COMMON PEDIATRIC

FRACTURES

INTRODUCTION
ANATOMY OF THE GROWING BONE
INJURY PATTERN OF BONE

PHYSEAL INJURIES
SPECIFIC SITES
DISTAL RADIUS
ELBOW
CLAVICLE
TIBIA

CHILD ABUSE

RELEVANCE
Nearly 20% of
children who
present with an
injury have a
fracture
42% boys, 27% girls
will sustain fracture
in childhood

INJURY PATTERN IN GROWING

BONES
Bones tend to BOW rather than BREAK
Compressive force= TORUS fracture
Aka. Buckle fracture

Force to side of bone may cause break

in only one cortex= GREENSTICK
fracture
The other cortex only BENDS

In very young children, neither cortex

may break= PLASTIC DEFORMATION

INJURY PATTERN IN GROWING

BONES
Bones tend to BOW rather than BREAK
Compressive force= TORUS fracture
Buckle fracture

Force to side of bone may cause break

in only one cortex= GREENSTICK
fracture
The other cortex only BENDS

In very young children, neither cortex

may break= PLASTIC DEFORMATION

INJURY PATTERN IN GROWING

BONES

Bones tend to BOW rather than BREAK

Compressive force= TORUS fracture
sForce to side of bone may cause break in
only one cortex= GREENSTICK fracture
The other cortex only BENDS
Buckle fracture

DIn very young children, neither cortex may

break= PLASTIC DEFORMATION
In very young children, neither cortex may
break= PLASTIC DEFORMATION

INJURY PATTERNS
CONT

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 likely to be injured with force
Periosteum is biologically active in children
and often stays intact with injury
This stabilizes fracture and promotes healing

INJURY PATTERNS
CONT

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 likely to be injured than soft
tissue
Periosteum is biologically active in children
and often stays intact with injury
This stabilizes fracture and promotes healing

Fractures Peculiar to
Children
Torus or buckling

A.
B. Greenstick
C. Bowing
D. Epiphyseal

Often only incomplete fracture line is seen

There are a variety of fractures that are more peculiar to children, and
included in this list are the torus or the buckling fracture. The cortex
becomes buckled or has a bump as a result of a compressive twisting
injury. A greenstick fracture, much like when you try to break off a
piece of a lilac bud on campus and it comes halfway off, breaks through
one cortex and the other remains intact. A similar type of injury can
occur in children. The bowing fracture, smooth curvature to the bone
without disruption of the cortex. Epiphyseal fractures, a variety of
fractures that actually involve the epiphyseal plate in various extents.
Often only an incomplete fracture line will be identified.

Buckle (TORUS) fracture

Compression failure of bone that
usually occurs at the junction of the
metaphysis and the diaphysis
Commonly seen in distal radius.
Inherently stable
Heal in 3-4 weeks with simple
immobilization.

Torus Fracture Radius

Can you identify the torus fracture on this pair of wrist films before I put
the arrows in place? Look carefully; look for any disruption of the
contours of the cortex. Normally the contour should be very smooth
with no sharp angulations. Here we see a small bump on the cortex
representing the site of the torus fracture; its also noted on the lateral
view as well.

Torus Fracture Radius

Here is another example of a torus fracture involving the radius with

buckling of the cortex as indicated by the yellow arrows.

Bowing
Fracture
Bowing fracture
of right fibula
Buckle fracture
of right tibia
Normal left for
comparison
Note the bowing fracture of the right fibula. The fibula has a slight
curvature convexity directed medially as a result of injury. There is also
on the same individual a buckling of the distal tibia, a buckle fracture.
Remember in paired bones, frequently both bones will either be
fractured or there will be a fracture dislocation. The left lower leg,
which is normal, is included for comparison purposes.

Greenstick fracture
Bone is bent and the tensile/convex
side of the bone fails.
Fracture line does not propagate to
the concave side of the bone,
therefore showing evidence of plastic
deformation.

Greenstick
Fracture Radius

Dorsal cortex
remains intact
Ventral cortex is
disrupted
Angulation is ventral
Here is an example of an individual with a
greenstick fracture. The dorsal cortex
remains intact while the ventral cortex is
disrupted. There is angulation directed
towards the ventral or palmar aspect or
anterior aspect of the forearm with the
patient in anatomic position.

 If the bone undergoes plastic

deformation, it is necessary to break
the bone on the concave side to
restore normal alignment, as the
plastic deformation recoils the bone
back to the deformed position

Complete fracture
Fracture completely propagates
through the bone.
Classified as spiral, transverse, or
oblique, depending on the direction
of the fracture line.

ANATOMY OF GROWING
BONE

Epiphysis
Physis
Metaphysis
Diaphysis
Periosteum

Terminology
Epiphyseal Plate = Growth Plate = Physis
Epiphysis

Secondary Ossification Center

Epiphysis and growth plate are NOT synonyms
The epiphysis is the bone located between the
articular surface and the physis

Metaphysis

Bone adjacent to the physis on the opposite side of

the epiphysis.

