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Pediatric fractures

Last updated: October 13, 2020

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Pediatric fractures often have distinct fracture patterns due to the unique properties of growing bones. The periosteum in growing bones is thicker and stronger than in adult bones, which is why children are more prone to more incomplete fractures, such as the greenstick fracture or torus fracture. In addition, the periosteum is metabolically active. This feature also explains why childhood fractures heal faster than fractures in adults. Salter-Harris fractures are fractures of the epiphyseal plate, also known as the growth plate or the physis of long bones. These fractures only arise in children and adolescents, whose skeletal growth is not yet complete. Salter-Harris fractures are classified into 5 types according to the extent of damage to the growth plate and joint involvement.

  • Definition: fractures in which the fracture line is either absent or does not completely traverse the width of the bone (an intact periosteum and cortex are seen on at least one side of the bone)
  • Mechanism of injury: : usually a result of indirect axial force (e.g., fall on an outstretched hand, fall from a height) that leads to bending stress (greenstick fracture) or impaction (torus fracture)
Characteristics of incomplete fractures [1][2]
Type of incomplete fracture Radiographic findings Most common site Treatment
Buckle fracture (torus fracture)
  • Disruption of the cortex on the side of the compressive force (concave side), which appears as a bulge
  • The convex side is intact.
  • Mild or no angulation at the fracture site
  • Immobilization with a splint or a cast for 3–4 weeks
Greenstick fracture
  • Disruption of the cortex and periosteum on the side of tension (convex side) with an intact periosteum and cortex on the side of compression (concave side)
  • Some degree of angulation is usually present.
  • Acceptable angulation*: immobilization with a cast
  • Greater than acceptable angulation: closed reduction followed by immobilization with a cast
Bowing fracture
  • No disruption of the cortex or periosteum
  • Angulation is present.

*Acceptable angulation on X-ray [3]

  • 0–5 years: lateral view: 10–30°; AP view: ≤ 10°
  • 6–10 years: lateral view: 10–20°; AP view: ≤ 10°
  • > 10 years: lateral view: 5–15°; AP view: 0°

In greenstick fractures, the bone bends and breaks like a green (young) stick.

Minor angulations in pediatric fractures do not require manual reduction because they are often compensated during remodeling and growth.

Overview [4]

Clinical features

  • History of trauma (e.g., fall or collision)
  • Joint pain at rest or with movement
  • Swelling of the joint
  • Hematoma
  • Focal tenderness to palpation around the physis
  • Decreased range of motion
  • Inability to bear weight on the injured side

Mild clinical symptoms may lead to misdiagnosis.

Salter-Harris fracture classification [6]

SALTER: S – straight across the joint (type I); A – above the joint (type II); L – lower (type III); TE – through everything (type IV); R – ruined or rammed (type V)

Diagnosis

  • X-ray (AP and lateral views): Physeal widening may be the only finding.
  • MRI: may be helpful if radiographic findings inconclusive

Treatment [2][4]

Complications

  • Disruption of growth and bone deformity (especially Salter-Harris types III–V)
    • Results in limb-length discrepancies and/or angular deformities
    • Younger patients are more likely to experience growth arrest.
  • Excessive limb growth (rare)
  1. Schweich P. Midshaft forearm fractures in children. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/midshaft-forearm-fractures-in-children?source=see_link§ionName=Greenstick%20fractures&anchor=H16#H16.Last updated: October 8, 2015. Accessed: February 14, 2017.
  2. Mathison DJ, Agrawal D. General principles of fracture management: Fracture patterns and description in children. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/general-principles-of-fracture-management-fracture-patterns-and-description-in-children?source=search_result&search=greenstick%20fracture&selectedTitle=1~14#H7.Last updated: June 18, 2015. Accessed: February 14, 2017.
  3. Schweich P. Distal forearm fractures in children: Initial management. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/distal-forearm-fractures-in-children-initial-management?source=see_link§ionName=Greenstick%20fracture&anchor=H30#H30.Last updated: March 7, 2016. Accessed: February 14, 2017.
  4. Levine RH, Foris LA, Nezwek TA, Waseem M. Salter Harris Fractures. StatPearls. 2020 .
  5. Larsen MC, Bohm KC, Rizkala AR, Ward CM. Outcomes of Nonoperative Treatment of Salter-Harris II Distal Radius Fractures: A Systematic Review.. Hand (New York, N.Y.). 2016; 11 (1): p.29-35. doi: 10.1177/1558944715614861 . | Open in Read by QxMD
  6. Cepela DJ, Tartaglione JP, Dooley TP, Patel PN. Classifications In Brief: Salter-Harris Classification of Pediatric Physeal Fractures. Clinical Orthopaedics and Related Research®. 2016; 474 (11): p.2531-2537. doi: 10.1007/s11999-016-4891-3 . | Open in Read by QxMD
  7. Hedström EM, Svensson O, Bergström U, Michno P. Epidemiology of fractures in children and adolescents. Acta Orthop. 2010; 81 (1): p.148-153. doi: 10.3109/17453671003628780 . | Open in Read by QxMD
  8. Vaquero-Picado A, González-Morán G, Moraleda L. Management of supracondylar fractures of the humerus in children. EFORT Open Reviews. 2018; 3 (10): p.526-540. doi: 10.1302/2058-5241.3.170049 . | Open in Read by QxMD
  9. Salter Harris Classification of growth plate fractures. http://www.wheelessonline.com/ortho/salter_harris_classification_of_growth_plate_fractures. Updated: May 31, 2012. Accessed: February 14, 2017.