Histological difference
Remaining of growth and
remodeling potentials

Fracture repair

Fracture healing
Rapid healing
Healing in side to side apposition ( bayonet ) is possible
Spontaneous correction of residual angulation
Younger , fracture site is close to physis, angulation
in plane of joint motion
Fracture may stimulate longitudinal growth by
increasing of blood supply : overgrowth phenomena

Physeal injuries
Common in injuries at or close to joint in
children

Salter-Harris classification

Salter-Harris classification

Salter-Harris classification

Thurston-Holland fragment or sign

Salter-Harris classification

Articular surface incongruity

Physeal arrest

Salter-Harris classification

Articular surface incongruity

Physeal arrest

Salter-Harris classification

Physeal healing
Through the cell column
Continue increase of cell
number in cell column
Metaphyseal response
increase bone replacement
in hypertrophic zone
Restore in 3-4 weeks

Physeal healing
Through the transition of
hypertrophic zone and
primary spongiosa
Fill with hematoma and fibroblastic
tissue
Disorganized cartilage
Metaphyseal vascular invasion
Vascular mediated bone formation

Physeal healing
Extended across all layer
Fibrous tissue fill gap of physis
and callus at metaphysis
Cell in germinal and hypertrophic
zone expand by divison , maturation
and matrix expansion
In large gap , fibrosis is remaining
and from osseous bridge

Physeal growth disturbance

Physeal arrest

Central

Peripheral

Linear

Physeal arrest
Entire physis :
shortening
Partial physis :
angular deformity ,
progressively

Diagnosis

Symptoms & Signs

Pain
Swelling
Deformity
Loss of functions

Symptoms & Signs

swelling

Symptoms & Signs

Deformity

Symptoms & Signs

Assessment of neurological signs and vascular
status are important but difficult.
Paper position : radial nerve
Rock position : median nerve
OK position : anterior interosseous nerve
Scissor : ulnar nerve

Radiological examination
Diaphyseal fractures : one joint above and
one joint below
Physeal fractures : x-ray of the joint ,
normal side may require
Splint is necessary

Principles of Treatment

Fractures
Rapid and high rate of union
Potential of remodeling
Most fractures treated by non-operative
treatment

Surgical indications : un-accepatable

reduction , specific site ,open fractures ,
multiple injuries

Traction

Cast

Reduction or not ?

Immobilization or fixation

Physeal injuries
Salter-Harris type I , II : no or less growth
disturbance : non-operative treatment
Salter-Harris type III , IV : if displaced
surgical treatment is required
Salter-Harris type IV : prevent further
physeal damage : immobilization , decrease
activity or non-weight bearing

Q&A

Common Pediatric Fractures

Incidence of fractures in long bones

Radius

45.1%

Humerus

18.4%

Tibia

15.1%

Clavicle

13.8%

Femur

7.6%

Fracture of distal part of radius & ulna

Most common in forearm fractures
Physeal fracture of radius , ulna
Distal metaphyseal fracture
Torus , Greenstick , complete
Galeazzi fracture-dislocation

10-year-old girl fall in outstretched hand. Pain at right wrist

Physeal injuries of distal radius

Common associated ulnar fracture
Neurovascular compromised : uncommon , median
nerve
Salter-Harris type II : most common
Treatment : displacement & Salter-Harris type
I ,II : closed reduction , short/long arm cast
Displaced III , IV , irreducible : surgery

A 10-year-old girl fall on outstretched hand. Pain at distal right forearm

Torus or Buckle fracture

One cortex
Protected immobilization , relief pain
Heal in 2-4 weeks
Bicortical disruption
Prolong immobilization
Heal in 3-6 weeks

Greenstick Fracture

Treatment depend on age , degree and

direction of displacement
Displaced should be closed reduction
Acceptable angular correction

