Pediatric Fractures in Developing Bone

Author(s): Mi Ran Shin, MD, Melissa Fleming, MD

Originally published:09/15/2015

Last updated:11/08/2019

1. DISEASE/DISORDER

Definition

Pediatric fractures include fractures in patients ranging from neonates to late adolescence. They have unique patterns and management different from that of adults due to distinctive anatomy, physiology, and biomechanics of developing bone.1

Etiology

Trauma is a leading cause of pediatric fractures, which are often associated with sports injuries, motor vehicle accidents (MVA), falls, and child abuse.

Stress or fatigue fractures may occur without a single specific incident of trauma. Other fractures which occur with low or no trauma may be termed pathological or fragility fractures and indicate pediatric osteopenia or low bone density for age. Differential diagnosis can include demineralization from paralysis or disuse, nutritional deficiency, chronic corticosteroid use, renal or hepatic disease, genetic conditions such as osteogenesis imperfecta or Caffey disease or any early onset neuromuscular disease causing poor bone development.  It is important to realize that these fractures may be mistaken for child abuse due to the apparent mismatch of history with injury.2,3

Epidemiology including risk factors and primary prevention

Fractures are common in children, occurring at a rate of 12 to 30 per 1000 children every year.4 Fractures account for 10 to 15% of childhood injuries. Approximately 42% of boys and 27% of girls will sustain a fracture between birth and 16 years of age. Overall incidence of childhood fractures has been rising in the United States.

Fracture incidence increases with age from birth to a peak between ages 10 to 14 years old. 5 Boys are more than 50% more likely than girls to sustain a fracture.5 Fractures of the lower arm are the most common, accounting for 18% of all fractures, followed by finger and wrist fractures.5

Fractures involving the growth plate constitute about 20% of all fractures in skeletally immature patients and peak at 13-14 years in boys and 11-12 years in girls.1

Wrist and forearm fractures account for nearly half of all pediatric fractures. The tibia is the most commonly fractured bone of the lower limb in children.1

Factors contributing to fractures include low socioeconomic status, African American race, obesity, summer season, and risk taking behaviors. Any risk factors for decreased bone density such as eating disorder or poor nutrition, chronic corticosteroid or performance-enhancing drug use, smoking, and genetic factors can contribute to both traumatic and low trauma fracture occurences.5,6

Sports-related injuries, including extreme sports, account for a majority of fractures in middle and high school age children. Popular recreational play devices such as Heelys, scooters, and all-terrain vehicles are highly associated with fractures.

High-velocity injuries such as MVAs and falls are common causes of pediatric multi-trauma with fractures.5

Patho-anatomy/physiology

Biomechanically different from adult bone, pediatric bone is significantly less dense, more porous and is penetrated by capillary channels. It is less stiff due to having a higher proportion of cartilage, which makes it easier to bend, allows greater energy absorption before fracture, and causes the fracture line to propagate differently compared to adult fractures.1 Also, children have decreased motor control and a greater head to body weight ratio, resulting in different patterns of fracture than adults.4 Pediatric periosteum is thicker and stronger, which can produce a larger callus more rapidly and allow faster healing and maintenance of the bone alignment.1,2

Pediatric long bone has three regions: epiphysis, physis (growth plate), and metaphysis. As compared to the ligaments or metaphysis, the physis is the anatomic weak point and is more likely to be damaged by external forces.1

The relationship between muscle and bone is complex. According to the theory by Frost, skeletal tissue is responsive to the forces exerted upon it and bone adapts to the mechanical loads that are placed upon it during muscle contraction. 7 Muscle can also promote bone mineral deposition toward the periosteum. Cortical bone geometry and muscle mass and size have positive relationships.

Certain pre-existing or genetic condition can predispose to fracture. One of them is having gracile bones, bones that are more slender than usual (over-tubulated) and occasionally deformed in other ways such as being abnormally curved. Conditions such as X-linked SMA, neurofibromatosis type 1, muscular dystrophy, osteogenesis imperfecta can have gracile bones and are at a higher risk for having fractures.

