Introduction to Pediatric
Orthopaedics:
Common Fractures
Stephen P. England, MD MPH
Department of Orthopaedic Surgery
Park Nicollet Orthopaedics
The Pediatric Skeleton
“Children are not simply small adults”
(though some adults are simply large
children)
Pediatric Skeleton
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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)
The Pediatric Skeleton
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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
Anatomy of the Pediatric Skeleton
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”
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
Anatomic Differences
Periosteum
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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
Anatomic Differences
Remodeling
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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
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
Classification of Children’s Fractures
Plastic
deformation
Buckle/Torus factures
Greenstick fractures
Complete fractures
Epiphyseal or Growth plate
fractures
Plastic Deformation
 Unique
to children
 Most commonly seen
in the ulna and fibula
 May rarely occur in
the femur as well
Plastic Deformation
 The
angular deformity
may be permanent
 Without a hematoma,
no significant callus will
form
 A fracture on the
tension does not
propagate
Buckle or “torus” fractures
 Injury
primarily in
early childhood
 Occurs at
metaphysealdiaphyseal junction
 Secondary to
compressive force
 Very common
 Heal in 2-3 weeks
Buckle fractures
 Also
known as
“torus” fractures
 Treated in a short
cast or splint for 2-3
weeks
 No long term
sequelae
Torus fracture = Buckle
fracture
 Torus
= Latin for a cushion of this shape
Torus fracture = Buckle
fracture
Torus
= Ring at column base
Torus fracture = Buckle fracture
 Torus
= Ring at column base
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”
Complete Fractures
Spiral
fractures
Oblique fractures
Transverse fractures
Epiphyseal fractures
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
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
Transverse Fractures
 Occur
from threepoint bending
 Butterfly fragments
may occur
 Small fracture
contact/surface
area
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
Salter-Harris
Salter-Harris Epiphyseal
Fracture Classification
Salter-Harris Type I
 The
periosteum
usually stays intact
and prevents
displacement
 The fracture runs
directly through the
growth plate
Salter-Harris Type II
 The
injury passes
through the growth
plate and out
through a portion of
the metaphysis
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
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
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
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
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
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
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
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
Supracondylar fracture –
Type 2
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Angulation of fractures
noted on the lateral xray
Most common type is
extended
Will require reduction of
angulation while
sedated
May require pins to
assure stability while
casted for 3-4 weeks
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
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 nonwalkers
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
Femoral Shaft Fractures
 Options
for children
between 5-12
include;
 immediate spica
 traction and spica
 compression plate
 external fixation
 flexible
intramedullary rod
 Submuscular plate
Femoral Shaft Fractures
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Adolescents require
most stable fixation
Spica casting is not
well tolerated
Options include:
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Compression plate
External fixation
Flexible
intramedullary rods
Rigid intramedullary
nails
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
Proximal Tibial Metaphyseal
Fractures
 Patient
may
develop ipsilateral
genu valgum
deformity
 Secondary to
“overgrowth” of
the tibia relative to
the fibula
 Treatment =
assurance, followup and
observation until
complete
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
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
Distal Fibular Physeal Fracture
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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
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
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
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)
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
Radiographs vs MRI
 Radiographs
are the
first line of
assessment
 MRI or CT scans are
necessary only if
radiographs are
deemed
“negative”.
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.
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