Age

Saggital :
boy

Saggital :
Girls

Frontal
plane

4-9

20

15

15

9-11

15

10

11-13

10

10

>13

Complete fracture of distal radius

Closed reduction and

casting or percutaneous
pinning in unstable
fracture

A 10-year-old boy fall on outstretched hand. Pain and deformity of right side

Galeazzi fracture-dislocation

Galeazzi fracture-dislocation
Fracture distal radius and dislocation of
distal radio-ulnar joint
Dorsal / volar
Closed reduction and long arm cast 6-10
weeks

Plastic deformation
Failure of bending force
Limitation of remodeling in
older child
Angulation > 10 in older > 6
years old : reduction , 3points molded

Monteggia fracture-dislocation

CLASSIFICATION
Bado's classification
Divides into 4 types of true Monteggia lesions
and equivalent lesions

True Monteggia Lesions

Type I
Anterior dislocation of the radial head with a fracture
of the ulnar diaphysis (mid-shaft)
The most common Monteggia injury in children
70% in most series

True Monteggia Lesions

Type II
The posterior dislocation of the radial head with an
associated ulnar diaphyseal or metaphyseal fracture
with posterior angulation
Most cases is an adult injury

True Monteggia Lesions

Type III
Lateral or anterolateral dislocation of the radial head
with a fracture of the ulnar metaphysis
Usually is a greenstick type
The second most common (23%)

True Monteggia Lesions

Type IV
Anterior dislocation of the radial head
with fractures of the ulna and radius
The least common (1%)
in both children and adults

Monteggia fracture-dislocation
Closed reduction , long arm cast

Pulled elbow

Forearm in pronation
Reduced by flexion and supination

Incidence of fractures in long bones

Radius

45.1%

Humerus

18.4%

Tibia

15.1%

Clavicle

13.8%

Femur

7.6%

4-year-old girl fall down. Pain at right elbow

Supracondylar fracture of humerus

Fall on outstretched hand in elbow
hyperextension
Posterior displacement

Gartlands classification

Type Ithe anterior cortex is

broken. The posterior cortex
remains intact, and there is
no or minimal angulation of
the distal fragment.
Type IIthe anterior cortex is
fractured and the posterior
cortex remains intact.
However, plastic deformation
of the posterior cortex, or
greensticking, allows
angulation of the distal
fragment.
Type IIIthe distal fragment
is completely displaced
posteriorly.

Treatment
Gartland type I : casting
Gartland type II and III : closed reduction
and percutaneous pinning
Open reduction in irreducible

Neurovascular injuries

Malunion : cubitus varus

A 4-year-old boy fall on outstretched hand. Pain at left elbow

Lateral condylar of humerus

Physeal injury of distal humerus

Milch
classification

Fat pad sign

Treatment
Type I : < 2mm displacement : long arm cast 3-5
days and repeat x-ray , continue 3-5 weeks
Type II : 2-4 mm displacement : closed reduction and
percutaneous pinning
Type III : Open reduction and internal fixation

Nonunion : cubitus valgus

Physeal arrest

Q&A

A 10-year-old boy got a car accident. Pain at left thigh ,

could not walk

Femoral shaft fracture

High energy trauma
Associated injuries common

Age

Treatment

NB- 24months

Pavlik harness
Immediate hip spica
Traction and hip spica

2-5 years

Immediate hip spica

Traction and hip spica
External fixation
Flexible IM rod

6-11y

Traction and hip spica

Flexible IM rod
Compression plate
External fixation

>12y to maturity

Flexible IM rod
Compression plate
Locked IM rod
External fixation

Traction

Bryants
Bryants traction
traction

Hip spica cast

Acceptable angulation
Age

Varus/valgus

Anterior/posterio
r

Shortening (mm)

NB-2years

30

30

15

2-5 years

15

20

20

6-10 years

10

15

15

11yeras to
maturity

10

10

Flexible intramedullary rod

Compression plate

2-year-old boy , limping

Toddler fracture

Toddler fracture
Long leg cast 3 weeks ( + 2 weeks short leg
walking cast)