Although most fractures in children heal well without long-term complications due to the reasons above, those fractures involving the physis and articular surfaces can cause more significant complications. Fractures that are in the plane of motion of the adjacent joint have the most remodeling potential; those angulated in the coronal plane have some; and those that are rotationally displaced have almost none.

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Besides common fractures such as transverse, oblique and spiral fractures, children have unique pediatric fracture patterns.

  1. Buckle or torus and greenstick fractures: Most frequently seen in forearm fractures
  2. Physeal fracture: Occurs in 21 to 30 percent of long bone fractures; common in distal radial physis;
    1. Salter-Harris classification (I to VI types) is often used. The higher the classification, the more likely it is for physeal arrest or joint incongruity to occur. One exception might be a completely displaced Salter-Harris type I fracture.
    2. Proximal humerus fracture has a low potential for causing growth disturbance while distal femur and tibia physeal fracture will affect growth.
  3. Plastic deformation where the bone shape is altered without fracture is common in the ulna
  4. Apophyseal avulsion

Specific secondary or associated conditions and complications

Child abuse concerns:

  1. A history of injury that is inconsistent between caregivers or different retellings by the same caregiver, delay in seeking care, or inconsistent with the observed injury or developmental capability of the child;
  2. Multiple fractures in different stages of healing;
  3. Epiphyseal-metaphyseal (“corner”) fractures from pulling and twisting forces;
  4. Rib fractures;
  5. Distal femoral metaphyseal fractures in 1 year old or younger

Complications of fracture:
Acute:

  1. Neurovascular injury
  2. Hemorrhage
  3. Fat embolism
  4. Compartment syndrome

Chronic:

  1. Premature growth plate fusion leading to limb length discrepancy
  2. Nonunion/pseudarthrosis
  3. Malunion
  4. Post-traumatic osteolysis
  5. Avascular necrosis
  6. Deep venous thrombosis or pulmonary embolism
  7. Refracture
  8. Complex regional pain syndrome

2. ESSENTIALS OF ASSESSMENT

History

A thorough history provided by the caregiver and/or patient is critical for assessment and management. However, toddlers or young children may not be able to describe their symptoms or surrounding circumstances. Helpful questions include:

  1. Characterization of the pain (location, intensity, quality, duration, progress, radiation, aggravating or alleviating factors) and whether the patient is able to bear weight
  2. Mechanism of injury (Was it witnessed? Is mechanism in proportion to injury and child’s developmental age?)
  3. Presence of neurological complications such as weakness or sensation changes
  4. Medical conditions and medication list
  5. In utero, birth, and neonatal history
  6. Developmental and behavior history
  7. Diet history, especially if the child appears undernourished
  8. Familial history of fractures or bone or collagen disorders
  9. History of prior fractures

Physical examination

A thorough physical exam of the symptomatic area or joint as well as the joint above and below is critical. Important features include:

  1. The child’s mood and behavior (i.e. irritable, tearful, guarding)
  2. Inspection: swelling, asymmetric deformities, abnormal limb angulation, limb length discrepancy, malnourishment, poor hygiene, soft tissue injuries, burns, erythema, skin changes such as ecchymosis or presence of multiple ecchymosis in different stages of healing
  3. Palpation: Temperature, point tenderness, and tightness
  4. Evaluation of the joint and distal neurologic and circulatory function: AROM and PROM, muscle tone, strength, contracture and joint effusion
  5. Gait including observing whether the patient is weight bearing
  6. Ophthalmologic examination for suspected child abuse (rule out retinal hemorrhages), observe for blue or icteric sclera

Clinical functional assessment: mobility, self care cognition/behavior/affective state

The patient’s behavior and functional capacity should be assessed and compared with status prior to injury. The assessment includes whether the patient is exhibiting a change in mood or behavior, difficulty bearing weight, or participating in age-appropriate activities (i.e. running, jumping, self-grooming, feeding, and socializing) after the injury.

Laboratory studies

Generally, imaging modalities rather than laboratory studies are performed for pediatric fractures.

In cases of suspected rickets, a 25-hydroxy Vitamin D level may be ordered.

