1. Introduction to Pediatric Orthopaedics: Common Fractures
Stephen P. England, MD MPH
Department of Orthopaedic Surgery
Park Nicollet Orthopaedics

3. The Pediatric Skeleton
“Children are not simply small adults”
(though some adults are simply large children)

4. Pediatric Skeleton Less dense and more porous Lower bending strength
Lower mineral content
Periosteum is very thick
Presence of growth plates (physes)
Ends of long bones are nonossified cartilage
Tendon may be stronger than bone insertion sites (adolescents)

5. The Pediatric Skeleton
Comminuted fractures are uncommon
Large pores in the immature cortex can prevent propagation (greenstick)
Long plastic phase with loading relative to mature bone (plastic deformation)
Fail with compression - buckle fracture
Remodeling potential of fractures

6. Anatomy of the Pediatric Skeleton

7. Anatomic Differences
Epiphysis - the cartilaginous end with a secondary ossification center
Physis- the growth plate
Metaphysis - cylindrical end of long bones. This portion is more porous and has a thinner cortex than the shaft
Diaphysis – principal portion of the long bone or “the shaft”

8. Anatomic Differences Growth Plates
The most obvious difference is the presence of growth plates and thick periosteum
Growth plate injuries may lead to significant growth disturbances if managed poorly
Reduction of the growth plate injury must be precise

9. Anatomic Differences Periosteum
Periosteum has greater bone forming potential in children
It helps to maintain alignment of simple fractures
It also reduces the amount of displacement of fractures
Can aid in the reduction of fractures

10. Anatomic Differences Remodeling
Remodeling may make reduction accuracy somewhat less important than in an adult
Occurs in the plane of a joint (25 degrees / metaphyseal region / less than 8 years old)
Will not occur for rotational deformity or for angular deformity not in the plane of the joint
>10 degrees of angulation in the midportion of long bones is not acceptable

11. Remodeling and Healing
The younger the patient the greater the remodeling potential
Side-to-side apposition of long bone fracture fragments may be acceptable as long as shortening doesn’t occur
Intra-articular fractures must be anatomically reduced and will not remodel
Nonunions are virtually unheard of in simple pediatric fracture

12. Classification of Children’s Fractures
Plastic deformation
Buckle/Torus factures
Greenstick fractures
Complete fractures
Epiphyseal or Growth plate fractures

13. Plastic Deformation Unique to children
Most commonly seen in the ulna and fibula
May rarely occur in the femur as well

14. Plastic Deformation The angular deformity may be permanent
Without a hematoma, no significant callus will form
A fracture on the tension does not propagate

15. Buckle or “torus” fractures
Injury primarily in early childhood
Occurs at metaphyseal-diaphyseal junction
Secondary to compressive force
Very common
Heal in 2-3 weeks

16. Buckle fractures Also known as “torus” fractures
Treated in a short cast or splint for 2-3 weeks
No long term sequelae

17. Torus fracture = Buckle fracture
Torus = Latin for a cushion of this shape

18. Torus fracture = Buckle fracture
Torus = Ring at column base

19. Torus fracture = Buckle fracture
Torus = Ring at column base

20. Greenstick Fractures
Occur when a bone is bent with failure of the tension side
Fracture doesn’t propagate entirely through the bone
Compressive side undergoes plastic deformation
“Incomplete fracture”

21. Complete Fractures Spiral fractures Oblique fractures
Transverse fractures
Epiphyseal fractures

22. Spiral Fractures Created by a rotational force on the bone
An intact periosteum enables easy reduction by reversing the rotational injury
Broad fracture surface area

23. Oblique Fractures Occur diagonally across diaphyseal bone
Usually at approximately 30 degrees to the axis of the bone
May cause significant disruption of the periosteum
Broad fracture surface area

24. Transverse Fractures Occur from three-point bending
Butterfly fragments may occur
Small fracture contact/surface area

25. Epiphyseal Fractures
Injuries to the epiphysis of a bone usually involve the growth plate
Problems are uncommon but potentially serious
Distal radial physis is the most commonly injured physis
Growth plate heals quickly in 3-6 weeks

26. Salter-Harris Salter-Harris Epiphyseal Fracture Classification

27. Salter-Harris Type I
The periosteum usually stays intact and prevents displacement
The fracture runs directly through the growth plate

28. Salter-Harris Type II
The injury passes through the growth plate and out through a portion of the metaphysis

29. Salter-Harris Type III
An intra-articular fracture that passes through the epiphysis until it hits the growth plate
Usually occurs when the growth plate is partially closed

30. Salter-Harris Type IV
An intra-articular fracture which involves the epiphysis as well as the metaphysis
The fracture line crosses the growth plate
The physis must be anatomically reduced to prevent osseus bridge formation

31. Salter-Harris Type V
Originally described as a crush injury to the growth plate.
Difficult to diagnosis
May appear to be a Type I
Fortunately, an uncommon injury

32. Common Fractures Buckle fracture of the distal radius/ulna
Supracondylar humerus fracture
Femoral shaft fractures
Proximal tibial metaphyseal fracture
Toddler’s tibial shaft fracture
Distal fibular Salter-Harris Type I/II fracture
Special Circumstances
Pelvic Avulsion Fractures

