Pediatric Orthopedic Surgery
In general, the younger the orthopedic patient, the greater is the chance for remodeling of bone. A fracture in a young person doesn’t have to be as tightly realigned because remodeling will take hold and the bone will heal properly.
The leading cause of death in the 1-14 year age group is an accidental injury. About 10-15 percent of all childhood injuries will involve bony injury. A large majority of these injuries will involve a finger or a toe. There has been an increase in bony injuries among children in the last 50 years—mostly because of a greater participation in sporting activities. The incidence of fracture is highest among boys with 42 percent of boys up until the age of 16 suffering from a fracture, compared to only 27 percent of girls in the same age range. Most boys will get their fracture at about sixteen years of age, while the peak age for fractures in girls being 12 years of age. Fortunately, it is rare for a young person to sustain an open fracture of any kind.
The bones of children contain more water and less mineral content when compared to adults. This makes the pediatric bone more supple; it takes more effort to fracture a pediatric bone. Children’s bones contain an area known as the epiphyseal plate. Because it is a weak point in the bone, fractures tend to occur along this plate, which is where the bone grows from. There is a thick periosteum surrounding the entire bony surface with the exception of the joint surfaces.
The growth plate is divided into four zones:
- Resting zone—the source of bone stem cells
- Proliferative zone—mitosis occurs and there is a matrix of primarily collagen
- Hypertrophic zone—the chondrocytes increase markedly in size
- Metaphyseal zone—the bone is beginning to be mineralized
In general, the ligaments in kids are stronger than the bone so there are more fractures in kids and sprains in adults.
Mechanism of Injury
Pediatric fractures happen at lower energy levels than is seen in adults. Torsion, bending, and compression are the main mechanisms of injury. Compression fractures are usually also called buckle fractures and occur at the metaphyseal-diaphyseal junction. Torus fractures can cause angular deformity but don’t cause physeal injury. Torus fractures are impacted so they are very stable and rarely require closed reduction.
In torsional injuries, the diaphysis fails before the epiphysis so that there is a spiral fracture to bone. In an older child, the injury is at the level of the epiphyseal plate. Fractures from bending forces usually lead to greenstick fractures, which do not go all the way through the bone. Some bending fractures do not show up on x-ray and yet they grow out with an angular deformity. Older kids with bending forces tend to get oblique fractures or butterfly segments. Buckling of the cortex may be the only sign of this type of fracture.
Most pediatric trauma cases need a full trauma evaluation including c-spine films, chest x-ray, pelvic x-ray and attention paid to the airway and circulation. A trauma team for pediatric patients often oversees these types of fractures.
Children are better tolerant of pain than adults so this must be taken into account when evaluating the pediatric trauma patient for injuries. Neurovascular assessment should be done initially and periodically thereafter because it might not show up right away. Compartment syndrome can happen with long bone fractures and this must be evaluated in pediatric patients.
Child abuse must be considered in pediatric trauma patients, especially if there is a transverse fracture of the femur in an infant or a transverse fracture of the humerus in a child under the age of 3. If the history is inconsistent with the pattern of injury then child abuse must be suspected. The same is true if there are fractures at various stages of injury or an unwitnessed injury. Bruising should alert the doctor to the possibility of child abuse. Hospital admission should be undertaken if child abuse is suspected.
X-rays should include the joint above and the joint below the level of the fracture. If the area of injury is unclear, the whole extremity should be x-rayed. Comparison x-rays of the opposite side of the body may be necessary in order to get a side-by-side comparison of the extremities for evaluation of subtle fractures.
Complicated fractures that may involve joints require a CT scan of the affected area. Bone scans are used whenever there is suspicion of tumors or osteomyelitis. Ultrasound can be used in babies with suspected epiphyseal disruption.
Classification of Pediatric Fractures
There is the Salter-Harris classification which describes different types of epiphyseal plate fractures. The different types depend on where in the epiphyseal plate the fracture has occurred. The Ogden classification is another way of describing epiphyseal injuries.
Treatment of Pediatric Fractures
The periosteum is tough so that pediatric fractures are easier to reduce. Unfortunately, the periosteum does not allow for traction to be very successful in pediatric fracture cases. The presence of a sharp fracture penetrating the periosteum can also prevent normal reduction of the fracture. Because childhood fractures heal very quickly, reduction should not be attempted if 5-7 days have elapsed since the time of injury. Fracture deformity can be allowed in many childhood fractures because they remodel so easily. The closer the fracture is to the joint, the more remodeling occurs so the fracture can be deformed and can still heal well. Midshaft fractures should have more attention paid to alignment.
Severely comminuted fractures in kids may need skin traction. Traction pins should be used to put traction on the bone. Conscious sedation can be done to reduce the fracture prior to applying traction. Casts or splints must include the joint above and the joint below the fracture site. If reduction cannot be done under conscious sedation, then general anesthesia may be required.
Complications of Pediatric Fractures
Some complications include growth arrest of the bone if the epiphyseal plate is damaged. There can be progressive angular or rotational deformities if only partial epiphyseal plate damage has occurred or there are metaphyseal fractures of bones like the proximal tibia. Osteonecrosis can occur if the circulation is not adequate in pediatric fractures.
Elk Grove Personal Injury Lawyer
I’m Ed Smith, an Elk Grove Personal Injury Lawyer who has been handling serious cases involving fractures in children since 1982. Call me anytime for free, friendly advice at (916) 694-0002 in Sacramento or (800) 404-5400 Elsewhere in California.
Image Attribution: By English: Senior Airman Tiffany Trojca [Public domain], via Wikimedia Commons