In suspected osteomyelitis, blood tests such as CBC (WBC), ESR, CRP, and blood, bone, and joint aspirate cultures may be performed.

Abnormal bone fragility should be suspected in case of fracture at femur, hip and spine without trauma. Consider testing for serum 25-hydroxyvitamin D, calcium, phosphate, creatinine, parathyroid hormone, thyroid stimulation hormone and free T4. Testing for growth and sex hormones, CPK, nutritional screening such as pre-albumin and tests for inflammatory bowel or celiac disease and genetic testing referral may be appropriate as well.6

Imaging

The first line imaging study is plain radiograph (AP and lateral views) including the proximal and distal joints.  Comparison with the unaffected side helps differentiate between normal growth plate versus pathologic fracture. If the child has low energy fractures, lateral thoracolumbar spine imaging is warranted since 40% of the vertebral fractures may be asymptomatic.6

A complete skeletal survey is warranted for suspected non-accidental trauma.  This survey includes AP views of the entire skeleton, with dedicated study of the hands, feet, and lateral views of the skull and spine.  Lateral views of the joints and orthogonal views of identified fractures may prove to be useful.4

When osteogenesis imperfecta is suspected, a skull x-ray should be ordered to check for the presence of wormian bones.

CT scanning is more sensitive for detection of subtle or occult fractures, as well as characterizing fracture patterns, such as comminuted and displaced fractures.3 However, given the large doses of ionizing radiation, it should be used with caution.

MRI is sensitive to detect osseous, cartilaginous and marrow lesions. MRI can also better characterize soft tissue injuries that may accompany a fracture. However, MRI is expensive and has prolonged scan times, requiring cooperation or sedation in children.3

Ultrasound is valuable in evaluating neonatal skeletal abnormalities, commonly used for hip exam.8

DEXA is the gold standard when low bone density is suspected.9

Supplemental assessment tools

In addition to a thorough physical examination and laboratory/imaging workup, orthopedic surgeons generally perform an additional physical examination under anesthesia at the time of surgery. This minimizes pain to the patient and eliminates any volitional guarding that the patient may exhibit while awake and conscious.

Early prediction of outcomes

Prognosis and recovery largely depend on the location and severity of injury. Fractures that involve the physis, epiphysis, and joint generally cause cessation of growth (physeal arrest), limb-length discrepancy, angular deformities, and joint incongruity.1,4

Environmental

The physical environment plays a role in the mechanism of injury. Physically active children may sustain a fracture during sports-related activities as a result of a fall or collision with another player or equipment.

Children with disabilities may sustain a fracture if they are placed in an unsafe environment that does not accommodate their functional deficits.

Social role and social support system

Lower-extremity fractures and prolonged immobilization can negatively affect the child’s adjustment and family function from the time of the injury to six months or a year later.5 When a previously independent child requires assistance for mobility, transportation, and ADLs due to injury, a supportive and familiar social system will help facilitate recovery and healing.

Professional issues

In cases of suspicion of child abuse, the clinician is legally obligated to make a report to Child Protective Services. The abused child should receive adequate supportive measures and counseling, and consideration of foster placement if the home environment and/or primary caregiver are unable to maintain and preserve the child’s safety.10

3. REHABILITATION MANAGEMENT AND TREATMENTS

Available or current treatment guidelines

There are no published general clinical guidelines for rehabilitation of pediatric fractures. The primary goals of rehabilitation in pediatric patients should focus on pain reduction, healing, rapid recovery of mobility, and avoidance of late complications of joint stiffness, muscle atrophy and disuse osteopenia. Children with multiple fractures will benefit more from early physical therapy. Depending on the stage of recovery, passive and active range of motion, soft tissue stretching techniques, strengthening exercises, prevention of abnormal movement patterns, promotion of appropriate alignment and gait training should be implemented to maximize functional outcome.