33. Buckle fractures of the radius
Secondary to routine falls onto an extended limb
Present with varied pain
Treatment = short arm cast or splint for approximately 3 weeks
Follow-up with x-rays to assess healing
No long term sequelae

34. Treatment =Short Arm Cast (SAC)
May be applied with a waterproof liner
Should allow for full motion of the thumb and fingers
A well molded splint works just as well as a cast

35. Supracondylar Humerus Fractures
Common elbow fracture after a fall onto an extended limb
Graded Types 1,2, or 3 based up displacement of fragments
Require referral for orthopaedic management

36. Supracondylar fracture – Type 1
Non-displaced fracture
Require approximately 3-4 weeks in a long arm cast
Do not need to be manipulated or pinned
Heal with no consequence if well aligned

37. Supracondylar fracture – Type 2
Angulation of fractures noted on the lateral x-ray
Most common type is extended
Will require reduction of angulation while sedated
May require pins to assure stability while casted for 3-4 weeks

38. Supracondylar Fracture – Type 3
Fracture is angulated and displaced
Requires a reduction and pinning to maintain alignment
Will require 3-4 weeks of casting
Common referral from adult orthopaedist

39. Femoral Shaft Fractures
Treatment depends upon age of patient and location/configuration of the fracture
Operative management is replacing traction and spica casting
High energy injury
Child abuse should be considered in non-walkers

40. Femoral Shaft Fractures
Spica casting is still commonly used for children <4 y.o.
Results are good as long as fracture is well-aligned
Healing time is approximately 8 weeks

41. Femoral Shaft Fractures
Options for children between 5-12 include;
immediate spica
traction and spica
compression plate
external fixation
flexible intramedullary rod
Submuscular plate

42. Femoral Shaft Fractures
Adolescents require most stable fixation
Spica casting is not well tolerated
Options include:
Compression plate
External fixation
Flexible intramedullary rods
Rigid intramedullary nails

43. Proximal Tibia Metaphyseal Fractures or“Cozen Fractures”
A non-displaced fracture with potential growth consequences
Patients present after a fall with minimal trauma
X-rays show minor fracture in the proximal tibial metaphysis
Patient requires a long leg cast for about 4 weeks

44. Proximal Tibial Metaphyseal Fractures
Patient may develop ipsilateral genu valgum deformity
Secondary to “overgrowth” of the tibia relative to the fibula
Treatment = assurance, follow-up and observation until complete resolution

45. Toddler’s Fracture
Common fracture in 2-3 year olds after a routine twisting fall
Present with limp or refusal to bear weight
x-rays in AP, lateral and oblique may be necessary to see the fracture line

46. Toddler’s Fracture
Patient is managed in a short leg cast and allowed to weight bear as tolerated
Follow-up x-rays in 3 weeks will show periosteal new bone
Non-displaced hairline fractures are managed in a “pediwalker”/boot

47. Distal Fibular Physeal Fracture
Present after an inversion injury or “twisted ankle”
Equivalent of an adult ankle sprain
Patient is point tender over the distal fibula rather than the lateral ligaments
Adjacent ligaments may be sprained as well

48. Distal Fibular Physeal Fracture
X-rays are usually negative for displacement
A small metaphyseal fragment (SH II) may be seen adjacent to the physis
Management is in a short leg cast for approximately 4 weeks

49. Pelvic Avulsion Fractures
Avulsion fractures result when the fracture fragment is pulled from the bone by forceful contraction of a tendon or ligament
Avulsion fractures are most common in adolescents engaging in athletic endeavors        
In the pelvis, the apophyses, are the most likely portions of the bone to avulse   
       

50. Pelvic Avulsion Fractures
Seen almost exclusively in adolescent athletes with a 2:1 male to female preponderance       
They occur most often in track events like hurdling and sprinting, or games like soccer or tennis        
Most common to avulse is the ischial tuberosity followed by anterior inferior iliac spine (AIIS) and the anterior superior iliac spine (ASIS)

51. Clinical Features
Acutely, the athlete experiences a sudden, shooting pain referred to the involved tuberosity
They may lose muscular function
Swelling a local tenderness may occur
The clinical findings of the fracture are similar to those of a soft tissue injury
Frequently missed on initial assessment

52. Radiographs vs MRI Radiographs are the first line of assessment
MRI or CT scans are necessary only if radiographs are deemed “negative”.

53. Treatment
These avulsion fractures require rest. In general, they will heal with 4 to 6 weeks of rest.
Crutches should be used for most of this time.
In rare cases, if the bony fragment is large or is torn away from its original site by a significant distance, surgery may be required.
Pain from a pelvic avulsion fracture may take 1 to 3 months to go away.
Return too soon and you may worsen the injury.

54. Conclusions
The vast majority of pediatric fractures can be treated as an outpatient in a cast
Childen are not simply small adults
The operative management of complex pediatric fractures have predictably good outcomes
Fractures involving the growth plates and/or joints must be dealt with carefully in order to avoid complications