Overview of Pediatric Fractures

For all its strength and durability, the human skeleton is still at risk of fractures,
particularly the long bones of the arms and legs. If hit hard enough or forced in the wrong
direction, bones can bend, crack, splinter, or even snap in two or more. However, the type of
fracture that occurs is often determined by an individual’s age and overall health as by
circumstance.
Types of Fractures
Pediatric fractures include fractures in patients ranging from neonates to late
adolescence. They have unique patterns and management different from adults due to distinctive
anatomy, physiology, and biomechanics of developing bone. Pediatric bones, for example, are
springy and resilient, and the periosteum (the membrane that envelops bones) is still quite thick.
Since the forces acting on a child’s skeleton are defined by its body size and weight, childhood
fractures rarely involve severe displacement of bone or injury to soft tissues.
According to Skin Penetration
Fractures can be classified through skin assessment whether the broken bone punctured
the skin or not. Open or compound break through the skin while fracture while the closed or
simple fractures remain the skin intact.
According to Completeness of the Break
Another way of identifying the type of fracture is by the completeness of the break.
Complete fractures separate the bone in two, while an incomplete fracture does not break the
bone all the way through.

Figure 5. Open vs. Closed and Complete vs. Incomplete Fractures

According to Fracture Lines
There are different types of Fractures according to their fracture lines, namely:
 1. Greenstick fractures are a common type of long bone pediatric fracture according to the
pattern, is characterized as incomplete where one side of the bone is broken, and the other
side is bent (cracks in only one side of the cortex).
2. Torus fractures, also known as buckle fractures, are also common in pediatrics which
are described as incomplete where compression of the bony cortex on one side with the
opposite cortex remains intact.
3. Transverse fractures pattern straight across the bone shaft (perpendicular to the long
axis).
4. Oblique fractures occur at an angle.
5. Spiral fractures result from a rotatory mechanism that twists around the bone shaft; on
x-rays, they are differentiated from oblique fractures by a component parallel to the
long axis of bone in at least one view.
6. Comminuted fractures are more common in adults having more than two bone
fragments. Comminuted fractures include segmental fractures (2 separate breaks in a
bone).
7. Avulsion fractures are caused by a tendon dislodging a bone fragment.
8. Impacted fractures are described as bone fragments being driven into each other,
shortening the bone; these fractures may be visible as an abnormal focal density in
trabeculae or irregularities in the bone cortex.

Figure 6. Common Pediatric Fracture Line Patterns

Fracture Hematoma
During a fracture, small blood vessels in the bone and surrounding muscle tissues often
rupture, causing bleeding and swelling at the fracture site called fracture hematoma. The
bleeding distends into the periosteum, full of nerve endings, and makes any pressure or
movement acutely painful. Blood also leaks into the surrounding tissues and can even travel
quite a distance from the fracture site, leading to additional pain and stiffness. The blood
eventually works its way to the skin’s surface, where it forms a bruise. And like all bruises, it
begins as a deep purple, then slowly changes to shades of green and yellow as the body reabsorbs
the blood.

Most Common Pediatric Fractures

The mechanisms of fracture change as children age. Younger children are more likely to
sustain a fracture while playing and falling on an outstretched arm. Older children tend to injure
themselves while playing sports, riding bicycles, and in motor vehicle accidents. Furthermore,
pediatric ligaments are more vital than adults; forces that would tend to cause a sprain in an older
individual will be transmitted to the bone and cause a fracture in a child. Caution should
therefore be exercised when assessing a young child diagnosed with a sprain.

1. Plastic Deformation is unique in children, mostly seen on the ulna where the bone shape
is altered without a fracture line. This happens when a large amount of force is produced
on the bone resulting in microscopic failure on the convex side, which does not propagate
to the concave side. The bone is angulated beyond its elastic limit, but the energy is
insufficient to produce a fracture. A bend in the ulna of more than 20 degrees in a 4-year-
old child should correct with growth.
2. Torus or Buckle fracture is the compression failure of bone that usually occurs at the
metaphysis and diaphysis junctions. These are commonly seen in the distal radius and are
inherently stable. The healing period is about three to four weeks with simple
immobilization.
3. Greenstick fracture is a bent bone, and the tensile/convex side of the bone fails most
frequently seen in the forearm. The fracture line does not propagate to the concave side
of the bone, therefore showing evidence of plastic deformation. In case of the bone has
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.
4. Complete fracture that is wholly propagated through the bone. This can be classified as
spiral, transverse, or oblique, depending on the direction of the fracture line.
a. Spiral Fractures are created by a rotational force and are considered low-velocity
injuries. An intact periosteal hinge enables the orthopedic surgeon to reduce the
fracture by reversing the rotational injury.
b. Oblique Fractures occur diagonally across the diaphyseal bone at 30 degrees to the
axis of the bone. This is deemed as unstable. Therefore, alignment is necessary.
Fracture reduction is attempted by immobilizing the extremity while applying
traction.
c. Transverse fractures are created by a 3-point bending force and can be easily
reduced by using the intact periosteum from the concave side of the fracture force.