At different disease stages

Most pediatric fractures can be treated with a cast without concern for developing joint contractures.4 Only 4-5% of fractures in children require surgery.1

Acute physeal fractures

  1. 90% non-operative treatment
    1. Salter-Harris Types I and II – generally with closed reduction using splint or cast
  2. 10% operative
    1. Salter-Harris Types III and IV – generally with open reduction
  3. Deformity may result
    1. Angular deformity
      1. Better tolerated in the upper extremity than the lower extremity
    2. Valgus vs. varus
      1. Valgus deformity is better tolerated than varus
    3. Flexion vs. extension
      1. Flexion is better tolerated than extension deformity
    4. Proximal vs. distal lower extremity
      1. Proximal deformity is better tolerated than distal deformity

Open Fractures

  1. Debridement, irrigation, antibiotics and reduction with stabilization

Pathological Fractures

  1. Surgery may decrease morbidity and immobilization
    1. Open reduction and internal fixation (ORIF) most common

Birth Fractures

  1. Clavicle, humerus, hip and femur are most commonly involved
  2. Rarely require surgery, but associated with nerve injury, infection, or dislocation

Fractures from Child Abuse

  1. Usually occur between birth and 2 years of age
  2. Most common locations: humerus, tibia and femur
  3. Rarely require surgery

Coordination of care

Coordination of care between a physiatrist, an orthopedic surgeon, endocrinologist, a physical therapist and/or an occupational therapist is recommended for a successful recovery of the child suffering a pathologic fracture. Depending on the pathophysiology, involvement of a geneticist for workup and management of a pathologic bone fracture should be considered. A neurologist may be helpful if an underlying neuromuscular condition is suspected. Most uncomplicated fractures may not need all specialties involvements and may not need therapy services.

Patient & family education

Family education includes monitoring the child’s neurovascular status, recognizing signs of compartment syndrome, and performing skin/wound care. Follow up is necessary to ensure appropriate progression of recovery. Age appropriate anticipatory guidance should also be routinely provided to prevent any additional injury. Early bone health counseling including healthy weight, calcium and vitamin D intake, and regular weight bearing physical activities should be provided.

Measurement of Treatment Outcomes including those that are impairment-based, activity participation-based and environmentally-based

Recovery is slower in older children and in children who have a longer period of immobilization and a more severe injury. Despite appropriate care, there is the possibility of developing a growth disturbance. Upper extremity fractures cause activity restriction in 72% of children for average of 14 days and lower extremity fractures cause activity restriction in 84% of children averaging 26 days.11

The 3 scales used to evaluate different modalities of treatment for musculoskeletal trauma are the Activities Scale for Kids, the Pediatric Functional Health Outcomes Instrument, and the Pediatric Outcome Data Collection Instruments.1

Other scales including region-specific outcome measures, which focus on body parts, combining physician-assessed parameters, functional abilities, and patient’s perception of pain.

Translation into Practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Healing is rapid in pediatric fractures because of the thickened and extremely osteogenic periosteum. Healing corresponds with the child’s age: the younger the child, the more rapidly the healing. In most cases of pediatric fractures, closed reduction followed by a short time in a cast restores normal function.12

Pediatric fractures should be treated as early as possible due to their fast healing. Early treatment may decrease later complications such as malunion or non-union.12

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

Computer-assisted corrective surgery has been proposed as a technique for reconstructing malunited long bone deformities. Three-dimensional computer assisted planning is thought to help understand the deformity and plan the surgery more thoroughly with improved precision.13

Ultrasound imaging has a role in evaluating pediatric fractures. The advent of inexpensive, portable, high-resolution ultrasound (US) machines for use at the emergency room bedside offers an alternative imaging paradigm for long bone fracture diagnosis and management. It avoids radiation from radiographs, and also it saves time by providing real-time image. New ultrasonography techniques for various fractures are being published with positive results.