Diaphysis

The shaft of the bone

Growth Plate Injuries

Occur by various mechanisms
Fracture
Frostbite
Disuse
Chronic Stress
Radiation Iatrogenic injury
Infection Neural involvement
Tumor
Electrical Injuries
Vascular impairment Burns
Metabolic abnormality

Growth Plate Injuries

When entire physis is arrested
Bone length is retarded
If bone ends are arrested, longitudinal
bone growth ceases completely

When only part of physis is damaged

Length retardation can be accompanied
by angular deformity

PHYSEAL INJURIES
Many childhood fractures involve the
physis
20% of all skeletal injuries in children
Can disrupt growth of bone
Injury near but not at the physis can
stimulate bone to grow more

SALTER HARRIS
Classification system to delineate
risk of growth disturbance
Higher grade fractures are more likely to
cause growth disturbance
Growth disturbance can happen with
ANY physeal injury

SALTER HARRIS CLASSIFICATION

I
Fracture passes
transversely
through physis
separating epiphysis
from metaphysis

II
III
IV
V

SALTER HARRIS CLASSIFICATION

I

II
Transversely through
physis but exits through
metaphysis
Triangular fragment

III
IV
V

SALTER HARRIS CLASSIFICATION

I
II

III
Crosses physis and
exits through epiphysis
at joint space

IV
V

SALTER HARRIS CLASSIFICATION

I
II
III

IV
Fracture extends
upwards from the joint
line, through the
physis and out the
metaphysis

SALTER HARRIS CLASSIFICATION

I
II
III
IV

V
Crush injury to growth
plate

PHYSEAL FRACTURES
MOST COMMON: Salter Harris ___

PHYSEAL FRACTURES
MOST COMMON: Salter Harris _II_
I and II effectively managed by primary
care with casting (most commonly)

Dont forget to tell Mom and Dad that

growth disturbance can happen with
any physeal fracture

ITS GOOD TO BE YOUNG

Children tend to heal fractures faster
than adults
Advantage: shorter immobilization times
Disadvantage: misaligned fragments
become solid sooner

Anticipate remodeling if child has > 2

years of growing left
Mild angulation deformities often correct
themselves
Rotational deformities require reduction
(dont remodel)

ITS GOOD TO BE YOUNG

Fractures in children may stimulate
longitudinal bone growth
Some degree of bone overlap is acceptable
and may even be helpful

Children dont tend to get as stiff as adults

after immobilization
After casting, callus is formed but still may
be fibrous
Avoid contact activities for 2-4 weeks once out
of cast

Diagnosis:
Need Adequate Imaging
Supplement
plain x-rays
High Index of
Suspicion
Comparison
Views
CT scan
MRI

Adequate Imaging
Child
with
knee
pain
Fracture
difficult
to see

Adequate Imaging
Oblique Xray
Easy to see
Salter III of
the distal
femur

Adequate Imaging
Final after
reduction and
internal fixation
with
comparison
view

Adequate Imaging
Child with
ankle pain
Fracture
difficult to
see

Adequate Imaging
CT shows a Salter
III (Tilleaux)
fracture of the
distal tibia
Tilleaux Fractures
occur near the end
of growth as
medial portion of
distal tibial physis
closes before the
lateral side closes

Tilleaux Fracture
Post-operative and final x-rays after
hardware removal without residual deformity

Treatment
Goal of treatment of all physeal fractures
is to maintain function and normal growth
Attainment of these goals is most likely when
all structures are anatomically reduced
Therefore goal is to obtain and maintain
anatomic reduction
May be done by open or closed means
All reductions should be gentle to prevent damage to
the delicate physeal cartilage
Forceful, repeated manipulations should be avoided!
PetersonHA.PhysealInjuriesandGrowthArrest.InBeaty
JH,KasserJR,eds.FracturesinChildren.Philadelphia,PA:
LippincottWilliamsandWilkins,2001;91130.

FRACTURES OF ABUSE
Majority of fractures in child < 1 year are
from abuse
High percentage of fractures <3yo = abuse

Greater risk of abuse: first-born, premature

infants, stepchildren, children with learning
or physical disabilities
Most common sites: femur, humerus, tibia
Also: radius, skull, spine, ribs, ulna, fibula

Child Abuse Concerns

Unexplained fractures in different
stages of healing as shown on radiology
Femoral fracture in child < 1 year
Scapular fracture in child without a clear
history of violent trauma
Epiphyseal and metaphyseal fractures
of the long bones
Corner or chip fractures of the
metaphyses

CHILD ABUSE
If suspected, skeletal survey should
be considered
Bone scan may be useful as
complementary study

CONCLUSIONS
Nearly 20% of children with injury
have a fracture
Always take post-reduction x-rays
Physeal injuries are common and
may have no radiographic findings
Treat as fracture!!

Dont forget to tell Mom and Dad

about possible growth problems