Pediatric Fractures

General Overview

  • Ligaments/tendons stronger than bone in young
  • Metaphysis/physis connection anatomic point of weakness
  • Children heal fracture faster
    • Soft callus at 2-3 weeks, hard callus at 3-12 weeks, remodeling months-years
  • Angulation deformities often remodeling if >2 years of growing (rotational deformities require reduction as they do not remodel)
  • Avoid contact activities 2-4 weeks out of cast (callus may still be fibrous)

Salter-Harris

  • 1- Same = Transverse through growth plate (X-rays may look normal, diagnosis made on clinically - swelling/tenderness over growth plate, treat and repeat imaging)
  • 2 - Above = Through metaphysis (most common)
  • 3 - Low = Through epiphysis
  • 4 - Through = Both metaphysis/epiphysis
  • 5 - Ram = Crush injury

Treatment

  • Usually, non-displaced type I-II fractures can be managed by casting and usually heal well
    • Should be monitored for 3-6 months after initial injury to ensure that normal bone growth resumes
  • Ortho referral
    • Type III-V fractures
    • Open fractures
    • Displaced intra-articular fractures
    • Vascular injury or compartment syndrome
    • Unstable
    • Rotational deformity
  • Pain control (ibuprofen)

Distal Radius

Torus/Buckle Fracture

  • Usually FOOSH
  • Removable wrist (volar) splint x 2-4 weeks
    • Start ROM if at 2w no tenderness (discontinue immobilization)
    • No need for repeat X-rays

Greenstick Fracture

  • Non-displaced
    • Short-arm cast x 2-4 weeks
  • Displaced >10 degrees angulation
    • Closed reduction (gentle steady pressure for physeal) under conscious sedation
    • Long-arm cast (elbow 90 degrees flexion, forearm in neutral rotation, and wrist in neutral flexion-extension
    • Repeat X-rays weekly
    • Remove cast at 4 weeks if healed clinically and radiographically

Physis Fracture

  • Non-displaced (if X-rays normal initially, tenderness over growth plate, immobilize x 2 weeks, re-image and re-assess)
    • Short-arm cast x 3-6 weeks

Elbow

  • Assess Vascular (Brachial) and Nerve (Ulnar/Anterior Interosseous Nerve)
    • Capillary refill, distal neurovascularity
    • Immobilize at flexion 20-30 degrees (least nerve tension) before X-rays to avoid further injury
  • X-ray approach
    • Fat pad (sail) sign, posterior always indicates effusion (rule out fracture)
    • Anterior humeral line should intersect middle 1/3 of capitellum (if not think supracondylar fracture)
    • Radiocapitellar line shoulder intersect capitellum, if not think radial head dislocation (rule out Monteggia fracture-dislocation)
    • Remember CRITOE (Capitellum, Radial head, Internal epicondyle, Trochlea, Olecranon, External epicondyle)
      • Age 1, 3, 5, 7, 9, 11
        • Consider image bilaterally

Supracondylar

  • For non-displaced, neurovascular intact
    • Long arm posterior splint then long arm casting with less than 90° of elbow flexion x 4 weeks with repeat X-ray

Lateral Condylar

  • FOOSH + Varus force
  • Non-displaced
    • Posterior splint, elbow 90°, weekly follow-up, if stable x2 weeks long-arm cast for 4-6 weeks

Proximal Humerus

  • Acceptable deformity
    • Age 1-4yo = 70° without displacement
    • Age 5-12yo = 40° and displacement <51% width of shaft
    • Age >12yo = 15° and displacement <30% width of shaft
  • If acceptable deformity, discuss conservative measures and consider Sarmiento brace with repeat X-rays in 2 weeks

Clavicular

  • Most commonly middle third of clavicle after fall on shoulder (or may be from FOOSH)
  • Broad arm sling (or figure of 8) 2 weeks until comfortable and fracture site non-tender
    • Repeat X-ray if lateral third fracture at 1 week (no repeat X-ray at middle-third)
    • ROM as tolerated (elbow/wrist/hand ROM throughout recovery)
    • Return to non-contact sports 6 weeks after injury
    • Avoid contact sports 1-2 months after healing
    • Advise that bony deformity possible
  • Refer to ortho if displaced medial or lateral third fracture

Tibial

  • Tibia fracture often occur with Fibula (look for plastic deformity)

Toddler's Fracture

  • Children <2yo learning to walk (often no history of trauma)
    • Fall with twisting motion or from significant height
  • Spiral fracture of distal/middle tibia (13-43% initial X-rays negative)
    • Pain with dorsiflexion of ankle
  • Rule out abuse (bruising, other fracture)
  • Non-displaced
    • Bent knee long-leg cast
      • X-rays weekly
      • May change to short-leg cast for 4-6 weeks if callus present
        • No evidence that casting speeds healing, but may decrease risk of displacement
      • Healing usually by 6-10 weeks
      • Varus deformity should remodel if <10 degrees
  • Refer to ortho if open, pathologic, displaced >10 degrees anterior angulation, >5 degrees varus/valgus angulation, >1cm shortening, concurrent tibia/fobular fracture