5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

Traditionally, the gold standard for treatment of pediatric long bone fractures has been conservative management. However, there is a trend in surgical management. For upper extremity shaft fractures, surgery has been reported to prevent functional deficits and cosmetic deformities of the humerus. For lower extremity fractures, surgery helps to achieve early mobilization and to compensate for heavier body weights of children. However, the data supporting operative techniques are limited.14

Bisphosphonates may be recommended for children with recurrent extremity fractures confirmed due to low bone density. 15 Bisphosphonates are usually administered as an IV infusion for those with osteogenesis imperfecta. It is not clear whether to use oral versus IV bisphosphonates in moderate cases of low bone density for age. It is also not clear whether correcting underlying medical conditions or nutritional deficiencies including correcting low vitamin D levels. The timing for giving bisphosphonate is also unclear – whether to treat the underlying conditions first, or wait until a long bone fracture has healed.16

REFERENCES

  1. Marcdante, Karen J. Kliegman RM. Nelson Essentials of Pediatrics – Fractures. 8th ed. (Mercdante, K. Kliegman R, ed.). Philadelphia: Elsevier; 2019. https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323511452004766?scrollTo=%23hl0000134. Accessed August 1, 2019.
  2. Calmar EA, Vinci RJ. The anatomy and physiology of bone fracture and healing. Clin Pediatr Emerg Med. 2002. doi:10.1053/epem.2002.127037
  3. Di Pietro MA, Brody AS, Cassady CI, et al. Diagnostic imaging of child abuse section on radiology. Pediatrics. 2009. doi:10.1542/peds.2009-0558
  4. Sawyer JR, Spence DD. Fractures and Dislocations In. Thirteenth Edition. Elsevier Inc.; 2016. doi:10.1016/B978-0-323-37462-0.00036-7
  5. Naranje SM, Erali RA, Warner WC, Sawyer JR, Kelly DM. Epidemiology of Pediatric Fractures Presenting to Emergency Departments in the United States. J Pediatr Orthop. 2016. doi:10.1097/BPO.0000000000000595
  6. Bachrach LK. Casting More Light on Pediatric Fractures. Pediatrics. 2019;144(2). doi:10.1542/peds.2019-1594
  7. Kindler JM, Lewis RD, Hamrick MW. Skeletal muscle and pediatric bone development. Curr Opin Endocrinol Diabetes Obes. 2015. doi:10.1097/MED.0000000000000201
  8. Homer CJ, Baltz RD, Hickson GB, et al. Clinical practice guideline: Early detection of developmental dysplasia of the hip. Pediatrics. 2000. doi:10.1542/peds.105.4.896
  9. Bachrach LK, Sills IN, Kaplowitz PB, et al. Clinical report – Bone densitometry in children and adolescents. Pediatrics. 2011. doi:10.1542/peds.2010-2961
  10. Mcdonald KC. Child abuse: Approach and management. Am Fam Physician. 2007.
  11. Escott BG, To T, Beaton DE, Howard AW. Risk of Recurrent Fracture: A Population-Based Study. Pediatrics. 2019;144(2):20172552. doi:10.1542/peds.2017-2552
  12. Frick SL. Skeletal Growth, Development, and Healing as Related to Pediatric Trauma. In: Green’s Skeletal Trauma in Children: Fifth Edition. ; 2014. doi:10.1016/B978-0-323-18773-2.00001-9
  13. Weigelt L;, Fürnstahl P;, Schweizer A. Computer-assisted corrective osteotomy of malunited pediatric radial neck fractures-Three-dimensional postoperative accuracy and clinical outcome. doi:10.1097/BOT.0000000000000970
  14. Lee SH, Yun SJ. Diagnostic Performance of Ultrasonography for Detection of Pediatric Elbow Fracture: A Meta-analysis. Ann Emerg Med. 2019. doi:10.1016/j.annemergmed.2019.03.009
  15. Vierucci F, Saggese G, Cimaz R. Osteoporosis in childhood. Curr Opin Rheumatol. 2017. doi:10.1097/BOR.0000000000000423
  16. Marini JC. Bone: Use of bisphosphonates in childrenproceed with caution. Nat Rev Endocrinol. 2009. doi:10.1038/nrendo.2009.58

Original Version of the Topic

Yuxi Chen, MD, Monika Desai, MD, Phuong U. Le, DO. Pediatric fractures in developing bone. Original Publication Date 09/15/2015.

Author Disclosure

Mi Ran Shin, MD
Nothing to Disclose

Melissa Fleming, MD
Nothing to Disclose

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