5. Physeal fractures are unique in pediatric patients affecting the growth plate (physis).
This may be caused by 1) crushing, 2) vascular compromise of the physis, or 3) bone
growth bridging from the metaphysis to the bony portion of the epiphysis. Damage to the
growth plate may result in 1) progressive angular deformity, 2) limb-length discrepancy,
or 3) joint incongruity. When the closure of only a part of the plate occurs, angular
deformities may be present. Most commonly, the distal radial physis is frequently the
injured physis. Complications are usually found when fractures of the distal tibia and
distal femur are involved. Most physeal injuries heal within three weeks. This rapid
healing provides a limited window for the reduction of deformity.

Physeal injuries are classified by the Salter-Harris (SH) classification system based on
the radiographic appearance of the fracture. This is a method used to grade fractures that
occur in children involving the growth plate, also known as the physis or physial plate.
The classification system grades fracture according to the involvement of the physis,
metaphysis, and epiphysis. The fracture grade has important implications for both
prognosis and treatment.

Figure 7. Salter Harris Classification of Physeal Injuries

a) Salter I (Slipped). This is when the fracture line extends through the physis or within
the growth plate. Type I fractures are due to the longitudinal force that splits the
epiphysis from the metaphysis. Beware that a normal radiograph cannot exclude a
physis injury in an asymptomatic pediatric patient. A radiograph may be average due
to lack of bony involvement, and mild to moderate soft tissue swelling may be noted.
Look for the widening of the physis or displacement of the epiphysis, which may
suggest a fracture. Diagnosis is based on clinical findings, such as focal tenderness or
swelling surrounding the growth plate. An example is Slipped Capital Femoral
Epiphysis (SCFE).
 b) Salter II (Above). These are when the fracture extends through both the physis and
metaphysis. These are most common and occur away from the joint space. When the
small corner of the metaphysis is visible, this is known as a corner sign or Thurston-
Holland fragment. Be careful in using the terms proximal and distal to describe the
extension because the position of the physis is relative to the metaphysis and is not
fixed. If the proximal end of the bone is involved, the physis is proximal to the
metaphysis, so this extends distally from the physis into the metaphysis. If it involves
the distal end of the bone, the physis is distal to the metaphysis, so this extends
proximally from the physis into the metaphysis.
c) Salter III (Lower). This is an intra-articular fracture extending from the physis into
the epiphysis. If the fracture extends the complete length of the physis, this type of
fracture may form two epiphyseal segments. Since the epiphysis is involved, damage
to the articular cartilage may occur.
d) Salter IV (Through/Transverse). This is also an intra-articular fracture, in which the
fracture passes through the epiphysis, physis, and metaphysis. As this fracture
involves the epiphysis, the articular cartilage may be damaged. Types III and IV
fractures carry a risk of growth retardation, altered joint mechanics, and functional
impairment. They, therefore, both require urgent orthopedic evaluation.
e) Salter V (Rammed/Ruined). This fracture type is due to a crush or compression
injury of the growth plate. In type V, the force is transmitted through the epiphysis
and physis, potentially disrupting the germinal matrix, hypertrophic region, and
vascular supply. Though Harris-Salter V fractures are very rare, they may be seen in
electric shock, frostbite, and irradiation cases. This fracture pattern results from
severe injury; these typically have a poor prognosis leading to bone growth arrest.

6. Supracondylar fracture is an injury to the humerus, or upper arm bone, at its narrowest
point, just above the elbow. Supracondylar fractures are the most common type of upper
arm injury in children. They are frequently caused by a fall on an outstretched elbow or a
direct blow to the elbow. These fractures are relatively rare in adults. Surgery isn’t
always required. Sometimes a hard cast may be enough to promote healing.
Complications of supracondylar fracture can include injury to nerves and blood vessels or
crooked healing (malunion).

There are different types of Supracondylar Fracture based on the degree of displacement
according to Gartland Classification, namely:
a) Type I: minimal or no displacement of the fracture. There is a regular anterior
humeral line on the x-ray. Often only abnormalities are abnormal fat pads.
b) Type II: with posterior displacement, the posterior cortex remains intact, and with
anterior displacement, the anterior cortex remains intact.
c) Type III: completely displaced with complete cortical disruption.2
d) Type IV: The periosteum is completely torn and is the most unstable type of fracture
(can only be diagnosed intraoperatively).
 Figure 8. Gartland Classification of Supracondylar Fracture

7. Apophyseal avulsion fractures of the pelvis are rare injuries that typically occur in
adolescent athletes. At this age, the secondary ossification at the apophyses coincides
with the hormonally induced strengthening of the muscles. Sudden large tension forces
can be applied through the musculotendinous units due to forceful concentric muscle
contraction or passive lengthening of the power, especially during sporting activities.
Because the cartilaginous growth plates at the apophyses of the adolescents are more
prone to trauma than the musculotendinous units, they may fail to result in an avulsion
fracture of the pelvis. Patients usually report a crack in the pelvic region during an
activity with a sudden onset of pain. The pain is more severe during activity and
decreases with rest. Clinical examination reveals local tenderness, limitation of motion,
and swelling.

References:
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